Minimally invasive treatment and internal fixation vs. extended lateral approach in calcaneus fractures of thalamic interest

Management of Acetabular Bone Loss in Hip Revision Arthroplasty: Case Series Presentation

Considering the increase in life expectancy in the general population and the need for a more active lifestyle, total hip arthroplasty has become an absolutely necessary surgical intervention to maintain these desired results. Along with the evolution of medicine and the increase in the quality and performance of the materials used to make prostheses, the number of patients who benefit from total hip replacement is constantly increasing, and proportionally, the number of patients who will require revision arthroplasty is increasing. Before discussing the need for hip arthroplasty revision, it is necessary to carry out a rigorous clinical and imaging examination for differential diagnosis with other pathologies such as low back pain, the presence of bone or soft tissue tumors, arterial occlusions and claudication, or other systemic diseases. One of the biggest challenges for the orthopedic surgeon in planning a hip revision is the compensation of the remaining acetabular bone defect, either as a result of the osteolysis process or following the process of removing the acetabular component, which in some cases can lead to severe bone loss that is difficult to anticipate in the preoperative planning. In this paper, we will present the short-term results of the use of reinforcement cages fixed with screws and cemented retentive acetabular cups in the case of hip revisions with extensive bone loss. The discussions that derive from the presented series of cases are related to the use of reinforcement cages, which are based on the principle of primary stability obtained with the help of screw fixation but whose risk of osteolysis and implant fixation damage is greater than in the case of implants that also associate biological integration at bone level. The use of reinforcement cages together with the retentive acetabular cup in the case of elderly patients with associated comorbidities, a moderate level of physical activity, and severe muscle insufficiency at the hip level as a result of not using the affected pelvic limb is still a viable solution that allows the patient to walk immediately after the surgery, avoiding the risk of dislocation (especially in patients who use the posterolateral approach) and avoiding morbidity induced by prolonged bed rest.

The Role of Serum and Peritoneal Biomarkers in Predicting Sepsis and Septic Multiorgan Failure in Patients With Secondary Peritonitis

Purpose Secondary peritonitis is still one of the most important causes of severe sepsis in the world; therefore, it is of utmost importance to identify biomarkers that could be employed for the purpose of selecting patients at high risk for developing life-threatening complications after emergency surgery. In view of this quest, our study seeks to reveal the possible role for serum and peritoneal concentrations of selected biomarkers, specifically presepsin, procalcitonin, monocyte chemoattractant protein-1 (MCP-1), high mobility group box 1 protein (HMGB-1) and interleukins (IL-6, -8, -10), in early prediction of sepsis and septic multiorgan failure for patients with secondary peritonitis. Methods We prospectively observed 32 selected patients with secondary peritonitis that underwent emergency surgery. Blood and peritoneal fluid samples were drawn at the time of surgery (T0), and after that, blood samples were taken at 24 (T1) and 48 (T2) hours postoperatively. Cytokines concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), a non-competitive variant, both in peritoneal fluid and serum. For determining whole blood concentration of presepsin and procalcitonin, PATHFAST™ assays (Polymedco, Cortlandt, New York) were used, based on the principle of non-competitive chemiluminescent enzyme immune-assay (CLEIA). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40325/6 April 2023). Results We found significant elevations in the peritoneal concentrations of interleukins 6, 8, 10, HMGB-1, and MCP-1 in all patients with secondary peritonitis at the moment of surgery; however, no clear correlation could be made based on this data with patient evolution. With regards to blood concentrations of the aforementioned serum cytokines and presepsin, procalcitonin (as already established markers of sepsis), our results showed good predictive value of presepsin for developing sepsis and septic multiorgan failure from the first hours in this patient category. All other biomarkers, despite having higher concentrations than baseline, in particular at 24-48 hours after surgery, had unpredictable dynamics that couldn't be correlated with the severity of the disease. Conclusion Cytokine production is the mainstay in developing sepsis and septic multiorgan failure in patients with secondary peritonitis; therefore, studying the dynamics of said cytokines seems of interest in finding tools to predict the development of sepsis or sepsis-related mortality. However, at the time, there seemed to be no clear correlation between the values of these cytokines and the development of complications.

