Optimizing Hip Replacement Procedure in Cerebral Palsy-Related Spastic Hip Dysplasia: A Case Report.

Cerebral palsy (CP) often results in severe hip issues, disrupting musculoskeletal development and mobility due to problems such as dislocations and contractures, aggravated by spasticity and heightened muscular tone. While total hip arthroplasty (THA) is required in CP patients, the procedure carries high risks due to concerns about dislocation and wear. This study explores a method of intraoperative navigation to precisely execute preoperative strategies for spinopelvic alignment and optimal cup placement. We discuss a case of a 22-year-old male CP patient with bilateral hip dislocations who experienced significant discomfort, impeding mobility and affecting his performance as a Paralympic rower. He underwent bilateral hip replacement surgeries, guided by preoperative gait analysis and imaging, with navigation aiding in accurate acetabular component placement and correction of excessive femoral anteversion using a modular stem. The patient achieved excellent stability in both standing and rowing postures. Overall, computer navigation enhances complex hip repair by facilitating intraoperative data collection and precise execution of preoperative plans. This approach may extend the lifespan of prostheses, particularly by achieving precise acetabular component placement based on spinopelvic alignment principles, thereby offering significant benefits for CP patients undergoing THA.

Ultrasonographic screening for developmental dysplasia of the hip: the Graf method revisited.

Until the 1980s, the diagnosis of developmental dysplasia of the hip (DDH) was based on clinical examination and radiographic imaging. In 1980, Reinhard Graf developed his own ultrasonographic method for the examination of the infant hip joint. Graf's method evaluates the osseous and cartilaginous coverage of the femoral head by the acetabulum in the infantile hip joint by measuring the angles α and ß. The validity of Graf method is that with these measurements the hip joint is further classified by Graf classification into types I to IV that guide treatment. Currently, Graf method is considered the gold standard examination for the diagnosis of DDH in many European countries. This review article aims to discuss the incidence, risk factors and pathophysiology of DDH, and to emphasize on the Graf method for the evaluation, classification, prevention and further management of this entity.

Orthobiologics: a review.

PURPOSE: The use of biologic materials in orthopaedics (orthobiologics) has gained significant attention over the past years. To enhance the body of the related literature, this review article is aimed at summarizing these novel biologic therapies in orthopaedics and at discussing their multiple clinical implementations and outcomes. METHODS: This review of the literature presents the methods, clinical applications, impact, cost-effectiveness, and outcomes, as well as the current indications and future perspectives of orthobiologics, namely, platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate, growth factors, and tissue engineering. RESULTS: Currently available studies have used variable methods of research including biologic materials as well as patient populations and outcome measurements, therefore making comparison of studies difficult. Key features for the study and use of orthobiologics include minimal invasiveness, great healing potential, and reasonable cost as a nonoperative treatment option. Their clinical applications have been described for common orthopaedic pathologies such as osteoarthritis, articular cartilage defects, bone defects and fracture nonunions, ligament injuries, and tendinopathies. CONCLUSIONS: Orthobiologics-based therapies have shown noticeable clinical results at the short- and mid-term. It is crucial that these therapies remain effective and stable in the long term. The optimal design for a successful scaffold remains to be further determined.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Higher Infection Rate after ACL Reconstruction with Hamstrings Tendon Autografts Compared with Bone Patellar Bone Tendon Autografts: A Review.

Infection after anterior cruciate ligament reconstruction is a rare but devastating complication resulting in a deleterious impact on knee function as well as an increased related cost for treatment and rehabilitation for the patients. There are conflicting reports regarding the rate of infection between bone patellar tendon bone (BPTB) and hamstrings tendon (HT) autografts for anterior cruciate ligament reconstruction. Therefore, we performed this review to summarize all the available data regarding the risk of infection after ACL reconstruction, to provide insight on the infection risk between BPTB and HT autografts, and to discuss current recommendations for the diagnosis and treatment of these infections. The incidence and risk of infection after ACL reconstruction with HT graft is higher compared with BPTB grafts. The most commonly subacute and late infections, quadruple type, need for cannulated instruments for harvesting, size and shape and fixation of the extra-tunnel material of the HT are important risk factors for infection. Combined antibiotics administration and adequate arthroscopic lavage and debridement are the optimal treatments for ACL reconstruction infection. Early diagnosis and treatment is the most important predictor for graft retention, which accounts more commonly for BPTB grafts. The treating physicians should be aware of the higher incidence of infection after ACL reconstruction with HT graft, as well as for the need for a high clinical suspicion for early diagnosis of the infection. These will increase the possibility of eradication of the infection and retention of the graft.

