A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options.

Background: Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management. Methods: A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates. Results: Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)). Discussion: Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Adipose-Derived Stem Cells and Tacrolimus Improve Nerve Regeneration in a Rat Sciatic Nerve Defect Model.

This study compared the effect of undifferentiated adipose-derived stem cells (ADSCs) vs tacrolimus (FK506) in peripheral nerve regeneration in a rat sciatic nerve complete transection model. Forty Wistar rats were equally distributed in four groups. In the SHAM surgery group, the sciatic nerve was exposed and no further intervention was done. In the conduit-alone group (the SLN group), a 10-mm nerve gap was created and bridged with a fibrin conduit filled in with normal saline. In the FK506 group, the fibrin conduit was injected with soluble FK506. In the ADSC group, the conduit was impregnated with undifferentiated ADSCs. Nerve regeneration was assessed by means of walking track analysis, electromyography, and neurohistomorphometry. Clinically and microscopically, nerve regeneration was achieved in all groups at 12 weeks. Walking track analysis confirmed functional recovery in the FK506 and ADSC groups, but there was no difference between them. Recovery in function was also achieved in the SLN group, but it was inferior (P<.05). Electromyography demonstrated superior nerve regeneration in the FK506 and ADSC groups compared with the SLN group (P<.05), with no difference between the FK506 and ADSC groups. Similarly, histology showed no difference between the FK506 and ADSC groups, although both outperformed the SLN group (P<.05). No complications were observed. Successful peripheral nerve regeneration can be accomplished after a 10-mm nerve defect treated with nerve conduits. Superior nerve regeneration may be expected when the conduits are loaded with undifferentiated ADSCs or FK506, with similar outcomes for ADSCs and FK506. [Orthopedics. 2023;46(6):e353-e361.].

Assessment of groundwater vulnerability to nitrates using the GIS-based DRASTIC and SI methods: a case study in Zacharo area, Greece.

A vulnerability assessment of the aquifers in the agricultural area of Zacharo in SW, Peloponnese, Greece, was conducted using the DRASTIC index and the susceptibility index (SI). Sensitivity analysis was conducted and thematic maps for each parameter were generated to analyse the impact of individual parameter on the collective groundwater vulnerability. Results derived from the DRASTIC and SI maps revealed that the extremely highly vulnerable zones are concentrated at three coastal sites in the western part of the study area. Data from these maps also indicate low vulnerability areas throughout the eastern part of the region. The distribution of nitrate concentrations in groundwater is better correlated with the DRASTIC (79.2%) compared to SI (60.2%). Neither method takes into consideration the impact of dilution and nitrate to ammonium reduction, on the nitrate content of groundwater, thus overestimating the vulnerability index. Moreover, the SI method overestimates the impact of olive groves' land use type on the susceptibility index, thus resulting to a lower correlation with the observed nitrate concentrations.

The "purse string" technique for anterior glenohumeral instability: long-term results 7-13-year follow-up.

PURPOSE: The "Purse-String Technique" (PST) is an arthroscopic horizontal mattress suture technique for recurrent anterior shoulder instability that uses a single double-loaded suture anchor at the 4-o' clock position, achieving a Bankart labral repair and an infero-superior capsular shift. In this study, we describe the long-term results of the PST. METHODS: The study included 69 individuals (70 shoulders), with a mean age of 30 years, who had recurrent post-traumatic anteroinferior instability. A purse-string suture anchor at the 4-o'clock position was used to address the Bankart lesion and capsular laxity, recreating the anterior glenoid bumper. All patients were assessed via telephone interview at a mean of 116 months after surgery (7-13-year follow-up). RESULTS: Postoperatively, the mean Constant score was 94, mean Rowe score was 93 and mean Walch-Duplay score was 89. 89% of patients resumed their preinjury sport activities, with 61% of patients achieving preinjury levels and most professional athletes returning to full activity. Seven patients had recurrent dislocation postoperatively (10% failure rate). Of these patients, three had revision arthroscopic stabilization, one patient had revision arthroscopic stabilization with remplissage, two had a Latarjet procedure, whereas one patient decided to seek no further treatment. CONCLUSION: The long-term results of PST are promising, with a low failure rate, high patient satisfaction and a high rate of return to sport. LEVEL OF EVIDENCE: Level IV; Case series; Treatment study.

Diabetes and COVID-19; A Bidirectional Interplay.

There seems to be a bidirectional interplay between Diabetes mellitus (DM) and coronavirus disease 2019 (COVID-19). On the one hand, people with diabetes are at higher risk of fatal or critical care unit-treated COVID-19 as well as COVID-19 related health complications compared to individuals without diabetes. On the other hand, clinical data so far suggest that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may result in metabolic dysregulation and in impaired glucose homeostasis. In addition, emerging data on new onset DM in previously infected with SARS-CoV-2 patients, reinforce the hypothesis of a direct effect of SARS-CoV-2 on glucose metabolism. Attempting to find the culprit, we currently know that the pancreas and the endothelium have been found to express Angiotensin-converting enzyme 2 (ACE2) receptors, the main binding site of the virus. To move from bench to bedside, understanding the effects of COVID-19 on metabolism and glucose homeostasis is crucial to prevent and manage complications related to COVID-19 and support recovering patients. In this article we review the potential underlying pathophysiological mechanisms between COVID-19 and glucose dysregulation as well as the effects of antidiabetic treatment in patients with diabetes and COVID-19.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study.

