The history of intramedullary nailing.

PURPOSE: To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology. METHOD: A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing. RESULTS: The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients. CONCLUSION: Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications.

Osteomyelitis of the femur effectively treated with medulloscopy debridement: a case report.

BACKGROUND: Medulloscopy refers to the visualization of the intramedullary canal with an arthroscope, providing access to the infection site without the need for an extensive approach therefore not compromising the surrounding soft tissue. It provides information regarding the extent of the infected endosteal surface of bone, and it allows a thorough debridement of the intramedullary canal in a controlled manner. Therefore, it can be used as an adjunct to traditional open surgical techniques, to perhaps help to visualize hard to see intramedullary areas. MATERIALS AND METHODS: This article reports a patient with chronic osteomyelitis of the distal metaphysis of the femur that was treated successfully with intramedullary debridement through medulloscopy. The sinus tract reaching down to the femoral bone and communicating with the intramedullary canal was excised, and a cortical window was formed through which the arthroscope was inserted and thorough irrigation of the intramedullary canal and excision of necrotic and infected bone was done. A second medulloscopy through the same approach was necessary 3 months later because of persistent infection. RE: SULTS: At 3-year follow-up, the patient was well without any clinical or radiographic evidence of recurrent infection. CONCLUSION: Medulloscopy can be very useful in localized osteomyelitis as an adjunct to traditional surgical techniques; it helps to visualize hard to see intramedullary areas and adequately addresses the infection, while the damage to surrounding soft-tissue is limited.

Chondrosarcomas of the small bones: analysis of 44 patients.

BACKGROUND: Chondrosarcomas of the small bones of the hands and feet are uncommon and account for less than 2% of all chondrosarcomas in the skeleton; a 4.2% rate of malignant degeneration of enchondromas to secondary chondrosarcomas has been reported. We performed this study to assess the outcome of the patients with chondrosarcomas of the small bones. We hypothesized that the presumed better prognosis of chondrosarcomas in these locations could be biased as the majority of these tumors tend to be of lower grades and are removed when still small sized, and that less aggressive surgery has an adverse effect on local control MATERIALS AND METHODS: We retrospectively studied the files of 44 patients with chondrosarcomas of the small bones of the hands and feet. There were 23 female and 21 male patients with a mean age of 50.9 years (range, 6-86 years). The mean follow-up was 13 years (range, 5-40 years). We recorded the patients' details including gender and age at diagnosis, type and duration of symptoms, tumor location and histology, type of surgery and complications, and outcome (local recurrences and metastases). RESULTS: The most common anatomical location for chondrosarcomas of the hands was the metacarpals and proximal phalanges. The most common presenting symptom was a slowly enlarging palpable mass. Overall, 36 chondrosarcomas were secondary to a pre-existing cartilaginous tumor. Patients with syndromes were affected in younger age compared to the others. The mean age at diagnosis was higher for higher grade chondrosarcomas. Overall, 13 patients (29.5%) experienced a local recurrence; the rate of local recurrence was higher after curettage regardless the histological grade of the tumors. After wide resection of the first local recurrence, five patients experienced local re-recurrence. Five patients (11.4%) experienced lung metastases, two patients at presentation. All these patients had a high grade chondrosarcomas. At the last follow-up, one patient with lung metastases died from disease, and another patient died from unrelated cause. CONCLUSIONS: The patients with chondrosarcomas of the small bones of the hands and feet may have a dismal outcome if treated improperly. A careful treatment planning is required to avoid unnecessary amputations. Curettage is associated with a high rate for local recurrence that should be treated with a more aggressive surgical resection to avoid re-recurrences. Although the risk is low, the patients may develop lung metastases, especially those with higher grade chondrosarcomas, therefore, they should be staged and followed closely.

Double fractures of the femur: a review of 16 patients.

BACKGROUND: Double ipsilateral femoral fractures account for 1-9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment. MATERIALS AND METHODS: We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used. RESULTS: Fourteen patients experienced union at a mean of 3 months (2-6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months. CONCLUSION: Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications.

Pleomorphic Liposarcoma Revisited.

