Application of Wearable Sensors Technology for Lumbar Spine Kinematic Measurements during Daily Activities following Microdiscectomy Due to Severe Sciatica.

BACKGROUND: The recurrence rate of lumbar spine microdiscectomies (rLSMs) is estimated to be 5-15%. Lumbar spine flexion (LSF) of more than 10° is mentioned as the most harmful load to the intervertebral disc that could lead to recurrence during the first six postoperative weeks. The purpose of this study is to quantify LSFs, following LSM, at the period of six weeks postoperatively. METHODS: LSFs were recorded during the daily activities of 69 subjects for 24 h twice per week, using Inertial Measurement Units (IMU). RESULTS: The mean number of more than 10 degrees of LSFs per hour were: 41.3/h during the 1st postoperative week (P.W.) (29.9% healthy subjects-H.S.), 2nd P.W. 60.1/h (43.5% H.S.), 3rd P.W. 74.2/h (53.7% H.S.), 4th P.W. 82.9/h (60% H.S.), 5th P.W. 97.3/h (70.4% H.S.) and 6th P.W. 105.5/h (76.4% H.S.). CONCLUSIONS: LSFs constitute important risk factors for rLDH. Our study records the lumbar spine kinematic pattern of such patients for the first time during their daily activities. Patients' data report less sagittal plane movements than healthy subjects. In vitro studies should be carried out, replicating our results to identify if such a kinematic pattern could cause rLDH. Furthermore, IMU biofeedback capabilities could protect patients from such harmful movements.

Three-Dimensional-Printed Proximal Radial Plate for Radial Reconstruction after Tumor Resection: Case Report and Literature Review.

Tumors in proximal radius are rare. Fibrous dysplasia (FD) describes a benign tumor of fibrous tissue that rarely occurs in proximal radius. We present the case of a 26-yr-old male with monostotic proximal radius FD. Follow-up forearm radiographs showed progressive radial cortex expansion and thinning. The patient was treated with lesion curettage, a synthetic bone graft substitute, and fixation with a three-dimensional (3D)-printed proximal radial plate. At 18-mo follow-up, forearm radiographs showed graft incorporation and the 3D-printed plate in place without signs of loosening. The patient was pain-free, had full range of motion in the elbow, and no restrictions to his daily activities.

The Effects of High-Intensity Interval Exercise on Skeletal Muscle and Cerebral Oxygenation during Cycling and Isokinetic Concentric and Eccentric Exercise.

The aim of the present study was to study the effects of cycling and pure concentric and pure eccentric high-intensity interval exercise (HIIE) on skeletal muscle (i.e., vastus lateralis) and cerebral oxygenation. Twelve healthy males (n = 12, age 26 ± 1 yr, body mass 78 ± 2 kg, height 176 ± 2 cm, body fat 17 ± 1% of body mass) performed, in a random order, cycling exercise and isokinetic concentric and eccentric exercise. The isokinetic exercises were performed on each randomly selected leg. The muscle and the cerebral oxygenation were assessed by measuring oxyhemoglobin, deoxyhemoglobin, total hemoglobin, and tissue saturation index. During the cycling exercise, participants performed seven sets of seven seconds maximal intensity using a load equal to 7.5% of their body mass while, during isokinetic concentric and eccentric exercise, they were performed seven sets of five maximal muscle contractions. In all conditions, a 15 s rest was adopted between sets. The cycling HIIE caused greater fatigue (i.e., greater decline in fatigue index) compared to pure concentric and pure eccentric isokinetic exercise. Muscle oxygenation was significantly reduced during HIIE in the three exercise modes, with no difference between them. Cerebral oxygenation was affected only marginally during cycling exercise, while no difference was observed between conditions. It is concluded that a greater volume of either concentric or eccentric isokinetic maximal intensity exercise is needed to cause exhaustion which, in turn, may cause greater alterations in skeletal muscle and cerebral oxygenation.

Neurological and neurourological complications of electrical injuries.

Electrical injury can affect any system and organ. Central nervous system (CNS) complications are especially well recognised, causing an increased risk of morbidity, while peripheral nervous system (PNS) complications, neurourological and cognitive and psychological abnormalities are less predictable after electrical injuries. PubMed was searched for English language clinical observational, retrospective, review and case studies published in the last 30 years using the key words: electrical injury, electrocution, complications, sequelae, neurological, cognitive, psychological, urological, neuropsychological, neurourological, neurogenic, and bladder. In this review, the broad spectrum of neurological, cognitive, psychological and neurourological consequences of electrical trauma are discussed, and clinical features characteristic of an underlying neurological, psychological or neurourological disorder are identified. The latest information about the most recently discovered forms of nervous system disorders secondary to electrical trauma, such as the presentation of neurological sequelae years after electrocution, in other words long-term sequelae, are presented. Unexpected central nervous system or muscular complications such as hydrocephalus, brain venous thrombosis, and amyotrophic lateral sclerosis are described. Common and uncommon neuropsychological syndromes after electrical trauma are defined. Neurourological sequelae secondary to spinal cord or brain trauma or as independent consequences of electrical shock are also highlighted.

