Early Outcomes and Complications of Surgically Treated Diabetic Hallucal Infection.

BACKGROUND: Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal diabetic foot infection (DFI) treated with either conservative surgery or amputation. METHODS: This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all diabetic foot ulcer (DFU) were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups. RESULTS: Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (P = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the reamputation rate for the amputation group was 23.1% (P = 0.2). CONCLUSIONS: The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seem to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to magnetic resonance imaging bone infection signal could be considered to minimize the risk of subsequent surgeries and reamputations.

Intraoperative live measurement of femoral head size for acetabular cup sizing: simple, accurate, and green!

PURPOSE: Templating is the first step in achieving a successful total hip arthroplasty. We hypothesize that native head size is highly correlated with implanted cup size. Therefore, the purpose of this study is to look for a correlation between sizes of the intra-operative measurement of the femoral head and the implanted cup. METHODS: This is a monocentric observational study conducted from December 2018 till January 2023. All patients admitted for a primary total hip arthroplasty were included and retrospectively reviewed. Intra-operative femoral head measurement, radiographic femoral head diameter, templated (planned) cup size, and definitive implanted cup size were recorded. RESULTS: The sample included 154 patients (85 female and 69 males) with a mean age of 66.2 ± 10.4 years. There were 157 THA cases; 82 on the right side and 75 on the left side. The native head size and acetate template on digital radiographs were the most significantly positively correlated with cup size (P < 0.0001) while the radiological head size was significantly negatively correlated with cup size (P = 0.009). The implanted cup was on average 2 ± 2 mm bigger than the native head size measured intra-operatively. CONCLUSION: The native femoral head diameter measured intra-operatively is a simple and reliable tool to help the surgeons choose the proper size of the acetabular cup, preventing complications during surgery hence optimizing results post operatively. This technique would contribute to a more ecofriendly orthopaedic reconstructive surgery.

The short external rotator muscles of the hip: a cadaveric study on 18 specimens with clinical implications.

PURPOSE: The short external rotator muscles (SERMs) of the hip are composed of six postural muscles that constitute a single functional unit that is aligned to coapt the articular surfaces of the hip joint, providing dynamic stability. This study aims to provide a morphometric evaluation of this unit that could benefice clinical practice. In particular, the implication of the morphology and direction of the hip triceps tendon when performing a posterolateral approach for total hip arthroplasty. METHODS: A total of 18 cadaveric hips were dissected rigorously. Variations of the origin, course and insertion of all SERMs were recorded and quantified. Measurements were conducted for the following parameters: total muscle lengths, intra-muscular and extra-muscular tendon lengths, muscle sagittal and frontal angles, and femoral neck length. Correlation was searched for between total muscle length and femoral neck length. RESULTS: Results were as follows: (a) the obturator internus and externus muscles insert quasi perpendicularly on the proximal femur, (b) both gemelli take distal insertion onto the tendon of the obturator internus to form the hip triceps tendon, (c) morphometric data of the studied parameters was reported, and (d) moderate to high correlation with femoral neck length was found for all muscles but the quadratus femoris. CONCLUSION: Our results showed that the direction of the hip triceps tendon is always orthogonal to the proximal femur in the frontal plane. Such anatomical reference could be used when performing total hip arthroplasty with the posterolateral approach. Future research is needed to assess whether the easy identification and re-insertion of the hip triceps could reduce leg length discrepancy and offset.

Monitoring negative pressure wound therapy for diabetic foot ulcers using WhatsApp.

Foot complications of patients with diabetes could lead to amputations and early death. Diabetic foot ulcers (DFU) are usually difficult to treat and impose huge financial burden. Monitoring wound progress is the mainstay of any treatment and alternatives to face-to-face consultations such as tele-medicine have been proposed. Very few papers explored the utility and effectiveness of monitoring DFU through instant messaging application such as WhatsApp. The aim of this study is to evaluate the validity of WhatsApp in monitoring diabetic wounds treated with negative pressure wound therapy (NPWT). Twenty-two patients were prospectively recruited. All patients had an initial face-to-face consultation and debridement. Dressings were changed twice per week at patient's residence and media files were sent by the wound nurse via Short Message Service (SMS). A subsequent face to face consultation was scheduled whenever a complication was suspected. The primary outcomes were the percentages of accurate cases a) where a new or recurrent infection was suspected, and a b) where a debridement was thought to be needed. Complete healing of the defect using NPWT was achieved in 10 patients and a skin graft procedure was needed in another 4 patients. Five patients needed further surgical debridement. Failure to heal was observed in 3 patients. Out of the seven cases where a new infection was suspected, five (71.5%) were confirmed on face-to-face consultation. No confirmed cases of infection were observed during follow-up for those estimated as clean. Out of the 11 cases where debridement was favored based on WhatsApp media files, confirmation of a needed debridement was recorded in 8 (73%) cases. NPWT monitoring of for diabetic foot and leg ulcers using WhatsApp application was found to be an excellent method to document and track the wound process and complications. The excellent specificity and high sensibility should encourage for common use by healthcare. The results of this study could be also valuable for patients living in rural areas and in case of future pandemics.

