Do intramedullary implants improve survival in elderly patients with trochanteric fractures? A retrospective study.

BACKGROUND AND HYPOTHESIS: There is currently no consensus regarding superiority of the intramedullary fixation over the sliding hip screw. Regional variation remains high and not backed up by solid evidence. Given these premises we aimed to analyze weather implant preference can influence the postoperative survival. Secondary objectives were determining the trend for implant choice and confounding factors associated with intramedullary nails compared to sliding hip screws. PATIENTS AND METHODS: Retrospective data was obtained from patient charts with the main diagnosis of extracapsular/ trochanteric fractures, corresponding to ICD S72.1 codes. Between 2008-2012, 441 patients underwent osteosynthesis with a dynamic hip screw and 155 with intramedullary nail respectively. The living status was determined by comparing the patient identification number against the national population evidence records. RESULTS: The lifetable shows similar survival for both implants over the 5 year period. The yearly mortality was 19.4% for the dynamic hip screw and 21.8% for the intramedullary implant respectively, even though the later were used predominantly in older patients. This age difference is significant according to both parametric and non-parametric tests whereas duration of hospital stay are similar. We found a clear increase in the proportion of intramedullary implants, for a total of 11.2% over the 5 year period. There is no difference for the one year mortality and overall survival between sliding screw plates and intramedullary constructs. CONCLUSIONS: A clear increase in the use of intramedullary implants for trochanteric fractures was observed. This is even more apparent for older ages, presumably due to an higher surgeon confidence with the biomechanical stability of the intramedullary constructs.

Drain tip cultures do not predict infections in primary total knee arthroplasty.

BACKGROUND AND AIM: The possibility to predict surgical site infections development could be of high prognostic value. We aimed to investigate whether cultures obtained from the tip of the closed passive wound drain may provide early signs of progression towards periprosthetic joint infections. MATERIALS AND METHODS: We performed an observational study on consecutive primary total knee arthroplasties performed in our department over 4 years by two high volume surgeons (it means they do a lot of arthroplasties/year; it is orthopedics specific). A total of 284 knees in 257 patients were included. Follow up was available for an average of 18.7 months. There were no simultaneous procedures. RESULTS: Nineteen (6.69%) drain tips yielded positive cultures, for a mean duration, from surgery to sample collection, of 1.63 (0.5) days. None of the positive drain tip cultures developed clinical signs of infection and all knees were healed at discharge after a mean of 13.78 days (SD= 3.34; range= 8-18). None of the 7 (2.46%) cases who developed deep infections had positive drain tip cultures. A true positive value of 0 led to a positive predictive value of 0, a negative predictive value of 97.34%, sensitivity of 0% and specificity of 93.14. CONCLUSIONS: The diagnostic use of passive drain tip cultures to detect early infections after total knee replacement is therefore absolutely useless.

Carpal tunnel release: transverse or longitudinal limited-incisions?

AIMS: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy of the upper extremity. Surgical decompression through a limited open palmar incision is still the most widely used treatment. The aim of this study was to compare two different incision surgical techniques for carpal tunnel surgery. PATIENTS AND METHODS: In this retrospective study, 41 patient hands (transverse surgery) were compared with 55 controls (longitudinal surgery) using, as validated outcome instruments, the "Boston Carpal Tunnel Questionnaire" for postoperative effectiveness to measure symptoms, disability and health-related quality of life. The patients were monitored just before the CTS surgery and then 4 weeks and 3 months after surgery. RESULTS: Complications resulted few and comparable for both techniques. Results showed similar outcomes in both procedures regarding symptoms release and function, except for one month results where function was better for the transverse incision (p<0.01) which required reduced time, anyway. CONCLUSIONS: The transverse incision technique proved a suitable optimal solution for carpal tunnel release. This technique, therefore, induces to a better tolerated scar at short term follow up, compared to a standard palmar longitudinal incision.

Reconstructed ACLs have different cross-sectional areas compared to the native contralaterals on postoperative MRIs. A pilot study.

