Long-term walking ability and patient satisfaction after lower limb functional surgery in patients affected by Charcot-Marie-Tooth disease: A retrospective study.

Structural foot deformities consequent to Charcot Marie Tooth (CMT) can be treated by functional surgery (FS). This study aims to evaluate both long-term walking ability and patients' satisfaction in CMT subjects who underwent FS during their lifetime. We conducted a retrospective observational study. Age, sex, CMT type, comprehensive surgical history, current walking ability assessed by the Walking Handicap Scale (WHS) and patients' global impression of change (pGIC) were retrieved from a custom database managed at our institution. WHS and pGIC were assessed between mid-2018 and mid-2019. Data from 79 patients were screened and 63 were included, 35W-28M, mean age 42 (15), with demyelinating (75%), axonal (20%), and other types (5%) of CMT, who underwent FS between 1967 and 2018. FS evolved significantly over the years from bone-related procedures (e.g., arthrodesis) to both bone and soft tissues-related procedures. The re-intervention rate decreased from 70% before 2000 to 32% in the last decade. Complications arose in five cases. FS was mainly performed on adults (73%). WHS was ≥ 5 in three-quarters of the sample (range 1-6) and was significantly affected by age groups in patients with demyelinating CMT (n=47, p<0.01, non-parametric ANOVA). Nearly 80% of patients were satisfied with FS (pGIC ≥ 4). In conclusion, CMT subjects who underwent FS surgery maintained a high gait efficiency in the long-term period, with middle to high levels of satisfaction in the majority of the cases. This confirms the validity of FS in the management of acquired foot deformities in CMT patients.

Development of a certification examination for orthopedic sports medicine fellows

Background: The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship. Methods: Orthopedic sports medicine fellows over 2 academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows' performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale. Results: Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair. Conclusion: There was a disparity between fellows' performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows' competence.

Contexte: Le but de cette étude était de concevoir un examen à plusieurs volets pour évaluer la compétence des moniteurs cliniques à la fin de leur formation en médecine sportive. Méthodes: Après leur formation de 2 ans pour devenir orthopédistes en médecine sportive, les moniteurs cliniques ont été invités à participer à l'étude. Leurs habiletés cliniques ont été évaluées au moyen d'examens cliniques objectifs structurés, de questionnaires à choix multiple, d'un rapport d'évaluation en cours de formation et d'un journal de bord chirurgical. Leur habileté à réaliser 3 techniques chirurgicales différentes a été évaluée au bloc opératoire et sur des cadavres : reconstruction du ligament croisé antérieur (RLCA), réparation arthroscopique de la coiffe des rotateurs (RACR) et intervention de Bankart sous endoscopie pour l'épaule. Les habiletés techniques ont été évaluées au moyen de listes de vérification spécifiques aux tâches validées et au moyen de l'outil d'évaluation globale ASSET (Arthroscopic Surgical Skill Evaluation). Résultats: Sur une période de 2 ans, 12 moniteurs ont été évalués. Le coefficient α de Cronbach pour les évaluations techniques a été supérieur à 0,8, et la fiabilité inter-examinateurs pour l'évaluation des interventions sur des cadavres a été supérieure à 0,78, soit une fiabilité jugée satisfaisante. Lors de l'évaluation au bloc opératoire, on a jugé que tous les moniteurs détenaient le niveau minimum de compétences pour exécuter les 3 techniques chirurgicales, à l'exception d'un seul qui n'a pas atteint le niveau de compétence pour la RLCA. À l'évaluation de leurs compétences pour les interventions sur des cadavres, 2 sur 12 (17 %) n'ont pas atteint le niveau minimum de compétence pour la RLCA, 2 sur 10 (20 %) pour la RACR et 3 sur 10 (30 %) pour l'intervention de Bankart. Conclusion: On a noté une disparité dans la compétence des moniteurs entre le bloc opératoire et le contexte cadavérique haute fidélité, ce qui donne à penser que le rendement technique au bloc opératoire pourrait ne pas être le moyen le plus approprié d'évaluer la compétence des moniteurs cliniques.

