Unclassified acetabular fractures: Do they really exist?

PURPOSE: Although Letournel classification is considered the corner stone for classifying acetabular fractures, however, it might not be perfectly inclusive. Unclassified fractures were reported by many authors. The aim of this case series is to report the incidence of unclassified acetabular fractures and description of these rare patterns and why they are considered unclassified acetabular fractures. METHODS: This is a retrospective consecutive case series. In the period between 1st January 2016 and 31st December 2017, 235 patients with 236 acetabular fractures were identified from our hospital records. Classification of the acetabular fractures according to Letournel was done by two surgeons. Any discrepancy in the classification between the two surgeons was resolved by the senior author. Before considering the fracture unclassifiable, all fractures were reviewed again by the two surgeon and the senior author. RESULTS: In the period between 1st January 2016 and 31st December 2017, 235 patients with 236 acetabular fractures were included in our study. Twenty-two fractures (9.3%) did not fit into any of the fracture types according to Letournel Classification as follows: 1 case (4.5%) was pure Quadrilateral plate fracture, 1 case (4.5%) was labral avulsion with tiny posterior wall rim, 1 case (4.5%) was pure articular impaction, 1 case (4.5%) was both columns fracture with posterior wall, 4 cases (18.2%) were anterior column and quadrilateral plate fracture, and 14 cases (63.8%) were T with posterior wall. CONCLUSION: Several acetabular fracture pattern could be considered unclassified fractures. These unique patterns may require special approaches or special fixation methods. However, this is not a call for a new classification for acetabular classification to include these new types. Subclassification or adding modifiers to Letournel classification can do the job.

Total hip arthroplasty for post-firearm hip arthritis complicated by coloarticular fistula: A case report.

Hip firearm injuries are rare injuries that could lead to serious complications, such as posttraumatic hip arthritis and coloarticular fistula. We report a case of a 25-year-old male who sustained a pelvic injury caused by a single bullet which led to a bilateral acetabular fracture, concomitant with a colon injury treated on an emergency basis by a diverting colostomy; acetabular fractures were treated conservatively by traction. After the patient recovered from the abdominal injury, he was presented with bilateral hip pain and limited motion; plain radiographs showed bilateral hip arthritis with proximal migration of the femoral head and bilateral acetabular defect classified as Paprosky type ⅢA. Reconstruction of the hips was performed using the same technique: impaction bone grafting for acetabular defect reconstruction and a reversed hybrid total hip arthroplasty (THA) 6 months apart. The patient presented with loosening of the left THA acetabular cup 3 years later, which was revised; then he presented with a discharging sinus from the left THA with suspicion of coloarticular fistula, which was confirmed using CT with contrast material. A temporary colostomy and fistula excision were performed, and a cement spacer was applied to the hip. After clearing the infection, a final revision THA for the left hip was performed. Treating post-firearm hip arthritis by THA is challenging, especially in the situation of neglected cases with the presence of an acetabular defect. Concomitant intestinal injury increases the risk of infection with the possibility of coloarticular fistula formation, which could present later. Working with a multidisciplinary team is paramount.

Preoperative stiffness is the most important predictor of postoperative patient's satisfaction after total knee arthroplasty.

PURPOSE: To predict the most important preoperative factor affecting the patient satisfaction after total knee arthroplasty (TKA) in trial to improve patient counselling process. METHODS: We retrospectively reviewed all patients who underwent primary TKA from January 1, 2018, to January 31, 2019, with minimum one-year follow-up for the previously collected patient-reported outcome measures (PROMs) as Oxford Knee Score (OKS) and Knee Injury and Osteoarthritis Outcome Score for joint replacement (KOOS, JR) preoperative, 6 months and 12 months postoperative. RESULTS: By using Oxford knee score at 12 months as dependent variable, we found a negative moderate spearman correlation between age and Oxford knee score at 12 months postoperative. Moderate negative spearman correlation was also found between Oxford knee score at 12 months postoperative and KOOS pain, stiffness and function scores at preoperative and 6 months postoperative, denoting higher satisfaction at 12 months with less perceived stiffness, pain and limited function at baseline and 6 months postoperative. A multivariate regression analysis was done using the oxford knee score at 12 months as dependent variable to detect the predictors of oxford knee score at 12 months postoperatively and showed that younger age and less perception of stiffness at baseline were significant predictors of higher Oxford knee score: higher satisfaction at 12 months postoperative. CONCLUSION: Preoperative stiffness can predict the postoperative satisfaction score more than any other factor. We also address the importance of combining more than one PROM in assessing patients as OKS and KOOS, JR.

