A Case of Polymyositis Associated with Cytomegalovirus Infection in a Patient with Hashimoto's Thyroiditis.

Polymyositis is a rare condition with an unknown etiology occurring more frequently in adult women. There is a lack of evidence on the coexistence of PM and CMV infection in a patient with hypothyroidism due to Hashimoto's Thyroiditis. However, the growing occurrence of both CMV infection and the simultaneous occurrence of autoimmune diseases points out a relationship, while the association direction remains unclear. Case outline: A 32-year-old woman recently treated for HT hypothyroidism was admitted to the hospital two weeks after being treated for common flu by the family doctor, complaining about a worsening condition with muscle pain, weakness, frequent falls, and fatigue. The first tests showed a normalized thyroid function, with elevated values of troponin and serum creatinine kinase (CK). The immunological tests revealed the presence of a high titer of CMV IgG antibodies and raised levels of CMV DNA. Pelvis MRI images demonstrated markedly elevated signals on the STIR sequences in the pelvis, thighs, and calves, indicating active and severe multifocal myositis. The diagnosis of PM was confirmed with the muscle biopsy on day 7 of hospitalization. The patient showed significant improvements within two weeks after the medical therapy and physiotherapy.

Heterotopic Ossification around the Elbow Revisited.

Heterotopic ossification (HO) is the process of ectopic bone formation in the periarticular soft tissues and is usually formed in the elbow, hip and knee joint as a complication of trauma, burns, brain injury or surgical procedures. The development of HO around the elbow joint can cause a severe limitation of range of motion (ROM) and may affect daily activities of the patient. Treatment of ectopic bone formation around the elbow is a challenge for many surgeons. Non-operative treatment usually fails to restore the ROM of the elbow joint; thus, surgery is necessary to restore the function of the joint. In the past, many surgeons suggested that a delayed excision of HO, until maturation of the ectopic bone, is the best option in order to avoid any possible recurrence. However, many authors now suggest that this delay may lead to complications such as muscular atrophy and formation of soft tissue contractures that can cause a greater impairment of elbow function; thus, early excision is a better option and can better restore the elbow ROM. We performed a literature research of articles that investigated which is the best time of HO excision and we also evaluated if the tethering effect of HO can lead to a greater impairment of the elbow function. We found numerous studies suggesting that a limitation in ROM of the elbow can appear from the tethering of the ectopic bone formation and not only from primary HO. Concerning the HO excision, there were no significant differences between patients who underwent delayed and early excision, concerning the recurrence rate of HO around the elbow. Patients who underwent early excision had better restoration of elbow ROM; thus, early excision, combined with a rehabilitation program, is reported to be the best option for these patients.

Lipoma Arborescens of the Upper Extremity With Anatomic Variation of the Palmaris Longus: A Case Report.

CASE: We present a case of a patient who suffered from wrist swelling and had symptoms of carpal tunnel syndrome. The patient underwent ultrasound and magnetic resonance imaging, in which signs of joint effusion and a fatty synovial lesion were presented. The treatment included open excision of the tumor. In addition, the palmaris longus muscle had an anatomic variation with proximal and distal tendon portions. The histopathological examination disclosed lipoma arborescens of the synovial membranes of the joints. CONCLUSION: The recognition of this entity and its characteristics are important not only for correct diagnosis but also for the appropriate treatment.

Topical use of tranexamic acid: Are there concerns for cytotoxicity?

Tranexamic acid (TXA) has revolutionized modern blood management in orthopaedic surgery, especially in total joint arthroplasty, by significantly reducing blood loss and transfusion rates. It is an antifibrinolytic agent and a synthetic derivative of the amino acid lysine, which can inhibit the activation of plasminogen and the fibrin breakdown process. The administration of TXA can be intravenous (IV), topical, and oral. In patients where the IV administration is contraindicated, topical use is preferred. Topical administration of the drug theoretically increases concentration at the operative site with reduced systemic exposure, reduces cost, and gives the surgeon the control of the administration. According to recent studies, topical administration of TXA is not inferior compared to IV administration, in terms of safety and efficacy. However, there are concerns regarding the possible toxicity in the cartilage tissue with the topical use of TXA mainly in hemiarthroplasty operations of the hip, unilateral knee arthroplasties, total knee arthroplasties where the patella is not resurfaced, and other intraarticular procedures, like anterior cruciate ligament reconstruction. The purpose of the present review is to present all the recent updates on the use of TXA focusing on the toxicity on chondrocytes and the articular cartilage that may or may not be provoked by the topical use of TXA.

Postoperative Delirium and Postoperative Cognitive Dysfunction in Patients with Elective Hip or Knee Arthroplasty: A Narrative Review of the Literature.

