Robotic Arm-Assisted Total Knee Arthroplasty: Anatomical Alignment and Mid-Term Outcomes from the First Cohort Originating in Greece.

Robotic arm-assisted total knee arthroplasty (RATKA) represents a haptic assistive robotic arm used for bone preparation. The purpose of this study was to present implant survivorship, complications and evaluate patients' satisfaction, clinical and functional outcome of RATKA with a minimum of 1-year follow-up. The Oxford Knee Score was recorded preoperatively and at last follow-up. Patients' satisfaction rates, as well as complications and re-operations were studied. Anatomical alignment including varus, valgus deformities and flexion, extension, pre-and postoperatively were evaluated. A total of 156 patients with mean age = 71.9 years were included in the study. The mean follow-up was 35.7 months, while one revision was performed due to infection. Statistically significant improvement of the Oxford Knee Score, as well as of the knee alignment deformities were recorded, while 99.4% of patients reported to be "very satisfied" or "satisfied" with the procedure. RATKA seems to be a safe, as well as reproductible procedure at short-and mid-term follow-up, while the accurate implant positioning may lead to favorable long-term outcomes.

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.

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.

Double fractures of the femur: a review of 16 patients.

BACKGROUND: Double ipsilateral femoral fractures account for 1-9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment. MATERIALS AND METHODS: We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used. RESULTS: Fourteen patients experienced union at a mean of 3 months (2-6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months. CONCLUSION: Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications.

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.

Rare aneurysmal bone cysts: multifocal, extraosseous, and surface variants.

Multifocal, extraosseous, and surface aneurysmal bone cysts are rare variants of the primary lesions. The clinicopathological features are similar, and the optimal treatment is surgical. Although local recurrences may occur, the prognosis is excellent. This review article introduces the readers to a rare diagnosis which they may have been previously unfamiliar with, presents the clinicopathological and imaging features of these rare aneurysmal bone cyst variants, and discusses their diagnosis and treatment. The clinicians who treat patients with aneurysmal bone cysts should be familiar with these uncommon entities and their differential diagnosis.

Complications of spine surgery for metastasis.

The spinal column represents the third most common site for metastases after the lungs and the liver, and the most common site for metastatic bone disease. With life-extending advances in the systemic treatment of cancer patients, the surgical procedures performed for spinal metastases will increase, and their related complications will increase unavoidably. Furthermore, considering the high complication rates reported in the spinal literature regarding spine surgery overall, it becomes clear that a better understanding of complications that the cancer patients with spinal metastases may experience is necessary. This article aims to summarize and critically examine the current evidence for complications after spine surgery for metastatic spinal disease, in both the perioperative and postoperative period. This paper would be useful for the treating physicians of these patients in their clinical practice.

Microsurgical reconstruction of complex oromandibular defects: An update.

Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.

Essex-Lopresti injuries: an update.

Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm.There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries.Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique versus another; however, they have shown special concerns with respect to the use of synthetic grafts.Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction. Cite this article: EFORT Open Rev 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072.

Outcomes of robotic-arm-assisted medial unicompartmental knee arthroplasty: minimum 3-year follow-up.

The purpose of this study was to determine implant survivorship, complications, and re-operation rates, after robotic arm-assisted unicompartmental knee arthroplasty (UKA) at intermediate follow-up. Patient satisfaction and clinical outcome were further investigated, in addition to an analysis of restoration of knee alignment. Fifty-one patients, who received a robotic arm-assisted medial UKA, were prospectively studied, and followed for a minimum of 3 years (mean 51.4 ± 4.5 months). Survival of implants, complications, reoperations, and patients' overall satisfaction were evaluated. WOMAC scores, as well as knee flexion, varus deformity and flexion contracture were further analyzed, before and after surgery. No implant failure or implant-related complication was recorded, and no revision surgery was performed at the last follow-up in any patient. Overall satisfaction was excellent; 96.1% of patients, at the latest follow-up, was satisfied or very satisfied, while none was dissatisfied or very dissatisfied. Total WOMAC score and each score's component was significantly improved after surgery. Knee alignment was significantly improved, as flexion increased, varus decreased, and flexion contracture also decreased. In conclusion, robotic-arm-assisted UKA, through accurate implant positioning, significantly improves range of motion and coronal plane alignment, in appropriately selected patients. Excellent overall satisfaction rates and clinical outcomes can be expected, at intermediate follow-up, along with excellent survival of implants and minimal to none surgery-related morbidity.

The role of parathyroid hormone (PTH) and vitamin D in falls and hip fracture type.