Methodology of surface electromyography in gait analysis: review of the literature.

Gait analysis is a significant diagnostic procedure for the clinicians who manage musculoskeletal disorders. Surface electromyography (sEMG) combined with kinematic and kinetic data is a useful tool for decision making of the appropriate method needed to treat such patients. sEMG has been used for decades to evaluate neuromuscular responses during a range of activities and develop rehabilitation protocols. The sEMG methodology followed by researchers assessed the issues of noise control, wave frequency, cross talk, low signal reception, muscle co-contraction, electrode placement protocol and procedure as well as EMG signal timing, intensity and normalisation so as to collect accurate, adequate and meaningful data. Further research should be done to provide more information related to the muscle activity recorded by sEMG and the force produced by the corresponding muscle during gait analysis.

Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures.

PURPOSE: To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures. METHODS: We prospectively studied 50 patients (33 women, 17 men; mean age, 80 years; range, 74-93 years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2 years (range, 1-5 years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail. RESULTS: Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2 cm (range, 3-10 cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups. CONCLUSION: Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.

Thromboembolism prophylaxis in orthopaedics: an update.

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery. Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018.

Fall Risk Assessment Metrics for Elderly Patients With Hip Fractures.

The most common surgery performed by orthopedic surgeons likely involves that for hip fractures. The incidence of hip fractures is anticipated to rise in the coming decades. Hip fractures most commonly occur in elderly women with osteoporosis after a fall from standing position. In an effort to reduce the incidence, improve the postoperative care, and accelerate the rehabilitation of hip fractures, it is important to evaluate the fall risk of these patients, as it is an objective indication of their level of physical activity. Metrics currently available for the evaluation of fall risk in the elderly vary widely, with each having been designed to assess a specific patient population. However, their applicability has often proved to be much broader than expected. This review summarizes the metrics available for fall risk assessment of elderly patients with hip fractures, describes their individual features and efficacy, and highlights those that seem to be more reliable for the assessment of rehabilitation of these patients after hip fracture surgery. [Orthopedics. 2018; 41(3):142-156.].

Dual head screw hip nailing for trochanteric fractures.

INTRODUCTION: There are limited information and inconclusive results for dual head screw intramedullary hip nails for trochanteric fractures. Therefore, we performed a prospective study to evaluate the healing of fractures, and survival, function, and complications of patients operated with this implant. METHODS: We prospectively studied 79 patients (61 women and 18 men; mean age: 84.7 years; range: 65-96 years) with a low-energy trochanteric fracture, treated with a dual head screw intramedullary hip nail from 2013 to 2016. The mean follow-up was 2.1 years (range: 1-3 years); seven patients were lost to follow up. This left 72 patients for further analysis. We evaluated the healing of fractures, and survival, function, and complications of patients. RESULTS: Fracture healing was evident in 70 patients (97.2%) at 2-3 months postoperatively. One patient experienced cut-out and z-effect phenomenon of the head screws. Another patient experienced a periprosthetic femoral diaphysis fracture at the distal tip of the nail. A third patient experienced an acute postoperative superficial skin infection that was treated successfully with wound dressing changes and a course of antibiotics. Sixteen patients (22.2%) deceased within 12 months postoperatively. In the remaining patients, the Harris Hip Score (HHS) at 12 months postoperatively was excellent in 16 (28.6%), good in 23 (41.1%), fair in 10 (17.8%), and poor in 7 patients (12.5%). The function declined after the patients' fracture. Fair and poor results were related to age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types. CONCLUSION: The dual head screw intramedullary hip nail is associated with high healing and low complication rates for intertrochanteric fractures. The function of the patients is good or excellent in most cases; however, it declines, especially for those patients with age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

PMMA Cement Allergy Misleading Total Knee Arthroplasty Infection.

Arthroscopic and prosthetic hip and knee joint infection are uncommon; however, devastating complications in adult reconstruction surgery. An acute onset of pain combined with effusion, erythema, warmth and fever are the typical signs of early infection. Hypersensitivity or allergic reactions to arthroplasty components, concerning mainly metal-to-metal bearings and metal-on-plastic total knee arthroplasties have also been reported. Inflammation associated with allergic reaction to any of these materials (metallic and/or acrylic bone cement) can plausibly cause a number of similar manifestations to infection such as loosening, instability, stiffness, arthrofibrosis, swelling, warmth, and pain. This article presents a patient without known polymethylmethacrylate (PMMA) bone cement allergy who experienced a prosthetic joint infection after a cemented total knee arthroplasty. The diagnosis of infection was misled by the wrong timing of cultures with respect to antibiotics cessation, and the documentation of PMMA cement allergy with allergiologic examination and patch testing.

Vascular Injury in Orthopedic Trauma.

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].

Complications After Hip Nailing for Fractures.