Calcaneal Fractures Management, Change of Clinical Practice in Recent Years from ELA to STA: A Systematic Review and Meta-Analysis

Background

Calcaneal fractures are serious injuries that mainly affect young, active people. As a result, these fractures may cause long-term impairment and have a major socioeconomic impact. The current updated systematic review and meta-analysis were conducted to evaluate the functional outcomes, re-operative risk, and complications associated with the treatment of displaced intra-articular calcaneal.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. The literature search was carried out using PubMed, Cochrane, MEDLINE, Google Scholar, and the EMBASE databases with the appropriate keywords.

Results

A total of 13 studies were included in this review. The follow-up months were diverse, ranging between 12 and 65 months in sinus tarsi approach (STA) and 12 to 76 months in extended lateral approach (ELA) methods. Time to surgery was shorter for the STA when compared to ELA (MD: 3.48; 95% CI 2.43 to 4.53; p < 0.00001). No significant difference was observed in functional outcomes between STA and ELA (MD: 0.34; 95% CI: -0.37 to 1.04; p = 0.35 > 0.05; I2 = 88%). In comparison to the ELA, the STA has significantly less wound healing complications (RR: 0.20; 95% CI 0.11 to 0.36; p 0.00001; I2 = 0%).

Conclusion

In conclusion, the STA technique in treating calcaneal fractures was significantly safer and more effective when compared to the ELA methods. The STA method of treatment was found to have a lower risk of complications and an infection rate, as well as a shorter operating and recovery time.

Restoring Anatomical Features in Primary Total Knee Arthroplasty

Today, the number of people affected by gonarthrosis symptoms is increasing proportionally. Total knee arthroplasty (TKA) is a successful intervention that aims to reduce pain and restore knee function. However, studies have shown that active young patients still have limitations in performing activities such as skiing, golfing, surfing, and dancing. Over the last few years, total knee arthroplasty has undergone significant changes. Most of the modern TKA implants are designed to reproduce the normal biomechanics of the knee joint, mimicking the physiological pattern with greater compliance in the medial compartment between the tibial insert and femoral condyle and less congruence on the lateral side. Unfortunately, functional outcomes are compromised in approximately half of TKA patients. This loss may be caused by the abnormal kinematics and inherent instability of many contemporary implants. The proper alignment of the femoral component during TKA is a crucial step that influences postoperative results. The position of the femoral component in the axial plane is responsible for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The main goal when choosing a type of prosthesis is to achieve an adequate recovery that leads to an improvement in mobility and an increase in the efficiency of the quadriceps.

Cerebral Tuberculosis in a Patient Following Treatment With Infliximab for Ankylosing Spondylitis: A Case Report

Ankylosing spondylitis (AS) mainly belongs to the group of axial spondylitis. It is a chronic inflammatory disease that primarily affects the spine, but can also affect peripheral joints. It is characterized by inflammatory lower back pain and morning stiffness. Tuberculosis is still a cause of morbidity and mortality in developing countries. Management of patients with AS consists of patient education, spinal mobility exercises, non-steroidal anti-inflammatory drugs (NSAIDs), corticotherapy, and anti-tumor necrosis factor alpha (TNF-α) biological agents. Anti-TNF-α biological agents have changed the prognosis of patients with AS. They contain anti-TNF-α monoclonal antibodies (golimumab, infliximab, adalimumab, certolizumab) and the soluble TNF-α receptor (etanercept). Hip and knee involvement is common in patients with AS, as evidenced in radiographs as bone erosion and joint space narrowing. The patient may have severe pain, stiffness, and loss of mobility, and the treatment involves surgery for joint arthroplasty. We present the case of a 63-year-old patient with axial spondyloarthritis who was treated with infliximab and developed cerebral tuberculosis after three years of biological therapy. The purpose of the study is to determine the possibility of resuming biological therapy at the time of AS reactivation, given the long-term treatment and adverse reactions of cortisone therapy (aseptic necrosis of the femoral head).