BACKGROUND: Fragility fractures of the hip are associated with high morbidity and mortality, and represent a rather devastating consequence of osteoporosis. Hip fractures are traditionally investigated as a whole, although it has been recently implied that distinct pathogenic mechanisms may lead either to trochanteric or subcapital fractures. AIMS: To investigate whether differences exist by hip fracture type with respect to serum 25(OH)D (vitamin D) and parathyroid hormone (PTH) levels, in addition to epidemiological and demographic data, including history of falls. METHODS: The inclusion criteria were met by 116 patients [48 men and 68 women; mean age 80.8 ± 8.5 (range 62-94) years]. Patients were analyzed according to hip fracture type, history of falls, and vitamin D and PTH status. RESULTS: Older age, recurrent falls, serum levels of PTH > 65 pg/ml, and severe vitamin D deficiency were found to be associated with trochanteric fractures. Additionally, older age, female gender, PTH > 65 pg/ml, and severe vitamin D deficiency were related to recurrent falls. Meanwhile, patients with absence of PTH response to low vitamin D levels, were not repeated fallers and suffered mostly from subcapital fractures. DISCUSSION AND CONCLUSION: Elevated PTH levels predispose both to falls and trochanteric fractures, while vitamin D-deficient patients with normal PTH levels are mostly related to subcapital fractures. It is thereby indicated that different pathophysiological processes lie behind subcapital and trochanteric fractures. A better understanding of these mechanisms may assist in the development of prevention strategies for individuals recognized at risk for falls and either type of hip fracture.

Similar femoral growth and deformity with one screw versus two smooth pins for slipped capital femoral epiphysis.

PURPOSE: To compare longitudinal growth and cam deformity of the proximal femur after treatment for slipped capital femoral epiphysis (SCFE) with one screw versus two smooth pins. METHODS: We studied 43 patients (29 males, 14 females; mean age, 12.1 years; range, 9.5-14 years) with idiopathic unilateral SCFE treated with in situ fixation with one cannulated screw (group A, n = 23) or two smooth pins (group B, n = 20). Anteroposterior and frog-leg radiographs of the pelvis were evaluated for each patient at initial presentation, post-operatively and at physeal closure. Longitudinal growth was evaluated using the femoral neck length (FNL), the caput-collum-diaphyseal (CCD) angle, and the articulo-trochanteric distance (ATD). Cam deformity was assessed using the anterior offset α-angle and the head-neck offset ratio (HNOR). The mean follow-up was 5.1 years (range, 4-7 years). RESULTS: Postoperatively, the mean CCD angle was 138.3°, the mean α-angle was 66.1° and the mean HNOR was - 0.030. At physeal closure, mean CCD angle significantly decreased to 133.6°, mean α-angle significantly reduced to 52.1°, and mean HNOR significantly improved to + 0.039. CCD, FNL, ATD, α-angle, and HNOR were not different between groups. CONCLUSIONS: One screw or two smooth pins result in similar longitudinal growth and deformity of the proximal femur after SCFE. The femoral head-neck junction remarkably improves until physeal closure; however, residual cam deformity is not avoided after in situ pinning. The complication rate with smooth pins is higher.

Sonication Improves the Diagnosis of Megaprosthetic Infections.

Limited data are available for the diagnosis of patients with tumors with infected endoprosthetic reconstructions. The purpose of this study was to evaluate whether sonication is effective for the diagnosis of infection and to compare it with tissue cultures. The files of 58 patients who underwent revision surgery for suspected infected endoprosthetic reconstructions were reviewed. Cultures were performed on 5 tissue samples obtained from each patient and on fluid obtained by sonication of the megaprosthesis. The sensitivity, specificity, and negative and positive predictive values of tissue and sonication fluid cultures were evaluated. Overall, tissue and sonication fluid cultures confirmed an infection in 42 of the 58 patients. In 36 of the 42 infected endoprosthetic reconstructions, tissue and sonication fluid cultures identified the same bacterial isolate. In 5 cases, a bacterial isolate was identified only in sonication fluid cultures, and in 1 case, a bacterial isolate was identified only in tissue cultures. The sensitivity and negative predictive value of sonication fluid cultures were statistically significantly better than those of tissue cultures, while the specificity and positive predictive value were not different between the 2 culture types. Compared with tissue cultures for the diagnosis of infected megaprostheses in patients with tumors, sonication fluid cultures are associated with a better sensitivity and negative predictive value and a similar specificity and positive predictive value. Therefore, sonication should be considered a useful adjunct for the optimal diagnosis and management of these patients. [Orthopedics. 2019; 42(1):28-32.].