The diabetic sausage toe: Prevalence, presentation and outcomes.

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow-up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems.

Basic haematological tests as inflammatory performance markers of patients treated either by conservative surgery or minor amputation for infected diabetic foot ulcers.

Basic inflammatory markers have been extensively studied to differentiate between non-infected and infected diabetic foot ulcers (DFUs). Very rarely, basic haematological tests such as white cell count (WCC) and platelet counts were used as performance markers for DFU infection severity. The aim is to investigate these biomarkers in patients with DFU treated exclusively with surgery. In this retrospective comparative study, we included 154 procedures comparing a conservative surgery group (n = 66 for infected DFU) and a minor amputation group (n = 88 for infected DFU with osteomyelitis). Outcomes were set as the preoperative values of: WCC, neutrophils (N), lymphocytes (L), Monocytes (M), Platelets (P), red cell distribution width (RDW) and the ratios N/L, L/M and P/L. Area under curve (AUC) of the receiver operating characteristic (ROC) was calculated based on the diagnosis of minor amputation as a positive result. Cutoff point values with the highest sensitivity and specificity were obtained for each outcome. The highest AUC values were for WCC (0.68), neutrophils (0.68), platelets (0.7) and P/L ratio (0.69) with corresponding cut-off values of 10,650/mm3 , 76%, 234,000/mcL and 265, respectively. The highest sensitivity was for the platelet count (81.5%) while the highest specificity was for L/M (89%) and P/L ratios (87%). Postoperative values showed similar results. Simple routine blood tests could serve as inflammatory performance markers to help predict the severity of infection in patients treated surgically for infected DFU.

Analysis of systemic risk factors between diabetic/vascular patients having primary lower limb amputations and re-amputations.

Background: Patients with diabetes mellitus (DM) are known to be predisposed to many complications in the lower extremities such as neuropathy, peripheral artery disease (PAD) and infection. Diabetic foot ulcers are complications of diabetes that can lead to lower extremity amputations, re-amputations and high mortality rates.Purpose: The aim of this study is to evaluate the risk factors associated with higher re-amputation rates in diabetic foot disease.Research Design: This is a mono-centric retrospective comparative study.Study Sample: the study included 136 patients, with a total of 193 procedures (111 primary amputations and 82 re-amputations) between 2011 and 2021.Data Analysis: The t-student test and Spearman correlation were used to look for mean differences and any relevant association, respectively. Multivariate logistic regression analysis was computed to look for independent variables.Results: Twenty-two (27%) and 60 (50%) of those who had major and minor amputations, respectively, had a re-amputation (p = 0.006). Besides diabetes (89%), the commonest risk factor associated with amputation was hypertension (86.7%), be it for primary amputation or re-amputation, followed by peripheral (PAD) and coronary artery diseases. Only three risk factors showed independent correlation with re-amputation; chronic kidney disease (r = 15%, p = 0.03), smoking (r = 15%, p = 0.03), and simultaneous presence of DM + PAD (r = 13.7%, p = 0.05).Conclusions: Factors that were significantly correlated with increased re-amputation rates have a clear pathologic pathway that affects vascularity and wound healing. Further studies should be aimed at developing a clear scoring system that can be used to stratify patient for re-amputation risk, and to better predict the results according to the severity of diabetes.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm.

BACKGROUND: The treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. METHODS: This is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. RESULTS: Outcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. CONCLUSIONS: Bone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Is diabetic neuropathy associated with vitamin D status? A meta-analysis.

