Preoperative Evaluation of Intramedullary Tibial Nail Measurements-A Review of the Literature and a New Technique Using Contralateral Radiographs and Digital Planning.

INTRODUCTION: An accurate selection of tibial nail and screws measurements is paramount in purpose to achieve proper tibial fracture reduction and fixation, avoid irritation of the soft-tissue envelope, and enable extraction of the nail in the future, if needed. To this date, many methods were suggested to determine the length and diameter of an intramedullary tibial nail, preoperatively and intraoperatively. Each method has its disadvantages, and most are lacking in accuracy. Digital aids are currently available for preoperative planning for many types of surgeries. METHODS: Retrospectively, 27 patients operated for diaphysial tibial fracture intramedullary nailing were selected. The contralateral leg was imaged using AP and lateral radiograph views. Six orthopaedic trauma surgeons used the TraumaCad program (Voyant Health) to plan the appropriate nail and distal locking screws measurements, while blinded from the actual hardware used in the operation. Later, they also conducted quality review regarding the operation carried out and suggested correction in measurements of the hardware. Intra-observer and inter-observer reliability was calculated. RESULTS: The inter-correlation coefficient for the planned nails was 0.97 and 0.84 (P < 0.001) in AP view for length and diameter, respectively, and similarly 0.98 and 0.86 (P < 0.001) in lateral view. The interclass correlation coefficient (ICC) for the locking screws length was 0.7 (P < 0.02) and 0.82 (P < 0.01) for the proximal and distal medio-lateral screws, respectively, and 0.9 (P < 0.001). The ICC between AP and lateral views was 0.98 for length and 0.96 for diameter (P < 0.001). The scores and corrections given by the examiners to the actual selected nail were ICC of 0.98 and 0.96 (P < 0.001) for length and diameter, respectively. The examiners suggested they would correct, post-factum, the length of the nail in average 28% and the diameter in average 30%. The average observer resulted in ICC of 0.94 and 0.91 (P < 0.001) in length and only 0.77 and 0.67 (P < 0.001) in diameter (AP and lateral views, respectively) when comparing the actual nail used and the post-factum plan. CONCLUSION: Preoperative planning of tibial fractures' nailing using imaging of the contralateral leg and a digital graphic planning program is an accurate and reliable method. It may serve to reduce errors, surgical time, and radiation dose in the operating room. This method could also be applied for surgical debriefing.

[NON-ARTHROPLASTY TREATMENT FOR KNEE OSTEOARTHRITIS].

INTRODUCTION: Osteoarthritis is characterized by marked pain, stiffness and reduced range of motion and is one of the most common causes of disability and reduced quality of life. The disease is diagnosed in 20% of the adult population; the prevalence rises to 50% of adults over 65 years of age. There are various treatment options in the early stages of knee osteoarthritis which are intended to postpone the need for arthroplasty, which is the gold standard treatment at the end-stage level of the disease. Evidence based medicine (EBM) facilitates optimized decision-making and treatment for an individual patient based on meta-analysis, randomize control studies and systematic reviews. Based on these studies, physical activity is an effective treatment option resulting in reduced disability and improved quality of life. Among other conservative treatment options, chondroitin, a food supplement, was found to be as effective as anti-inflammatory medication with a lower side effect profile. Similar results were found for intra-articular injections of hyaluronic acid, while intra-articular injections of platelet rich plasma (PRP) were found to be the most effective of all the above. No advantage was reported for knee arthroscopy over conservative treatment options even when examining those patients with combined symptomatic meniscal tear and knee osteoarthritis. Non-steroidal anti-inflammatory medication (NSAIDS) and opiate treatment have limited long term effect on reducing pain, disability and improving quality of life. These drugs can have a high rate of substantial side effect. Hence, their use should be limited, especially in the elderly population, and safer modalities should be explored.

[A NEW PLAYER IN THE FIELD OF SHOULDER SURGERY - THE REVERSE SHOULDER ARTHROPLASTY].

