Thoracic Cage Deformity Correction in Patients with Lenke Type 1 Adolescent Idiopathic Scoliosis.

Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

Similar complication and readmission rates following simultaneous versus staged bilateral total hip arthroplasty.

PURPOSE: To compare short-term complications and readmission rates, in patients treated with simultaneous versus staged bilateral total hip arthroplasty (THA) within a year from the index procedure. METHODS: We reviewed the charts of patients that underwent simultaneous and staged-within a year-bilateral THA, between 2016 and 2020. Preoperative baseline characteristics were evaluated, while differences in terms of 30-day major and 30-day minor complications and readmission rates were compared between the groups. RESULTS: One-hundred-sixty patients (mean age, 64.3 years; SD, ± 11.7) were identified. Seventy-nine patients were treated with simultaneous (Group A) and eighty-one patients with staged (Group B) THA. There were no differences in baseline characteristic between the two groups (p > 0.050). Group A was more likely to receive general anesthesia (43% vs. 9.9%, p < 0.001) and had longer total operative time (182.8 vs. 128.0 min, p < 0.001). Group A had an overall shorter total length of hospital stay (5.8 vs. 8.6 days, p < 0.001). No differences in transfusion rates (p = 0.229) and no differences in major and minor complications (p > 0.05) were identified. Postoperative visits at the emergency department or readmissions were similar between the two groups (p > 0.050). CONCLUSION: This study shows that similar complication and readmission rates are expected after simultaneous and staged THA. Simultaneous bilateral THA is a safe and effective procedure, that should be considered for patients that present with radiologic and clinical bilateral hip disease.

High degree of consensus amongst an expert panel regarding focal resurfacing of chondral and osteochondral lesions of the femur with mini-implants.

INTRODUCTION: The rationale for the use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions is still under debate. The evidence supporting best practise guidelines is based on studies with low-level evidence. A consensus group of experts was convened to collaboratively advance towards consensus opinions regarding the best available evidence. The purpose of this article is to report the resulting consensus statements. METHODS: Twenty-five experts participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted via an online survey of two rounds, for initial agreement and comments on the proposed statements. An in-person meeting between the panellists was organised during the 2022 ESSKA congress to further discuss and debate each of the statements. A final agreement was made via a final online survey a few days later. The strength of consensus was characterised as: consensus, 51-74% agreement; strong consensus, 75-99% agreement; unanimous, 100% agreement. RESULTS: Statements were developed in the fields of patient assessment and indications, surgical considerations and postoperative care. Between the 25 statements that were discussed by this working group, 18 achieved unanimous, whilst 7 strong consensus. CONCLUSION: The consensus statements, derived from experts in the field, represent guidelines to assist clinicians in decision-making for the appropriate use of mini-implants for partial resurfacing in the treatment of femoral chondral and osteochondral lesions. LEVEL OF EVIDENCE: Level V.

Neuromuscular activity of the lower-extremities during running, landing and changing-of-direction movements in individuals with anterior cruciate ligament reconstruction: a review of electromyographic studies.

PURPOSE: Running, jumping/landing and cutting/change of direction (CoD) are critical components of return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR), however the electromyographic (EMG) activity patterns of the operated leg during the execution of these tasks are not clear. METHODS: A systematic review was conducted to retrieve EMG studies during running, jumping/landing and cutting/(CoD) in ACLR patients. MEDLINE, PubMed, SPORTDiscus and Web of Science databases were searched from 2000 to May, 2022 using a combination of keywords and their variations: "anterior cruciate ligament reconstruction" OR "ACLR", "electromyography" OR "EMG", "running", "jumping" OR "landing", "cutting" OR "change-of-direction" OR "CoD". The search identified studies comparing EMG data during running, landing and cutting/(CoD) between the involved limb and contralateral or control limbs. Risk of bias was assessed and quantitative analyses using effect sizes were performed. RESULTS: Thirty two studies met the inclusion criteria. Seventy five percent (24/32) of the studies reported altered EMG activity pattern of the ACLR leg during running, jumping/landing and cutting/(CoD) when compared with either the healthy control leg or the contra-lateral leg. Twelve studies showed decreased, delayed or earlier onset and delayed peak in quadriceps EMG activity with small to large effect sizes and 9 studies showed increased, delayed or earlier onset and delayed peak in hamstrings EMG activity with small to large effect sizes. Four studies showed a "hamstrings-dominant" strategy i.e. decreased quadriceps coupled with increased hamstrings EMG activity in both running and jumping/landing irrespective of graft type. One study reported that on the grounds of decreased quadriceps activity, lower hamstrings EMG activity was predictive of ipsilateral re-injury in ACLR patients. CONCLUSION: This systematic review of Level III evidence showed that the ACLR leg displays decreased quadriceps or increased hamstrings EMG activity or both despite RTS. Simultaneous decreased quadriceps and increased hamstrings EMG activity was shown for both running and jumping/landing. From a clinical perspective this "hamstrings dominant" strategy can serve as a protective mechanism against graft re-injury. LEVEL OF EVIDENCE: III.