Several studies have been conducted to investigate the relation between 25-hydroxyvitamin D [25(OH)D] level and diabetic neuropathy (DN). However, there is still no clear conclusion due to differences in study design and cut-off values used in the published work, in addition to the absence of a comprehensive meta-analysis (MA) on the topic. The present systematic review and MA therefore aims at clarifying the association between vitamin D level and peripheral DN in patients with type 2 diabetes mellitus. Primary research studies that explored the association between 25(OH)D level and diabetic peripheral neuropathy in type 2 diabetes were located from Medline, EMBASE, Web of Science, Cochrane Library, CINHAL and Google Scholar. Twenty-six studies met the inclusion criteria with 6277 participants where 2218 were diabetic with DN, 2959 were diabetic without DN and 406 were healthy. Diabetic patients with DN showed significantly lower serum 25(OH)D compared with patients without DN (standardised mean difference (SMD) of -0·92 (95 % CI -1·18, -0·65, I2 = 93·3 %, P < 0·0001). The pooled OR value of vitamin D deficiency was higher in patients with DN, 1·84 (95 % CI 1·46, 2·33, P < 0·0001) and 2·87 (95 % CI 1·10, 7·52, P = 0·03) when using fixed-effects and random-effects models, respectively. Vitamin D deficiency has been found to be highly prevalent among diabetic patients with neuropathy. Since 25(OH)D has been implicated in glucose haemostasis and showed benefit in reducing neuropathy symptoms, its supplementation is warranted for this population of patients.

Major acetabular defects: outcomes of first revision total hip arthroplasty using Kerboull cross-plate with allograft and cemented dual mobility cup at a maximum follow-up of fourteen years.

BACKGROUND: The use of dual mobility cups (DMC) has been shown to reduce hip instability after revision surgery. For severe acetabular bone loss, reconstruction with a Kerboull cross-plate and bone allograft would contribute to restoring native hip position and bone stock. Only two papers reported on the combination of Kerboull cross-plate with bone allograft and cemented DMC in revision total hip arthroplasty (THA). METHODS: This is a monocentric retrospective study (28 cases) of first-time revision THA using such a construct in American Association of Orthopaedic Surgeons (AAOS) grade III and IV acetabular bone defect. Detailed demographic, clinical and radiographic results were recorded and evaluated. RESULTS: With a mean follow-up of six ± 3.63 years, no case of instability was reported. The modified Harris Hip Score (mHHS) was 88.4 ± 10.1. No hook fracture or mechanical failure was observed. Non-progressive radiolucent lines were recorded. Osteointegration of the allografts was observed in all cases with a mean Grodet score of 7.9 ± 0.97. CONCLUSIONS: In first revision THA, the use of a Kerboull cross-plate with allograft and a cemented DMC in AAOS grade III and IV acetabular bone defects demonstrated excellent clinical and radiological outcomes with no recorded cases of dislocation or mechanical failure.

Locating the danger zone to avoid injury to the sural nerve during Achilles calcaneal tendon repair. A systematic review of cadaveric studies with clinical implications.

INTRODUCTION: Although iatrogenic injuries to the sural nerve (SN) are commonly encountered in calcaneal (Achilles) tendon (CaT) repair surgeries, the relationship between both structures have anatomical variations. A quantitative evidence synthesis has not been yet conducted. Our systematic review aims to better define the safe zone where the SN crosses the lateral border of CaT. METHODS: Electronic databases were searched to locate relevant anatomical studies recording details regarding the distance at which SN crosses the CaT. The Checklist for Anatomical Reviews and Meta-Analyses (CARMA) was followed. The primary outcome was the mean distance from CaT insertion to SN crossing site, to locate a safe zone. The secondary outcome was the mean horizontal distance from the SN to the CaT lateral border. RESULTS: Seven studies met the inclusion criteria with a total of 204 cadaveric limbs. The danger zone was located 2 cm distal and proximal to the mean distance of the crossing point. The mean distance from CaT insertion to the SN crossing site was 9.91 ± 0.67 cm. The mean horizontal distance between SN and the CaT lateral border decreased from a mean of 19.8 ± 2.06 mm at the calcaneal tuberosity level to 3.6 ± 0.4 mm at 10 cm proximal to the tuberosity. DISCUSSION: This review demonstrated that 10 cm is the average distance from the CaT insertion onto the calcaneal tuberosity to the point of crossing of the SN. A safe zone would be 2 cm away proximally and distally from the crossing point. We recommend placing the proximal lateral sutures away from this region. This finding should help surgeons avoid SN injuries during open or percutaneous approaches for calcaneal tendon rupture.

Tarsal tunnel syndrome secondary to accessory or variant muscles: a clinical and anatomical systematic review.