Ultrasonographic Evaluation of The Effects of Orthodontic or Functional Orthopaedic Treatment on Masseter Muscles: A Systematic Review and Meta-Analysis.

Objectives: This review investigated the effects of orthodontic or functional orthopedic therapy on masseter muscle thickness through the use of ultrasonography (US) in growing subjects when compared with untreated subjects. Materials and Methods: This review systematically assessed studies that investigated growing subjects undergoing orthopedic therapy for the correction of malocclusion of vertical, sagittal and transversal plane. Electronic databases (CENTRAL, MEDLINE-PubMed, Scopus and Web of Science) were searched up to February 2019, including available RCTs and CCTs, without language restrictions. The primary outcome was the effect of orthopedic or functional treatment on masseter muscle thickness. The risk of bias of included studies was assessed through the Newcastle-Ottawa quality assessment scale with the aim of defining their methodological quality. A random-effects meta-analysis analyzing mean differences with 95% confidence intervals was used for quantitative analysis. Results: The search retrieved 749 titles, but the studies selection resulted in a final sample of 5 CCTs. The studies retrieved data from 233 children (age range: 5-22 years) and were conducted at university dental clinics. Children were treated for Class II malocclusion, increased vertical dimension or lateral cross-bite variably with rapid or slow maxillary expansion, twin block, bite block, mandibular activators, quad helix, alone or in combination. Risk of bias was assessed as medium for three studies, low for one and high for another. The meta-analysis determined that at the end of orthopedic or functional treatment masseter muscle thickness, measured through the use of US, is significantly reduced (MD -0.79 mm; 95% CI -1.28 to -0.31). The reduction in muscle thickness, therefore, could be considered an indicator for the evaluation of the success of therapy with orthodontic appliances. Conclusions: Although the meta-analysis revealed that US could be considered a less invasive and effective method to evaluate the masseter muscle thickness, single-blinded RCTs, are required to confirm US reliability in this field of application. This review was registered on PROSPERO with the following registration number: CRD42018068402.

Reporting Standards in Clinical Studies Evaluating Bone Marrow Aspirate Concentrate: A Systematic Review.

PURPOSE: To perform a systematic review of clinical studies evaluating bone marrow aspirate concentrate (BMAC) in the treatment of musculoskeletal pathology to compare levels of reporting with recently published minimum standards. METHODS: A systematic review of the clinical literature from August 2002 to August 2017 was performed. Human clinical studies published in English and involving the administration of BMAC for musculoskeletal applications were included. Studies evaluating non-concentrated preparations of bone marrow aspirate or preparations of laboratory cultured cells were excluded. Studies evaluating the treatment of dental or maxillofacial conditions were excluded. Similarly, in vitro studies, editorials, letters to the editor, and reviews were excluded. Levels of reporting were compared with previously published minimum standards agreed on through an international Delphi consensus process. RESULTS: Of 1,580 studies identified on the initial search, 46 satisfied the criteria for inclusion. Considerable deficiencies in reporting of key variables including the details of BMAC preparation and composition were noted. Studies reported information on only 42% (range, 25%-60%) of the variables included within established minimum reporting standards. No study provided adequate information to enable the precise replication of preparation protocols and accurate characterization of the BMAC formulation delivered. CONCLUSIONS: We found that all existing clinical studies in the literature evaluating BMAC for orthopaedic or sports medicine applications are limited by inadequate reporting of both preparation protocols and composition. Deficient reporting of the variables that may critically influence outcomes precludes interpretation, prevents other researchers from reproducing experimental conditions, and makes comparisons across studies difficult. We encourage the adoption of emerging minimum reporting standards for clinical studies evaluating the use of mesenchymal stem cells in orthopaedics. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

[Use of antibiotics in bones : Prophylaxis and current treatment standards]. / Anwendung von Antibiotika im Knochen : Prophylaxe und aktuelle Therapiestandards.