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.].

Femoral condyle resurfacing using an inlay metal implant: low revision rate of 266 patients in a 5-10 years follow-up.

PURPOSE: To assess the clinical outcome and survival of an inlay resurfacing prosthesis for focal femoral condyle chondral and osteochondral defects. METHODS: Two hundred sixty-six patients (mean age, 38.25 years; range 25-56 years) with symptomatic femoral condyle chondral and osteochondral defects were reviewed. The mean follow-up period was 7.3 years (range 5-10 years). The medial femoral condyle was involved in 229 and the lateral condyle in 37 patients. Previous cartilage surgery was done in 235 patients. All patients were treated with focal femoral condyle resurfacing with the HemiCAP® device. The preoperative and the last follow-up values of the Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), 36-item Short Form Survey (SF-36) and Visual Analogue Scale (VAS) were examined. Complications, reoperation rate and survival were analyzed. RESULTS: At the last follow-up, all clinical score values showed significant improvement as compared with the corresponding preoperative values (p < 0.001). Age presented a negative correlation with KOOS (p = 0.03) and SF-36 improvement (p = 0.014). Kellgren-Lawrence grade influenced OKS (p = 0.036). BMI, gender, side, medial or lateral condyle and size did not affect the outcome. Patients who had previous biological cartilage procedures demonstrated better clinical improvement in comparison with those that did not have prior surgery (p < 0.05). Survival was 96.2% at 10 years, using as endpoint implant revision or/and progression of osteoarthritis. The cumulative hazard for any-reason reoperation was 12.0%. CONCLUSIONS: Femoral condyle resurfacing using the HemiCAP® device is an effective treatment option to address focal chondral and osteochondral defects. It can be successfully used either as a primary procedure or after prior biological cartilage reconstruction. Subjective clinical outcomes are expected to be good to excellent in mid- to long term, while reoperation and revision rates are low. Progression of osteoarthritis is the most common mode of failure; thus, patient selection is very important. LEVEL OF EVIDENCE: Level IV, retrospective case series.

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.

Marika Daniilidou, MD. The First Female Orthopaedic Surgeon in Greece.

Dr Marika Daniilidou was born in 1902 in Asia Minor. Her family was forced to immigrate to Greece, in 1922. Despite the horrendous difficulties of the era, she pursued undergraduate and postgraduate studies in the University of Berlin, Germany, and she specialized in orthopaedic surgery. In 1937, she became the first female certified orthopaedic surgeon in Greece. In 1947, she was the only female orthopaedic surgeon among the 22 founders of the Hellenic Association of Orthopaedic Surgery and Traumatology (HAOST). She became a true role model for the next generations of Greek women surgeons.

Osteosynthesis-associated infection of the lower limbs by multidrug-resistant and extensively drug-resistant Gram-negative bacteria: a multicentre cohort study.

