From second webspace syndrome to second cross over toe: Clinical and radiological findings following Weil osteotomy with no soft tissue procedure.

BACKGROUND: The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both. The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure. METHODS: A retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery. RESULTS: Twenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001). CONCLUSION: Medial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Proximal medial gastrocnemius release: Muscle strength evaluation.

BACKGROUND: Contracture of the gastrocnemius has been associated with different foot and ankle pathologies. The present study's aim is to evaluate the effect of the proximal medial gastrocnemius release (PMGR) in triceps surae strength. METHODS: Prospective study with 14 patients (12 women; mean age 52 years). Inclusion criteria were patients undergoing PMGR due to forefoot and/or hindfoot injury with medial gastrocnemius contracture that has not improved with physical therapy. Isometric and isokinetic force evaluation tests with an isokinetic dynamometer (Con-Trex) were performed preoperatively, at 6 and 12 months postoperative, of both limbs. RESULTS: After isokinetic assessment, the statistically significant difference in the preoperative isometric strength of the triceps between the two ankles was confirmed, being stronger the asymptomatic limb. An improvement in the triceps strength in isokinetics was observed at 60°/s at 6 months after surgery (p=0.008), that was maintained after one year (p=0.05). No differences were observed at 120°/sec speed. CONCLUSION: Patients with gastrocnemius contracture present a decrease in isometric force with respect to the asymptomatic limb preoperatively. There is an improvement in isokinetic strength after 6 months postoperatively.

Vascularized Periosteal Flaps Accelerate Osteointegration and Revascularization of Allografts in Rats.

BACKGROUND: Surgical reconstruction of large bone defects with structural bone allografts can restore bone stock but is associated with complications such as nonunion, fracture, and infection. Vascularized reconstructive techniques may provide an alternative in the repair of critical bone defects; however, no studies specifically addressing the role of vascularized periosteal flaps in stimulating bone allograft revascularization and osseointegration have been reported. QUESTIONS/PURPOSES: (1) Does a vascularized periosteal flap increase the likelihood of union at the allograft-host junction in a critical-size defect femoral model in rats? (2) Does a vascularized periosteal flap promote revascularization of a critical-size defect structural bone allograft in a rat model? (3) What type of ossification occurs in connection with a vascularized periosteal flap? METHODS: Sixty-four rats were assigned to two equal groups. In both the control and experimental groups, a 5-cm critical size femoral defect was created in the left femur and then reconstructed with a cryopreserved structural bone allograft and intramedullary nail. In the experimental group, a vascularized periosteal flap from the medial femoral condyle, with a pedicle based on the descending genicular vessels, was associated with the allograft. The 32 rats of each group were divided into subgroups of 4-week (eight rats), 6-week (eight rats), and 10-week (16 rats) followup. At the end of their assigned followup periods, the animals were euthanized and their femurs were harvested for semiquantitative and quantitative analysis using micro-CT (all followup groups), quantitative biomechanical evaluation (eight rats from each 10-week followup group), qualitative confocal microscopic, backscattered electron microscopic, and histology analysis (4-week and 6-week groups and eight rats from each 10-week followup group). When making their analyses, all the examiners were blinded to the treatment groups from which the samples came. RESULTS: There was an improvement in allograft-host bone union in the 10-week experimental group (odds ratio [OR], 19.29 [3.63-184.50], p < 0.05). In contrast to control specimens, greater bone neoformation in the allograft segment was observed in the experimental group (OR [4-week] 63.3 [39.6-87.0], p < 0.05; OR [6-week] 43.4 [20.5-66.3], p < 0.05; OR [10-week] 62.9 [40.1-85.7], p < 0.05). In our biomechanical testing, control samples were not evaluable as a result of premature breakage during the embedding and assembly processes. Therefore, experimental samples were compared with untreated contralateral femurs. No difference in torsion resistance pattern was observed between both groups. Both backscattered electron microscopy and histology showed newly formed bone tissue and osteoclast lacunae, indicating a regulated process of bone regeneration of the initial allograft in evaluated samples from the experimental group. They also showed intramembranous ossification produced by the vascularized periosteal flap in evaluated samples from the experimental group, whereas samples from the control group showed an attempted endochondral ossification in the allograft-host bone junctions. CONCLUSIONS: A vascularized periosteal flap promotes and accelerates allograft-host bone union and revascularization of cryopreserved structural bone allografts through intramembranous ossification in a preclinical rat model. CLINICAL RELEVANCE: If large-animal models substantiate the findings made here, this approach might be used in allograft reconstructions for critical defects using fibular or tibial periosteal flaps as previously described.

