Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients.

BACKGROUND: Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients. MATERIALS AND METHODS: We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1-11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs. RESULTS: All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius. CONCLUSIONS: Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.

Plantar Subluxation of First Metatarsal with Intercuneiform Dislocation: A Case Report of a New Type of Lisfranc Injury.

Lisfranc injuries result when the bones or ligaments that support the midfoot are torn, and the classifications of these injuries are based on the coronal displacement of the metatarsals. On the saggital plane, the first metatarsal is usually dorsally dislocated due to dorsal ligament weakness. We present a case report of a 29-year-old woman who sustained a Lisfranc injury of her right foot with plantar subluxation of the first metatarsal, which was treated with open reduction and internal fixation of the first metatarsal and fusion of the second metatarsal.

Bilateral Femoral Neck Fracture Following an Epileptic Seizure in a Patient with Severe Vitamin D Deficiency: A Case Report.

Simultaneous bilateral femoral neck fractures represent a rare entity and are usually associated with bone metabolism disorders, chronic steroid treatment, epileptic convulsions, or high-energy trauma. Here we report a case of bilateral femoral neck fracture in a patient with severe vitamin D deficiency following an epileptic seizure. Anteroposterior and lateral radiographs of the pelvis revealed Garden III femoral neck fractures on both hips. A single-stage operation involving bilateral uncemented bipolar hemiarthroplasties using the anterolateral approach was performed. Three months postoperatively, the patient was able to ambulate independently. Simultaneous bilateral femoral neck fractures following an epileptic seizure is a rare injury. In our case, severe vitamin D deficiency and chronic use of antiepileptics predisposed the patient to this condition. Orthopaedic surgeons and other clinicians should be aware of such an uncommon pathology. A multidisciplinary team approach is essential in identifying risk factors and optimizing inpatient management and postoperative rehabilitation. A single-stage bilateral procedure with an uncemented bipolar hip hemiarthroplasty in order to reduce cement disease in this frail patient has been successful in restoring functional capacity and allowing the patient to return to his preinjury ambulatory status.

Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Overlapping surgery is defined as two cases occurring in separate operating rooms (ORs), where the same attending surgeon conducts the critical surgical portions of each case at different times. Although it has been suggested that this established practice may improve the utilization of resources, allow for more opportunities to teach surgical trainees, and facilitate timely access to care, there is still no consensus on its use in elective orthopaedic surgery, such as total joint arthroplasty (TJA). METHODS: A systematic review and meta-analysis of the literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles investigating the use of overlapping and single operating room TJA. Relevant data, including surgical time, intraoperative complications, postoperative complications, mortality rate, revision rate, and readmission rate, were extracted and recorded. RESULTS: Six articles were included (35,938 patients: 17,677 overlapping and 18,261 nonoverlapping). Overall revision rates were 1.2% and 1.1% for the overlapping and nonoverlapping cohorts, respectively (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 0.93 to 1.53). The overall intraoperative complication rate was 1.6% for both cohorts (OR = 0.98; 95% CI: 0.79 to 1.23), and the overall postoperative orthopaedic complication rates were 2.0% and 1.95% within the overlapping and nonoverlapping OR cohorts, respectively (OR = 1.07; 95% CI: 0.89 to 1.29). The readmission rate was 4.6% in the overlapping group and 4.2% in the nonoverlapping group (OR = 0.88; 95% CI: 0.70 to 1.11). Two studies with comparable groups reported markedly increased surgical time in the overlapping group compared with the nonoverlapping group. DISCUSSION: Overlapping surgery was found to be as safe as nonoverlapping surgery in patients undergoing TJA. Although overlapping TJA surgery is associated with satisfactory short-term revision rates, prolonged follow-up is required to further assess the medium-term and long-term outcomes of overlapping surgery compared with nonoverlapping surgery. Finally, although overlapping TJA surgery might be associated with increased OR time, this difference is not clinically relevant.

Functional and Surgical Outcomes After Endoprosthetic Reconstruction With Expandable Prostheses in Children: A Systematic Review.