Comparison of Bone-Patella Tendon-Bone and Four-Strand Hamstring Tendon Grafts for Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Introduction To date, the proper choice of graft for anterior cruciate ligament (ACL) reconstruction remains a matter of conflict. We aimed to compare the clinical and functional outcomes of the two most commonly utilized autografts, bone-patella tendon-bone (BPTB) and four-strand hamstring tendon (HT) graft, at 6 and 12 months after surgery. Methods In a prospective randomized study, we included a total of 60 patients undergoing ACL reconstruction, thirty in BPTB and thirty in HT group. All patients were amateur athletes and were evaluated at 6 and12 months after surgery for: (a)postoperativefunctionality of the operated knee by the Tegner, the Lysholm and the International Knee Documentation Committee (IKDC) scoring scales, (b) anterior cruciate ligament (ACL) instability of the operated knee compared to the healthy contralateral knee by the KT-1000 arthrometer and (c) theextension and flexion muscle strength of the operated knee by a CYBEXisokinetic dynamometer.  Results Patients in the two groups did not differ regarding demographics, and pre-injury functionality status. Significantly more patients in the HT group (n=6) compared to the BPTB group (n=1) experienced ACL re-rupture and underwent revision surgery before follow-up end (p=0.044). All patients, regardless of graft, showed significant improvement within each group of functional assessments by Lysholm, Tegner and IKDC scores, as well as of Cybex measurements -with an increase of peak torque at 60° extension and 180°extension and 60° flexion and 180° flexion- at 12 months compared to 6 months follow-up (p<0.05). However, there was no difference between the two groups regarding knee function improvement or extension measurements neither at 6 nor 12 months. Contrarily, the BPTB graft group had higher values of peak torque (Nm) at 60° and 180° flexion compared to the HT group, both at 6 (p=0.014 and 0.029, respectively) and 12 months (p=0.033 and 0.030, respectively). Postoperative stability was similar between the two groups at 12 months (p=0.519). Conclusion Both BPTB and HT grafts present with benefits and drawbacks and remain viable autograft options for primary ACL reconstruction as each has, although HT grafts seem to be more susceptible to re-rupture. The graft selection should be based on the needs and activities of each patient.

A Systematic Approach for Stronger Documentation of Anterior Cruciate Ligament Graft Choice.

Numerous studies have focused on determining the optimal choice between the two most used anterior cruciate ligament (ACL) reconstruction autografts. In order to address this matter, we performed a systematic review of every meta-analysis published on the PubMed platform between 2001 and 2020, comparing the functional outcomes, the static stability parameters, as well as the postoperative and long-term complications of the patellar tendon (BPTB) autograft and hamstrings (HT). We retrieved a total of 26 meta-analyses that met our criteria, and the characteristics and outcomes of every meta-analysis, as well as subgroup analysis regarding the type of the study design, number of strands of HT autograft, and fixation method, were extensively recorded. The majority of the meta-analyses showed that there were no significant differences between BPTB and HT in terms of functional outcomes and static stability parameters while HT autografts seem to be superior to BPTB regarding kneeling pain and anterior knee pain. Other outcomes seem to be affected by the number of strands of the HT autograft, the fixation technique, and the type of study design, indicating superiority of the four-strand HT autograft with the use of an extra-cortical button fixation. Overall, there is no clear superiority of BPTB over HT autografts for ACL reconstruction, as both types present similar outcomes in the majority of postoperative parameters. Autograft selection should be individualized according to each patient's needs and more RCTs are warranted in order to reach safer results on the appropriate autograft type.

Osteomyelitis of the femur effectively treated with medulloscopy debridement: a case report.