TRest as a New Diagnostic Variable for Chronic Exertional Compartment Syndrome of the Forearm: A Prospective Cohort Analysis of 124 Athletes.

OBJECTIVES: To measure the accuracy of currently used intracompartmental pressure (ICP) diagnostic variables for forearm chronic exertional compartment syndrome (CECS) and a new ICP diagnostic variable, TRest, the recovery time between the maximum ICP and return to resting pressure. DESIGN: Retrospective cohort. Level evidence IV. SETTING: University-affiliated tertiary hospital. PARTICIPANTS: Patients with suspected forearm CECS, 1990 to 2014. INTERVENTIONS: All patients underwent physical examination and exertional stress test, preceded and followed by measuring ICP in all suspicious CECS. Surgery was proposed when indicated. Minimum follow-up was 18 months. Final diagnosis was established at the final follow-up. MAIN OUTCOME MEASURES: Intracompartmental pressure measurements: PRest (baseline/pre-exercise pressure), P1 min (pressure 1 minute after exercise), P5 min (pressure 5 minutes after exercise), and TRest. Patients rated their pain and completed Quick-DASH in all follow-ups. Patients ultimately were classified into 4 groups (true positives, true negatives, false positives, and false negatives) for each ICP measurement relative to the final diagnosis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: A total of 124 male athletes were diagnosed with CECS, 27 bilateral. Accuracy with standard ICP diagnostic variables was lower (sensitivity 73.5%, specificity 84.2%, positive predictive value 97%, and negative predictive value 31.4%) than with TRest (SN 100%, SP 94.7%, PPV 99.3%, and NPV 100%); 23% of patients would have been missed following the standard ICP diagnostic criteria. CONCLUSIONS: Diagnostic thresholds for current standard ICP measurements should be lowered. TRest, a new measure, might be more accurate.

LISS plate for treatment of distal femur fracture. Clinical and functional outcomes.

The aim of the present study is to evaluate the use of the Less Invasive Stabilization System (LISS) plate for distal femoral fractures, examining variables such as type of fracture and length of plate. A retrospective study of 30 patients with a distal femoral fracture, treated with a distal femur LISS plate (Synthes) was performed. Average age was 71 years old (20-101). According to the AO classification, 16 fractures were type A, 5 type B, and 9 type C. The consolidation index and clinical outcomes measured with Knee Society Score (KSS) questionnaire were evaluated. Fracture consolidation took an average time of 16 weeks (14-20). Mean KSS was 77,3 (50-97) at the 2-year follow-up visit, observing better outcomes on type C fractures (84,25). According to the KSS score, only two cases were described with bad functional outcomes (6%). Distal femur fractures treated with the LISS plate achieved 94% of good and acceptable outcomes. Unlike the previously published, the best results were obtained with AO type C fractures, probably associated to the lower age (mean 53 years old) and better functional recovery capacity of this group.

Return to prelesional Tegner level after anatomic anterior cruciate ligament reconstruction.

INTRODUCTION: Injury and surgery of the anterior cruciate ligament (ACL) are very frequent within the sports environment. The purpose of the present study is to assess the level at which a group of athletes were able to return to play (RTP) after ACL reconstruction, and most importantly, the time for RTP. MATERIALS AND METHODS: A prospective study with patients who presented an ACL injury and underwent ligament reconstruction surgery; a bone-tendon-bone reconstruction and a minimum follow-up of 24 months. The rates of RTP as well as correlations with IKDC and KT-1000 were collected. RESULTS: 42 patients were included (mean age 31.7 years old). Mean Tegner level was 6.7. 9.5 % of patients returned to sports 6 months after surgery, 52.3 % at 1 year, and 73.8 % at 2 years after ACL reconstruction. 11 patients did not achieve their preoperative Tegner level after 2 years of follow-up. Levels of KT-1000 of the operated side were normal, and IKDC levels reached 90 % of total. CONCLUSIONS: Fear to a new injury, psychological factors, personality, type of life, and sports level previous to the injury are factors that influence when it comes to RTP after an ACL surgery. Level of evidence Level II descriptive analysis.