A Narrative Review of Patellar Resurfacing Versus Non-resurfacing in Total Knee Arthroplasty

The number of individuals who experience the symptoms of gonarthrosis rises proportionally as life expectancy rises and the population becomes more active. The purpose of total knee arthroplasty (TKA) is to lessen pain and restore knee function, and it has a high success rate. The restoration of patellar tracking in addition to the proper alignment of the femoral and tibial components contributes to the success of the arthroplasty and the patient's happiness. Replacement of the knee is not an easy process. One of the major objectives of total knee replacement is to achieve the proper rotation of the femoral components. A critical step that affects postoperative outcomes in total knee arthroplasty is the correct alignment of the femoral component. The axial plane of the femoral component is to blame for flexion stability, knee joint kinematics, flexion alignment, and patellar tracking. The patella is the largest sesamoid bone in the human body, and its major role is to enhance the quadriceps' moment arm, which allows the knee to expand. The distribution of patellofemoral compressive pressures during knee flexion and the centralization of the quadriceps muscles' multidirectional pull during extension are both critical functions of the patella. After primary knee arthroplasty, there are 8% more cases of anterior knee discomfort than there were before. Whether or not the patella was resurfaced, patients with primary TKA experience anterior knee discomfort. Patella baja is caused by excessive joint line elevation, which causes persistent overload and discomfort. The design of the TKR might have an impact on postoperative patellofemoral problems. After TKR, patellofemoral maltracking and patellar dislocation are often caused by surgical mistakes.

Metagenomic Next-Generation Sequencing for Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) after arthroplasty is a major complication, which requires significant resources, resulting in high costs for the medical system. In recent years, significant progress has been made in the diagnosis and treatment of periprosthetic infections, the identification of the pathogen being the central element in the establishment of targeted antibiotic therapy. Next-generation sequencing (NGS) or metagenomic NGS (mNGS) represents a promising, fast alternative, with increased specificity and sensitivity compared to identification methods using conventional culture media, thus enabling an increased rate of identification of pathogenic microorganisms and antibiotic resistance genes (ARG). The purpose of this article was to highlight new molecular diagnostic methods for periprosthetic joint infections and their involvement in treatment efficiency. NGS technologies are cutting-edge techniques that may challenge the PJI diagnostic model.

Melorheostosis: A Review of the Literature and a Case Report

Background and Objectives: Melorheostosis, also referred to in the literature as Leri's disease, is an unusual mesenchymal dysplasia with the clinical appearance of benign sclerosing bone dysplasia; it frequently occurs in late adolescence. Any bone in the skeletal system can be affected by this disease, though the long bones of the lower extremities are the most common, at any age. Melorheostosis has a chronic evolution, and symptoms are usually absent in the early stages. The etiopathogenesis is still unknown, however, numerous theories have been proposed that could explain the appearance of this lesion formation. An association with other benign or malignant bone lesions is also possible, and associations with osteosarcoma, malignant fibrous histiocytoma, or Buschke-Ollendorff syndrome have also been reported. There have also been reported cases of the malignant transformation of a pre-existing melorheostosis lesion into malignant fibrous histiocytoma or osteosarcoma. The diagnosis of melorheostosis can be made only based on radiological images, but, due to its polymorphism, additional imaging investigations are often necessary and sometimes only a biopsy can establish a definite diagnosis. Because there are currently no guidelines for treatment based on scientific evidence, due to the low number of cases diagnosed worldwide, our objective was to highlight the early recognition and specific surgical treatments for better prognosis and outcomes. Materials and Methods: We conducted a review of the literature consisting of original papers, case reports, and case series and presented the clinical and paraclinical characteristics of melorheostosis. We aimed to synthesize the treatment methods available in the literature as well as determine possible future directions related to the treatment of melorheostosis. Furthermore, we presented the results of a case of femoral melorheostosis admitted to the orthopedics department of the University Emergency Hospital of Bucharest in a 46-year-old female patient with severe pain in the left thigh and limitation of joint mobility. Following the clinical examination, the patient complained of pain in the middle third of the left thigh in the antero-medial compartment; the pain appeared spontaneously and was aggravated during physical activity. The pain started about two years prior, but the patient experienced complete pain relief after the administration of non-steroidal anti-inflammatory drugs. In the last six months, the patient presented an increase in pain intensity without significant improvement following the administration of non-steroidal anti-inflammatory drugs. The patient's symptoms were mainly determined by the increase in the volume of the tumor and the mass effect on the adjacent tissues, especially on the vessels and the femoral nerve. The CT examination and bone scintigraphy showed a unique lesion in the middle third of the left femur and no oncological changes in the thoracic, abdominal, and pelvic regions; however, at the level of the femoral shaft, there was a localized cortical and pericortical bone lesion formation that surrounded approximately 180 degrees of the femoral shaft (anterior, medial, and lateral). It had a predominantly sclerotic structure but was associated with lytic areas with thickening of the bone cortex and areas of periosteal reaction. The next therapeutic gesture was to perform an incisional biopsy using a lateral approach at the level of the thigh. The histopathological result supported the diagnosis of melorheostosis. Additionally, immunohistochemical tests completed the data obtained after the microscopic examination through the classic histopathological technique The patient was discharged and included in a full medical recovery program for eight weeks in a specialized medical center, during which she also received analgesic treatment in maximum doses, but without improvement regarding her symptoms. Taking into account the chronic evolution of the pain, the complete lack of response to conservative treatment after eight weeks, and the lack of treatment guidelines in the case of melorheostosis, a surgical approach needed to be considered. The surgical option in this case, considering the circumferential location of the lesion at the level of the femoral diaphysis, was a radical resection. The surgical approach consisted of segmental resection to healthy bone tissue and reconstruction of the remaining defect with a modular tumoral prosthesis. At the 45-day postoperative control, the patient no longer complained of pain in the operated-on limb and was mobile with full support without gait difficulties. The follow-up period was one year, and the patient presented complete pain relief and a very good functional outcome. Results: In the case of asymptomatic patients, conservative treatment seems to be a good option with optimal results. However, for benign tumors, it remains unclear whether radical surgery is a viable option. Conclusions: Melorheostosis remains an incompletely understood disease, given the limited number of cases worldwide, and thus, there is a lack of clinical guidelines regarding specialized treatment.