OBJECTIVE: The current trends in anterior cruciate ligament (ACL) reconstruction aim not only to restore the position and footprint of the native ACL, but also its shape and biomechanical function. The objective of our study was to determine whether the in vivo shape of the healed graft differs from the native ACL. PATIENTS AND METHODS: We performed bilateral MRI examinations on patients with successful unilateral ACL reconstruction for an average period of 3 years. The imaging acquisitions were performed using 1.5 T field strength and T2 FSE axial oblique sequence at 2 mm spacing. We than averaged the ratio between the maximum width and thickness as well as the surface area in pixels using ImageJ (National Institutes for Health) and compared it with the native ACLs using the paired t-test. RESULTS: For both quadrupled hamstrings and B-PT-B neoligaments, the mid-portion area was significantly higher (p < 0.001) than the native contralateral ACL: 41.82/31.39 mm2 and 37.05/32.08 mm2, respectively. The surface area of the neoligaments mid-portion was on average 33.23% higher than the native ACL for the quadrupled hamstrings and 15.49% for the B-PT-B, respectively. The native contralateral ACL was also significantly thinner throughout the mid-portion (p < 0.001) than both B-PT-B and quadrupled hamstrings neoligaments, with a width-thickness ratio of 2.57 vs 1.97 and 2.57 vs 1.39, respectively. CONCLUSIONS: Our study showed that, several years after successful anatomic single bundle ACL reconstruction using an ipsilateral autograft, the mid-portion shape and cross-sectional area are not restored compared to the uninjured contralateral knee. This effect was more prevalent with hamstrings and less prominent when B-PT-B were used.

Anterior cruciate ligament reconstruction and determination of tunnel size and graft obliquity.

OBJECTIVE: Increase in ACL (anterior cruciate ligament) reconstructions has led to a higher prevalence of patients with postoperative symptoms which require investigation. We aimed to investigate the utility of magnetic resonance imaging (MRI) and computer tomography (CT) in determining tunnel size and graft obliquity after single bundle ACL reconstruction. PATIENTS AND METHODS: A retrospective comparison was made on 29 symptomatic knees after anatomic single bundle (trans AM) and transtibial ACL reconstructions which had both MRI and CT scans at an average of 1.3 years postoperatively (2 months-5.7 years). We compared CT and MRI (T2 sequence) tunnel size and graft obliquity estimates using Pearson correlation and t-test. We also compared MRI's of ACL reconstructed knees with hamstrings or patellar autografts, which were confirmed by operative protocol as either antero-medial (AM) technique (n=21) or trans-tibial (TT) technique (n=19). The surgeries were performed for an average of 6.29 (4-10) years for the TT group and 1.3 (0-3) years for the AM group, respectively. The graft inclination was measured relative to the tibial plateau using DICOM software. Statistical analysis used the mean value for each case and the data were processed using the non-parametric Kruskal-Wallis test to determine the difference in graft obliquity and tunnel placement. RESULTS: Tunnel size estimates correlate well between CT and MRI on axial scans: R2=0.795 and 0.630 for femur and tibia respectively. The position of the tunnels and graft obliquity were found to differ on MRI images in both coronal and sagittal planes. Coronal graft obliquity averaged 72.38° (ranging from 69° to 76°) using the AM technique and 75.47° (ranging from 72° to 78°) with TT technique. Sagittal graft inclination angle was 54.5 (51-58.5) and 63.68 (59-69.5) respectively. MRI proves to be the most useful imaging method in determining outcome after ACL reconstruction. However, for a better revision of the ACL reconstructions, CT can offer a clearer image of tunnels and bone stock. A more anatomical graft positioning increases obliquity in coronal and sagittal planes and, thus, becomes difficult to assess both tunnels in a single slice. CONCLUSIONS: The anatomic single bundle reconstruction technique has been found to more accurately reproduce the femoral footprint and the orientation of the graft compared to the TT technique where the appropriate tibial tunnel placement resulted in a more vertical graft.

Clinical relevance of altered bone immunopathology pathways around the elbow.

Normal healing of fractures is a complex process that relies heavily on a cascade of consecutive activations of immune cells and mediators. This mechanism somewhat overlaps with all processes related to bone metabolism, from the absence of unions to heterotopic ossifications and osteoporosis. We aimed to review and describe this intricate process of bone metabolism with particular focus on abnormal function and to exemplify it with a series of clinical cases which could justify their practical importance. The elbow has great potential for fracture healing but it is very sensitive to prolonged immobilization which can easily lead to intra-articular adherences and stiffness. In addition, the interosseus membrane facilitates communication between the regenerative environments when both radius and ulna are fractured. Such extensive injuries, around the proximal forearm, can lead to heterotopic ossifications and synostosis, which decrease sagittal range of motion through impingement and even block rotational movement through bone bridges. Increased knowledge and awareness of the biological mechanism of fracture healing, will have great improvement in the pharmacological adjuvant treatment of elbow injuries.

