Increased stability of short femoral stem through customized distribution of coefficient of friction in porous coating.

Stress shielding and aseptic loosening are complications of short stem total hip arthroplasty, which may lead to hardware failure. Stems with increased porosity toward the distal end were discovered to be effective in reducing stress shielding, however, there is a lack of research on optimized porous distribution in stem's coating. This study aimed to optimize the distribution of the coefficient of friction of a metaphyseal femoral stem, aiming for reducing stress shielding in the proximal area. A finite element analysis model of an implanted, titanium alloy short-tapered wedge stem featuring a porous coating made of titanium was designed to simulate a static structural analysis of the femoral stem's behavior under axial loading in Analysis System Mechanical Software. For computational feasibility, 500 combinations of coefficients of friction were randomly sampled. Increased strains in proximal femur were found in 8.4% of the models, which had decreased coefficients of friction in middle medial areas of porous coating and increased in lateral proximal and lateral and medial distal areas. This study reported the importance of the interface between bone and middle medial and distal lateral areas of the porous coating in influencing the biomechanical behavior of the proximal femur, and potentially reducing stress shielding.

A reduction in tumor volume exceeding 65% predicts a good histological response to neoadjuvant chemotherapy in patients with Ewing sarcoma.

OBJECTIVE: No consensus exists for tumor volume response criteria in patients with Ewing sarcoma. This study aimed to identify an optimal cutoff for predicting a good histological response by analyzing tumor volume changes and tumor necrosis after neoadjuvant chemotherapy. MATERIALS AND METHODS: We performed a retrospective analysis of 184 Ewing sarcoma patients, analyzing tumor volume changes before and after neoadjuvant chemotherapy. Patients were divided into two groups based on histological response: good (tumor necrosis ≥ 95%) and poor (tumor necrosis < 95%) responders. The receiver operating characteristic (ROC) area under the curve (AUC) method was used to determine the optimal thresholds for predicting the histological response. Additionally, the prognostic value of this cutoff for relapse-free survival was assessed. RESULTS: Out of 184 patients, 83 (45%) had tumor necrosis ≥ 95%, while 101 (55%) had tumor necrosis < 95%. ROC analysis identified the optimal cutoff for a good histological response as over 65% tumor volume reduction (AUC = 0.69; p < 0.001). Patients with volume reduction of ≥ 65% had a higher likelihood of a good histological response than those with lesser reductions (p = 0.004; odds ratio = 2.61). Multivariable analysis indicated a correlation between poor histological response and reduced relapse-free survival (hazard ratio = 2.17; p = 0.01), while tumor volume reduction itself did not impact survival. CONCLUSION: We reported that a tumor volume reduction of ≥ 65% was able to predict a good histological response in Ewing sarcoma patients. We recommend preoperative tumor volume assessment to identify patients at greater risk for poor histological response who could benefit from more intensive chemotherapy protocols or additional radiotherapy.

Histological and imaging features of myoepithelial carcinoma of the bone and soft tissue.

OBJECTIVE: To depict histological and imaging features of myoepithelial carcinoma of the bone and soft tissue. MATERIALS AND METHODS: We retrospectively examined histological features in 22 patients with myoepithelial carcinoma of the bone (4 patients) and soft tissue (18 patients) at a single institution. Imaging analysis of 15 patients (bone, 3 patients; soft tissue, 12 patients;) with preoperative images involved classifying lytic bone lesions via the modified Lodwick-Madewell classification; the growth patterns of soft tissue lesions were classified as well-defined, focally invasive, or diffusely invasive. RESULTS: Local recurrence occurred in eight out of 22 patients (36.3%). Four of 22 patients (18.2%) had metastasis at presentation, whereas 11 of 22 patients (50.0%) had distant metastasis during follow-up. Severe cytological pleomorphism was observed in 14 of 22 patients (63.6%), and 10 of 22 tumors (45.5%) showed ≥ 10 mitoses/10 high-power fields. Vascular invasion was observed in 10 of 22 patients (45.5%). Extracapsular/extraskeletal infiltration into the surrounding tissues was assessed in 20 patients, with 14 of them (70%) showing infiltration beyond the tumor border. Regarding imaging of bone lesions, two patients had Ludwick type IIIB, whereas one patient had type II. The growth pattern of soft tissue lesions was well-defined in two patients (16.7%), focally invasive in seven patients (58.3%), and diffusely invasive in three (25.0%) out of 12 patients. CONCLUSION: Myoepithelial carcinoma of the bone and soft tissue presents high risk of local recurrence and distant metastasis. Histological and imaging features might be important to understand the aggressive behavior of the tumor.

