Medial open wedge high tibial osteotomy is a viable option in young patients with advanced arthritis in a long-term follow-up.

PURPOSE: This study aimed to evaluate the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) as a treatment option for advanced medial compartment knee osteoarthritis (OA) Kellgren-Lawrence (K-L) III and IV. METHODS: Patients with severe medial compartment arthritis, who underwent MOWHTO with locking plate between 2003 and 2015, were retrospectively reviewed. A locking plate for the osteotomy was utilized. Preoperative and postoperative patients' evaluation was performed using the International Knee Documentation Committee Score (IKDC), the Oxford Knee Score (OKS), the Knee Injury Osteoarthritis Outcome Score (KOOS) and the Short Form-12 Score (SF-12). Standardized standing whole-limb X-rays were taken to evaluate the mechanical tibiofemoral angle (mTFA) and proximal medial tibial angle (PMTA), and the severity of OA. RESULTS: A total of 32 patients, 35 knees (27 males, five females) of which 21 were classified as K-L Grade III and 14 as K-L Grade IV, and mean age 47.1 ± 9.17 years old, who were followed for 13.6 years (range 7-20 years), were included in the study. During the follow-up period, three knees required conversion to total knee replacement (91.5% survival rate). All clinical outcome scores (KOOS, OKS, IKDC and SF-12) showed a significant improvement compared to preoperative status (p < 0.05). Preoperative mTFA and PMTA were significantly corrected immediately after surgery and retained this improvement at the last follow-up. CONCLUSION: MOWHTO with a locking plate is an effective method to treat severe medial compartments. Clinical and radiological results are satisfactory and the survival rate is 91.5%, at a mean follow-up of 13.6 years after the procedure. LEVEL OF EVIDENCE: Level IV.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study.

PURPOSE: Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures. PATIENTS AND METHODS: Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications. RESULTS: Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality. CONCLUSIONS: Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment.

PURPOSE: To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole. MATERIALS AND METHODS: Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent. RESULTS: In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well. CONCLUSION: 1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Satisfactory functional and radiological outcomes can be expected in young patients under 45 years old after open wedge high tibial osteotomy in a long-term follow-up.

PURPOSE: To report the long-term outcomes of medial open wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis in patients younger than 45 years old. It was hypothesized that the correction of knee alignment would result in preservation of knee function in a long-term follow-up. METHODS: Patients under 45 years old, who underwent MOWHTO for symptomatic medial compartment knee osteoarthritis between 2001 and 2005 were retrospectively reviewed after a minimum of 10 years. The osteotomy was performed utilizing a locking plate without the use of bone graft. Patients were evaluated pre- and postoperatively using the International Knee Documentation Committee Score, the Oxford Knee Score, the Knee injury Osteoarthritis Outcome Score and the Short Form-12 Score. Standardized standing whole-limb radiographs were also obtained to assess mechanical tibiofemoral angle (mTFA) and the grade of osteoarthritis. RESULTS: A total of 20 patients (18 males, 2 females, mean age 35.4 years) with a mean follow-up of 12.3 years were included in the study. During the follow-up period, one patient required conversion to total knee replacement (95% survival rate). All clinical outcome scores (IKDC, KOOS, OKS, and SF-12) significantly improved postoperatively (p < 0.05), with no significant deterioration over time. Preoperative varus alignment with an mTFA of - 5.8 ± 2.4° was corrected to 2.5 ± 1.9° immediately after surgery (p < 0.05), and remained 2.2 ± 1.7° at the last follow-up. Furthermore, no significant radiographic progression of osteoarthritis was observed. CONCLUSIONS: MWOHTO with a locking plate is an effective joint preservation method to treat medial compartment OA in active patients less than 45 years. Clinical and radiological results are satisfactory and the survival rate is 95%, 12 years after the procedure. LEVEL OF EVIDENCE: Level IV therapeutic, retrospective, cohort study.

Management of scaphoid nonunions with vascularized bone grafts from the distal radius: mid- to long-term follow-up.

