Traumatic Posterior Atlantoaxial Dislocation With an Associated Fracture: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To investigate the clinical presentation, mechanism of injury, patients' characteristics, diagnosis, treatment, and prognosis of traumatic posterior atlantoaxial dislocation with fracture (TPAD). BACKGROUND: TPAD is an extremely rare entity, with a limited number of cases reported in the literature. Although rare, a thorough understanding of the pathogenesis and management of such cases is required due to the high risk of spinal cord compression and the severity of neurological deficits. We conducted a systematic review of all cases of TPAD with fractures reported in the literature. METHODS: This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. Relevant literature was retrieved from the Pubmed database. All published English-written studies involving human subjects with relevant data regarding TPAD were included. RESULTS: Two case series and 20 case reports published between 1924 and 2021 describing 28 patients with TPAD were included. The median age at presentation was 51.5 years, with male predominance (83%). The most common fracture pattern was Anderson and D'alonzo type II odontoid fracture (78%). Neurological exam at presentation was intact in 52% of patients. The primary diagnostic imaging was computed tomography employed in 96% of cases. The management consisted of 2 stages protocol, initially, a temporary axial traction was employed (54%), and later definitive surgical treatment was employed (93%). The posterior surgical approach was favored in 82% of cases. CONCLUSION: TPAD with fracture occurred in the majority of cases with Anderson and D'alonzo type II odontoid fracture, predominantly in males. Diagnosis is usually established based on computed tomography imaging; further imaging may not be indicated as it does not seem to alternate the patient's management course. Surgical intervention was employed in almost all cases, with favored results through posterior C1-C2 fusion. LEVEL OF EVIDENCE: Level-IV.

Excessive Sagittal Slope of the Tibia Component during Kinematic Alignment-Safety and Functionality at a Minimum 2-Year Follow-Up.

The aim of this study was to assess the safety and functional outcomes of excessive sagittal alignment in the unrestricted kinematic alignment technique for total knee arthroplasty (TKA). A retrospective, single-center study was conducted between 2018 and 2020, including patients undergoing primary TKA with a minimum 2-year follow-up. EOS imaging conducted before and after surgery was reviewed for overall alignment, and a number of measurements were taken, including sagittal tibial slope and other tibia and femur component positioning. Patients were interviewed and asked to fill out several questionnaires including a visual analog scale, the Oxford Knee Score, and the Knee Injury and Osteoarthritis Outcome Score. Overall, 225 patients (66.7%) had a sagittal tibial slope angle above 5° (excessive) and 112 (33.3%) patients had an angle under 5° (moderate). A significant improvement in pain and function scores was observed in both groups following the surgery (p < 0.001). There were no significant differences between the moderate and excessive groups in the average VAS, OKS or the various subtypes of the KOOS score. However, there was a slight but significant difference in the number of patients achieving MCID in KOOS symptoms. There were no cases of early failure or loosening. Unrestricted KA and the excessive sagittal alignment of the tibial component seem to be reliable and safe in terms of restoring daily function and alleviating pain after a minimum of 2 years following the surgery.

Minimum 2-Year Radiographic and Clinical Outcomes of Unrestricted Kinematic Alignment Total Knee Arthroplasty in Patients with Excessive Varus of the Tibia Component.

Kinematic alignment (KA) total knee arthroplasty (TKA) has gained much attention in recent years. However, debate remains on whether restrictions should be made on the tibia cut. The purpose of this study was to assess the safety and functional outcomes of excessive varus cuts. A single-center, retrospective analysis of consecutive patients undergoing TKA between 2018 and 2020 who had a minimum 2-year follow-up was conducted. EOS™ imaging conducted before and after surgery was analyzed for overall alignment, as well as for tibia and femur component positioning on the coronal planes. Patients were interviewed and asked to fill several questionnaires, including the visual analog score, Oxford knee score, and knee injury and osteoarthritis outcome score. Overall, 243 patients (71.9%) had a coronal tibial plate angle under 5° (moderate) and 95 patients (28.1%) had an angle above 5° (excessive). There were no significant differences between the moderate and excessive groups in patient-reported outcomes, nor were there differences in the number of patients achieving the minimal clinical difference. There were no cases of catastrophic failure or loosening. Unrestricted KA and excessive varus of the tibial component appears to be safe and efficient in relieving pain and restoring function for a minimum of 2 years following surgery.

