Standing on shoulder of giants: the incredible legacy of the Judet family in orthopaedic surgery.

In orthopaedic surgery, as well as other areas in medicine, it is common for a surgical technique to carry the original authors' name describing the procedure. The Judet family represents a unique history, since several orthopaedic procedures are known as "Judet's technique". The aim of this historic review is to outline the genealogy of the orthopaedic arm of the Judet family, while crediting each surgical procedure to the specific family member that described the technique.

Novel implant design for comminuted posterior wall acetabular fractures.

BACKGROUND: In recent years, the medical community has witnessed a notable increase in high-energy traumatic injuries, leading to a surge in complex fracture patterns that challenge existing treatment methodologies. Among these, the posterior approach to acetabular fractures stands out for offering direct visualization of the retro-acetabular surface, with current fixation methods relying on 3.5 mm low-profile reconstruction plates and various other implants. Despite the effectiveness of these methods, there is a burgeoning demand for a singular, adaptable implant that not only streamlines the surgical process but also optimizes patient outcomes. METHODS: In an innovative approach to address this need, three-dimensional (3D) models of the posterior acetabular wall were meticulously crafted using AutoCAD® software. The chosen material for the implant was 316L surgical steel for its durability and strength. The design of the implant featured a low-profile mesh structure, which was instrumental in facilitating osteosynthesis. This design allowed for the placement of screws of varying lengths in multiple directions, ensuring the initial reconstruction of the joint in an anatomical position without hindering the placement of the definitive implant. The primary objective was to secure the fixation and stabilization of the fracture by specifically targeting the smaller bone fragments. A comparative analysis was then conducted between this novel plate and a conventional 316L surgical steel, seven-hole, 3.5 mm reconstruction plate through finite element analysis. RESULTS: The comparative analysis unveiled that both plates demonstrated comparable deformation capacities, with no significant differences in load-bearing capabilities observed. This finding suggests that the innovative plate can match the performance of traditional plates used in such surgeries. CONCLUSIONS: The finite element analysis revealed that the newly developed anatomical plate for posterior wall acetabular fractures meets the necessary physical and mechanical criteria for permanent implementation in patients with these fractures. This breakthrough represents a promising advancement that could simplify surgical procedures and potentially elevate patient outcomes. LEVEL OF EVIDENCE II: This study is classified as a Level II, diagnostic study.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study.

INTRODUCTION: Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS: A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS: Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION: Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II: a prospective study.

PURPOSE: Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers. METHODS: A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. RESULTS: In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2 mm (P = 0.057) and 2.3 mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM. CONCLUSION: The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II. LEVEL OF EVIDENCE: Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.

Peri-implant femoral fractures: Challenges, outcomes, and proposal of a treatment algorithm.

PURPOSE: Non-prosthetic peri-implant fractures are challenging injuries. Multiple factors must be carefully evaluated for an adequate therapeutic strategy, such as the state of bone healing, the type of implant, the time and performed personnel of previous surgery, and the stability of fixation. The aim of this study is to propose a rationale for the treatment. METHODS: The peri-implant femoral fractures (PIFFs) system, a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF, based on the type of the original implant (extra- vs. intra-medullary), implant length and fracture location. The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment, respectively. In addition, all complications were noticed. Continuous variables were expressed as mean and standard deviation, or median and range according to their distribution. Categorical variables were expressed as frequency and percentages. RESULTS: This is a retrospective case series of 33 PIFFs, and the mean post-operative Parker mobility score was (5.60 ± 2.54) points. Five patients (15.1%) achieved complete mobility without aids (9 points) and 1 (3.0%) patient was not able to walk. Two other patients (6.1%) were non-ambulatory prior to PPIF. The mean follow-up was (21.51 ± 9.12) months (range 6 - 48 months). There were 7 (21.2%) complications equally distributed between patients managed either with nailing or plating. There were no cases of nonunion or mechanical failure of the original implant. CONCLUSION: The proposed treatment algorithm shows adequate, reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures. In addition, it may become a useful tool to optimize the use of the classification, thus potentially improving the outcomes and minimizing complications.

Can CT-based assessment of lateral malleolus anatomy indicate when and how to perform an intramedullary fixation in distal fibula fractures? An analysis of 150 ankles.