Treatment of bone sarcomas in children is associated with wide tumor re-section and segmental reconstruction. The optimal surgical approach is still under debate in the literature. During the past decade, the application of expandable prostheses has gained remarkable attention because it improves patients' appearance and allows limb growth preventing leg length discrepancy. A systematic review of the literature was performed to identify studies focusing on the functional and surgical outcomes of the application of expandable endoprostheses. [Orthopedics. 2019; 42(4):184-190.].

Thromboembolism prophylaxis in orthopaedics: an update.

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery. Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018.

Total Scapulectomy and Shoulder Reconstruction Using a Scapular Prosthesis and Constrained Reverse Shoulder Arthroplasty.

Malignant tumors of the scapula are rare, and limb salvage surgery after tumor resection is challenging. The authors present a series of 6 patients who were treated by total scapulectomy and reconstruction with a custom-made scapular prosthesis and a constrained reverse shoulder arthroplasty. Postoperative oncologic and functional outcomes were assessed. The mean follow-up was 37 months (range, 9-84 months). Clear surgical margins were achieved in all patients. At the last follow-up, 4 patients showed no evidence of disease and 2 had died of systemic metastatic disease. Although shoulder function was limited, all shoulders were painless and stable and the patients retained satisfactory hand, wrist, and elbow function. [Orthopedics. 2018; 41(6):e888-e893.].

Harvesting, Isolation and Differentiation of Rat Adipose-Derived Stem Cells.

BACKGROUND: Adipose tissue is one of the most attractive sources of stem cells because it can be easily harvested and yields a greater stromal cell density. The multilineage potential of adiposederived stem cells (ADSCs) demonstrates their significant impact within the field of tissue engineering, with studies successfully demonstrating the ability to produce a range of tissue types. However, although a broad spectrum of applications has already been suggested, many important scientific and medical questions remain unanswered before the clinical application of ADSCs in humans. Importantly, clarification of the biology and identification of the differences of ADSCs from various areas of the body is required. In this continuous endeavor, research in rat models plays an important role in the development of new knowledge. METHODS: A literature review was done to summarize all information regarding harvesting, isolation, expansion, cryopreservation and differentiation of rat ADSCs. A Wistar rat model was also used to describe harvesting sites of adipose tissue, and to characterize the ADSCs using Fourier-transform infrared (FT-IR) spectroscopy and phase contrast microscopy. AIMS: To discuss all relevant considerations for harvesting, culture, differentiation and phenotypic characterization of ADSCs, to provide a comprehensive roadmap of this process, to identify the differences between ADSCs obtained from various adipose tissues of the rat, and to provide FT-IR spectroscopy marker bands that could be used as fingerprints to differentiate the types of adipose tissues.

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.

Spondylitis transmitted from infected aortic grafts: a review.

Graft infection following aortic aneurysms repair is an uncommon but devastating complication; its incidence ranges from <1% to 6% (mean 4%), with an associated perioperative and overall mortality of 12% and 17.5-20%, respectively. The most common causative organisms are Staphylococcus aureus and Escherichia coli; causative bacteria typically arise from the skin or gastrointestinal tract. The pathogenetic mechanisms of aortic graft infections are mainly breaks in sterile technique during its implantation, superinfection during bacteremia from a variety of sources, severe intraperitoneal or retroperitoneal inflammation, inoculation of bacteria during postoperative percutaneous interventions to manage various types of endoleaks, and external injury of the vascular graft. Mechanical forces in direct relation to the device were implicated in fistula formation in 35% of cases of graft infection. Partial rupture and graft migration leading to gradual erosion of the bowel wall and aortoenteric fistulas have been reported in 30.8% of cases. Rarely, infection via continuous tissues may affect the spine, resulting in spondylitis. Even though graft explantation and surgical debridement is usually the preferred course of action, comorbidities and increased perioperative risk may preclude patients from surgery and endorse a conservative approach as the treatment of choice. In contrast, conservative treatment is the treatment of choice for spondylitis; surgery may be indicated in approximately 8.5% of patients with neural compression or excessive spinal infection. To enhance the literature, we searched the related literature for published studies on continuous spondylitis from infected endovascular grafts aiming to summarize the pathogenesis and diagnosis, and to discuss the treatment and outcome of the patients with these rare and complex infections.