A new device used in the restoration of kinematics after total facet arthroplasty.

Facet degeneration can lead to spinal stenosis and instability, and often requires stabilization. Interbody fusion is commonly performed, but it can lead to adjacent-segment disease. Dynamic posterior stabilization was performed using a total facet arthroplasty system. The total facet arthroplasty system was originally intended to restore the natural motion of the posterior stabilizers, but follow-up studies are lacking due to limited clinical use. We studied the first 14 cases (long-term follow-up) treated with this new device in our clinic. All patients were diagnosed with lumbar stenosis due to hypertrophy of the articular facets on one to three levels (maximum). Disk space was of normal height. The design of this implant allows its use only at levels L3-L4 and L4-L5. We implanted nine patients at the L4-L5 level and four patients at level L3-L4. Postoperative follow-up of the patients was obtained for an average of 3.7 years. All patients reported persistent improvement of symptoms, visual analog scale score, and Oswestry Disability Index score. Functional scores and dynamic radiographic imaging demonstrated the functional efficacy of this new implant, which represents an alternative technique and a new approach to dynamic stabilization of the vertebral column after interventions for spine decompression. The total facet arthroplasty system represents a viable option for dynamic posterior stabilization after spinal decompression. For the observed follow-up, it preserved motion without significant complications or apparent intradisk or adjacent-disk degeneration.

Acute abdominal complications following hip surgery.

Hip surgeries are some of the most common and successful orthopedic procedures. Although rarely, abdominal complications do occur and are associated with unfavorable outcomes.We aimed to identify and describe the severe abdominal complications that appear in patients under-going elective or traumatic hip surgery. A four year retrospective electronic database research identified 408 elective primary hip replacements,51 hip revisions and 1040 intra and extracapsular proximal femur fractures. Out of these, three males and 4 females between 64 - 84 years old were identified to have developed acute abdominal complications: perforated acute ulcer (3),acute cholecystitis (2), volvulus (1), toxic megacolon with peritonitis (1) and acute colonic pseudo-obstruction (1).Complications debuted 3 - 10 days after index orthopedic surgery. Acute perioperative abdominal complications are rarely encountered during orthopedic surgery. When these do occur, they do so almost exclusively in patients with hippathology, comorbidities and most often lead to life threatening situations. We thus emphasize the need for early identification and appropriate management by both orthopedic and general surgery doctors in order to improve patient safety.

Meniscal tears left in situ during anatomic single bundle anterior cruciate ligament reconstruction.

OBJECTIVES: Anterior cruciate ligament (ACL) injuries are a common finding in sports medicine. Our scope is to investigate whether stable, incomplete medial meniscus tears could be left untreated during single bundle anatomic anterior cruciate ligament reconstruction. PATIENTS AND METHODS: A prospective observational study on 597 knees from a single surgeon cohort, using the same reconstruction technique, found 23 medial and 48 lateral meniscus tears which could be left untreated. RESULTS: None of the cases required reintervention during the first postoperative year. In fact, 21.7% of the medial meniscus group and 14.6% of the lateral group had potential residual symptoms that were not confirmed and gradually disappeared within one year. A comparison of Cincinnati Knee, IKDC scores and limb symmetry index values (calculated using the triple hop for distance into the two groups) found no differences for the last two variables (both p = 0.065) and was marginal for the first score (p < 0.05). The between groups comparisons, performed in the KT-1000, also yielded no difference (p = 0.11). CONCLUSIONS: We than concluded that incomplete meniscal tears, left in situ at the time of anterior cruciate ligament reconstruction, could have favorable outcomes as long as decisions are carefully weighed with regard to the length of the lesion. Also, at least in this perspective, anatomic single bundle has proved a sufficient stabilizer for anterior translation of the tibia.

Arthroscopic debridement compared to intra-articular steroids in treating degenerative medial meniscal tears.