PURPOSE: The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy. METHODS: 77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05. RESULTS: The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05). CONCLUSION: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks.

Open reduction and internal fixation of Ideberg type IA glenoid fractures: Tricks, pearls, and potential pitfalls based on a retrospective cohort of 33 patients focusing on the rehabilitation protocol.

INTRODUCTION: The standard treatment of anterior glenaoid fractures carrying > 20% of the glenoid fossa is open reduction and internal fixation (ORIF). In the herein study, we report our outcomes in a retrospective cohort of anterior and anteroinferior glenoid rim fractures using an accelerated postoperative rehabilitation protocol. A secondary aim is to describe the surgical steps for ORIF of anterior and anteroinferior glenoid rim fractures using the anterior axillary approach, describing the tricks, pearls, and pitfalls of this surgical technique. METHODS: A retrospective cohort of skeletally mature patients treated for an anterior glenoid rim fracture carrying > 20% of the glenoid fossa during a 10-year period were operated on using a vertical axillary incision, osteosynthesis with 2.0-mm cortical screws, and labral repair with small diameter metallic anchors and non-absorbable sutures. Rehabilitation began on the first postoperative day, including passive external rotation exercises and active-assisted flexion, adduction, and abduction exercises as tolerated. The exercises are performed with the patient sitting or lying down. Phase 1 is continued for 6-10 weeks until the patient regains painless, normal, or near-normal ROM. Usually by 10 weeks, the fracture and labrum are healed, so phase 2 rehabilitation begins with strengthening and ROM exercises. Radiologic and clinical outcomes, including active range of motion (ROM), glenohumeral stability, and visual analogue scale (VAS) were measured. RESULTS: About 33 patients (35 fractures) had complete medical records and pre- and post-operative imaging exams available for further analysis regarding the surgical protocol, with a mean of 4.8 years. The mean DASH questionnaire was 3.75 ± 9.0 and the mean CM score was 62.5 ± 0.1. Active flexion and internal rotation were recovered in all patients, while external rotation presented an average loss of 8° (p = 0.12) and abduction of 5° (p = 0.33). The mean VAS was 1.1 ± 0.8. No patient reported major or disabling symptoms, or great difficulty or inability to perform daily or recreational activities. No patient presented residual instability of the glenohumeral joint. CONCLUSION: In this retrospective cohort, ORIF using a vertical axillary incision, osteosynthesis with 2.0-mm screws, and labral repair with small diameter metallic anchors and non-absorbable sutures was a safe approach, with a minimal risk of complications and residual instability. The accelerated postoperative rehabilitation protocol, allowing immediate passive external rotation of the operated shoulder, resulted in a non-significant loss of ROM compared to the contralateral side. Therefore, we recommend this management strategy for anterior glenoid rim fractures in patients with unstable shoulder joint after traumatic glenohumeral dislocation. LEVEL OF EVIDENCE IV: Therapeutic Study (Surgical technique and Retrospective cohort).

Computed Tomography Does Not Improve Intra- and Interobserver Agreement of Hertel Radiographic Prognostic Criteria.

Background and Objectives: Proximal humerus fractures are the second most frequent site of avascular necrosis (AVN), occurring in up to 16% of cases. The Hertel criteria have been used as a reference for the prediction of humerus head ischemia. However, these are based solely on the use of radiographs, which can make interpretation extremely difficult due to several reasons, such as the overlapping fragments, severity of the injury, and noncompliant acute pain patients. The objectives of the study were to evaluate the role of computed tomography (CT) in the interpretation of the Hertel criteria and to evaluate the intra- and interobserver agreement of orthopedic surgeons, comparing their area of expertise. Materials and Methods: The radiographs and CT scans of 20 skeletally mature patients who had fractures of the proximal humerus were converted to jpeg and mov, respectively. All images were evaluated by eight orthopedic surgeons (four trauma surgeons and four shoulder surgeons) in two different occasions. The intra- and interobserver agreement was assessed by using the Kappa coefficient. The level of significance was 5%. Results: There was a weak-to-moderate intraobserver agreement (κ < 0.59) for all examiners. Only the medial metaphyseal hinge greater than 2 mm was identified by 87.5% of evaluators both in the radiographic and CT examinations in the two rounds of the study (p < 0.05). There was no significant interobserver agreement (κ < 0.19), as it occurred only in some moments of the second round of evaluation. Conclusions: The prognostic criteria for humeral head ischemia evaluated in this study showed weak intra- and interobserver agreement in both the radiographic and tomographic evaluation. CT did not help surgeons in the primary interpretation of Hertel prognostic criteria used in this study when compared to the radiographic examination.