INTRODUCTION: Reverse shoulder arthroplasty (RSA) in its modern design was first introduced over 25 years ago and approved by the American FDA over ten years ago. This type of prosthesis allows treatment of glenohumeral joint disease among patients with severe rotator cuff deficiency once thought to be inoperable. Modifications to the prosthesis design, along with improved surgical technique, led to better clinical outcomes and lower complication rates, which subsequently led to an increase in the usage of this implant device. The promising results led shoulder specialists to re-assess and expand the indications for surgery, which currently also include complex fractures of the proximal humerus in the elderly population. In this review we will cover the history and evolution of the RSA prosthesis, indications and contraindications, along with up-to-date outcomes and complications.

Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures.

BACKGROUND CONTEXT: Timely interpretation of computed tomography (CT) scans is of paramount importance in diagnosing and managing spinal column fractures, which can be devastating. Out-of-hospital, on-call spine surgeons are often asked to evaluate CT scans of patients who have sustained trauma to the thoracolumbar spine to make diagnosis and to determine the appropriate course of urgent treatment. Capturing radiographic scans and video clips from computer screens and sending them as instant messages have become common means of communication between physicians, aiding in triaging and transfer decision-making in orthopedic and neurosurgical emergencies. PURPOSE: The present study aimed to compare the reliability of interpreting CT scans viewed by orthopedic surgeons in two ways for diagnosing, classifying, and treatment planning for thoracolumbar spine fractures: (1) captured as video clips from standard workstation-based picture archiving and communication system (PACS) and sent via a smartphone-based instant messaging application for viewing on a smartphone; and (2) viewed directly on a PACS. STUDY DESIGN: Reliability and agreement study. PATIENT SAMPLE: Thirty adults with thoracolumbar spine fractures who had been consecutively admitted to the Division of Orthopedic Surgery of a Level I trauma center during 2014. OUTCOME MEASURE: Intraobserver agreement. METHODS: CT scans were captured by use of an iPhone 6 smartphone from a computer screen displaying PACS. Then by use of the WhatsApp instant messaging application, video clips of the scans were sent to the personal smartphones of five spine surgeons. These evaluators were asked to diagnose, classify, and determine the course of treatment for each case. Evaluation of the cases was repeated 4 weeks later, this time using the standard method of workstation-based PACS. Intraobserver agreement was interpreted based on the value of Cohen's kappa statistic. The study did not receive any outside funding. RESULTS: Intraobserver agreement for determining fracture level was near perfect (κ=0.94). Intraobserver agreement for AO classification, proposed treatment, neural canal penetration, and Denis classification were substantial (κ values, 0.75, 0.73, 0.71, and 0.69, respectively). Intraobserver agreement for loss of vertebral height and kyphosis were moderate (κ values, 0.55 and 0.45, respectively) CONCLUSIONS: Video clips of CT scans can be readily captured by a smartphone from a workstation-based PACS and then transmitted by use of the WhatsApp instant messaging application. Diagnosing, classifying, and proposing treatment of fractures of the thoracic and lumbar spine can be made with equal reliability by evaluating video clips of CT scans transmitted to a smartphone or by the standard method of viewing the CT scan on a workstation-based PACS. Evaluating video clips of CT scans transmitted to a smartphone is a readily accessible, simple, and inexpensive method. We believe that it can be reliably used for consultations between the emergency physicians or orthopedic or neurosurgical residents with offsite, on-call specialists. It might also enable rural orcommunity emergency department physicians to communicate more efficiently and effectively with surgeons in tertiary referral centers.

[THE EVOLUTION IN TREATING MENISCAL TEARS--FROM RESECTION TO SUTURING].

The meniscus has an important biomechanical role in the normal function of the knee including load bearing, shock absorption and joint stability. Tears of the meniscus are one of the common sports injuries. The knowledge that total meniscectomy causes early development of degenerative changes has raised the prevalence of meniscal tear repair in order to preserve as much as possible of the meniscal tissue. The type of tear (degenerative of traumatic), shape and location have a critical effect on healing ability after suture of the tear and thus will determine the treatment plan.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study.

BACKGROUND: Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem. METHODS: Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions. RESULTS: Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3). CONCLUSIONS: The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

Reverse shoulder arthroplasty with a short metaphyseal humeral stem.