BACKGROUND: Treatment of bone infection is difficult due the systemic administration of antibiotics, which means that only low concentrations reach the inflamed bone tissue. Loss of bone stock is common in osteomyelitis and device associated infection. Local antibiotics are administered in several ways for prophylactic purposes and also for treatment of bone infection. We intend to show the options and limitations of clinical use of antibiotic-loaded bone grafts. SUITABILITY: Bone grafts are a suitable carrier system for antibiotics. Bone grafts may be loaded with a variety of antimicrobial agents so that individual therapies may be carried out. Critical systemic side effects are unlikely even though extreme high drug concentrations are obtained locally, if the thresholds for loading with antibiotics are respected. Thus, antibiotic-loaded bone grafts are appropriate for prophylaxis and therapy as well. If processing is done in the operating theatre compliance to the legal rules must be respected. RULES: Due to a lack of standardised procedures for loading, application and performance of the application of antibiotic-loaded bone grafts medical societies are being asked to initiate consensus meetings in order to issue recommendations or guidelines with respect to antibiotic-loaded bone grafts to establish reliable rules for surgeons using these devices.

The stepwise introduction of innovation into orthopedic surgery: the next level of dilemmas.

The optimum method for the appropriate introduction of innovative technologies into orthopedics is a vital but vexing issue. Compromises in the introduction process are driven by (a) the magnitude of the problem addressed (incidence and severity), (b) the advantages and risks of the proposed solution, and (c) the "universal dilemma," meaning the inherent "gap" between all the nonhuman supporting data and the unknowns of both efficacy and long-term safety in large human usage over many years. Drawing on the data generated and the actual decision tree used in the introduction of a new highly cross-linked polyethylene as a case study, this article illustrates these "subsequent dilemmas."

Custom solution for personal protective equipment (PPE) in the orthopaedic setting: retrofitting Stryker Flyte T5 PPE system.

The coronavirus disease 2019 pandemic has meant that there is growing pressure on hospital resources, not least the availability of appropriate personal protective equipment (PPE), particularly face masks and respirator masks. Within the field of orthopaedic surgery, it is a common sight to see surgeons wearing 'space suits' (SSs) which comprise a helmet, hood and surgical gown. In this study, the authors made modifications to two different SS systems to incorporate a high-efficiency particulate air (HEPA) filter into the fan inlet to assess their potential as re-usable PPE systems for surgeons with regard to protection from a virus spread via respiratory droplets. The testing was carried out using particle counters upstream and downstream on a mannequin wearing two different SS systems with and without modifications to the fan inlet. The results show that using a layer of HEPA filter, cut to size and sealed to the fan inlet in the helmet, will reduce downstream particulates at the user's mouth by >99.5%; this is equivalent to a respirator mask. HEPA filter material is relatively cheap and can be used repeatedly, making this a viable alternative to disposable, and even resterilized, respirator masks in the setting of a respiratory-droplet-spread viral pandemic.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature.

BACKGROUND: Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases. METHODS: A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded. RESULTS: A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product. CONCLUSIONS: Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

[Complication after vertebroplasty in patient with senile osteoporosis: strategical therapy to revise?]. / Complicanza fratturativa dopo intervento di vertebroplastica in corso di osteoporosi senile: strategia terapeutica da rivedere?

Compression fractures are common in patients with osteoporosis and they are crippling. By 1892, Julius Wolff et al. realized that mechanical loads can affect bone architecture in living beings, but the mechanisms responsible for this effect were unknown, and it had no known clinical applications. In 2003 we know how this effect occurs and some of its applications. Vertebroplasty and kyphoplasty are relatively new techniques used to treat painful vertebral compression fractures. Percutaneous vertebroplasty is a therapeutic, interventional radiologic procedure. The technique consists of the percutaneous puncture of the affected vertebral body, followed by injection of bone cement into a vertebral body for the relief of pain, and the strengthening of the bone. This procedure also carries a risk of complications, and the fracture risk of vertebrae adjacent to cement vertebrae may be increased. The authors describe a case of vertebrae's fractures adjacent to cement vertebrae that are occurred in a patient with senile osteoporosis.