Sagittal alignment assessment after short-segment lumbar fusion for degenerative disc disease.

PURPOSE: To investigate whether differences in spinopelvic parameters, and especially spinopelvic alignment, could be associated with adjacent segment disease (ASD) or pseudarthrosis after short-segment lumbar fusion. METHODS: Retrospective study of patients offered mono- or bisegmental transforaminal lumbar interbody fusion (TLIF) with polyetheretherketone (PEEK) or titanium cages, due to degenerative disease. Of 419 patients, 32 (7.6%) presented pseudarthrosis (nonunion group), 29 (6.9%) developed symptomatic ASD (ASD group), and 358 patients (85.5%) showed evidence of uncomplicated fusion (control group). Standard spinopelvic parameters were measured in all patients before and after surgery. The differences of the values within the parameters (Δ values) were also calculated. A comparative analysis within and among groups was performed. Patients were also analyzed by cage characteristics (large vs small, titanium vs PEEK). RESULTS: All studied parameters changed significantly after surgery both in the control and ASD group, while in the nonunion group, only LL and PI-LL changed significantly (PI-LL increased from 10 ± 11° to 14 ± 10°, p = 0.008). Patients in the nonunion group presented greater SS before and after surgery, greater PI-LL after surgery, and higher PI, while ASD patients presented greater absolute mean ΔPT value. Age, size, and type of cage were not related to fusion, nonunion, or ASD. CONCLUSIONS: Greater SS, greater PI, and a PI-LL mismatch greater than 10° are associated with failed bony fusion, while ASD is related to a greater difference between the pre-operative and post-operative values of PT. Neither the type nor the size of cage seem to have a significant impact on either solid bony fusion, nonunion, or ASD rates. Thus, we recommend on the study of patients' sagittal alignment in the pre-operative setting even when treating patients with short-segment lumbar interbody fusion.

Gunshot and blast injuries of the extremities: a review of 45 cases.

Gunshot wounds and blast injuries constitute a major public health problem, as the increasing availability of firearms and explosives in conjunction with increasing violence in the city setting have brought this reality into civilian life. Extremities are most commonly involved; therefore, orthopedic surgeons should be trained to manage these types of injuries. Complete and accurate assessment of the injury itself is of great importance, as it will determine the severity and the risk of patients. High-risk injuries from missiles and injuries from explosions are associated with moderate or poor outcomes, major complications, and increased need for multiple surgical procedures. On the other hand, low-risk injuries frequently present optimal results and rather low morbidity. The role of microsurgery is essential, especially in the high- and very high-risk injuries, since complex and multiple reconstructions have to be performed, which include the utilization of free flaps, nerve grafts, and tendon transfers.

Reduction techniques for difficult subtrochanteric fractures.

Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.

Current concepts for the evaluation and management of diabetic foot ulcers.

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.

Rare diseases of bone: Erdheim-Chester and Rosai-Dorfman non-Langerhans cell histiocytoses.

Non-Langerhans cell histiocytosis (N-LCH) summarizes a group of rare diseases with different clinical presentations, pathogenesis and morphology. These include primary cutaneous N-LCH, cutaneous N-LCH with systemic involvement, and primary extracutaneous systemic forms with occasional cutaneous involvement.The juvenile (JXG) and non-juvenile xanthogranuloma (N-JXG) family of histiocytoses are N-LCH: the JXG family consisting of the JXG (cutaneous), xanthoma disseminatum (cutaneous and systemic) and Erdheim-Chester disease (ECD; systemic); and the N-JXG family consisting of the solitary reticulohistiocytoma (cutaneous), multicentric reticulohistiocytosis (cutaneous and systemic) and Rosai-Dorfman disease (RDD; systemic).ECD is a clonal disorder from the JXG family of N-LCH; RDD is a reactive proliferative entity from the non-juvenile xanthogranuloma family of N-LCH.ECD and RDD N-LCH are rare disorders, which are difficult to diagnose, with multi-organ involvement including bone and systemic symptoms, and which respond to therapy in an unpredictable way.The key to successful therapy is accurate identification at tissue level and appropriate staging. Patients should be observed and monitored in a long-term pattern. Prognosis depends on disease extent and the organs involved; it is generally good for RDD disease and variable for ECD. Cite this article: EFORT Open Rev 2018;3:381-390. DOI: 10.1302/2058-5241.3.170047.