Scaphoid nonunion represents a challenging problem that leads to disability if neglected. Vascularized bone grafts are proposed to augment the local biology and increase the likelihood of union but long-term outcomes are sparse. In this work, we present the mid- to long-term outcome of 140 scaphoid nonunions managed with vascularized bone grafts from the distal radius. Sixteen patients underwent concomitant closed wedge osteotomy of the distal radius because of arthritic changes. There were 130 males and ten females, with mean time from injury to surgery 3.3 years. Delayed presentation was associated with arthritic changes. Forty-two patients had avascular necrosis of the proximal pole and sixteen had more severe arthritic changes. The mean follow-up was 10 years. Pain decreased postoperatively but range of motion did not improve but only in early reconstructions. Grip strength reached 79% of the non-injured hand. Mayo modified wrist score improved from 56 to 84 (p < 0.001). Except one, all the rest 139 nonunions healed in a mean time of 9 weeks. MRI evaluation in 77 patients revealed healing at a mean of 3 months postoperatively even in cases of avascular necrosis. Scaphoid length, carpal height, and scapholunate angle increased, but capitolunate did not change significantly. The presence of arthritis preoperatively was associated with progression of arthritic changes after 10 years. Treatment of scaphoid nonunions with vascularized bone grafts from distal radius reliably led to highest rate of bone healing with good mid- to long-term outcomes. Enhancement of the local biology and reconstitution of scaphoid and carpal height resulted in improved function mostly in early interventions.

Traumatic tibialis anterior tendon rupture: treatment with a two-stage silicone tube and an interposition hamstring tendons graft protocol.

A novel technique for managing ruptured tibialis anterior tendon complicated by infection and tendon substance loss in a young adult is described. A two-stage reconstruction technique with a silicon tube and tendon autograft was performed. At first, after local control of the infection, scar excision and placement of a silicone tube was performed. Ten weeks later, ipsilateral hamstrings tendons were harvested and bridged the 7 cm tendon gap. Eighteen months later, the patient has excellent clinical and functional outcome.

Operative management of humeral nonunions. Factors that influence the outcome.

UNLABELLED: The purpose of this study is to present the outcome of surgically treated humeral nonunions and find factors that affect the outcome. Forty-two patients with humeral nonunions (30 shaft, 7 proximal and 5 distal) were reviewed in a prospective manner. Treatment was based on a specific algorithm. Demographics, time to union, range of motion, functional outcome and complications were recorded and analysed. RESULTS: Mean follow-up was 78 months and mean time to union was 4.3 months. Infection was associated with delayed union of the pseudarthrosis, while range of motion was negatively affected by the location (proximal) and the AO type of the initial fracture. Complication rate was 17%. CONCLUSION: The surgical management of humeral nonunions yields a favourable outcome with reduced rate of complications. Infection prolonged healing time, while proximal location of the nonunion and the type B or C fracture according to AO/OTA classification adversely affected range of motion.

Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse.

PURPOSE: To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction. METHODS: Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores. RESULTS: Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected. CONCLUSIONS: Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Development of Prediction Model for 1-year Mortality after Hip Fracture Surgery.

Purpose: Hip fractures are associated with increased mortality. The identification of risk factors of mortality could improve patient care. The aim of the study was to identify risk factors of mortality after surgery for a hip fracture and construct a mortality model. Materials and Methods: A cohort study was conducted on patients with hip fractures at two institutions. Five hundred and ninety-seven patients with hip fractures that were treated in the tertiary hospital, and another 147 patients that were treated in a secondary hospital. The perioperative data were collected from medical charts and interviews. Functional Assessment Measure score, Short Form-12 and mortality were recorded at 12 months. Patients and surgery variables that were associated with increased mortality were used to develop a mortality model. Results: Mortality for the whole cohort was 19.4% at one year. From the variables tested only age >80 years, American Society of Anesthesiologists category, time to surgery (>48 hours), Charlson comorbidity index, sex, use of anti-coagulants, and body mass index <25 kg/m2 were associated with increased mortality and used to construct the mortality model. The area under the curve for the prediction model was 0.814. Functional outcome at one year was similar to preoperative status, even though their level of physical function dropped after the hip surgery and slowly recovered. Conclusion: The mortality prediction model that was developed in this study calculates the risk of death at one year for patients with hip fractures, is simple, and could detect high risk patients that need special management.