PURPOSE: Many etiologies are known to lead to a tarsal tunnel syndrome (TTS). One rare cause is mass-occupying lesions, and particularly accessory or variant muscles (AVM). This study aimed to systematically collect published clinical cases of TTS caused by AVM. METHODS: An electronic literature search was conducted from inception to April 2021. The diagnosis of AVM should be reported in one of the following methods: ultrasonography, magnetic resonance imaging (MRI), or per-operatively. Data extraction included types and prevalence of accessory muscles, clinical presentation and diagnosis, and treatment modalities. Twenty-five studies were identified with a total 39 patients (47 ankles). RESULTS: The prevalence of TTS was reported in only two studies (9%). Forty-nine AVM were identified with the accessory flexor digitorum longus being the most common (52%). The most common sign/symptoms were tenderness (78.7%), pain (82.9%), dysesthesia (57.4%), Tinel sign (44.6%), and a swelling (25.5%). Decompression and excision were the most commonly performed procedures. Four accessory/variant muscles in the ankle have the potential to induce a tarsal tunnel syndrome. CONCLUSION: This review highlights the clinical and imagery specificities of TTS secondary to accessory or variant muscles. Mass-occupying etiology should be included in the list of differential diagnoses whenever a posterior tibial nerve compression is suspected.

The gracilis and semitendinosus muscles: a morphometric study on 18 specimens with clinical implications.

INTRODUCTION: The pes anserinus consists of the sartorius, semitendinosus, and gracilis muscles. They coalesce together with the leg fascia to form the anserine plate. The semitendinosus and gracilis both form the deep layer of this plate and are clinically relevant for ligament reconstruction. The aim of the study is to report a detailed morphometric evaluation of the semitendinosus and gracilis muscles and assess their clinical implications. METHODS: Using a rigorous dissection process on 18 cadaveric hips, measurements of both the semitendinosus and gracilis muscles with bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, and (c) intra-muscular and extra-muscular (free) tendon lengths. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed. RESULTS: The total muscle and the distal intra-muscular tendon length of the St and Gr are correlated with the total femur length. When compared to gracilis, the total muscle and distal intra-muscular tendon lengths of the ST are much better correlated with the total femur length. The free distal tendon length for both muscles did not show a significant correlation with any of the femoral bone lengths. CONCLUSION: The variability of tendon length of the ST/Gr poses a significant challenge to surgeons. This study reports a detailed morphometric evaluation of the ST/Gr hamstring muscle and tendons. It revealed a positive correlation between the femoral length and the ST/Gr graft lengths. This could help orthopedic surgeons in predicting the graft lengths pre-operatively and develop better planning for reconstructive surgeries.

Evidence-based conservative limb preserving surgery for the diabetic foot complications: A systematic review of systematic reviews.

BACKGROUND: Limb preserving surgery for the treatment of diabetic foot complications (DFC) has been shown to yield excellent results and better outcomes when compared to non-surgical standard of care. The quality of the articles reporting the results of limb preserving surgery in treating DFC is quite low. The aim of this study was to evaluate the published systematic reviews and meta-analyses that looked at the efficacy of limb preserving surgery in treating DFC. METHODS: PubMed, Cochrane Library and Google Scholar were searched for all systematic reviews and meta-analyses on limb preserving surgery in DFC. The Joanna Briggs Institute (JBI) critical appraisal tool for systematic reviews was used to appraise studies' quality. RESULTS: 22 systematic reviews and meta-analyses with a total of 10,559 patients met the inclusion criteria. Five reviews reported on surgical treatment of diabetic Charcot, 5 reviews on bony procedures and 12 reviews on soft tissue procedures for treating DFU. The results of each review were reported. The vast majority of the studies were of Level IV of evidence. The mean JBI score was 9.82. CONCLUSIONS: There is an underuse of the available limb preserving operations for the treatment of DFC despite excellent results and variety of procedures available in the literature, especially for Charcot neuroarthropathy and diabetic foot and toe ulcers.

Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis.