BACKGROUND: Medulloscopy refers to the visualization of the intramedullary canal with an arthroscope, providing access to the infection site without the need for an extensive approach therefore not compromising the surrounding soft tissue. It provides information regarding the extent of the infected endosteal surface of bone, and it allows a thorough debridement of the intramedullary canal in a controlled manner. Therefore, it can be used as an adjunct to traditional open surgical techniques, to perhaps help to visualize hard to see intramedullary areas. MATERIALS AND METHODS: This article reports a patient with chronic osteomyelitis of the distal metaphysis of the femur that was treated successfully with intramedullary debridement through medulloscopy. The sinus tract reaching down to the femoral bone and communicating with the intramedullary canal was excised, and a cortical window was formed through which the arthroscope was inserted and thorough irrigation of the intramedullary canal and excision of necrotic and infected bone was done. A second medulloscopy through the same approach was necessary 3 months later because of persistent infection. RE: SULTS: At 3-year follow-up, the patient was well without any clinical or radiographic evidence of recurrent infection. CONCLUSION: Medulloscopy can be very useful in localized osteomyelitis as an adjunct to traditional surgical techniques; it helps to visualize hard to see intramedullary areas and adequately addresses the infection, while the damage to surrounding soft-tissue is limited.

Can Initial Hematocrit Predict Blood Transfusions, Hospital Cost, and Mortality in Polytrauma Patients?

Knowing the initial hematocrit of a polytrauma patient can assist his trauma management. This paper describes a four-year study of 88 polytrauma patients. Fifty-nine were transfused, and eight were women (13.5%). The mean cost of the first hospitalization of patients who were transfused was 14,503 €; the mean cost of patients who were not transfused was 5,718 €. HCT did not correlate with ICU stay; nor did days of hospitalization. The mean HCT of those who died was not much different from that of survivors (33.23 with standard deviation [SD] 7.43 versus 32.37 with SD 5.89). This study showed that initial HCT does not correlate with days of hospitalization or days in ICU, but that transfusion can predict higher total cost.

Mitchell's osteotomy augmented with bio-absorbable pins for the treatment of hallux valgus: A comparative finite element study.

BACKGROUND: There is an inadequacy of conventional means to assess the surgical outcomes of a bunion surgery. We used the Finite Element Analysis for evaluating the typical Mitchell's procedure outcomes with or without bio-absorbable pins. METHODS: We developed a 3D FE model based on the CT images of a female volunteer with hallux valgus. A typical procedure was simulated on the foot model and two pins were virtually inserted for enhancing the fixation. We validated our model by comparing the predicted pressure results with the plantar pressure measured by a specific platform. RESULTS: The comparison of the plantar pressure distribution revealed similar patterns. A greater displacement was observed on the medial side of the osteotomy, but it was decreased after using pins. The maximum average pressure under the 1st metatarsal head was decreased after the osteotomy. The respective pressure under the 3rd and 5th metatarsal head was decreased more after using pins, while, under the 2nd and 4th metatarsal head, an increase was developed. CONCLUSION: The use of pins had no significant influence on the healing process but gave additional stability inside the osteotomy and could be used in cases where enhancement is needed. The surgeon should be familiar with the expected stress rising to the other metatarsal, considering the concomitant pathology or the additional interventions that should be performed.

Polytrauma: Treatment, Cost, and Associated Factors.

Trauma is a multifactor problem with economic, social, and political burdens. In this article, we estimate its economic extension. This 3-yr study includes 69 patients above 14 yr of age, who experienced multiple traumatic injuries. We review their economic impact on the National Health System of Greece. Mean patient age is 38.91 yr, and most are male (85.5%), nonsmoking (69.6%), and without open fractures (78.3%). As a result of their injuries, most patients (76.8%) stayed in the intensive care unit (ICU), underwent surgery (76.8%), were transfused (68.1%), and became infected (63.8%). Mean cost was 16,365.65€, median cost 10,399.07€, minimum value 554.17€, and maximum value 89,243.52€. Of the 69 patients, 12 died. The number of polytrauma patients is relatively small compared to the total amount of patients in hospital care, but their impact on health services is very high. Patients admitted to the ICU are at great risk of infection, which can almost triple financial cost and increase hospital stay.

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.

Reconstruction of a Neglected Tibial Plateau Fracture Malunion with an Open-Book Osteotomy: A Case Report.