BACKGROUND: The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae. METHODS: We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded. RESULTS: The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. CONCLUSION: Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Raw and modified palygorskite in water treatment applications for low-concentration ammonium removal.

Raw palygorskite (Pal) samples went under acid (H-Pal), NaCl (Na-Pal), and CaCl2 treatment (Ca-Pal) in order to be examined as ammonium (NH4 + ) sorbents from aqueous solutions. The samples were characterized by XRD and FT-IR techniques to examine potential structural differences after modifications, and batch kinetic experiment series were applied to determine the optimal conditions for NH4 + removal. According to thermodynamic analysis, the removal reaction for sodium- and calcium-treated samples was endothermic (ΔΗ0  > 0, 1.65 kJ/mol and 24.66 kJ/mol, respectively), in contrast with the exothermic reactions of raw and acidic-treated palygorskite samples (ΔΗ0  < 0, -37.18 kJ/mol and -27.56 kJ/mol respectively). Moreover, each sample presented a different order of sorbed ions preference, whereas the strong affinity for Ca2+ sorption was common in all cases since the NH4 + removal inhibited. Nevertheless, a similar pattern was followed for raw and modified samples at isotherm study, rendering the linear form of Freundlich isotherm to express better the NH4 + sorption on palygorskite sample, indicating that it is a heterogeneous procedure. In all cases, the NH4 + maximum uptake was within 15 min using 8 g/L of each sorbent, especially for the Na-Pal sample, which could reach almost 100% removal of low concentration NH4 + . PRACTITIONER POINTS: Modified palygorskite samples were tested for NH4 + removal from aqueous solutions. NaCl-treated palygorskite had the higher removal efficiency, which could reach almost 100% removal of low concentration NH4 + . NH4 + maximum uptake was within 15 minutes using 8 g/L of each sorbent. NH4 + adsorption was an endothermic reaction for NaCl- and CaCl2 -treated palygorskite sorbents. NH4 + adsorption was an exothermic reaction for raw and acid-treated palygorskite sorbents.

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients.

INTRODUCTION: Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique. METHODS: A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed. RESULTS: Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty. CONCLUSION: This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

Reduction techniques for difficult subtrochanteric fractures.

Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.

Correlation of ultrasound cross-sectional area of the median nerve, nerve conduction studies and 2-point discrimination.

INTRODUCTION: The purpose of this study was to determine the correlation between a measure of physical performance, a measure of physiology and a measure of anatomy in the setting of carpal tunnel syndrome (CTS). METHODS: A retrospective review of 215 consecutive patients with suspected CTS was conducted. All patients were evaluated with static 2-point discrimination (2PD), ultrasound (US) measurement of the median nerve cross-sectional area (CSA), and nerve conduction studies (NCS). Correlations between 2PD and US and NCS parameters were calculated. The ability of US/NCS to predict 2PD was evaluated. RESULTS: Analysis failed to prove a statistically significant correlation between 2PD and median nerve CSA. A weak correlation was detected between 2PD and NCS parameters. When 2PD was used as a reference standard, NCS parameters combined had the greatest sensitivity, followed by US. CONCLUSIONS: Currently used diagnostic tests (NCS and US) correlate poorly with 2PD. Muscle Nerve 000: 000-000, 2018 Muscle Nerve 59:236-239, 2019.

Similar femoral growth and deformity with one screw versus two smooth pins for slipped capital femoral epiphysis.

PURPOSE: To compare longitudinal growth and cam deformity of the proximal femur after treatment for slipped capital femoral epiphysis (SCFE) with one screw versus two smooth pins. METHODS: We studied 43 patients (29 males, 14 females; mean age, 12.1 years; range, 9.5-14 years) with idiopathic unilateral SCFE treated with in situ fixation with one cannulated screw (group A, n = 23) or two smooth pins (group B, n = 20). Anteroposterior and frog-leg radiographs of the pelvis were evaluated for each patient at initial presentation, post-operatively and at physeal closure. Longitudinal growth was evaluated using the femoral neck length (FNL), the caput-collum-diaphyseal (CCD) angle, and the articulo-trochanteric distance (ATD). Cam deformity was assessed using the anterior offset α-angle and the head-neck offset ratio (HNOR). The mean follow-up was 5.1 years (range, 4-7 years). RESULTS: Postoperatively, the mean CCD angle was 138.3°, the mean α-angle was 66.1° and the mean HNOR was - 0.030. At physeal closure, mean CCD angle significantly decreased to 133.6°, mean α-angle significantly reduced to 52.1°, and mean HNOR significantly improved to + 0.039. CCD, FNL, ATD, α-angle, and HNOR were not different between groups. CONCLUSIONS: One screw or two smooth pins result in similar longitudinal growth and deformity of the proximal femur after SCFE. The femoral head-neck junction remarkably improves until physeal closure; however, residual cam deformity is not avoided after in situ pinning. The complication rate with smooth pins is higher.