BACKGROUND: Five-year mortality and amputation frequencies after new-onset diabetic ulceration have been reported up to 55% and 74%, respectively. for patients with lower-extremity amputation. Following Charcot arthropathy, these frequencies were reported with wide variations. The aim of this meta-analysis is to provide a quantitative evaluation of amputation and mortality frequencies in a diabetic patient with a Charcot foot arthropathy. METHODS: Electronic search strategy was applied on Medline, Web of Science, Cochrane Library and Google Scholar since inception to December 2021. Extracted data included study design, sample and patients characteristics, diabetes type and duration, lab results, ulcers at diagnosis, co-morbidities and follow up period. Meta-analysis reporting random-effects values was used to generate the weights results. RESULTS: A total of 16 studies were included in the quantitative meta-analysis with a pooled sample of 2250 patients with 2272 Charcot feet. Two studies including 255 patients yielded a 1-year mortality frequency of 4% (95% CI = 0.018-0.065). Seven studies including 1706 patients reported a 5-year mortality frequency of 24.5% (95% CI = 0.172-0.326, I² = 88.5%). Four studies including 277 patients yielded a seven plus year mortality frequency of 16% (95% CI = 0.065-0.289, I² = 84.3%). Ten studies including 871 foot yielded an amputation frequency of 15% (95% CI = 0.067-0.258, I² = 93.6%) where 9% where major amputations (95% CI = 0.062-0.127, I² = 60%) and 5% were minor amputations (95% CI = 0.004-0.126, I² = 94.7%) CONCLUSION: Diabetic Charcot arthropathy yields marked risk of amputation and mortality. However, mortality frequencies were unexpectedly lesser compared to those related to the published frequencies associated with diabetic foot ulcers.

The internal pedal amputation as a salvage procedure in diabetic and ischemic foot infection. A meta-analysis.

BACKGROUND: Osteomyelitis of the diabetic foot is a very challenging condition and amputation is often indicated. In some cases where the infection is localized and the surrounding soft tissue is mildly involved, an internal pedal amputation (IPA) based on resection and limited excision of the infected bone have been suggested as a viable option. This systematic review aims to look for the effectiveness of this technique in treating selected cases of diabetic foot osteomyelitis. METHODS: A systematic literature search was conducted using multiple electronic databases from inception. Eight studies met the inclusion criteria; one retrospective comparative study, six retrospective observational studies and one prospective observational study. RESULTS: Based on a pooled sample of 545 patients followed over a mean period of 27.7 ± 15.2 months, the weighted results were as follows: (a) healing rate was 87.7% (95% CI = 0.757-0.959), (b) time for healing was 7.1 ± 2.9 weeks, (c) wound infection rate was 5.6% (95% CI = 0.030-0.089), (d) wound dehiscence rate was 8% (95% CI = 0.010-0.204), (e) ulcer recurrence rate was of 10% (95% CI = 0.037-0.188), and (f) amputation rate was 2.8% (95% CI = 0.001-0.085) whilst all were minor amputations. CONCLUSION: The findings support the selection of toe/ray sparing surgery via IPA as a viable surgical option for selected cases of focal osteomyelitis secondary to diabetic foot infection. The results would indicate that when the ulcer size could be adequately reduced, removing the infected bone while preserving the soft tissue envelope could yield high chance of success with few serious complications.

Is there an association between anemia and diabetic foot ulcers? A systematic review and meta-analysis.

Anemia was found to be prevalent in patients with diabetes mellitus. Higher rates of anemia were reported in patients having diabetic foot ulcers (DFU). With the presence of an altered microcirculation, the potential negative effects of anemia might impede ulcer healing leading to higher rates of amputation and mortality. Medline, Embase, Scopus, CINAHL, Cochrane Library, and Google Scholar, were searched for from inception to locate relevant papers reporting any association between anemia and diabetic foot ulcers. The meta-analysis included 15 studies with 2895 patients. The weighted prevalence anemia rates of the total, mild-to-moderate DFU, and severe DFU groups were as follows: 69.7%, 49.5%, and 73%, respectively. For the hemoglobin level outcome, the same samples yielded the following pooled means: 11.00 ± 1.13, 12.08 ± 0.8, and 10.57 ± 0.68 g/dl. Individual studies showed association between low levels of hemoglobin and higher rates of non-healing ulcer, amputation, and mortality. This review demonstrated (a) a clear association between the presence of anemia and diabetic foot ulcers, (b) a clear association between the severity of anemia and the severity of DFUs, and (c) that anemia could be a predictor of amputation and mortality. Whether anemia is a predictor of adverse outcomes or an independent risk factor is to be further investigated.

Dual-mobility cups could yield lesser infections than conventional cups: a meta-analysis of comparative studies.