Risk of complications and implant survival of surgical treatment of proximal femoral metastasis: a meta-analysis.

PURPOSE: The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. METHODS: We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. RESULTS: We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). CONCLUSION: Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component.

Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis.

PURPOSE: There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections. METHODS: We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases. RESULTS: We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively. CONCLUSION: Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.

Fracture of femoral neck in modular total hip arthroplasty: a systematic review of the literature.

BACKGROUND: Modular femoral stems have the advantage of anatomic hip reconstruction by restoring the femoral offset thus minimising the bearing surface wear, implant loosening and dislocation. AIM: This study aims to investigate the existing literature on modular neck fractures, to identify predisposing factors and guide the decision-making process in the management of these difficult cases. METHODS: A systematic literature review was conducted until July 2022. PRISMA guidelines were followed, eligibility criteria were set, and methodology assessment of included studies was conducted based on MINORS criteria, size and primary outcome. Data were extracted and analysed thoroughly. RESULTS: 5657 studies were initially screened; the full texts of 124 records were assessed and finally, 32 reports were included. There were 7 clinical studies and 25 case reports. A total of 4825 patients (5204 hips) with a mean age 62.38 years and a mean BMI 29.06 kg/m2 were analysed in the 7 clinical studies. The reported overall weighted revision rate was 0.86%, while the weighted mean modular neck fracture rate was 0.26%. The usual history was sudden experience of hip pain and instability. The average time interval to neck fracture was 4.57 (range 3-4.7) years and a long modular neck was identified in 91.17% of them. Data from case reports showed a mean age and average BMI of 55.85 and 31.63 kg/m2. 82.35% of the patients were male. Necks were fractured after an average time interval of 64.5 ± 8.8 months. CONCLUSIONS: The incidence of modular neck fracture is significant. The profile of a male, obese patient with a long modular neck increased risk of neck fracture. Microstructural investigation of the retrieved implants demonstrated a higher incidence of fracture line in the base of the neck junction and at its anterolateral distal part. Surgeons should be aware of this complication while using or revising such protheses.

What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis.

BACKGROUND: The purpose of the present study was to systematically review the current treatment strategies for the treatment of Neer type IIB distal clavicle fractures in terms of functional outcome and complication rates and to examine the most appropriate surgical method by comparing all the available surgical techniques and implants. METHODS: We performed a systematic review of the existing literature (2000-2021) in accordance with the PRISMA statement. We searched PubMed, Scopus, Web of Science, Research Gate and Google Scholar using the general terms 'distal AND clavicle AND fracture' to capture as many reports as possible. The MINORS tool was used to assess the risk of bias of the nonrandomized studies. We categorized the reported surgical techniques into four main types: open or arthroscopic coracoclavicular (CC) stabilization, locking plate fixation with or without CC augmentation, hook plate fixation and acromioclavicular joint (ACJ) transfixation. We reported findings for two main outcomes: clinical results and complication rates categorized into major and minor. RESULTS: Our database search yielded a total of 630 records; 34 studies were appropriate for qualitative analysis. There were 790 patients, with a mean age of 40.1 years, a female percentage of 37% and a mean follow-up period of 29.3 months. In total, 132 patients received a hook plate, 252 received a locking plate, 368 received CC stabilization and 41 received transacromial transfixation. All studies were retrospective and had fair MINORS scores. Locking plate, CC stabilization and ACJ transfixation showed similar clinical results but were much better than hook plate fixation; CC augmentation did not significantly improve the outcome of locking plate fixation. The rate of major complications was similar among groups; hook plate and AC joint transfixation had the worst rates of minor complications. Open CC techniques were slightly better than arthroscopic techniques. CONCLUSIONS: The present systematic review for the optimal fixation method for Neer type IIB fractures of the distal clavicle showed similar major complication rates among techniques; the hook plate technique demonstrated inferior clinical results to other techniques. Open CC stabilization and locking plate fixation without CC augmentation seem to be the best available treatment options.