Purpose: The purpose of this study was the clinical and therapeutic assessment of lower-limb osteosynthesis-associated infection (OAI) by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), which have been poorly studied to date. Methods: A prospective multicentre observational study was conducted on behalf of ESGIAI (the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group on Implant-Associated Infections). Factors associated with remission of the infection were evaluated by multivariate and Cox regression analysis for a 24-month follow-up period. Results: Patients ( n = 57 ) had a history of trauma (87.7 %), tumour resection (7 %) and other bone lesions (5.3 %). Pathogens included Escherichia coli ( n = 16 ), Pseudomonas aeruginosa ( n = 14 ; XDR 50 %), Klebsiella spp. ( n = 7 ), Enterobacter spp. ( n = 9 ), Acinetobacter spp. ( n = 5 ), Proteus mirabilis ( n = 3 ), Serratia marcescens ( n = 2 ) and Stenotrophomonas maltophilia ( n = 1 ). The prevalence of ESBL (extended-spectrum ß -lactamase), fluoroquinolone and carbapenem resistance were 71.9 %, 59.6 % and 17.5 % respectively. Most patients ( n = 37 ; 64.9 %) were treated with a combination including carbapenems ( n = 32 ) and colistin ( n = 11 ) for a mean of 63.3 d. Implant retention with debridement occurred in early OAI (66.7 %), whereas the infected device was removed in late OAI (70.4 %) ( p = 0.008 ). OAI remission was achieved in 29 cases (50.9 %). The type of surgery, antimicrobial resistance and duration of treatment did not significantly influence the outcome. Independent predictors of the failure to eradicate OAI were age > 60  years (hazard ratio, HR, of 3.875; 95 % confidence interval, CI95 %, of 1.540-9.752; p = 0.004 ) and multiple surgeries for OAI (HR of 2.822; CI95 % of 1.144-6.963; p = 0.024 ). Conclusions: Only half of the MDR/XDR GNB OAI cases treated by antimicrobials and surgery had a successful outcome. Advanced age and multiple surgeries hampered the eradication of OAI. Optimal therapeutic options remain a challenge.

Rib Hump Deformity Correction in Patients with Adolescent Idiopathic Scoliosis: A Comparison of Three Spinal Fusion Systems.

The aim of the present study is to control the hypothesis that the rib hump deformity can be adequately corrected when applying vertebral derotation. We retrospectively studied patients treated with full pedicle screw systems (group A), hybrid constructs (group B), and Harrington rod instrumentation (group C). No costoplasties were performed in the patients included in our study. Derotation was applied in groups A and B. The rib hump deformity was assessed on lateral radiographic studies by rib index (RI). Of the 72 patients that were finally included in our study, 30 patients (24 females and 6 males; mean age, 14.5 ± 2.2 years) were treated with a full pedicle screw system, 23 patients (19 females and 4 males; mean age, 13.8 ± 1.9 years) were treated with a hybrid construct, and 19 patients (16 females and 3 males; mean age, 14.3 ± 2 years) received the Harrington rod instrumentation. In all groups RI was significantly corrected after surgery. Before surgery no difference in RI was found among groups; however, after surgery RI was found significantly higher in group C as compared to groups A and B. The between-group analysis revealed that the correction of RI, and thereby the rib hump deformity correction, did not significantly differ among the three patient groups. In conclusion, it cannot be suggested based on the present study that vertebral derotation alone can offer an adequate correction of the rib hump deformity. Further, the development of rib cage deformity and its degree of interdependence with the scoliotic spinal deformity has to be further investigated and assessed, as it seems that it may not necessarily result directly from the primary vertebral deformity.

The Evolution of Orthopaedics in Greece: From Ancient Heritage to Modern Times.

Greece, one of the oldest civilizations of the world, fundamentally contributed to the establishment and evolution of medicine and surgery. Undoubtedly, the foundations of the orthopaedic science are dated back to antiquity. The journey of the orthopaedic art was inaugurated with the poems of Homer and incarcerated through the practices of Hippocrates and Galen. Their deep knowledge of the musculoskeletal conditions and their treatment was generously bequeathed to humanity. This heritage acted as the catalyst for the establishment of orthopaedics in the modern Greek era. In this article, we tried to illustrate the evolution of the orthopaedic art in Greece from antiquity to modern times, reviewing the available evidence from scientific articles, books, historical manuscripts, old newspapers, and biographies. We summarize the most important events, and we identify the pioneers that shaped this new surgical branch, creating the modern Greek orthopaedic discipline.

Cross-cultural adaptation and validation of the Musculoskeletal Tumor Society (MSTS) scoring system and Toronto Extremity Salvage Score (TESS) for musculoskeletal sarcoma patients in Greece.