CASE: Surgical management of tibial plateau fractures can be challenging, and complications can be devastating. We report the case of a lateral tibial plateau fracture malunion with an associated intra-articular depression, which we treated with an open-book osteotomy, obviating the need for an early corrective osteotomy or knee arthroplasty. CONCLUSION: A tibial plateau fracture malunion can be reconstructed. The surgical team should give priority to salvage options, which can obviate or delay the need for and the implications of an early total knee arthroplasty, especially in a young and active patient.

Posterior shoulder dislocation with a reverse Hill-Sachs lesion treated with frozen femoral head bone allograft combined with osteochondral autograft transfer.

Management of a posterior shoulder dislocation with an associated reverse Hill-Sachs lesion is challenging, both diagnostically and therapeutically. Diagnosis is frequently delayed or missed, whereas the resulting humeral head defect is often larger and more difficult to salvage than in anterior shoulder dislocations. This report presents the case of a 29-year-old male with a recurrent posterior shoulder dislocation associated with a large reverse Hill-Sachs defect, treated with bone augmentation of the lesion with a combination of fresh femoral head allograft and a locally harvested humeral head autograft transfer, with a successful outcome. Level of evidence V.

Survival after multiple traumas is associated with improved outcomes from gram-negative sepsis: Clinical and experimental evidence.

OBJECTIVES: We investigated the susceptibility to Gram-negative sepsis after multiple traumas (MT). METHODS: From a prospective cohort of 5076 Greek patients with sepsis, 16 with Gram-negative bacteremia after MT were compared with 204 patients well-matched for severity, comorbidities and appropriateness of antimicrobials; circulating mononuclear cells were isolated and stimulated for the release of interleukin (IL)-10. Male C57Bl6J mice were subject to MT (right pneumothorax and right femur fracture) followed after 72 h by the intravenous challenge with Pseudomonas aeruginosa. Survival was recorded and splenocytes were isolated for cytokine stimulation. RESULTS: 28-day mortality after MT was 18.8% compared to 48.0% of comparators (48.0%) (odds ratio 0.25, p: 0.035). This was confirmed after logistic regression analysis taking into consideration comorbidities and age. Stimulation of IL-10 was enhanced from MT patients. Survival of mice challenged by P. aeruginosa 72 h after MT was prolonged compared to mice challenged by P. aeruginosa without prior MT. Cytokine production was decreased 24 h after MT and restored 96 h thereafter. Production of IL-10 was particularly pronounced from splenocytes of mice challenged by P. aeruginosa after MT. CONCLUSIONS: Survival after MT is accompanied by favorable immune responses allowing survival benefit from Gram-negative sepsis. This is associated with increased IL-10 release.

LARS Artificial Ligament Versus ABC Purely Polyester Ligament for Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Graft choice for anterior cruciate ligament (ACL) reconstruction is of critical importance. Various grafts have been used so far, with autografts long considered the optimal solution for the treatment of ACL-deficient knees. Limited data are available on the long-term survivorship of synthetic grafts. PURPOSE: To compare the functional outcome and survivorship of ACL reconstructions performed using the LARS (ligament augmentation and reconstruction system) ligament and the ABC (active biosynthetic composite) purely polyester ligament. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The results of 72 patients who underwent primary arthroscopic ACL reconstruction with the LARS ligament and 31 cases with an ABC purely polyester ligament were reviewed. The mean follow-up periods for the LARS and ABC groups were 9.5 and 5.1 years, respectively. A survivorship analysis of the 2 synthetic grafts was performed using the Kaplan-Meier method with a log-rank test (Mantel-Cox, 95% CI). Lysholm, Tegner activity, Knee injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) scores as well as laxity measurements obtained using a KT-1000 arthrometer were recorded for all intact grafts, and a Mann-Whitney U test was used for comparison reasons. RESULTS: The rupture rates for LARS and ABC grafts were 31% (95% CI, 20%-42%) and 42% (95% CI, 25%-59%), respectively. For intact grafts, the mean Lysholm score was good for both groups (90 for the LARS group and 89 for the ABC group), with the majority of patients returning to their preinjury level of activities, and the mean IKDC score was 90 for the LARS group and 86 for the ABC group. CONCLUSION: The rupture rates of both LARS and ABC grafts were both high. However, the LARS ligament provided significantly better survivorship compared with the ABC ligament at short- to midterm follow-up (95% CI).