Arthroscopic Treatment of a "Bucket-Handle Like Tear" Lesion of the Medial Meniscus.

Menisci are involved in providing shock absorption, knee stability, and load transfer. Age, tear pattern, location, size and extent, repair time and technique, and patient habits are among various factors that affect meniscal healing. Meniscus repair has become the procedure of choice for the treatment of meniscal tears. However, treatment of meniscal tears in patients over 40 years of age is still debatable. Rare patterns of lesions have been described in the literature. We report a zone 2, partial thickness, "bucket-handle like tear" medial meniscal lesion with two attached ends in a 48-year-old male patient with persistent symptoms after six months of conservative treatment. Arthroscopic excision and debridement were performed. At a six-month follow-up, the patient regained 90% of his functional capacity.

Morbidity and Mortality After Second Hip Fracture With and Without Nursing Care Program.

Background Hip fractures are an increasingly common injury among older people who usually experience significantly worse mobility, independence in function, health, quality of life, and high rates of institutionalization. Studies have shown that only 40-60% of participants recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while for those who are independent in self-care prior to the fracture, 20-60% still require assistance for various tasks one or two years after the fracture. As the cumulative incidence of a second hip fracture has been estimated to reach 8.4%, prevention of the second hip fracture is a major concern of the health system and the society focused mainly on lifestyle modifications, osteoporotic treatment, and fall-prevention strategies. The aim of the present study was to compare morbidity/mortality, functional results, and type of recovery between the first and second hip fractures in elderly patients. Methods Patients with a contralateral hip fracture were prospectively recruited during a three-year period (2016-2019). Level of independence, gait aids, type of rehabilitation, American Society of Anesthesiologists (ASA) physical status, Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale were evaluated at admission for the second fracture and at the last reexamination. Results Twenty-seven out of 33 patients, aged 87.93±6.6, underwent surgery for contralateral hip fracture and followed up for 42.52±16.46 months; the mean interval between the two fractures was 39.63 months. The HHS averaged 86.19±12.18 and 59.01±32.83 and the WOMAC 86.37±12.09 and 68.22±26.18 before and after the second fracture, respectively. The mortality rate was 37.03%, 14.8±12.93 months after the second operation, with a significant relationship between the mortality time and the interval between fractures (p=0.028). Twelve and 14 of the patients received geriatric nursing care after the first and second fracture, respectively, without significant improvement in their functional results compared to home care. Mobility of nursing care patients after the second fracture was significantly improved (p=0.019). Conclusions Mortality is higher in the second year after the second hip fracture and strongly correlated with the time interval between fractures. A higher possibility to return in previous mobility status occurs after geriatric nursing care.

Long-Term Functional Outcomes and Complications of Intra-Articular (AO type B, C) Distal Humerus Fractures in Adults: A Retrospective Review.