Osteonecrosis risk after steroids-related treatment of COVID-19 is not negligible: A cross sectional study.

BACKGROUND & AIMS: During the pandemic, steroids use at various dosages and durations for the treatment of COVID-19 patients, especially in hospitalized patients, was a common and effective strategy. However, steroid administration is associated with osteonecrosis as an adverse event. The aim of the study was to examine the prevalence of skeleton osteonecrosis in COVID-19 patients treated with or without steroids. METHODS: Eighty randomly selected hospitalized COVID-19 patients were analyzed, of which 40 were managed with a published protocol including steroids and 40 did not receive steroids. Demographics and laboratory measurements including white blood cells count, C-reactive protein and ferritin were retrieved from the medical records. All patients underwent magnetic resonance imaging of the hips, shoulders, and knees. Subsequently, all patients were clinically examined and Oxford hip score (OHS) and EuroQol- 5 Dimension (EQ-5D-5 L) were documented. RESULTS: Three patients (3/40; 7.5 %) treated with steroids were diagnosed with femoral head osteonecrosis. None of the patients in the non-steroid-treated group developed osteonecrosis. There were no differences between the two groups regarding OHS and EQ-5D-5 L. Patients with osteonecrosis had higher ferritin levels, received higher doses of corticosteroids (median dose 2200 mg), and had longer hospitalization. CONCLUSIONS: COVID-19-related therapy with steroids resulted in lower prevalence of osteonecrosis than that previously recorded in patients with severe acute respiratory syndrome caused by coronavirus-type-1. However, this risk seems not negligible and therefore, high clinical suspicion for early diagnosis is warranted, given the fact that a great proportion of hospitalized patients received steroids during the COVID-19 pandemic.

Acute Bilateral Achilles Tendon Rupture in a Middle-Aged Patient: A Rare but Debilitating Injury.

Acute Achilles tendon (AT) rupture is an infrequent yet incapacitating injury that demands prompt diagnosis and effective intervention. While unilateral ruptures are more common, bilateral occurrences are exceedingly rare, particularly without predisposing factors. This case report presents an instance of a 52-year-old male patient who suffered a bilateral AT rupture during a soccer game. Physical examination and ultrasound confirmed bilateral AT tears, prompting surgical repair. The surgical procedure involved trimming the degenerated tendon ends, using a modified Krackow repair technique, and finally suturing the paratendon. Postoperatively, a tailored rehabilitation program was employed, encompassing bed-to-chair transfer for six weeks and partial weight-bearing afterward using Achilles braces. At the last follow-up, at nine months, the patient was able to walk bearing full weight with satisfactory clinical and functional outcomes. This report underscores the successful management of a rare case of bilateral acute AT rupture through surgical intervention and a tailored rehabilitation protocol. Bilateral AT ruptures necessitate an individualized approach, taking into account the complexities of simultaneous bilateral injuries.

Revision total hip arthroplasty for aseptic loosening compared with primary total hip arthroplasty for osteoarthritis: long-term clinical, functional and quality of life outcome data.