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common complications following total knee arthroplasty (TKA) and total hip arthroplasty (THA), affecting the length of hospital stay and increasing medical complications. Although many papers have been published on both conditions in this setting, no reviews have currently been written. Thus, the purpose of our study is to summarize the current literature and provide information about POD and POCD following elective THA or TKA. Our literature search was conducted in the electronic databases PubMed and the Cochrane library. We found that POD is a common complication following elective THA or TKA, with a median incidence of 14.8%. Major risk factors include older age, cognitive impairment, dementia, preoperative (pre-op) comorbidities, substance abuse, and surgery for fracture. Diagnosis can be achieved using tools such as the confusion assessment method (CAM), which is sensitive, specific, reliable, and easy to use, for the identification of POD. Treatment consists of risk stratification and the implementation of a multiple component prevention protocol. POCD has a median incidence of 19.3% at 1 week, and 10% at 3 months. Risk factors include older age, high BMI, and cognitive impairment. Treatment consists of reversing risk factors and implementing protocols in order to preserve physiological stability. POD and POCD are common and preventable complications following TKA and THA. Risk stratification and specific interventions can lower the incidence of both syndromes. Every physician involved in the care of such patients should be informed on every aspect of these conditions in order to provide the best care for their patients.

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon.

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects. Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle. All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction. Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.

Neonatal brachial plexus injuries and their impact on growing bone. An experimental study.

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.

Microsurgery training: A combined educational program.

A proposed microsurgical training program is presented that includes all the existing training methods, such as simulation in nonliving models, virtual reality simulation system and exercise in living models. Our experience in microsurgery training over the last decades indicates the need of evolution in training programs. This can be achieved with the introduction of new technologies into education and training. The first primary results of the described training program are promising, however this system needs to be assessed by training greater number of microsurgeons. Furthermore, more complex scenarios (such as whole operations) should be inserted into the virtual reality simulation system to create a more interactive experience.

Vascularized pedicled graft from distal radius for scaphoid nonunion with double stabilization: A long term follow up study.

PURPOSE: The aim of the present study is to present the long-term efficacy of the graft of the distal radius based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for the treatment of scaphoid nonunion with a proposed treatment of double stabilization with Kirschner wires and external fixator. METHODS: Between 2007 and 2013 we retrospectively reviewed 11 patients who were operated for established scaphoid nonunion with pedicled vascularized distal radius graft based on the 1,2 ICSRA in our department. Stabilization of the graft was achieved with Kirschner wires and the wrist was immobilized with a transarticular external fixator. All patients were evaluated pre- and post-operatively both clinically and radiologically. The DASH score was also completed by the patients before and after the operation. The minimum follow-up of the patients was 5 years. RESULTS: The mean age of the patients was 28.64 years (range, 18-49 years). Ten patients were males (90.91%) and one female (9.09%). In all patients, union was achieved. The mean time of union was 11.2 weeks (range, 8-18 weeks). The mean follow-up was 61.32 months (range, 60-72 months). Compared to the contralateral hand there was noticed 14° lack in flexion and 18° in extension. The mean DASH score showed also significant improvement from 23.1 (range, 9.4-50.6) preoperatively to 4.72 (range, 0-22.8) during the last follow-up. CONCLUSION: The 1,2 ICSRA distal radius graft consists a trustworthy pedicled vascularized graft for the treatment of nonunion presenting very promising long-term outcomes.

Ulnar intraneural cysts as a cause of cubital tunnel syndrome: presentation of a case and review of the literature.

INTRODUCTION: Intraneural cysts usually involve the common peroneal nerve, and in many cases, they are causing symptoms due to neural compression. It is hypothesized that these cysts originate from the adjacent joints while articular pathology is a major contributing factor for the formation of these lesions. Although ulnar nerve is the second most commonly affected nerve, these lesions usually develop distally at the Guyon tunnel, so cubital tunnel syndrome due to epineural cysts is very rare. In such cases, elaborate preoperative work-up is mandatory and surgical treatment should follow certain well-defined principles. CASE DESCRIPTION: A 60-year-old female patient presented with complaints of pain along the medial side of her elbow, forearm and hand and a tingling sensation in the same distribution for the past 2 months. The patient had sustained an injury 15 years ago, and a distal humerus fracture was diagnosed at that time. Radiological signs of posttraumatic elbow arthritis were evident at the initial evaluation. The patient was diagnosed with cubital tunnel syndrome which was further confirmed by nerve conduction studies, and she underwent surgical decompression of the nerve. During surgery, intraneural cysts were identified and addressed by excision, while dissection of the articular branch of the nerve was also performed. Pain and numbness subsided shortly after surgery, while the patient remained free of symptoms until the last follow-up.

The effect of peripheral nervous system in growing bone biomechanics. An experimental study.