Pain in donor site after BTB-ACL reconstruction with PRGF: a randomized trial.

INTRODUCTION: Anterior cruciate ligament (ACL) tears are highly incident injuries in young athletes within our work area. The use of the patellar graft, despite being the treatment of choice, presents post-operative problems such as anterior knee pain, which limits its use and leads to preference being taken for alternative grafts. Our aim was to evaluate if the application of PRGF reduces anterior knee pain in donor site in BTB-ACL reconstruction. MATERIALS AND METHODS: 43 patients were included in the double-blinded and randomized clinical trial comparing two patient groups who underwent ACL reconstruction using patellar tendon graft, comparing anterior knee pain with and without the application of PRGF at the donor site after harvesting the graft. RESULTS: The PRGF group showed decreased donor site pain in comparison to the control group, with significant differences in the first two months of follow-up. CONCLUSION: The application of PRGF decreased donor site pain compared to the control group.

Gluteus maximus impairment in femoroacetabular impingement: a tensiomyographic evaluation of a clinical fact.

INTRODUCTION: the aim of the present study is to evaluate the mechanical and contractile properties of the gluteus maximus (GM) muscle in patients with femoroacetabular impingement (FAI). Our hypothesis is that the clinical observation of GM pain would be evidenced by tensiomyographic impairment in muscle function. MATERIALS AND METHODS: A prospective, cross-sectional, intra-group comparative study was conducted to assess the neuromuscular changes of lower extremity muscles in patients with FAI. Fifty-one patients with clinical and radiographic diagnosis of FAI for at least 3 months were included. The rectus femoris (RF), adductor magnus (AM), and GM of both lower extremities of all patients were evaluated with tensiomyography (TMG). The values of TMG of the affected lower extremity were compared to those of the healthy contralateral side. The parameters obtained in this study were maximal displacement (Dm), and contraction time (Tc). RESULTS: The Tc of the injured GM was significantly higher compared to the healthy side (p = 0.01). There were no significant side-to-side differences in the Dm of the GM (p = 0.13), either in the Tc and Dm of the RF (p = 0.15 and p = 0.8, respectively) and AM (p = 0.25 and p = 0.75, respectively). CONCLUSIONS: FAI is associated with impairment of contraction time in the GM of the injured compared to the healthy side. Impairment of the GM may be monitored to evaluate response to conservative or surgical treatment.

The international Hip Outcome Tool-33 (iHOT-33): multicenter validation and translation to Spanish.

BACKGROUND: The international Hip Outcome Tool-33 (iHOT-33) is a 33-item self administered outcome measure based on a Visual Analogue Scale response format designed for young and active population with hip pathology. The aim of the present study is to translate and validate the iHOT-33 into Spanish. METHODS: 97 patients undergoing hip arthroscopy were included in this prospective and multicenter study performed between January 2012 and May 2014. Crosscultural adaptation was used to translate iHOT-33 into Spanish. Patients completed the questionnaire before and after surgery. Feasibility, reliability, internal consistency, construct validity (correlation with Western Ontario and McMaster Universities Osteoarthritis Index), ceiling and floor effects and sensitivity to change were assessed for the present study. RESULTS: Mean age was 48 years old. Feasibility: 41.2 % patients had no blank questions, and 71.3 % of patients had fulfilled all but one or two questions. Reliability: ICC for the global questionnaire was 0.97, showing that the questionnaire is highly reproducible. Internal consistency: Cronbach's alpha was 0.98 for the global questionnaire. Construct validity: there was a high correlation with WOMAC (correlation coefficient >0.5). The Ceiling effect (taking into account the minimum detectable change) was 12.1 % and the floor effect was 21.6 %, for the global questionnaire. Large sensitivity to change was shown. CONCLUSION: the Spanish version of iHOT-33 has shown to be feasible, reliable and sensible to changes for patients undergoing hip arthroscopy. This validated translation of iHOT-33 allows for comparisons between studies involving either Spanish- or English-speaking patients. LEVEL OF EVIDENCE: Prognostic study, Level I.