PURPOSE: The aim of this study was the comparative assessment of long-term clinical (subjective and objective), functional and quality of life outcome data between primary and revision THA. METHODS: 122 patients (130 hips) who underwent cementless revision THA of both components (TMT cup, Wagner SL stem, Zimmer Biomet) for aseptic loosening only (Group A) were compared to a matched group of 100 patients (100 hips) who underwent cementless primary THA for osteoarthritis (Synergy stem, R3 cup, Smith & Nephew) (Group B). Outcomes were evaluated with survival analysis curves, Harris Hip Score (HHS), WOMAC, Oxford Hip Score (OHS), Short-Form Health Survey (SF-12) and EQ-5D-5L scales. Mobility was assessed with walking speed, Timed Up And Go Test (TUG), Parker Mobility Score, Lower Extremity Functional Scale (LEFS) and UCLA scores. RESULTS: At a mean follow-up of 11.1 (8-17) years a cumulative success rate of 96% (95% CI, 96-99%) in Group A and 98% (95% CI, 97-99%) in Group B with operation for any reason as an endpoint was recorded. Statistically significant differences between groups were developed for WOMAC (Mann-Whitney U-test, p = 0.014), OHS (Mann-Whitney U-test, p = 0.020) and physical component of SF-12 scores (Mann-Whitney U-test, p = 0.029) only. Group A had less improvement in function as compared with group B. In Group A, in multiple regression analysis, patients' cognition (p = 0.001), BMI (p = 0.007) and pain (p = 0.022) were found to be independent factors influencing functional recovery (WOMAC). Similarly, pain (p = 0.03) was found to influence quality of life (EQ-5D-5). CONCLUSIONS: In the long term, revision THA shows satisfactory but inferior clinical, functional, and quality of life outcomes when compared to primary THA. Residual pain, BMI and cognitive impairment independently affect functional outcomes.

Venous thromboembolism and major adverse cardiovascular events in patients with hip fractures suffering from SARS-CoV-2 infection: a systematic review.

INTRODUCTION: Hip fractures represent 1 of the most common injuries in older adults. They are associated with increased perioperative morbidity and mortality. Additionally, current research suggests that SARS-COV-2 infection may worsen the prognosis of the hip fracture patients who undergo hip fixation. The aims of the present study were: (1) to determine the rate of specific adverse events including VTE (venous thromboembolism) and major adverse cardiovascular events (MACEs) in patients with hip fracture and concomitant SARS-CoV-2 infection undergoing surgery; and (2) to examine if the aforementioned population is at increased risk for VTE and MACEs, when compared to SARS-CoV-2 free patients with hip fracture. METHODS: PubMed, EMBASE, Cochrane, Web of Science, Google scholar and medRxiv were searched from March 2020 to January 2021 for English language studies with patients suffering from hip fractures and SARS-COV-2 -CoV-2. 2 researchers were involved in the data extraction and the quality assessment of the studies respectively. RESULTS: The literature search yielded a total of 1256 articles of which 14 were included in the systematic review and 7 in the meta-analysis respectively. The estimated pooled rate for VTE and MACE were 4.3% and 6.3% respectively. Patients with hip fracture and concomitant SARS-CoV-2 infection who undergo surgery are at increased risk for VTE, when compared to SARS-CoV-2 free patients (odds ratio 2.8 [95% CI, 1.1-7.1]). These patients are also at increased risk for MACE postoperatively as indicated by the odds ratio 2.4 (95% CI, 1.0-5.8). The quality of the studies was moderate. CONCLUSIONS: Although there is a lack of high-quality data it seems that patients with hip fractures and concomitant SARS-CoV-2 infection are facing a 2.8 and 2.4 times increased risk for VTE and MACE.

Postacute sequelae of SARS-CoV-2 infection. Osteonecrosis must not be overlooked.

Recovery from COVID-19 is not always uneventful, especially in critically ill hospitalized patients. Persistent symptoms including fatigue/ weakness, shortness of breath, anxiety, and depression have been described at one-year follow-up. Furthermore, symptoms from the musculoskeletal system like joint pain or stiffness are underreported in studies with long-term follow-up of up to one year. Infection with SARS-CoV-2 itself has been associated with endothelial damage, and together with high-dose corticosteroid treatment, it is predisposed to the dissemination of microthrombi and the development of femoral head osteonecrosis (FHOn), as it has been shown during the previous (2003-2004) coronavirus outbreaks. A resurgence of FHOn cases is anticipated but this is not reflected in the existing studies with long-term follow-up. Prompt diagnosis is critical for early treatment and possibly for the hip joint preservation. Patients with COVID-19 treated with corticosteroids should be screened for avascular necrosis early after discharge from the hospital. Every healthcare worker involved in the management of these patients should maintain a high level of suspicion and should be alert when patients report symptoms such as vague aches at the buttocks, hip area, adductors, and/or above the knee. Studies are needed to identify risk factors for FHOn including disease severity, type of steroid, cumulative dose, and duration of treatment.