OBJECTIVE: There are several factors which affect bone growth. One of them is the peripheralnervous system whose effect on the biomechanics has not been extensively studied. The purpose of this study is to assess the effect of peripheral nervous system in bone biomechanics in an experimental rat model. MATERIALS & METHODS: 27 male Wistar rats were used. In all animals, the roots of the right brachial plexus were dissected and after that the animals were divided into three groups A, B and C. The animals were sacrificed six, nine, and twelve months respectively after the denervation. Both humerus were resected and biomechanical analysis was performed. RESULTS: According to the findings of the present study the denervated bones sustain less loading before fracture and they become also more elastic. Additionally, in greater time after denervation plastic deformity is noticed. CONCLUSION: Apart from structural changes, the peripheral nerves are responsible for biomechanic changes in the bones such the greater elasticity of the bone and the reduced strength.

Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy.

Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.

Reverse sural artery flap: a reliable alternative for foot and ankle soft tissue reconstruction.

INTRODUCTION: Soft tissue defects of foot and ankle are challenging due to the susceptibility of the area to trauma and the complexity of the region. Several flaps have been described for wound coverage after surgical debridement at this location. The purpose of this study is to present the reverse sural flap for covering soft tissue defects at the ankle and foot. MATERIALS AND METHODS: From July 2014 to November 2017, ten patients with soft tissue defect at the ankle and foot were retrospectively reviewed. There were nine men and one woman with a mean age of 40.5 years (range 17-71 years). Seven patients were smokers and five were diabetics. The mean size of the defect was 50.5 cm2. All operations were performed by the same microsurgical team. At a mean follow-up of 21 months (range, 18 to 24 months), we evaluated wound healing and complications. RESULTS: In nine patients, the soft tissue defect was successfully covered. In four patients, venous congestion was noticed, whereas in one patient, there was total necrosis of the flap. In all cases, the donor site was healed uneventfully. CONCLUSION: The reverse sural artery flap is a reliable alternative for wound coverage at the ankle and foot, with low complication and morbidity rate. Nevertheless, it is a demanding microsurgical operation that requires knowledge of the anatomy and surgeons' experience.

Traumatic upper plexus palsy: Is the exploration of brachial plexus necessary?

Brachial plexus injuries are major injuries of the upper limb resulting in severe dysfunction usually in young patients. Upper trunk injuries of the brachial plexus account for approximately 45% of brachial plexus injuries. Treatment options for upper trunk brachial plexus injuries include exploration of the plexus and microsurgical repair using nerve grafts or nerve transfers. Several published studies presented the results of both techniques, but there are few studies which compared these two techniques. This article summarizes the treatment options for upper trunk brachial plexus injuries, discusses the merits and demerits of each technique, and presents authors' proposed treatment for these injuries.

Current concepts in peripheral nerve surgery.

The injuries of the peripheral nerves are relatively frequent. Some of them may lead to defects which cannot be repaired with direct end-to-end repair without tension. These injuries may cause function loss to the patient, and they consist a challenge for the treating microsurgeon. Autologous nerve grafts remain the gold standard for bridging the peripheral nerve defects. Nevertheless, there are selected cases where alternative types of nerve reconstruction can be performed in order to cover the peripheral nerve defects. In all these types of reconstruction, the basic principles of microsurgery are necessary and the surgeon should be aware of them in order to achieve a successful reconstruction. The purpose of the present review was to present the most current data concerning the surgical options available for bridging such defects.

The role of new oral anticoagulants in orthopaedics: an update of recent evidence.

Rivaroxaban, dabigatran, apixaban and edoxaban are the four available new oral anticoagulants (NOAC) which are currently approved for venous thromboembolism prophylaxis after total hip and knee replacement. Large phase 3 and phase 4 studies comparing NOAC with low molecular weight heparins have shown similar results regarding the efficacy and safety of these two categories of anticoagulants. Management of bleeding complications is a matter of great significance. Three reversal agents have been developed: idarucizumab, andexanet alfa and ciraparantag. Idarucizumab is now commercially available. Regarding the perioperative management of NOAC, two main scientific groups have published their own recommendations. The European Heart Rhythm Association recommends 48-h period of stoppage preoperatively for factor Xa inhibitors and at least 3 or 4 days for dabigatran, while the French Study Group on Thrombosis and Haemostasis recommends 5-day discontinuation for all NOAC. Conventional clot tests can only be used as rough indicators for laboratory assessment of the activity of NOAC. Specific laboratory tests have been developed for more accurate measurements of NOAC blood levels, including a dilute thrombin time test (Hemoclot test) and the ecarin clot test for dabigatran and chromogenic anti-factor Xa assays for direct factor Xa inhibitors. Due to the beneficial properties of NOAC, these drugs are gaining ground in daily orthopaedic practice, and many studies are being conducted in order to extend the indications of these anticoagulants agents.