Pertrochanteric fractures in elderly patients represent a major health issue. The available surgical options are fixation with extramedullary devices, intramedullary nailing, and arthroplasty. Intramedullary nailing for hip fractures has become more popular in recent years. Advantages of intramedullary nailing for hip fracture fixation include a more efficient load transfer due to the proximity of the implant to the medial calcar, less implant strain and shorter lever arm because of its closer positioning to the mechanical axis of the femur, significantly less soft tissue disruption and periosteal stripping of the femoral cortex, shorter operative time and hospital stay, fewer blood transfusions, better postoperative walking ability, and lower rates of leg-length discrepancy. Compromise of the posteromedial cortex and/or the lateral cortex, a subtrochanteric extension of the fracture, and a reversed obliquity fracture pattern represent signs of fracture instability, warranting the use of intramedullary nailing. However, the use of intramedullary nailing, with its unique set of clinical implications, has introduced a new set of complications. The reported complications include malalignment, cutout, infection, false drilling, wrong lag screw length and drill bit breakage during the interlocking procedure, external or internal malrotation (≥20°) of the femoral diaphysis, elongation of the femur (2 cm), impaired bone healing, periprosthetic fracture distal to the tip of the nail, fracture collapse, implant failure, lag screw intrapelvic migration, neurovascular injury, secondary varus deviation, complications after implant removal, trochanteric pain, and refracture. Many of these complications are related to technical mistakes. This article reviews intramedullary nailing for the treatment of pertrochanteric femoral fractures, with an emphasis on complications.

Percutaneous repair of acute Achilles tendon rupture: a functional evaluation study with a minimum 10-year follow-up.

OBJECTIVE: The purpose of this study was to present the functional outcomes of percutaneous tenorrhaphy of the Achilles tendon with a minimum follow-up of 10 years. METHODS: The medical records of patients who underwent percutaneous surgery for acute unilateral Achilles tendon rupture between 2000 and 2004 were retrospectively reviewed. RESULTS: A total of 11 male patients met the inclusion criteria and were followed for a mean of 12.6 years (range: 10-13 years). The average age at the time of surgery was 39.3 years (range: 29-53 years). Patients returned to work at an average of 2.7 months (range: 1-4 months) after surgery and to normal daily activities (NDA) at an average of 4.1 months (range: 3-6 months) postoperatively. The mean strength ratio between the injured and normal sides was 90%. Compared with the contralateral normal side, the thickness of the operated tendon increased by a mean of 0.7 cm, while the circumference of the affected calf diminished by a mean of 1.1 cm. No difference in active and passive range of motion (ROM) was recorded between the affected and the contralateral normal ankle joints. Isometric plantar flexion was 87% of normal. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after surgery. The sensory defect had completely resolved by 6 months postoperatively. CONCLUSION: Long-term outcomes of our series support the effectiveness of percutaneous tenorrhaphy in Achilles function rehabilitation of patients with acute ruptures.

Lateral versus medial approach for intra-articular knee injections.

OBJECTIVE: The aim of this study was to determine whether the medial or the lateral mid-patellar approach is the most reliable for intra-articular knee injections. METHODS: The study included 76 knees of 76 patients divided into 2 groups. The first group consisted of 38 patients with a knee injury and resultant knee effusion. The second group included 38 patients without any known knee pathology. Patients were matched according to age and gender. The medial joint opening (medial patellofemoral angle) was calculated on a T1-weighted transverse image by measuring the anatomic angle between the femur and the patella. The lateral joint opening (lateral patellofemoral angle) was calculated in a similar way. RESULTS: The medial patellofemoral angle was significantly higher than the lateral patellofemoral angle in both groups (p<0.001). CONCLUSION: The medial patellofemoral angle is significantly higher than the lateral patellofemoral angle in both healthy knees and knees with effusion. Therefore, the medial approach appears to be more accurate for intra-articular knee injection due to the medial joint's larger opening.

Snakebites of fingers or toes by viperidae family members: an orthopaedic approach.

The purpose of this study was to review current principles of therapy for affected patients and determine whether an emergent surgical approach or expectant management should be selected in cases of snakebites of fingers or toes by Viperidae family members. Over the past five years (January 2004 to December 2009), 12 patients bitten by Vipera ammodytes were admitted in our department. We retrospectively reviewed their demographic and epidemiological characteristics as well as their symptoms, laboratory findings, and complications. All snake bites occurred at the extremities (fingers and toes). The main complications were oedema, disseminated intravascular coagulation, and decrease in haematocrit. None of the patients developed compartment syndrome or required surgical debridement. The majority of the patients with snakebites of fingers or toes by Vipera ammodytes can be treated conservatively. Surgery is indicated only in case of compartment syndrome, where fasciotomies should be performed without delay after diagnosis.

Ilizarov treatment of humeral shaft nonunion in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity.

Nonunion of the humeral shaft in patients with antiepileptic drug associated metabolic bone disorder constitute a challenging surgical problem difficult to treat due to seizure activity, osteoporosis, and poor stabilization options. We report a case of nonunion of the humeral shaft in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity successfully treated with Ilizarov external fixator and a follow-up of 4 years.