Individualized tibial tubercle-trochlear groove distance-to-patellar length ratio (TT-TG/PL) is a more reliable measurement than TT-TG alone for evaluating patellar instability.

PURPOSE: To evaluate the intra/inter-rater and diagnostic reliability of the sagittal plane adjusted patellar instability ratios (PIRs) compared to tibial tubercle-trochlear groove (TT-TG) distance alone while employing a matched case-control analysis for age and sex to minimize a potential confounding effect. METHODS: A retrospective case-control study was performed of all knee MRI studies of patients diagnosed with patellar instability, between 2005 and 2020 at a regional tertiary medical centre. Using a 1:1 case-control matching of sex and age at the time of the diagnosis, one control subject was assigned to each case of patellar instability. Measurements of TT-TG distance, sagittal patellar length (PL), sagittal patellar tendon length (PTL), TT-TG/PL ratio, and TT-TG/PTL ratio were conducted. Two orthopaedic surgery residents and a senior musculoskeletal radiologist were assigned to assess the intra- and inter-rater reliability. Inter-class coefficients were calculated (ICC). The receiver operating characteristic (ROC) curve and area under curve (AUC) for each parameter were compared to evaluate for diagnostic reliability. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated and a multivariable logistic regression model was performed to control for possible confounders. RESULTS: The study included 324 individuals (162 case-control matched pairs). In terms of intra- and inter-rater reliability, TT-TG/PL and TT-TG/PTL ratios showed an excellent correlation within and between readers (TT-TG/PL; intra-rater ICC 0.94 and inter-rater ICC 0.92, TT-TG/PTL; intra-rater ICC 0.91 and inter-rater ICC 0.88). The ROC curve showed a slightly greater AUC of the TT-TG/PL ratio compared to TT-TG distance alone (0.75 vs 0.73, p < 0.001). When applying the pathologic cutoff of TT-TG ≥ 20 mm and TT-TG/PL ≥ 0.5; the calculated odds ratios for the above cutoff were as follows; TT-TG distance alone had an OR of 14 (95% CI 1.8-106.5, p = 0.011) and OR for TT-TG/PL ratio was 23 (95% CI 3.1-170.3, p = 0.002). In the multivariable analysis, while controlling for height and weight, only the association between TT-TG/PL ratio and patellar dislocation remained statistically significant with an adjusted OR of 2.7 (CI 1.3-5.4, p = 0.006), compared to TTTG distance alone (OR = 1.9, n.s.). CONCLUSIONS: Patellar instability ratios are significantly more reliable compared to TT-TG distance alone for the evaluation of patellar instability. Patellar instability ratios present superior diagnostic reliability, sensitivity and specificity, and intra\inter rater reliability. Thus, patellar instability ratios could function as a valuable diagnostic tool for the evaluation of patellar instability. LEVEL OF EVIDENCE: III.

Additive Effect of MCP in Combination with Cefotaxime Against Staphylococcus aureus.

BACKGROUND: Pectin is a heterogeneous polysaccharide present in plants and citrus fruits. It exhibits different beneficial biological activities. Conflicting reports exist about the antimicrobial effect of pectin and its derivatives. OBJECTIVE: In this study, we investigate the antimicrobial effect of Modified Citrus Pectin (MCP) against Staphylococcus aureus, a pathogen showing increasing rates of antimicrobial resistance worldwide. METHOD: Forty-three clinical isolates of S. aureus were obtained from a hospital in North Lebanon. Minimum Inhibitory Concentrations (MICs) and Minimum Bactericidal Concentrations (MBCs) were determined using MCP after determining its optimum pH activity. The combination between MCP and cefotaxime was then investigated for S. aureus isolates using the checkerboard technique. RESULTS AND DISCUSSION: The optimum pH for the activity of MCP was 6.0. MIC and MBC values against S. aureus ranged between 0.39-50 µg/µl and 3.13-50 µg/µl, respectively. These values are promising for using MCP in the inhibition of some S. aureus isolates at relatively low concentrations. Combination experiments showed an additive effect in most S. aureus strains between MCP and cefotaxime, and a synergistic effect in two strains. These preliminary findings open the way for further investigation into the therapeutic potential of MCP in the treatment of S. aureus infections. CONCLUSION: MCP demonstrates in vitro antimicrobial activity alone and in combination with cefotaxime against S. aureus.