Factors affecting bone growth.

Bone growth and development are products of the complex interactions of genetic and environmental factors. Longitudinal bone growth depends on the growth plate. The growth plate has 5 different zones-each with a different functional role-and is the final target organ for longitudinal growth. Bone length is affected by several systemic, local, and mechanical factors. All these regulation systems control the final length of bones in a complicated way. Despite its significance to bone stability, bone growth in width has not been studied as extensively as longitudinal bone growth. Bone growth in width is also controlled by genetic factors, but mechanical loading regulates periosteal apposition. In this article, we review the most recent data regarding bone growth from the embryonic age and analyze the factors that control bone growth. An understanding of this complex system is important in identifying metabolic and developmental bone diseases and fracture risk.

Modeling of blood flow through sutured micro-vascular anastomoses.

Microanastomosis is a surgical procedure used to reconnect two blood vessels using sutures. The optimal microanastomosis may be predicted by assessing the factors that influence this invasive procedure. Blood flow and hemodynamics following microanastomosis are important factors for the successful longevity of this operation. How is the blood flow affected by the presence of sutures? Computational Fluid Dynamics (CFD) is a powerful tool that permits the estimation of specific quantities, such as fluid stresses, that are hardly measurable in vivo. In this study, we propose a methodology which evaluates the alterations in the hemodynamic status due to microanastomosis. A CFD model of a reconstructed artery has been developed, based on anatomical information provided by intravascular ultrasound and angiography, and was used to simulate blood flow after microanastomosis. The 3D reconstructed arterial segments are modeled as non-compliant 1.24 - 1.47 mm diameter ducts, with approximately 0.1 mm arterial thickness. The blood flow is considered laminar and the no-slip condition is imposed on the boundary wall, which is assumed to be rigid. In analyzing the results, the distribution of the wall shear stress (WSS) is presented in the region of interest, near the sutures. The results indicate that high values of WSS appear in the vicinity of sutures. Such regions may promote thrombus formation and subsequently anastomotic failure, therefore their meticulous study is of high importance.

An alternative graft fixation technique for scaphoid nonunions treated with vascular bone grafting.

PURPOSE: To present our experience with vascularized bone grafting based on the 1,2-intercompartmental supraretinacular artery for the management of established scaphoid nonunion and to investigate the efficacy of graft immobilization with a combination of Kirschner wires and transarticular external fixation. METHODS: A retrospective chart and radiographic review was conducted for patients with the diagnosis of scaphoid nonunion of the proximal pole or the waist treated with the 1,2-intercompartmental supraretinacular artery-based vascularized graft and fixed with a combination of Kirschner wires and transarticular external fixation between 2007 and 2011. RESULTS: We observed 23 consecutive patients for a mean of 34 ± 4 months. All patients were males with mean age of 25 ± 5 years. All patients had scaphoid nonunion and associated humpback deformity. The mean duration of nonunion was 7 ± 1 months. All scaphoid nonunions united after the index procedure at a mean of 10 ± 1 weeks. Two patients had avascular necrosis of the proximal pole based on the preoperative magnetic resonance imaging findings. After surgery, deformity correction was achieved in all patients, as recorded by the decrease in the lateral intrascaphoid angle and the increase in the dorsal scaphoid angle. At the last follow-up, no patients reported wrist pain. The mean Disabilities of the Arm, Shoulder, and Hand score improved significantly from 32 ± 12 before the operation to 5 ± 3 at the last postoperative visit. All patients showed statistically significant improvement in the range of motion and the grip strength of the involved wrist. CONCLUSIONS: The results of this study support the combined use of Kirschner wires and transarticular external fixation for fixation of a 1,2-intercompartmental supraretinacular artery-based vascular bone graft in the treatment of scaphoid nonunions. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Use of intercostal nerves for different target neurotization in brachial plexus reconstruction.

Intercostal nerve transfer is a valuable procedure in devastating plexopathies. Intercostal nerves are a very good choice for elbow flexion or extension and shoulder abduction when the intraplexus donor nerves are not available. The best results are obtained in obstetric brachial plexus palsy patients, when direct nerve transfer is performed within six months from the injury. Unlike the adult posttraumatic patients after median and ulnar nerve neurotization with intercostal nerves, almost all obstetric brachial plexus palsy patients achieve protective sensation in the hand and some of them achieve active wrist and finger flexion. Use in combination with proper muscles, intercostal nerve transfer can yield adequate power to the paretic upper limb. Reinnervation of native muscles (i.e., latissimus dorsi) should always be sought as they can successfully be transferred later on for further functional restoration.