Patellar Fractures: An Innovative Surgical Technique With Transosseous Suture to Avoid Implant Removal.

PURPOSE: To describe a new surgical procedure and its outcomes: osteosynthesis with high-resistance sutures, avoiding metallic implants. Open sky osteosynthesis with Kirschner and cerclage wiring is the current gold standard for patella fractures. Favorable functional outcomes have been observed, although implant removal is required in many cases due to the prominent wires under the skin. New implants have been sought after to minimize the need for second surgeries. METHODS: Eight patients, aged between 25 and 61 years, with a minimum follow-up of 24 months, were included in the present study. The surgical procedure consists of open reduction followed by internal fixation performing 3 longitudinal tunnels crossing double high-resistance sutures within these tunnels and suturing among them. Next, an anterior cerclage with parenchymal suture was performed. RESULTS: During follow-up, no secondary fracture displacement was observed. No patient required or requested implant removal. Functional outcomes were equitable to other surgical techniques. CONCLUSION: Despite the relatively small number of patients, osteosynthesis with high-resistance suture presents as an acceptable alternative within patella fracture treatment, being safe and with similar functional outcomes when compared with other techniques. Furthermore, no second surgeries for implant removal were required during the present study.

Clinical outcomes of trochanteric syndrome endoscopically treated.

BACKGROUND: Greater trochanteric pain syndrome (GTPS) is clinically defined as greater trochanter pain with mechanical characteristics. Most cases of GTPS are resolved with conservative treatment. Surgical techniques are reserved for those who had unsatisfactory results with conservative treatment. PURPOSE: The aim of the present paper is to describe the outcomes observed within endoscopic treatment of peritrochanteric pathology. METHODS: Twenty-three patients were included in the present study, undergoing surgery between January 2010 and December 2011, diagnosed with GTPS and surgically treated with endoscopy. All patients were evaluated with Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) Modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS). The Scales were assessed before surgery and at 3, 6 and 12 months postoperatively. RESULTS: All scores showed statistically significant differences (p < 0.001) within all periods. CONCLUSION: The endoscopic technique has proven to be safe and reproducible with good and excellent results, thus being an additional surgical procedure to consider within therapeutic management of greater trochanteric pain syndrome. LEVEL OF EVIDENCE: IV. Case series.

Validation of the Spanish version of the Hip Outcome Score: a multicenter study.

BACKGROUND: The Hip Outcome Score (HOS) is a self-reported questionnaire evaluating the outcomes of treatment interventions for hip pathologies, divided in 19 items of activities of daily life (ADL) and 9 sports' items. The aim of the present study is to translate and validate HOS into Spanish. METHODS: A prospective and multicenter study with 100 patients undergoing hip arthroscopy was performed between June 2012 and January 2013. Crosscultural adaptation was used to translate HOS into Spanish. Patients completed the questionnaire before and after surgery. Feasibility, reliability, internal consistency, construct validity (correlation with Western Ontario and McMaster Universities Osteoarthritis Index), ceiling and floor effects and sensitivity to change were assessed for the present study. RESULTS: Mean age was 45.05 years old. 36 women and 64 men were included. Feasibility: 13% had at least one missing item within the ADL subscale and 17% within the sport subscale. Reliability: the translated version of HOS was highly reproducible with intraclass correlation coefficient of 0.95 for ADL and 0.94 for the sports subscale. Internal consistency was confirmed with Cronbach's alpha >0.90 in both subscales. Construct validity showed statistically significant correlation with WOMAC. Ceiling effect was observed in 6% and 12% for ADL and sports subscale, respectively. Floor effect was found in 3% and 37% ADL and sports subscale, respectively. Large sensitivity to change was shown in both subscales. CONCLUSION: The translated version of HOS into Spanish has shown to be feasible, reliable and sensible to changes for patients undergoing hip arthroscopy. This validated translation of HOS allows for comparisons between studies involving either Spanish- or English-speaking patients. LEVEL OF EVIDENCE: Prognostic study, Level I.