PURPOSE: To perform translation, cross-cultural adaptation, and validation of the Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scoring system in Greek patients with lower extremity sarcoma. METHODS: The Greek version of the MSTS for the lower extremity and TESS questionnaires was developed using previously reported methods. Included were 100 patients with musculoskeletal sarcoma who underwent limb salvage surgery. The test-retest reliability [interclass correlation coefficient (ICC) between 2 different time points], internal consistency (Cronbach's alpha), construct validity (Kaiser's criteria, Eigenvalue > 1 rule), and external validity (Short form-36, Spearman's Rho) were assessed. RESULTS: The test-retest reliability (ICC was 0.99 for MSTS-LE and 1 for TESS) and internal consistency were high (Cronbach's alpha was 0.763 for MSTS-LE and 0.924 for TESS) for both questionnaires. Based on the Scree plot, the number of factors retained was 1 for MSTS-LE and 2 for TESS. The TESS showed a strong correlation with SF-36 (Spearman's rho = 0.714, p < 0.001), but the correlation between MSTS for lower extremity and SF-36 was weak (Spearman's Rho = 0.313, p = 0.002). CONCLUSIONS: The Greek version of both the MSTS for lower extremity and TESS questionnaire showed sufficient reliability, internal consistency and good performance using the loading factor analysis when used postoperatively in Greek patients who underwent surgical resection of lower extremity sarcoma. However, only the TESS showed strong correlation with the SF-36, indicating that MSTS for lower extremity was not as powerful for the evaluation of the global health status of these patients.

Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe.

PURPOSE: This study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery training in Europe by conducting an online survey among orthopaedic trainees. METHODS: The survey was conducted among members of the Federation of Orthopaedic and Trauma Trainees in Europe (FORTE). It consisted of 24 questions (single-answer, multiple-answer, Likert scales). Orthopaedic trainees' demographic data (six questions), clinical role changes (four questions), institutional changes due to the COVID-19 pandemic (nine questions), and personal considerations (five questions) were examined. RESULTS: Three hundred and twenty-seven trainees from 23 European countries completed the survey. Most trainees retained their customary clinical role (59.8%), but a significant number was redeployed to COVID-19 units (20.9%). A drastic workload decrease during the pandemic was reported at most institutions. Only essential activities were performed at 57.1% of institutions and drastic disruptions were reported at 36.0%. Of the respondents, 52.1% stated that faculty-led education was restricted and 46.3% pursued self-guided learning, while 58.6% stated that surgical training was significantly impaired. Concerns about the achievement of annual training goals were expressed by 58.2% of the participants, while 25.0% anticipated the need for an additional year of training. CONCLUSIONS: The SARS-CoV-2 pandemic significantly affected orthopaedic and trauma training in Europe. Most trainees felt the decrease in clinical, surgical, and educational activities would have a detrimental effect on their training. Many of them consulted remote learning options to compensate training impairment, stating that after the COVID-19 pandemic electronic educational approaches may become more relevant in future.

Autologous matrix-induced chondrogenesis for the treatment of osteochondral lesions of the talus: A systematic review.

This study was performed to determine whether Autologous Matrix-Induced Chondrogenesis (AMIC) is an effective and safe treatment option for patients with symptomatic Osteochondral defects of the Talus (OCTs) and to identify factors that influence the clinical outcome. A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three reviewers independently conducted the literature search using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. The databases were queried using the terms "autologous" AND "matrix" AND "induced" AND "chondrogenesis." Thirteen studies were eligible for review. All studies that compared the preoperative and postoperative mean values of different clinical/functional scores showed significant clinical improvement. The final postoperative mean Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score ranged from 50.9 to 74.5. The included studies indicated that age and body mass index may have a detrimental impact on the postoperative outcome. A higher re-intervention rate is expected with the open technique, mainly because of hardware removal after malleolar osteotomy. This data analysis demonstrated that both arthroscopic and open AMIC procedures are effective and safe for the treatment of OCTs. Level IV, systematic review of therapeutic studies.

Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study.

PURPOSE: To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis. MATERIALS AND METHODS: Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months. RESULTS: The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05). CONCLUSIONS: Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique. LEVEL OF EVIDENCE: Level II; Prospective Randomized Comparative Study.

Addition of 100 mg of Tramadol to 40 mL of 0.5% Ropivacaine for Interscalene Brachial Plexus Block Improves Postoperative Analgesia in Patients Undergoing Shoulder Surgeries as Compared to Ropivacaine Alone-A Randomized Controlled Study.