Prospective randomized comparison between ultrasound-guided saphenous nerve block within and distal to the adductor canal with low volume of local anesthetic.

BACKGROUND AND AIMS: The anatomic site and the volume of local anesthetic needed for an ultrasound-guided saphenous nerve block differ in the literature. The purpose of this study was to examine the effect of two different ultrasound-guided low volume injections of local anesthetic on saphenous and vastus medialis nerves. MATERIALS AND METHODS: Recruited patients (N = 48) scheduled for orthopedic surgery were randomized in two groups; Group distal adductor canal (DAC): Ultrasound-guided injection (5 ml of local anesthetic) distal to the inferior foramina of the adductor canal. Group adductor canal (AC): Ultrasound-guided injection (5 ml local anesthetic) within the adductor canal. Following the injection of local anesthetic, block progression was monitored in 5 min intervals for 15 min in the sartorial branches of the saphenous nerve and vastus medialis nerve. RESULTS: Twenty two patients in each group completed the study. Complete block of the saphenous nerve was observed in 55% and 59% in Group AC and DAC, respectively (P = 0.88). The proportion of patients with vastus medialis weakness at 15 min in Group AC, 36%, was significantly higher than in Group DAC (0/22), (P = 0.021). CONCLUSIONS: Low volume of local anesthetic injected within the adductor canal or distally its inferior foramina leads to moderate success rate of the saphenous nerve block, while only the injection within the adductor canal may result in vastus medialis nerve motor block.

Donor's site evaluation after restoration with autografts or synthetic plugs in rabbits.

AIM: To investigate donor site's area histological and immunohistochemical knee cartilage appearances after resurfacing iatrogenic defects with biosynthetic plugs orautografts. METHODS: Thirty New Zealand White rabbits were used in this study. A full-thickness cylindrical defect of 4.5 mm (diameter) × 7 mm (depth) was created with a hand drill in the femoral groove of every animal. In Group A (n = 10) the defect of the donor site was repaired with a biosynthetic osteochondral plug, in Group B (n = 10) with an osteochondral autograft, while in Group C (control group of 10) rabbits were left untreated. RESULTS: Twenty-four weeks postoperatively, smooth articular cartilage was found macroscopically in some trocleas' surfaces; in all others, an articular surface with discontinuities was observed. Twenty-eight out of 30 animals were found with predominantly viable chondrocytes leaving the remaining two -which were found only in the control group- with partially viable chondrocytes. However, histology revealed many statistical differences between the groups as far as the International Cartilage Repair Society (ICRS) categories are concerned. Immunofluoresence also revealed the presence of collagen II in all specimens of Group B, whereas in Group A collagen II was found in less specimens. In Group C collagen IIwas not found. CONCLUSION: The matrix, cell distribution, subchondral bone and cartilage mineralization ICRS categories showed statistically differences between the three groups. Group A was second, while group B received the best scores; the control group got the worst ICRS scores in these categories. So, the donor site area, when repairing osteochondral lesions with autografting systems, is better amended with osteochondral autograft rather than bone graft substitute implant.

The Potentially Positive Role of PRPs in Preventing Femoral Tunnel Widening in ACL Reconstruction Surgery Using Hamstrings: A Clinical Study in 51 Patients.

Purpose. In this study, the early and midterm clinical and radiological results of the anterior cruciate ligament (ACL) reconstruction surgery with or without the use of platelet rich plasma (PRP) focusing on the tunnel-widening phenomenon are evaluated. Methods. This is a double blind, prospective randomized study. 51 patients have completed the assigned protocol. Recruited individuals were divided into two groups: a group with and a group without the use of PRPs. Patients were assessed on the basis of MRI scans, which were performed early postoperatively and repeated at least one-year postoperatively. The diameter was measured at the entrance, at the bottom, and at the mid distance of the femoral tunnel. Results. Our study confirmed the existence of tunnel widening as a phenomenon. The morphology of the dilated tunnels was conical in both groups. There was a statistical significant difference in the mid distance of the tunnels between the two groups. This finding may support the role of a biologic response secondary to mechanical triggers. Conclusions. The use of RPRs in ACL reconstruction surgery remains a safe option that could potentially eliminate the biologic triggers of tunnel enlargement. The role of mechanical factors, however, remains important.