Evaluation of Titanium-Coated Pedicle Screws: In Vivo Porcine Lumbar Spine Model.

OBJECTIVE: Many studies have addressed the problem of loosening pedicle screws in spinal surgery, which is a serious concern. Titanium coating of medical implants (arthroplasty) is common, but few studies involving in vivo spine models have been reported. We evaluated the radiological, mechanical, and histological characteristics of titanium-coated pedicle screws compared with uncoated or hydroxyapatite-coated pedicle screws. METHODS: Three different types of pedicle screws, i.e., uncoated, hydroxyapatite-coated, and titanium-coated, were implanted into the lumbar 3-4-5 levels of 9 mature miniature pigs. Radiological evaluation of loosening of pedicle screws was performed. Peak torsional extraction torque was tested in the 42 screws from 7 miniature pigs at 12 weeks postoperatively. The implant-bone interface of the remaining 12 pedicle screws from 2 miniature pigs in each group was assessed by micro-computed tomography and histologic studies. RESULTS: The incidence of loosening at 12 weeks postoperatively was not significantly different between the titanium-coated pedicle screw group and the other groups. The titanium-coated pedicle screw group exhibited the greatest mean extraction torsional peak torque at 12 weeks postoperatively (P < 0.05). Quantitative micro-computed tomography data were greatest in the titanium-coated pedicle screw group (P < 0.05). Histologic findings showed osteointegration with densely packed new bone formation at the screw coating-bone interface in the titanium-coated pedicle screw group. CONCLUSIONS: Fixation strength was greatest in the titanium-coated pedicle screw group. Osteointegration at the interface between the titanium-coated implant and bone produced prominent and firm bonding. The titanium-coated pedicle screw is a promising device for application in spinal surgery.

Two-month longitudinal study of mechanical properties of absorbable sutures used in orthopedic surgery.

BACKGROUND: This is the first study assessing the properties of large-diameter degradable sutures relevant for orthopedic applications over the course of in vitro incubation for 2 months. The data we present here provide guidance to the orthopedic surgeon in predicting the long-term performance of suture materials used everyday in surgical practice. METHODS: Five different absorbable (Vicryl, Maxon, Monocryl, PDS II, Vicryl rapide) and one non-absorbable (Ethibond) suture materials were tested. Measurements were made at five time points during the 56 days of incubation under physiological conditions (37.0 ± 0.02 °C; pH 7.4 ± 0.2). The following variables were recorded: load to failure, strain at maximal load as elongation normalized to original length, stiffness as the ratio of load to displacement on the linear proportion of the stress strain curve, and hysteresis as area under the curve of the stress strain curve. RESULTS: Vicryl was the strongest fiber on day 0 (195 N); however, by day 42, the tensile strength of the suture reduced to 14 N. Between days 14 and 28, PDS II (171 N) and Maxon (182 N) sustained the highest loads. Monocryl (p = 0.003) and Maxon (p < 0.001) showed an increasing strain with time, whereas Vicryl (p = 0.002) and Vicryl rapide (p = 0.007) revealed an increasing material stiffness. Furthermore, both Vicryl (p = 0.053) and Monocryl (p < 0.001) had an increasing hysteresis with ongoing degradation. Maxon, PDS II, and Ethibond showed stable material properties during the 2 months. CONCLUSIONS: The three absorbable sutures Vicryl, PDS II, and Maxon could sustain higher loads during the first 2 weeks than the non-absorbable Ethibond. Unexpectedly, Maxon and PDS II maintained their elastic properties in spite of their proceeding degradation and loss of tensile strength.

Optimization of intramedullary nailing by numerical simulation of fracture healing.