Knee arthroplasty and bleeding: when to remove drainages.

PURPOSE: The aim of this study is an attempt to clarify the productive time of drainages as we find that the use of drains in knee arthroplasty is controversial, and there is no consensus regarding their length-time maintenance. We analysed the survival curve of bleeding within three surgical techniques for knee arthroplasty and the effect of two variables on survival curve. METHODS: One hundred and eighty-eight out of 234 knees were included in the study, and patients were divided into three groups according to the surgical technique: conventional total knee arthroplasty (TKA), subvastus TKA and unicompartmental knee arthroplasty. Variables of study were type of surgery, number and placement of drains. RESULTS: Mean of survival curve for postoperative bleeding time was 16 h (95 % CI: 15.4; 16.6). The risk for longer bleeding increased 1.38-fold with each additional drain used (95 % CI 1.1; 1.8). CONCLUSIONS: According to the present study, drains can be safely removed at around 17 h postoperative. Bleeding time reduces as less drains are applied. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Anterior Cruciate Ligament Reconstruction with Autologous Hamstring Single- versus Double-Bundle Graft: A Prospective Study with 10-Year Follow-up.

The purpose of the present study was to compare the clinical and subjective outcomes of anterior cruciate ligament (ACL) reconstruction using an autologous hamstring double bundle (DB) with a single bundle (SB) after a 10-year follow-up. A prospective comparative cohort study was performed of 47 consecutive patients with ACL rupture included between May 2006 and March 2008. Inclusion criteria were less than 2 years since the injury date, no previous surgery on the affected knee, and having closed growth plates. Patients were divided into two groups: (1) SB group (n = 25) and (2) DB group (n = 22). Patients underwent evaluation before surgery and at 1 and 10 years postoperatively. The clinical evaluation included the International Knee Documentation Committee (IKDC) Questionnaire, pivot shift test, and single hop test, as well as X-rays (anterior drawer X-rays on a Telos stress radiography). Range of motion (ROM) was assessed at 10-year follow-up. Both groups were similar in terms of baseline characteristics. Post hoc power analysis showed that among 30 and 226 patients would be needed for statistical significance, depending on the outcome. With the numbers available, no significant differences were observed in subjective IKDC, anterior stability (measured with Telos), and functional test outcomes (single hop test) between both groups at 1 and 10 years postoperatively. Regarding rotational instability (pivot-shift test), DB group was significantly superior (p = 0.002). Regarding ROM, no significant differences were observed between groups. No failure was registered in any of the groups. ACL reconstruction (ACLR) with an autologous hamstring, both with bundles and DB, shows overall better outcomes compared with the status before surgery. DB ACLR provides better rotational control of the knee, an outcome that is maintained after 10 years.

Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot.

BACKGROUND: One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital. METHODS: We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared. RESULTS: A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001). CONCLUSIONS: The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Association Between Stability and Urologic Lesions in Pelvic Ring Fractures. A Case Series Report.

PURPOSE: Pelvic ring fractures represent a subgroup of potentially serious injuries due to the fractures themselves, as well as the associated injuries. In fact, over 4% of cases have concomitant lower urinary tract injuries. The aim of this study was to analyze the relationship between the instability of pelvic ring fractures and the presence of lower urinary tract lesions. MATERIALS AND METHODS: A retrospective review of patients with pelvic ring fractures at our center between 2007 and 2015 was performed. Fractures were categorized according to the Tile classification system. Patients with lower urinary tract lesions were selected and categorized according to the lower urinary tract lesion identified (urinary bladder, urethral or combined). Subsequently, a statistical analysis was carried out to assess the association between these variables. RESULTS: 614 patients with pelvic ring fracture were included, corresponding to 260 (42.3%) men and 354 (57.7%) women. 25 patients (4.1%) were diagnosed of lower urinary tract injury (17 bladder injuries, 8 urethral injuries and 0 combined injuries). Urethral injuries were more frequent among men (1.9% incidence in men vs 0.8% in women). A lower incidence of lower urinary tract lesions was detected in stable pelvic ring fractures (type A, p 0.02). Overall, type C3 showed the highest incidence of lower urinary tract lesions (22.2% incidence, p = 0.04). CONCLUSION: In our series, a greater incidence of higher urinary tract injuries was observed in patients with unstable pelvic ring fractures (Tile type B and C) with respect to stable fractures (Tile type A). Therefore, a high index of suspicion should be maintained in order to identify high risk patients.