PURPOSE: Reverse shoulder prostheses have been gaining popularity in recent years. A short metaphyseal stem design will allow bone stock preservation and minimize stem related complications. We examined the clinical and radiographic short-term outcome of a short metaphyseal stem reverse shoulder arthroplasty. METHODS: Thirty-one patients, with a mean follow-up of 36 months (24-52), were evaluated clinically with the Constant-Murley score, patient satisfaction and pain relief scores. The fixation of the glenoid and humeral components, subsidence and notching were evaluated on radiographs. The indications were cuff tear arthropathy (22), fracture sequelae (five) and rheumatoid arthritis (four). RESULTS: The average Constant score improved from 12.7 (range two to 31) pre-operatively to 56.2 (range 17-86) postoperatively. It rose from 13.5 to 58.3 in patients with Cuff arthropathy, from 15.8 to 62.0 in revision arthroplasty, from 10.2 to 47.4 in those with fracture sequelae, and from 11.5 to 55.3 in patients with rheumatoid arthritis. The overall mean patient satisfaction score improved from 2.4/10 to 8.5/10 and mean pain score improved from 0.8/15 to 12.5/15. We found an overall improvement in active forward flexion from 46.8 to 128.5° and from 41.6 to 116.5° in abduction. No humeral loosening or subsidence was observed. Two cases of grade 1-2 glenoid notching were reported. Overall there were three intra-operative fractures that did not affect the operation and healed without affecting the good results. There were five late traumatic periprosthetic fractures, only one of them required a revision surgery to a stemmed implant and the rest healed without surgery. There were two early dislocations that had to be revised. CONCLUSIONS: The clinical and radiographic evaluation of a bone preserving metaphyseal humeral component in reverse shoulder arthroplasty is promising, with good clinical results, no signs of loosening or subsidence.

Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?

BACKGROUND: Propionibacterium acnes is a common pathogen in infections after shoulder surgery. Recent reports found positive P acnes cultures in a high percentage of patients who had revision shoulder arthroplasty for "aseptic loosening" without any overt signs of infection. Isolation of P acnes is difficult, and by use of conventional microbiological protocols of 48-hour incubation, a considerable proportion of patients with possible P acnes infection may remain unidentified. We recently noted P acnes in shoulder joint cultures in patients undergoing primary shoulder replacement for glenohumeral arthropathy without any signs of infection. METHODS: We collected aspirates and biopsy specimens from 55 consecutive patients with arthritic shoulders undergoing primary joint replacement and examined them for the presence of P acnes. Special measures were taken to ensure that the specimens were carefully taken from within the joint to reduce the risk of contamination to minimal. RESULTS: In 23 of 55 consecutive patients (41.8%) undergoing primary shoulder joint replacement, P acnes was found in the joint fluid and tissues taken before the insertion of the implants. All these patients were treated early postoperatively with pathogen-directed specific dual oral antibiotic treatment for 4 weeks. In none have any signs of infection developed. DISCUSSION AND CONCLUSION: This finding of a high incidence of P acnes in joints before arthroplasty may suggest a role of P acnes in the pathogenesis of glenohumeral arthropathy. In addition, it raises the question of whether development of painful joint replacement later on and presumed aseptic loosening do, in fact, comprise an unrecognized low-grade infection that has been present since before the index operation.

The prognostic value of high-sensitive C-reactive protein and cardiac troponin T in young and middle-aged patients with chest pain without ECG changes.

BACKGROUND: There is growing evidence of the prognostic importance of inflammatory markers in angina pectoris. However, the independent value of high-sensitive C-reactive protein (hsCRP), cardiac troponin T (cTnT), or their combination has not been established in young patients with angina pectoris without ECG changes. Therefore, we assessed the 6-month prognostic values of serum hsCRP and cTnT in young and middle-aged patients who were admitted to the hospital with chest pain but without ECG changes. METHODS: Forty young or middle-aged patients (45+/-10 years old; two females) were included in the study. All had chest pain for the first time without ST-T changes or any other ECG changes and with normal CPK-MB levels. Blood was drawn on admission, separated, and serum was frozen at -80 degrees C for 1 year until thawed and studied as one batch in order to measure hsCRP and cTnT levels. A clinical follow-up was done for 6 months. RESULTS: Our findings showed that the strongest independent marker of an adverse outcome was the hsCRP level on admission (sensitivity 66.7%; specificity 94.1%); cTnT level added a little to the specificity (97.1%), but did not add to the sensitivity that was found by hsCRP level. CONCLUSIONS: hsCRP level on admission could be an independent prognostic marker in young and middle-aged patients with angina pectoris without ECG changes and without CPK-MB elevation.