Management of femoral head fractures through surgical hip dislocation (SHD): a demanding but safe technique.

INTRODUCTION: Femoral head fractures considered to be rare injuries. Surgical intervention is indicated for major fragment displacement or in the presence of instability. Surgical management can be achieved through either Anterior, posterior, and trans-trochanteric surgical approaches. Surgical hip dislocation (SHD) has been advocated by many authors to be a safe and effective alternative way of management. The aim of this study was to report on the accuracy of fracture reduction, procedure safety, and outcomes of using SHD in the management of femoral head fractures. PATIENTS AND METHODS: Between 2011 and 2017, 31 patients presented with femoral head fracture were treated through SHD. At a mean follow-up of 48 months, 27 patients were available for the study with a mean age of 33.8 years. Patient demographics, clinical evaluation according to modified Harris hip score and modified Merle d'Aubigne and Postel score, radiographic fracture reduction according to Matta's criteria, and any complications were reported. RESULTS: Excellent and good clinical outcomes were reported in 25 (92.6%) and 24 (89%) patients according to the modified Harris hip and modified Merle d'Aubigne and Postel scores, respectively. Anatomic fracture reduction was achieved in 21 (77.8%) patients. Two (7.4%) patients developed AVN, one (3.6%) patient developed hip OA (grade 3 according to Tönnis classification), and five (18.5%) patients developed asymptomatic Brooker stage I heterotopic ossification. No infection or trochanteric flip osteotomy fragment non-union was reported. CONCLUSIONS: SHD offers a safe and efficient approach for femoral head fractures management with acceptable clinical outcomes as well as complication rates. Giving the advantage of fully exposing the femoral head and the acetabulum which enables the surgeon to anatomically reduce the fracture and treat any associated injuries, SHD is recommended besides other approaches for the management of femoral head fractures.

Internal rotation of the tibial component in total knee arthroplasty can lead to extension deficit.

PURPOSE: Stiffness is a common problem following total knee arthroplasty (TKA). Mal-rotated components have been claimed to be the major cause of pain and limited motion after TKA. The present study investigates whether intra-operative intentional malrotation of the tibial component would change in vivo kinematics. The hypothesis is excessive internal rotation of the tibial component would result in postoperative extension deficit. METHODS: Thirty-one patients were enrolled in this study. After completing bony cuts and proper soft tissue balancing, the femoral and tibial trials were impacted and fixed using small pins. Lateral radiographs were used to measure and compare intraoperative full knee extension during normal and after intentional internal rotation of the tibial component. The extension deficit angles were also compared between the posterior stabilised (PS) and cruciate retaining (CR) implants. RESULTS: For normal tibial component rotation, the median (interquartile range) extension deficit was 0° (4). The mean tibial trial intentional internal rotation was 21.2° (± 4.5). The median (interquartile range) extension deficit significantly increased to 6° (4) after tibial component internal rotation (p = 0.001). The use of PS spacers resulted in a significantly greater extension deficit after intentional internal rotation 9° (5) compared to that of the CR implant 1° (4) (p = 0.001). CONCLUSION: Internal rotation of the tibial component in total knee arthroplasty can lead to postoperative extension deficit. This could be attributed to interference with "screw home" mechanism that requires full external rotation of the tibia on the femur. Consequently, this deficit may cause pain and knee stiffness following TKA. LEVEL OF EVIDENCE: III.

Accuracy of plain antero-posterior radiographic-based methods for measurement of acetabular cup version.

INTRODUCTION: Acetabular cup version is crucial for successful total hip arthroplasty (THA). Many methods have been described for measurement of cup version angle. The aim of this study is to assess the accuracy of five commonly used methods for measurement of acetabular cup version in plain antero-posterior views of the pelvis and hip. MATERIAL AND METHODS: Sixty primary THA cases were subjected postoperatively to plain A-P of the pelvis (AP-P), A-P view of the hip (AP-H), and computed tomography (CT) imaging. The acetabular cup version was measured in AP-P and AP-H by five methods (Lewinnek, Widmer, Hassan et al., Ackland et al., and Liaw et al.). These measurements were compared to the CT measurement. RESULTS: All plain X-ray methods showed no significant differences from the CT, except those of Hassan et al. in AP-H, and Widmer and Ackland et al. in AP-P. CONCLUSIONS AND RECOMMENDATIONS: For measurement of acetabular cup version angle, we recommend the use of Lewinnek and Liaw et al. methods both in AP-P and in AP-H, while Hassan et al.'s method is recommended in AP-P only, and Widmer and Ackland et al.'s methods in AP-H only.