Introduction Treatment of intra-articular fractures of the distal humerus is challenging due to their complexity, comminution, and associated complications. The evolution of surgical approaches and the design of elbow-specific implants over the last decades have failed to improve clinical and radiological outcomes. Studies are sparse regarding the long-term influence of surgical treatment of these types of fractures in the upper limb function. The purpose of the current study was to retrospectively review the long-term functional outcome and complications of all intraarticular (AO type B, C) distal humerus fractures treated surgically in a university hospital during the last 25 years. Material and methods The study included patients who were surgically treated for an intra-articular distal humerus fracture between March 1991 and May 2016. Our initial search, using ICD-10 codes, identified 63 patients in the specific time period. Twelve patients had died, nine declined to participate, eight had emigrated, nine could not be located and one patient was excluded as he suffered from quadriplegia unrelated to the initial injury. The remaining 25 patients (mean age at surgery 44.2±19.67) were included in a follow-up study protocol. Functional outcome was evaluated according to Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Pain was assessed using the Numerical Pain Rating Scale (NPRS) and subjects were asked to rate their satisfaction. Perioperative and late complications were recorded as well. Results The average follow-up was 158.16 ± 73.73 months. The average score was 89.4 ± 12.36 for MEPS, 42.68 ± 4.03 for OES, and 8.1 ± 15.38 for the QuickDASH. The patient satisfaction was rated 3.8 ± 1.08 on average. The mean flexion of the affected elbow was 137.6 ± 12.68 degrees while extension deficit was present in 14/25 patients, with a mean of 8.6 ± 8.96 degrees. We did not observe any mal- or non-unions. The re-operation rate was 32% primarily due to stiffness and irritation from the hardware. We noticed one spontaneously resolved ulnar nerve palsy, one combined radial, and ulnar nerve palsy after extensive arthrolysis that also resolved two cases of heterotopic ossification, one case of implant failure, and two cases of infection - one superficial, which was managed with antibiotics, and the other was deep managed with surgical drainage. Conclusions In our series, we found a satisfying range of motion, good functional outcome, and adequate ability to perform daily activities at a very long follow-up. Posttraumatic arthritis, whenever present, does not seriously affect functional performance. Level of evidence: IV.

Treatment of Prosthetic Joint Infection due to Listeria Monocytogenes. A Comprehensive Literature Review and a Case of Total Hip Arthroplasty Infection.

As reported in contemporary literature, prosthetic joint infection (PJI) caused by Listeria monocytogenes (LM) is a rare infection affecting mainly immunocompromised patients. It is considered a late complication occurring months or years after the arthroplasty that is treated with, or without, implant retention, in one-stage or two-stage surgical procedures, and long-term administration of antibiotics. We reviewed the published studies in the English language and present a case of a patient who underwent total hip arthroplasty (THA) and had been affected by this infection. Our patient was successfully treated with 3 months of antibiotics (ampicillin and TMP/SMX) and a two-stage surgical procedure. The success rates of conservative treatment and one-stage or two-stage procedures are dependent on appropriate patient selection and chronicity of the infection. Ιmmmunocompromised patients are susceptible to PJI caused by LM and should be advised that consumption of unpasteurized dairy products increases the risk of this atypical infection.

A Case of Bilateral Galeazzi Fracture-Dislocations.

Bilateral Galeazzi fracture-dislocations are extremely rare injuries and only a few case reports have been described so far in the literature. Herein, we report the case of a 31-year-old bicyclist who sustained bilateral Galeazzi fracture-dislocations after a collision with a car. Both radial shaft fractures were simple (AO type 22-A2.3), at the same level (Type I: <7.5 cm from the joint line), and without severe comminution having their apex located dorsally. Internal fixation was accomplished in both fractures with an 8-hole, 3.5-mm locking plate; the stability of the distal radioulnar joint (DRUJ) was assessed with several intraoperative tests and found to be stable so that no additional stabilization was necessary. Postoperatively, the forearms were immobilized in a long forearm cast for four weeks. At the last follow-up evaluation, six years postoperatively, the patient was pain-free, had a full range of motion with a total Mayo wrist score of 95 in both wrists. Bilateral Galeazzi fracture-dislocations are rare injuries requiring proper radial fracture management and thorough assessment of DRUJ stability.

Injury to the Medial Superior Genicular Artery After Isolated Posterior Cruciate Ligament Reconstruction: A Case Report.

CASE: A 19-year-old male patient with isolated posterior cruciate ligament (PCL) rupture underwent arthroscopic reconstruction using reinforced synthetic ligament (LARS system). Three weeks postoperatively, he presented with active bleeding from the medial side of his knee, near the proximal interference screw. An angiogram revealed extravasation from the medial superior genicular artery which was successfully embolized. One week later, he returned with active bleeding from the same area, located just under the initial coiling; a second embolization during superselective angiography was successful. CONCLUSION: Although rare, minor vascular injuries are a risk inherent to PCL surgery.

Postoperative Pain Scores After Open Inguinal Hernia Repair: Comparison of Three Postoperative Analgesic Regimens.

INTRODUCTION: Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis. AIM: The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair. METHODS: A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation. RESULTS: The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001). CONCLUSION: The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.