OBJECTIVES: Virtually all early cases of knee osteoarthritis have degenerative medial meniscus lesions accompanying the chondral defects on MRI. It is difficult to determine if the symptoms are caused by the unstable meniscus or by osteoarthritis, hence unclear guidance towards treatment. We, therefore, aimed to determine the clinical improvement following arthroscopic meniscectomy compared to intraarticular administration of corticosteroids for degenerative ruptures of the medial meniscus in the presence of early stage medial compartment knee osteoarthritis. PATIENTS AND METHODS: We included 120 consecutive cases of nontraumatic symptomatic knees which had degenerative lesions of the medial compartment (cartilage and meniscus) on MRI's. They were randomized to receive either intraarticular steroid injection or arthroscopic debridement. We also analyzed the correlation between BMI, age, gender, MRI, intraoperative aspect of the meniscus and cartilage and clinical improvement using the Oxford Knee Score up to one year. At one month there was significant improvement of the scores for all the examined cases. Also at one month, the arthroscopic group performed better in terms of symptom improvement. This was maintained for 79% of the knees in the arthroscopic group and 61% in the intraarticular steroid injection respectively, out of those available for follow up at one year. RESULTS: At one month, symptoms reappeared for 12 patients in the steroid group and 7 in the arthroscopy respectively. Gender and age did not correlate with treatment, whereas extrusion of the meniscus, bone marrow edema, duration of the clinical symptoms, obesity and a low preoperative score were negative prognostic factors. CONCLUSIONS: Degenerative medial meniscal tears, in the presence of osteoarthritis, can only marginally benefit from arthroscopic debridement over intraarticular steroid injections in short term follow up. When considering individual cases, factors become more predictive when analyzed in group.

Application of acrylic spacers for long bone defects after tumoral resections.

INTRODUCTIONS: Tumoral resections pose serious challenges because sufficient removal has to be balanced against function preservation. A particular type of resection is encountered when the tumor is located in the diaphysis. It can lead to an important gap which cannot always amend to bone grafting in the same procedure. PATIENTS AND METHODS: The aim of the paper is to evaluate the long term outcome of segmental bone loss in patients with malignant tumors removed from diaphyseal regions and treated by intramedullary nailing and polymethylmethacrylate spacer. The limb function was then evaluated using a range of motion by the Musculoskeletal Tumor Score (MSTS) and the perceived quality of life measured by the EORTC QLQ-C30. RESULTS: There were no immediate postoperative local or systemic complications and no failures of the nail/cement construct. All cases were allowed immediate weight bearing (lower limb) and none were immobilized (upper limb). The average length of the bone defect was 9 (6-14) centimeters. The average follow-up was 2.5 (1-4) years. CONCLUSIONS: Polymethylmethacrylate cement spacers, over intramedullary nailing, have statistically proved a feasible and inexpensive procedure with limited complications, low surgical stress and favorable functional outcomes. It can be a definitive therapy for advanced cases, as well as temporary solution which can be successfully converted to secondary bone grafting.

Our experience in Helicobacter pylori infection and gastric MALToma.

OBJECTIVE: A number of recent studies have expanded our understanding of Helicobacter pylori (Hp) infection and of the pathogenesis of MALT lymphoma. The purpose of this paper is to perform a retrospective analysis of the clinical characteristics of gastric MALT lymphoma and its relationship with H. pylori infection in authors' experience. MATERIALS AND METHODS: We report nineteen patients observed during 10 years, presenting with gastric MALTomas at any stage. The staging classification and the presence of H. pylori infection have been assessed, and the chosen therapy also. RESULTS: The most part of our patients underwent surgery, still now resulting the most effective therapy. None of the patients had eradicating therapy due to their poor compliance and because the most part of cases were observed before the time of clinical validation of such treatment. CONCLUSIONS: In our series, surgery was effective for treatment of gastric MALT lymphomas. Surgery and chemotherapy remain, in accord with literature data, the best treatment for gastric MALTomas. Hence, because Hp may play a role in the development of such pathology in certain patients, antibiotic treatment for Hp eradication should not be discouraged in these patients, especially in them with low grade gastric MALT lymphomas. In fact, the failure of this therapy will not modify either survival or later recourse to surgical and/or radio- and chemotherapy.

Helicobacter pylori infection and gastric MALTomas: an up-to-date and therapy highlight.