Sexual dimorphism of the posterior condylar offset of the femur and the medial posterior slope of the tibia in non-arthritic knees of Egyptian adults: an MRI study.

BACKGROUND: The aim of this magnetic resonance imaging (MRI) study was to investigate controversial sexual dimorphism of the posterior condylar offset of the femur (the offset) and the posterior slope of the tibia (the slope) in non-arthritic knees of Egyptian adults. METHODS: On 100 male and 100 female MRIs of non-arthritic knees, linear measurements of the distal part of the femur (the offset) and the angular measurements of the proximal part of the tibia (the slope) were performed and compared regarding sex and ethnicity. The intraclass correlation coefficient (ICC) was used to test the interrater agreement. RESULTS: Both offsets and the lateral offset ratio were larger in males (p < 0.001), the medial offset ratio, and the medial slope in females (p from < 0.001 to 0.007), whereas the lateral slope was sex-free (p = 0.41). Irrespective of sex, however, the medial offset with its ratio, and the medial slope were larger than their counterparts (p < 0.001). Our means of the offsets, their ratios, and the slopes mostly differed from those of other ethnicities (p from ≤ 0.001 to 0.004). ICCs > 0.8 proved MRI's precision was high. CONCLUSION: There was a sexual dimorphism of both the offset and the medial slope in non-arthritic knees of Egyptian adults. We believe future designs of knee implants should consider these differences in order to improve postoperative range of motion and patients' satisfaction after total knee arthroplasty. Level of evidence Level III Retrospective Cohort Study. Trial registration ClinicalTrials.gov identifier: NCT03622034, registered on July 28, 2018.

Surgical hip dislocation in fixation of acetabular fractures: Extended indications and outcome.

BACKGROUND: Surgical hip dislocation has been described as an excellent method for reduction and fixation of acetabular fractures. It allows a 360-degree access to the acetabulum and acetabular dome. However, reproducibility of this technique is still a concern. The primary outcome of this study was to investigate the short term functional and radiological outcome with the use of surgical hip dislocation in acetabular fractures. The secondary outcome was to describe different indications and methods of reduction using this technique. METHODS: This is a retrospective consecutive case series for the use of surgical hip dislocation in acetabular fractures. Between July 2013 and February 2017, we used this technique to manage 36 cases of acetabular fractures. Two patients were lost to follow up leaving 34 patients eligible for the study. All surgeries were done by a 5-years and a 10-years' experience surgeons in pelvic and acetabular trauma surgeries. Through Gibson approach, we used the technique of surgical hip dislocation as described by the Bernese group. Different methods of fracture reduction were used. Intraoperative grading of cartilage injury was done using Disler's grading system. Postoperative fracture reduction was evaluated using the criteria described by Matta. Clinical evaluation was done using the modified Merle d'Aubigne ́ and Postel system. RESULTS: The mean intra-operative blood loss was about 700 ± 35.4 ml. The mean units of blood transfused were 1 ± 0.1 unit. The mean surgical time was 135 ± 11.7 minutes. Anatomical reduction was achieved in 27 patients (79.4%). At a mean of 30 ± 16.8 months (median = 26 and IQR 22) follow up, the functional score was excellent in 5 (14.7 %), very good in 8 (23.5%), good in 9 (26.5%), fair in 2 (5.8%), and poor in 10 (29.4%) patients. Four patients (11.7%) developed AVN at a mean of 8 months postoperatively. Conversion to THA was done in 5 patients (14,7%). Trochanteric osteotomy showed osseous healing in all cases. No patient developed nerve injury or infection. One patient developed severe (grade III) heterotopic ossification. CONCLUSIONS: Besides the indications of surgical hip dislocation mentioned before as reduction of the anterior column in T and Transverse fractures, associated femoral head fractures, intraarticular fragments, and labral injuries, it can be used in other indications as entrapped posterior wall, roof impaction, pure impaction injuries and cranial extension of the posterior wall fractures. The technique is reproducible; however, the learning curve is steep and needs to be performed by experienced acetabular trauma surgeons.

Debridement, Antibiotics, and Implant Retention for an Early Periprosthetic Infection After Unicompartmental Knee Arthroplasty: A Technical Note.