Due to the annular gap between intramedullary (IM) nails and the endosteal surface, high interfragmentary movement can occur under loading. This could prolong the healing time, particularly for thin IM nails that are often used for unreamed IM nailing. The aims of our study were to determine the influence of the nail diameter on the healing time of human tibial shaft fractures and to investigate whether the healing time could be shortened by increasing the stiffness of the implant material. Therefore, a corroborated numerical model for simulating the fracture healing process in humans was used to simulate the healing process of human tibial fractures treated with IM nails. The calculated healing time (up to 71 weeks) was longest for transverse fractures treated with thin IM nails made of titanium. That the healing time was disproportionately long depended on the nail diameter, and could be greatly reduced by using a thicker nail or using steel instead of titanium. To avoid a prolonged healing time, the nail should be thick, and the annular gap should be as narrow as possible. Alternatively, using steel instead of titanium may also help to avoid a prolonged healing time.

Non-rigid immobilisation of odontoid fractures.

Despite various reports on the management of odontoid fractures, there is no consensus on the subject, and the appropriate treatment still remains controversial. While untreated fractures or fractures treated only with a cervical orthosis seem to have the highest rate of non-union, the need for rigid external stabilisation has never been substantiated. In a retrospective analysis we reviewed 26 patients with acute type II and III fractures of the odontoid, treated with a cervical orthosis only. Study inclusion was limited to fractures that had a fracture gap of less than 2 mm, an initial antero-posterior displacement of less than 5 mm and angulation of less than 11 degrees, less than 2 mm displacement on lateral flexion/extension views, and were without neurological deficits. These fractures were defined as stable. There were 19 (73.1%) type II and 7 (26.9%) type III fractures; in 10 (38.5%) of these fractures the odontoid was displaced and/or angulated. The overall complication rate was 11.4% ( n=3). One patient suffered from pulmonary embolism, in two patients (7.7%) with initially minimally displaced fractures, secondary internal stabilisation had to be performed because of persistent instability. In 20 (77%) of the remaining fractures healing was uneventful. In 4 nondisplaced fractures (15%) fibrous union was documented. Three of these patients were over 65 years old. The overall fusion rate was 73.7% for type II and 85.7% for type III fractures. At follow-up 39% of the patients were free of symptoms; however, the clinical outcome did not correlate with the radiological findings. According to our findings, stable type II and type III fractures of the odontoid can be successfully treated with non-rigid immobilisation, even if they are displaced. A thorough assessment of the stability of the odontoid with lateral flexion/extension views or dynamic fluoroscopy is recommended to evaluate the appropriate treatment. Non-rigid immobilisation may be an option in selected cases with stable injuries.

Experiência com a modelagem nasoalveolar precoce em um recém-nascido portador de fissura lábio-alveolar / Experience with early nasoalveolar molding in a clefted child

O tratamento das fissuras lábio-palatinas evoluiu muito nas últimas décadas. O tratamento atual da deformidade inclui técnicas ortopédicas de modelagem nasoalveolar como a Modelagem Nasoalveolar Passiva (MNA), que tem por objetivo a redução da largura da fissura alveolar e do palato, bem como da modelagem da região nasal afetada, logo após o nascimento. A MNA é iniciada na primeira semana de vida e se continua durante os primeiros meses, até a data do fechamento cirúrgico do lábio. O presente artigo relata o caso de um recém-nascido com diagnóstico ultrassonográfico de fissura lábio-alveolar. O diagnóstico precoce possibilitou o encaminhamento para o especialista, de tal forma que o tratamento foi iniciado logo após o nascimento. Ao final da MNA, a operação de correção da fissura nasoalveolar determinou o fechamento completo do defeito, e o aspecto da região tratada se assemelhava ao do lado não afetado.

The care of lip and palate clefts has progressed a lot in the last decades. Current treatment of the deformity includes orthopedic techniques of nasoalveolar molding such as the passive Nasoalveolar Molding (NAM), which is intended to reduce the width of the alveolar and palate cleft, as well as reshaping the affected nasal area, soon after birth. NAM is indicated to be performed in the first week of life and be continued over the next months, up to the eventual surgical closure of the lip. The present paper reports the case of a newborn with an ultrasonographic diagnosis of cleft alveolus and lip. Early diagnosis made it possible to promptly refer the patient to a specialist, so that treatment began soon after birth. At the end of NAM, the procedure to correct the nasoalveolar cleft determined the complete closure of the defect, and the aspect of the treated area can be appreciated.