Background and objectives: Brachial plexus block is commonly used in shoulder surgery, as it provides satisfactory surgical conditions and adequate postoperative pain control. However, there are contradictory reports regarding the addition of tramadol to the injected regional anesthetic solution. We performed a prospective randomized study to evaluate the effectiveness of tramadol as an adjuvant to ropivacaine during interscalene brachial plexus block and assess its impact on the opioid consumption and the early postoperative pain in patients that underwent shoulder surgery. Materials and Methods: Eighty patients scheduled for elective shoulder surgery and anesthesia via interscalene brachial plexus block were randomly divided into two groups. In group A (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL (100 mg) of tramadol was administered during the brachial plexus block, while in group B (n = 40), a solution of 40 mL of ropivacaine 0.5% and 2 mL NaCl 0.9% (placebo) was administered. The effectiveness and duration of sensory and motor blocks were recorded in both groups. The sensory block was assessed recording the loss of sensation to pin prick test over the skin distribution of the axillary, radial, and musculocutaneous nerves. The motor block was assessed using the modified 3-point Bromage score (0-2 points). Cumulative morphine consumption and pain, using the Visual Analog Scale (VAS), were evaluated in both groups at 2, 4, 8, and 24 h after surgery. Results: Sensory block onset was achieved earlier in group A than in group B (5.21 ± 3.15 minutes (min) vs. 7.1 ± 4.51 min, p = 0.029). The motor block onset was similar between the two groups (13.08 ± 6.23 min vs. 13.28 ± 6.59 min; p = 0.932). The duration of the sensory block was longer in group A as compared to group B (13 ± 2.3 h vs. 12 ± 2.8 h; p = 0.013). The duration of the motor block did not present any difference between the groups (10 ± 2.2 h vs. 10 ± 2.8 h; p = 0.308). Differences in morphine administration were not significant at 2, 4, and 8 h, however, morphine consumption was found to be decreased in group A 24 h postoperatively A (p = 0.04). The values of VAS were similar at 2, 4, and 8 h, however, they were lower in group A at 24 h (p < 0.013). Conclusions: Combined regional administration of tramadol and ropivacaine during interscalene brachial plexus block improves the time of onset and the duration of the sensory block, while it is associated with reduced morphine consumption during the first 24 h after shoulder surgery.

Total Calcaneus Resection and Reconstruction Using a 3-dimensional Printed Implant.

Considering the specific anatomic features of the foot, below-knee amputation is the treatment of choice for foot malignancies. However, advances in imaging modalities, adjuvant therapies, and improved surgical techniques have made foot salvage surgery increasingly possible. The calcaneus is an unusual location for malignant tumors, and there is limited information about foot salvage. Currently, 3-dimensional printed implants may successfully address reconstruction challenges after tumor resection. The authors present 2 patients with Ewing's sarcoma of the calcaneus who underwent total calcaneus resection and reconstruction using a custom-made 3-dimensional printed implant. [Orthopedics. 2019; 42(2):e282-e287.].

Similar 2-point discrimination and stereognosia but better locognosia at long term with an independent home-based sensory reeducation program vs no reeducation after low-median nerve transection and repair.

STUDY DESIGN: Prospective controlled study. INTRODUCTION: Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. PURPOSE OF THE STUDY: The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. METHODS: We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). RESULTS: Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. CONCLUSION: A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.

Extensor Carpi Ulnaris Tenodesis Versus No Stabilization After Wide Resection of Distal Ulna Giant Cell Tumors.

BACKGROUND: The necessity of stabilizing the residual ulnar stump after distal ulna tumor resection remains controversial. The authors retrospectively compared the outcome of patients who underwent wide resection of distal ulna giant cell tumors (GCTs) and reconstruction with tenodesis of the extensor carpi ulnaris (ECU) or without reconstruction. METHODS: Between 2007 and 2015, 9 patients (6 females, 3 males; mean age, 36.8 years; range, 24-65 years) who underwent distal ulna resection for GCT of bone were retrospectively reviewed. The mean resection length was 8.1 cm. Five patients had no reconstruction, whereas 4 patients had stabilization of the ulnar stump using ECU tenodesis. With a mean follow-up of 3.6 years (2-9 years), the functional outcome using the quick Disability of Arm, Shoulder and Hand (DASH) score; Musculoskeletal Tumor Society score and grip strength; as well as the oncological outcome were evaluated. RESULTS: Musculoskeletal Tumor Society functional scores were more than 24 in 7 patients and 20 to 24 in 2 patients (mean, 27.6 or 92%). Quick DASH scores ranged from 0 to 27.3 (mean, 11.1). In both groups, similar scores were observed ( P > .5). No patient had instability or pain related to the stump. There was no ulnar translation or subluxation of the radiocarpal joint. Grip strength in the operated hand, controlled for handedness, was 11% less than in the contralateral hand, although there was no difference between groups ( P > .4). All patients were disease-free at the latest follow-up. CONCLUSIONS: The distal ulna may be widely resected with or without stabilization of the residual ulnar stump, yielding satisfactory local disease control and functional outcome.