Early periprosthetic joint infection in unicompartmental knee arthroplasty (UKA) is shown to have a detrimental effect on the success of UKA surgery not only because of the sequences of the infection but also due to the other healthy lateral compartment. It is well known that Oxford meniscal bearing UKA is a very precise procedure that the use of any excessive force may have an injurious effect on the future prosthesis stability with a higher risk of bearing dislocation. This technical note aims at describing how to deal with a case of early periprosthetic joint infection in a female patient who underwent debridement, wash, implant retention and change of the mobile bearing insert including the demonstration of a difficult step during this procedure.

Anthropometric measurements of non-arthritic knees in an Egyptian population: an MRI-based study.

BACKGROUND: Knee anthropometric characteristics were evaluated for different ethnicities; however, data from North African populations are deficient. The primary aim was to investigate the Egyptian knees' anthropometric characteristics as a representative of North African populations. Secondary aims are as follows: (1) to study the anthropometric gender difference, (2) to compare results with other ethnic groups, and (3) to study the mismatch in comparison to geometric characteristics of modern TKA implant designs. METHODS: Two hundred normal knee MRI scans (100 females and 100 males, aging from 18 to 60) were obtained for analysis. Linear measurements (anteroposterior (AP), mediolateral (ML), and aspect ratio (AR)) of the planned cut surface of the distal femur (f) and the proximal tibia (t) were evaluated. RESULTS: A significant difference between both sexes was found, males had larger measurements in anteroposterior [fAP: 60.97 ± 3.1 vs 54.78 ± 3.3 (P < 0.001), tAP: 46.89 ± 3.0 vs 41.35 ± 2.9 (P < 0.001)] and mediolateral [fML: 74.89 ± 3.2 vs 67.29 ± 3.7 (P < 0.001), tML: 76.01 ± 3.0 vs 67.26 ± 3.2 (P < 0.001)], the mean femoral and tibial AP and ML measurements were different from other ethnic groups. None of the seven studied TKA systems matched the largest ML or the smallest AP dimensions of the distal femur in the current study population. CONCLUSION: A significant difference was found between males' and females' knee anthropometric characteristics. Some of the commonly used TKA implants in our area could not provide a perfect fit and coverage. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03622034 , registered on July 28, 2018.

COVID-19. An update for orthopedic surgeons.

The COVID-19 pandemic has affected our world in a short period of time, and the orthopedic surgery practice was not an exclusion. Elective care was deferred in most health care facilities and emergency care was continued with strict precautions. With rapid progression of the pandemic, the response of the medical community is also rapidly changing in all aspects of delivering care. This led to a large number of publications with reports, guidelines, measures, ways to react to the crisis, and post-pandemic predictions and speculations. In this review we aimed at summarizing all the relevant information to the orthopedic surgery community. To do this, a comprehensive search was performed with all related terms on two scientific search engines, PubMed and SCOPUS, and the results were filtered by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. The result was 72 articles that were further reduced to 33 articles after full text reading. The resultant information was organized under 5 main headings; the impact of pandemic on the orthopedic practice, COVID-19 and the trauma patient, elective and emergency surgeries during the pandemic, peri-operative management of the patient with COVID-19, Miscellaneous effects of the pandemic such as those on training programs and the evolution of telemedicine. This review represents the most up to date information published in the literature that is a must-know to every orthopedic surgeon.

All types of component malrotation affect the early patient-reported outcome measures after total knee arthroplasty.

PURPOSE: Outcomes following total knee arthroplasty (TKA), whether clinical, radiological or survival analysis, have been well-studied. Still, there are some concerns about patient satisfaction with the outcome of the surgery and factors that might contribute to a suboptimal result. This study aims to determine if there is correlation between primary TKA malalignment and early patient-reported outcome measures (PROMs). MATERIALS AND METHODS: Sixty patients, who had primary TKA and a minimum of 2 years of follow up, were recruited for a detailed clinical and radiological examination. Knee alignment was measured in the coronal, sagittal and axial planes. Normal and the outlier measurements of the patients' knees were defined and the clinical results (PROMs) compared to see if there was a statistically significant difference. RESULTS: Correlation between postoperative limb malalignment in the coronal and the sagittal planes and PROMs was not significant. Conversely, there was significant negative correlation between all types of malrotation and PROMs. CONCLUSIONS: Although malalignment has been linked to inferior outcome and implant survival, our results showed that coronal and sagittal limb malalignment has no significant effect on early PROMs. However, all types of component rotational malalignment significantly worsen early PROMs.

Femoral malalignment after gamma nail insertion in the lateral decubitus position.

INTRODUCTION: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position. METHODS: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides. RESULTS: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019). DISCUSSION: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus -valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.