Clinical, functional and radiographic outcomes after revision total hip arthroplasty with tapered fluted modular or non-modular stems: a systematic review.

PURPOSE: The aim of the study was to systematically evaluate clinical outcomes of tapered fluted stems, either monoblock or modular, in revision total hip arthroplasty. METHODS: PubMed, EMBASE and Web of Science and Cochrane databases were systematically searched by 2 researchers. Clinical studies reporting primarily on survival and re-revision rates, and secondarily on subsidence, dislocation, intraoperative fractures, periprosthetic fractures and infection were included. 2 investigators assessed the quality of the studies. RESULTS: 46 studies were included in this review, reporting on 4601 stem revisions. The pooled re-revision rate was 5.1% and long-term survival ranged from 75% to 98.5%. No differences were observed between monoblock and modular stems regarding re-revision rate, dislocation rate, periprosthetic fracture rate or infection rates. Monoblock stems exhibited more subsidence and modular stems displayed more intraoperative fractures. CONCLUSIONS: Satisfactory results can be obtained with the use of tapered fluted end-bearing stems. Monoblock stems offer the same clinical results as modular stems.

Tibial Nerve Palsy: An Atypical Presentation of a Popliteal Cyst.

Popliteal cysts represent one of the commonest knee pathologies in the adult population. The vast majority of cases may be treated conservatively as symptoms tend to resolve spontaneously. However, few patients may experience persistent pain and nerve-related symptoms not responding to conservative management. We present a case of a 46-year-old patient who suffered from tibial nerve palsy due to a popliteal cyst that was treated successfully with combined open and arthroscopic procedure. It is important to understand that popliteal cysts rarely may lead to tibial nerve entrapment and in selected cases operative management may be indicated.

Giant Hip Synovial Cyst Causing Deep Vein Thrombosis and Femoral Head Osteonecrosis in a Rheumatoid Arthritis Patient.

Hip synovial cysts are rare. However, in patients with Rheumatoid Arthritis (RA) they present in higher frequency than in general population. Herein, we present an unusual case of a 67-year-old man with RA that presented with unilateral leg oedema and Deep Vein Thrombosis (DVT). Computed tomography (CT) scan revealed a giant cystic lesion adjacent to the right hip joint with longitudinal diameter of 14 cm. Magnetic Resonance Imaging (MRI) confirmed the characteristics of the cyst. Interestingly enough, there was evidence of osteonecrosis of the femoral head. CT guided Fine Needle aspiration (FNA) of the fluid revealed fluid consistency similar to synovial fluid, while it excluded infectious process and malignancy. Patient was finally treated with total hip arthroplasty 3 months after the initiation of low molecular weight heparin (LMWH) in treatment dose.

Diffuse pigmented villonodular synovitis of the knee joint: 3-year follow-up of a case report.

Pigmented villonodular synovitis (PVNS) is a proliferative, recurrent and locally invasive disease of the synovium. The symptoms of the disorder are not typical and thus it is very often misdiagnosed. Most of the times, magnetic resonance imaging presents the nodular model of development and sets the basis for the diagnosis. The final diagnosis will be set by the pathological evaluation of the lesion's biopsy. PVNS may be localized (nodule with a clear boundary with/without presence of single pedicle) or diffuse (extensive involvement of the adjacent nerves and vessels). Depending on the extension of the PVNS, a different management approach is performed, lesion excision vs. resection, followed by radiotherapy respectively. We report a case of diffuse PVNS in the knee joint, treated with surgical excision and adjuvant radiotherapy as well as follow-up imaging after a time period of 3 years.