Limb Salvage after Lower-Leg Fracture and Popliteal Artery Transection-The Role of Vessel-First Strategy and Bone Fixation Using the Ilizarov External Fixator Device: A Case Report.

Open traumatic lesion of the popliteal artery is relatively rare. Ischemia time longer than 6 h and severity of limb ischemia have been shown to be associated with an increased risk of limb loss. Severe local infection is critical in the presence of major soft tissue trauma or open fractures. We report the case of a young female who suffered a traumatic transection of the popliteal artery associated with an open fracture of the distal tibia and fibula managed by direct vessel reconstruction with an end-to-end repair and skeletal stabilization initially with half-pin external fixation, then replaced by an Ilizarov circular frame. The patient had a very satisfactory outcome, but the fracture healed malunited, later corrected by open reduction and internal fixation with lag-screwing and a neutralization plate.

Anterior minimally invasive plating osteosynthesis technique (MIPO) for humeral shaft fractures: an anatomical study of neuromuscular structures at risk.

OBJECTIVE: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero-Livani) for humeral shaft fractures. METHODS: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero-Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. RESULTS: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14-13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. CONCLUSION: The modified Belangero-Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. LEVEL OF EVIDENCE: Level IV; Case series with no comparison group; Treatment study.

Expanding the indications for calcaneal plates beyond foot fractures: a technical trick and case series.

Although non-locking calcaneal plates are designed to treat calcaneal fractures, they present some interesting characteristics that justify using them beyond their current application in fractures of the foot. Calcaneal plates are malleable, have an increased footprint area for fracture containment or buttressing, and present several hole options for screw placement in different trajectories, thereby providing proper fixation even in comminuted fracture patterns. The aim of this study is to describe the unconventional use of calcaneal plates in the orthopaedic trauma scenario.

New fixation method for Pauwels type III femoral neck fracture: a finite element analysis of sliding hip screw, L-shaped, and L-shaped with medial plate.

OBJECTIVE: In this study, we aimed to evaluate the biomechanical behavior of three fixations for Pauwels type III fractures (sliding hip screw (SHS), L-shaped, and L-shaped with medial plate), by finite element analysis (FEM). METHODS: Three internal fixators were developed to treat Pauwels type III fracture by finite elements: SHS; L-shaped; and L-shaped with medial plate. Under the same conditions, localized and total vertical fracture displacement, maximum and minimum principal and von Mises stresses were evaluated. RESULTS: The localized and total vertical displacement evaluated for the SHS, L-shaped, and L-shaped with medial plate were 0.15 mm, 0.17 mm, and 0.07 mm (localized), and 4.52 mm, 6.97 mm, and 6.83 mm (total), respectively. The maximum values obtained in the upper region of the femoral neck for the internal fixations were 1.43 MPa, 1.29 MPa, and 1.24 MPa, and the minimum values obtained in the lower region of the femoral neck were - 0.73 MPa, - 1.09 MPa, and - 1.03 MPa, respectively. The maximum Von Mises peak stress values were 6.35 MPa, 10.7 MPa, and 16.2 MPa for the fixation models using the SHS, L-shaped, and L-shaped with medial plate, respectively. CONCLUSION: The present FEM analysis showed that SHS yields better results in terms of total vertical displacements, maximum distribution, and Von Mises peak stresses reduction. On the other hand, the L-shaped construction plus a medial plate decreases localized vertical displacements and maximum principal distribution when compared to the SHS and L-shaped constructions. These results demonstrate that both constructions, SHS and L-shaped plus a medial plate, are biomechanically efficient for the fixation of Pauwels type III femoral neck fractures.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

Effects of long-term cysteamine treatment in patients with cystinosis.