Checkrein deformity: a case report of two patients with hallux deformity and pain following mandibular reconstruction in oral cancer treatment.

BACKGROUND: Checkrein deformity is an uncommon disease with a well-described etiology. It is characterized by a dynamic deformity of the hallux or great toe. We report two cases of checkrein deformity due a fibular graft harvesting in two patients with a mandibular bone defect secondary to an oral cancer treatment. CASE REPORT: We report two young patients with mandibular cancers that had been treated several years before our visit and were currently free of disease. The patients had a mandibular bone defect due to the maxillofacial treatment, solved with a free fibular graft. The current complaint was a great toe deformity that caused pain and made them walk with difficulties. Diagnosis was a checkrein deformity, and after a surgical release of the flexor hallucis longus tendon, both cases returned to normal activities with no walking limitations. CONCLUSION: Our cases highlight that an accurate patient examination is warranted following these reconstructions as many of them can be misdiagnosed, and a relatively simple surgery can improve the patients' limitations.

Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip.

BACKGROUD: Untreated osteonecrosis of the femoral head ultimately leads to secondary coxarthrosis. The aim of this study was to determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. We also sought to determine whether this treatment improved clinical outcomes and reduced the need for total hip arthroplasty. METHODS: Eighteen hips were included in the present study. All of them underwent core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate between 2007 and 2012. The cell concentrate was obtained from the posterior iliac crest and processed and implanted during the same surgical procedure. Patient demographic data, clinical data including modified Harris hip score, and radiological data were collected preoperatively, postoperatively, and during the follow-up period. Also, survival endpoints were analyzed: time of femoral head collapse and need for total hip arthroplasty. RESULTS: The mean age of patients was 37.8 years (standard deviation [SD], 9.31 years). The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months). CONCLUSIONS: The results obtained in this study suggest that core decompression combined with implantation of autologous bone marrow concentrate and tricalcium phosphate will not prevent radiographic progression of early stage osteonecrosis of the hip. These finding also suggest that the absence of indications for hip replacement alone is not an indicator of good response to the treatment, and it is important to note the radiological results.

Author Correction: Precision and safety of Multilevel Cervical Transpedicular Screw Fixation with 3D Patient-Specific Guides; A Cadaveric Study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain.

INTRODUCTION: The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistribution of resources to meet hospitals' current service needs during this pandemic. The aim of this study was to provide an overview of the impact of the pandemic, and its corresponding State of Emergency, on a tertiary traumatology emergency service. METHODS: An observational study was performed at a tertiary hospital within the Spanish National Health System. Four different periods were studied, including the first 20 days of Spain's current State of Emergency, from March 14 to April 02, 2020 (Period 4). This period was compared to the 20-day period prior to the State of Emergency (Period 3), and to matching periods in the two previous years (Periods 1 and 2). A total of 6,565 patient visits were analyzed: 1909 in Period 1 (29.1%), 2161 in Period 2 (32.9%), 1983 in Period 3 (30.2%), and 512 in Period 4 (7.8%). Variables collected included patient age and sex, insurance type, discharge destination and reason for hospital admission. RESULTS: The patients' mean age was 55.1 years old (Standard Deviation (SD): 22.1), and 51.8% were women (3495/6565). During the COVID-19 pandemic, there were significant reductions in total visits to the trauma emergency department, workplace accidents, traffic accidents and number of hospital admissions, particularly during Period 4. However, no statistically-significant differences were found in the number of osteoporotic hip fractures admitted between the four periods. The numbers of hospital admissions for osteoporotic hip fracture were 42 during Period 1, 41 during Period 2, 43 during Period 3 and 36 during Period 4. CONCLUSIONS: While most traumatological presentations decreased in frequency over the course of the outbreak, the number of osteoporotic hip fractures remained stable. Thus, contingency plans in times of crisis need to be carefully targeted, and to keep in mind certain public health issues that do not decrease, despite a State of Emergency, like osteoporotic hip fractures.