During the last 20 years Helicobacter pylori (Hp) has been, undoubtly, the star of gastroenterology and microbiology, so much to deserve the "Nobel prize 2005" for biology and medicine to its discoverers. More recently, an increased interest arised on Hp and its linkages with other medical fi elds such as immunology, surgery and dentistry. The outcome of the pathologies due to such bacterium is dependent on many factors, including bacterial genotype, host physiology and genetics, and environmental factors such as diet. In spite of its clear involvement in some pathologies like acute and chronic gastritis, peptic ulcer and gastric cancer, very little is known about another pathology recently proved to be closely associated to the infection by Hp: the gastric MALToma, which account for 7% of all newly diagnosed non-Hodgkin's lymphoma. The chronic infection of the gastric mucosa from Helicobacter pylori primes a complex pathogenic process which could determine the onset of the gastric cancer through some intermediary steps. On these bases, in 1994, the International Agency for Cancer Research (IARC) defined this bacterium a "class I carcinogenic agent" for gastric cancer. The MALT lymphomas are the most frequent lymphoid neoplasms of the digestive tract; we can also observe other and more rare lymphomatous tumours with specific clinical patterns, like the T-lymphoma associated with lymphomatous polyposis and enteropathy. The development of gastric lymphomas is usually preceded by the acquisition of lymphatic tissue, after inflammatory stimuli and particularly after the infection from Hp, which organizes itself with the characteristics of the MALT. Recently, a number of papers have highlighted the remarkable efficacy of Hp eradicating therapy in patients with low-grade MALT lymphoma of the stomach without other modalities, e.g. surgery and systemic chemotherapy. The aim of this study is to be helpful for a comprehensive understanding the possible connections between Hp and gastric MALT lymphoma, evaluating the best therapy strategies, surgical and non surgical, actually available for its treatment.

Thromboembolic risk after knee endoprosthesis.

Thromboembolic complications are the most frequent associated pathologies after knee replacement. The secondary deep vein thrombosis in the knee arthroplasty is often low symptomatic or asymptomatic and, sometime, it could lead to fatal pulmonary embolism. This is the main purpose recommending an antithrombotic prophylaxis. In this study 214 patients operated for knee arthroplasty and receiving low molecular heparin therapy were enrolled. They were clinically and echo/radiologically monitored for thromboembolic and/or hemorrhagic complications on the 2nd, 7th, 14th and 45th day from surgery. Results showed that only 45% of the cases developed DVT (deep vein thrombosis) out of which 17% could be objectively verified by ultrasonography and phlebography. In only one case massive pulmonary embolism with fatal evolution was discovered. It was not found any major bleeding except in four cases in which local haematomas were discovered (most probably related to anticoagulant treatment). This study concluded that the administration of low molecular weight heparin after knee arthroplasty significantly reduces the risks of thromboembolism in conditions where the increase of hemorrhagic complications doesn't result statistically significant.

[Knee osteotomy versus unicompartmental knee replacement in the treatment of unicompartmental knee arthritis]. / Osteotomia versus proteza unicompartimentala de genunchi în tratamentul gonartrozei unicompartimentale.

Unicompartmental arthritis of the knee is defined as a condition characterized by degenerative articular cartilage in the medial or lateral aspect of the tibiofemoral joint, which may be associated with meniscal disruption, ligamentous instability, and malalignment. The treatment of unicompartmental arthritis of the knee remains a challenge to the orthopaedic surgeon. When non-operative procedures and arthroscopic debridement fail the surgical treatment consist of one of three options: realignment osteotomy, unicompartmental knee replacement or total knee replacement. This article is a review regarding the actual place occupied by the osteotomy and the unicompartmental knee replacement in the treatment of unicompartmental knee arthritis and which parameters lead to a good patient selection in order to obtain successful outcomes.

[The role of patellar lateral release and augmentation of median retinaculum of patellae in treatment of femoro-patellar malalignment]. / Rolul sectiunii retinaculului rotulian lateral si augmentarii retinaculului rotulian median în rezolvarea mal-alinierilor femuropatelare.

Patellar misalignment is more common than usually supposed; many patients learn to live with this affection without seeing a doctor. A large number of open surgical procedures were described for treatment of misalignment of extensor mechanism of knee. We want to present our method which consisted in arthroscopic lateral release and augmentation of medial retinaculum. We had 47 patients with femoro-patellar misalignment treated with this method. The results were appreciated by clinical and radiological criteria (patellar glide test, patellar tilt test, Macnab scores, Merchant angle). The follow-up was two years. Only 17% had recurrence of clinical signs.