Cystinosis is a rare autosomal-recessive lysosomal storage disease with high morbidity and mortality. It is caused by mutations in the CTNS gene that encodes the cystine transporter, cystinosin, which leads to lysosomal cystine accumulation. Patients with infantile nephropathic cystinosis, the most common and most severe clinical form of cystinosis, commonly present with renal Fanconi syndrome by 6-12 months of age, and without specific treatment, almost all will develop end-stage renal disease (ESRD) by 10-12 years of age. Early corneal cystine crystal deposition is a hallmark of the disease. Cystinosis also presents with gastrointestinal symptoms (e.g., vomiting, decreased appetite, and feeding difficulties) and severe growth retardation and may affect several other organs over time, including the eye, thyroid gland, gonads, pancreas, muscles, bone marrow, liver, nervous system, lungs, and bones. Cystine-depleting therapy with cysteamine orally is the only specific targeted therapy available for managing cystinosis and needs to be combined with cysteamine eye drops for corneal disease involvement. In patients with early treatment initiation and good compliance to therapy, long-term cysteamine treatment delays progression to ESRD, significantly improves growth, decreases the frequency and severity of extrarenal complications, and is associated with extended life expectancy. Therefore, early diagnosis of cystinosis and adequate life-long treatment with cysteamine are essential for preventing end-organ damage and improving the overall prognosis in these patients.

Tetracycline Residues in Bovine Muscle and Liver Samples from Sicily (Southern Italy) by LC-MS/MS Method: A Six-Year Study.

We examined a total of 369 bovine liver and muscle samples for the detection of oxytetracycline (OTC), tetracycline (TC), chlortetracycline (CTC), and doxycycline (DOX) residues by implementation and validation of a LC-MS/MS method. The method showed good recovery values between 86% and 92% at three levels of concentrations. The linearity tests revealed r² > 0.996 for all the tetracyclines examined. Furthermore, the Youden test revealed that the method was robust. Only 14.4% of the samples showed OTC and TC residues in a concentration range of 10.4⁻40.2 µg kg-1. No CTC and DOX residues were found in all the samples analyzed. Liver samples showed the highest average values (31.5 ± 20.6 and 21.8 ± 18.9 for OTC and TC, respectively). The results showed a low incidence of TCs in all the samples examined, in comparison with other studies reported in the literature. A significant decrease in TC residues frequency was found from 2013 (p < 0.05). This work reports for the first time epidemiological data on the presence of TC residues in liver and muscle samples of cattle farmed in Sicily (Southern Italy). The very low incidence of TC residues indicates a continuous improvement in farming techniques in Southern Italy, which is essential to ensure consumers' protection.

Stability of L-shaped and inverted triangle fixation assemblies in treating Pauwels type II femoral neck fracture: a comparative mechanical study.

PURPOSE: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures. METHODS: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2). RESULTS: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002). CONCLUSION: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

Extracorporeal Life Support for Refractory Cardiac Arrest from Accidental Hypothermia: A 10-Year Experience in Edinburgh.

BACKGROUND: Cardiac arrest caused by accidental hypothermia is a rare phenomenon with a significant mortality rate if untreated. The consensus is that these patients should be rewarmed with extracorporeal life support (ECLS) with the potential for excellent survival and neurologic outcomes. However, given the lack of robust data and clinical trials, the optimal management of such patients remains elusive. OBJECTIVE: In this single-center study, we looked at the outcomes of all adult patients undergoing salvage ECLS for cardiac arrest caused by accidental hypothermia over a 10-year period from June 2006 to June 2016. METHODS: These data were obtained from the Royal Infirmary of Edinburgh cardiothoracic surgery database. The patients' hard copy case notes, TrakCare (InterSystems Corp, Cambridge, MA), picture archiving and communications system (PACS), and WardWatcher databases were used to cross-check the accuracy of the acquired data. RESULTS: Eleven patients met the inclusion criteria. The etiology of hypothermia was exposure to cold air (64%) and cold water immersion (36%). Two (18%) were treated with extracorporeal membrane oxygenation and the rest with cardiopulmonary bypass. The mean age was 51 years (range 32-73), and the mean core body temperature on admission was 20.6°C (range <18-24°C). The overall survival rate to hospital discharge was 72%, with 75% of survivors having no chronic neurologic impairment. CONCLUSION: Our case series shows the remarkable salvageability of patients suffering prolonged cardiac arrest caused by accidental hypothermia, particularly in the absence of asphyxia, trauma, or severe hyperkalemia. ECLS is a safe and effective rewarming treatment and should be used to aggressively manage this patient group.