Pleomorphic liposarcoma (PLPS) is the rarest and more aggressive subtype of liposarcomas, accounting for 10% of all liposarcomas. The diagnosis should be considered after the detection of multivacuolated pleomorphic lipoblasts in biopsy specimens. Wide-margin resection is the treatment of choice. Complementary treatment options, such as radiation therapy and chemotherapy, are debatable in terms of their contribution to curing patients with PLPS. This article reviews the clinical, histopathological, and molecular characteristics of PLPS and discusses the latest trends in the management, therapeutic strategies, and novel investigations of the subject. [Orthopedics. 2023;46(2):e72-e80.].

Shamrock Lumbar Plexus Block for Hip Hemiarthroplasty in a High Risk Elderly Patient with Hip Fracture.

Hip fractures in the geriatric population are associated with high morbidity and mortality rate. Early surgical fixation is of major importance, as it is one of the factors that contribute to patient optimization. However, these patients usually present a high burden of comorbidities, including aortic stenosis that could affect their treatment. Despite major advances in anesthetic and surgical techniques, severe aortic stenosis remains an independent, important risk factor for patients undergoing anesthesia for noncardiac surgery. In these patients, general and/or neuraxial anesthesia should be avoided; peripheral nerve blockade is a viable option. This article presents a 96-year-old hip fracture patient with severe aortic stenosis and aspiration pneumonia that successfully underwent hip hemiarthroplasty under peripheral nerve blockade as sole anesthesia.

The Hippocratic Oath: Analysis and Contemporary Meaning.

The Hippocratic oath is traditionally taken by medical school graduates at the time of their graduation, either in its original form or in a modern variation. It is considered the earliest expression of medical ethics, establishing principles of ethics that remain of paramount significance today. However, it was written in antiquity, whereas medicine has been constantly evolving. This article reviews, analyzes, and interprets each section of the oath to determine to what extent it remains relevant to contemporary medicine. [Orthopedics. 2021;44(5):264-272.].

Diagnostic Value of IL-1ß, IL-17A, and IL-17F Serum Levels in Patients with Upper Extremity Infections.

We prospectively studied 51 patients (38 men and 13 women; mean age, 52 years) with upper extremity infections. Body mass index (BMI), smoking habits, and comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, thyroid disease, and the site and type of infection were recorded. The 0-10 point Visual Analogue Scale (VAS) was used to evaluate the pain of the affected limb, and the Quick DASH Score was used to assess the severity of upper limb injury. ESR, CRP, and WBC, as well as serum levels of IL-1ß, IL-17A, and IL-17F were measured. The serum levels of IL-1ß and IL-17F were not elevated in the majority of the patients. In contrast, 14 patients (27.4%) had elevated levels of IL-17A. However, serum levels of IL-17A were not correlated with sex, age, BMI, comorbidities, fever, VAS score, WBC, CRP, ESR, and IL-17F. A trend to significance was observed between IL-17A and DASH score, and a strong association was observed between IL-17A and IL-1ß. No correlation was detected between serum levels of IL-17A and type of isolated bacteria, Gram stain, site and type of infection. After controlling the impact of sex, age, and BMI, a trend to significance was observed between IL-17A and VAS score, and a marginal significance was observed between IL-17A and DASH score.

Echinococcosis of the spine.

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine.More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord.As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely.Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization.This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients' outcomes.The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130.

Type IIIB Tibial Tubercle Avulsion Fracture: A Case Report.

Tibial tubercle avulsion fractures are uncommon injuries that are seen mostly in adolescent male patients during athletic activities. The mechanism of injury usually involves a strong eccentric contraction of the quadriceps femoris muscle when the proximal tibial physis is closing, leading to failure of the physis at the patellar tendon insertion. The treatment of patients with tibial tubercle avulsion fractures depends on the fracture pattern; it can be conservative with immobilization in a long leg cast in extension for 6 weeks with minimal displacement (< 2 mm) and/or acceptable displacement after closed reduction/cast application. Or it can be surgical. This article presents a 14-year-old boy with an Ogden type IIIB tibial tubercle avulsion fracture that was misdiagnosed on radiographs at presentation as type IB. Open reduction and cannulated screw osteosynthesis was done. The outcome was excellent after a 12-week rehabilitation protocol.