INTRODUCTION: Dual-mobility cups (DMC) are gaining popularity mainly for their reduced rate of dislocation following total hip arthroplasty (THA). Currently, indication for DMC use extends beyond patients with high risk of dislocation or revision THA cases. Many authors reported DMC outcomes in primary THA for all aetiologies. However, some reports claimed that the use of DMC is accompanied with higher rates of infection compared with conventional cups (CC) in both primary and revision THA. RESEARCH QUESTION: Does the use of DMC generate higher rates of infection when compared with conventional cups? OBJECTIVES: The aim of this meta-analysis was to look for significant difference in the rate of post-operative infection between DMC cups and conventional cups. METHODOLOGY: MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched since inception. Only studies with comparative design reporting the outcome infection rate were included. RESULTS: Seventeen retrospective comparative studies were located comprising 248,541 patients: 16,020 in the DMC group and 232,521 in the CC group. The mean follow-up period was 37.5 ± 42 and 50.2 ± 48.7 months for the DMC and CC groups, respectively. The meta-analytical results indicated the following: (a) significantly lesser infections following DMC compared with CC in revision THA (odds ratio (OR) = 0.75 (95% CI = 0.653 to 0.874, P = 0.0002, I2 = 25%); (b) for primary THA and for large-sampled registries, significance was found using only the fixed-effects model estimate; and (c) no significant difference was found for the subgroup of cohort studies. CONCLUSION: Our results clearly refute the claim that DMC would yield higher rates of infection. On the contrary, the findings demonstrated that the use of DMC reduces the risk of post-operative infection in revision THA and a similar lower infection trend for primary THA when compared with the standard cups.

Prevalence, variants, and morphometrics of Palmaris Longus tendon: a magnetic resonance imaging study.

PURPOSE: The palmaris longus (PL) tendon present a high degree of variations; the commonest is its absence which could reach more than 40% in some populations. The PL tendon is highly relevant in hand reconstructive surgery; however, MRI variations of PL tendon have been exceptionally reported. To this, this study investigated PL tendon variations using MRI in a Lebanese population. METHODS: This is a retrospective study of distal forearm MRI examinations to evaluate the presence, anatomical variations and morphometric of PL tendon. The outcomes were set as overall frequency, gender-based and side-base frequencies, correlations between prevalence and gender/side, morphological variants, thickness, and width of PL tendon. RESULTS: The sample comprised 335 patients including a total of 339 MRI scans. The PL was present in 221 wrists (65.2%), and bilaterally in only one (25%) out of the 4 bilateral cases. All PL were located using the Axial T1 views. Univariate and multivariate analyses showed no correlation with side, gender, or Tesla power. The only morphological variation was a reversed PL in 2 cases (0.6%). The mean width was 4.24 ± 1.2 mm. The mean thickness was 2.75 ± 0.6 mm. CONCLUSION: As far as we know, this is the first study to report the total array of variations of PL tendon using MRI, and its prevalence in a Lebanese population. The mean width of PL tendon calculated with high quality MR imaging was found to be similar to that reported by cadaveric studies.

Morphometric analysis of all 24 hip muscles: A cadaveric study of 18 hip specimens with proposal of a new classification of muscles.

PURPOSE: There are few papers investigating the morphometry of hip muscles and reporting either a single muscle or a group of synergistic muscles. With the development of hip joint simulation, hip arthroplasty implants, and gait analysis, a set of biometric data covering all the muscles that act on the hip joint is needed. METHODS: Using a rigorous dissection process on 18 cadaveric hips, measurements of all 24 hip muscles and bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, (c) intra-muscular and extra-muscular (free) tendon lengths, (d) bone angles, (e) muscle pennation, sagittal, and frontal angles, (f) muscle weight, (g) muscle volume, (h) muscle cross-sectional area, and (i) and bending moment. Data on more than 12,000 morphometric or anatomical parameters were collected. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed. Based on their compliance, muscles were classified using the ratio of belly length over the sum of intra-muscular and free tendons. RESULTS: Values of the neck, shaft, and total femur lengths were highly correlated in relation to each other. The long muscles and the pelvitrochanteric muscles were highly correlated with femoral bone lengths. The proximal and distal intra-muscular tendon lengths were correlated to the total muscle length for all long muscles, independently of free tendon (extra-muscular) or muscle belly lengths. A very significant correlation was found between muscle weight variations among specimens. Three groups of muscles were identified based on their compliance. CONCLUSION: This is the first comprehensive anatomical morphometric study which includes all the 24 muscles acting on the hip joint. It generates a unique anatomical dataset comprising all necessary data for musculoskeletal modeling and arthroplasty implants of the hip joint. A new muscle classification was proposed based on compliance where muscles of the same group would exhibit similar compliance and functional anatomy.