Current concepts for the evaluation and management of diabetic foot ulcers.

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.

Harvesting, Isolation and Differentiation of Rat Adipose-Derived Stem Cells.

BACKGROUND: Adipose tissue is one of the most attractive sources of stem cells because it can be easily harvested and yields a greater stromal cell density. The multilineage potential of adiposederived stem cells (ADSCs) demonstrates their significant impact within the field of tissue engineering, with studies successfully demonstrating the ability to produce a range of tissue types. However, although a broad spectrum of applications has already been suggested, many important scientific and medical questions remain unanswered before the clinical application of ADSCs in humans. Importantly, clarification of the biology and identification of the differences of ADSCs from various areas of the body is required. In this continuous endeavor, research in rat models plays an important role in the development of new knowledge. METHODS: A literature review was done to summarize all information regarding harvesting, isolation, expansion, cryopreservation and differentiation of rat ADSCs. A Wistar rat model was also used to describe harvesting sites of adipose tissue, and to characterize the ADSCs using Fourier-transform infrared (FT-IR) spectroscopy and phase contrast microscopy. AIMS: To discuss all relevant considerations for harvesting, culture, differentiation and phenotypic characterization of ADSCs, to provide a comprehensive roadmap of this process, to identify the differences between ADSCs obtained from various adipose tissues of the rat, and to provide FT-IR spectroscopy marker bands that could be used as fingerprints to differentiate the types of adipose tissues.

Scientific Misconduct (Fraud) in Medical Writing.

Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176-e183].

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.

Spondylodiscitis revisited.

Spondylodiscitis may involve the vertebral bodies, intervertebral discs, paravertebral structures and spinal canal, with potentially high morbidity and mortality rates.A rise in the susceptible population and improved diagnosis have increased the reported incidence of the disease in recent years.Blood cultures, appropriate imaging and biopsy are essential for diagnosis and treatment.Most patients are successfully treated by conservative means; however, some patients may require surgical treatment.Surgical indications include doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain. Cite this article: EFORT Open Rev 2017;2:447-461. DOI: 10.1302/2058-5241.2.160062.

Giant cell tumor of bone revisited.

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic malignant bone tumor. It accounts for 4-10% of all bone tumors and typically affects the meta-epiphyseal region of long bones of young adults. The most common site involved is the distal femur, followed by the distal radius, sacrum, and proximal humerus. Clinical symptoms are nonspecific and may include local pain, swelling, and limited range of motion of the adjacent joint. Radiographs and contrast-enhanced magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosis. Surgical treatment with curettage is the optimal treatment for local tumor control. A favorable clinical outcome is expected when the tumor is excised to tumor-free margins, however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Local adjuvants have been used for improved curettage, in addition to systematic agents such as denosumab, bisphosphonates, or interferon alpha. This article aims to discuss the clinicopathological features, diagnosis, and treatments for GCT of bone.

Trans-Scaphoid Transcapitate Perilunate Fracture-Dislocation.

Trans-scaphoid transcapitate (TSTC) perilunate fracture-dislocation (PLFD) is a rare type of perilunate injury. Because of the rarity and complexity of this entity, initial diagnosis may be delayed and the extent of osseous and ligamentous lesions underestimated. Early surgical treatment by open reduction and fracture stabilization is recommended to avoid complications such as avascular necrosis, nonunion, posttraumatic arthritis, and functional impairment. In this article, we report the case of a 32-year-old man who sustained a TSTC-PLFD. We describe the radiographic and intraoperative findings, review the current surgical principles for reduction and stabilization of this injury, and assess the clinical and radiologic outcomes.

Intercalary reconstructions after bone tumor resections: a review of treatments.

An intercalary reconstruction is defined as replacement of the diaphyseal portion of a long bone after segmental skeletal resection (diaphysectomy). Intercalary reconstructions typically result in superior function compared to other limb-sparing procedures as the patient's native joints above and below the reconstruction are left undisturbed. The most popular reconstructive options after segmental resection of a bone sarcoma include allografts, vascularized fibula graft, combined allograft and vascularized fibula, segmental endoprostheses, extracorporeal devitalized autograft, and segmental transport using the principles of distraction osteogenesis. This article aims to review the indications, techniques, limitations, pros and cons, and complications of the aforementioned methods of intercalary bone tumor resections and reconstructions in the context of the ever-growing, brave new field of limb-salvage surgery.