Comminuted intraarticular calcaneal fractures: Multiplanar VA locked plating and interlocked nailing incorporate longitudinal strut and provide superior stability - a biomechanical cadaveric study

Treatment of comminuted intraarticular calcaneal fractures remains controversial and challenging. The aim of this study was to investigate the biomechanical performance of three different methods for fixation of such fractures. Comminuted calcaneal fractures, including Sanders III AB fracture of the posterior facet and Kinner II B fracture of the calcaneocuboid joint (CCJ) articular calcaneal surface, were created in 18 human cadaveric lower legs by osteotomizing. The ankle joint, medial soft tissues and midtarsal bones along with their ligaments were preserved. The specimens were randomized to three groups for fixation with either (1) 2.7 mm variable-angle locking lateral calcaneal plate (Group 1), (2) 2.7 mm variable-angle locking anterolateral calcaneal plate in combination with one 4.5 mm and one 6.5 mm cannulated screws (Group 2), or (3) interlocking calcaneal nail with 3.5 mm screws in combination with three separate 4.0 mm cannulated screws (Group 3). All specimens were biomechanically tested to failure under axial loading in midstance foot position. Each test commenced with a quasi-static compression ramp from 50 to 200 N, followed by progressively increasing cyclic loading at 2 Hz. Starting from 200 N, the peak load of each cycle increased at a rate of 0.2 N/cycle. Interfragmentary movements were captured by motion tracking. In addition, mediolateral X-rays were taken every 250 cycles with a triggered C-arm. Böhler angle after 5000 cycles (1200 N peak load) increased significantly more in Group 1 compared to both other groups (P ≤ 0.020). Varus deformation of 10° between the calcaneal tuberosity and the lateral calcaneal fragments was reached at significantly lower number of cycles in Group 1 compared the other groups (P ≤ 0.017). Both cycles to 10° plantar gapping between the anterior process and the calcaneal tuberosity fragments, and 2 mm displacement at the CCJ articular calcaneal surface revealed no significant differences among the groups (P ≥ 0.773). From a biomechanical perspective, treatment of comminuted intraarticular calcaneal fractures using anterolateral variable-angle locking plate with additional longitudinal screws or interlocked nail in combination with separate transversal screws provides superior stability as opposed to lateral variable-angle locked plating only.

A nomogram for predicting post-operative wound complications after open reduction and internal fixation for calcaneal fractures

The purpose of our study was to determine the risk factors for post-operative wound complications (PWCs) after open reduction and internal fixation (ORIF) for calcaneal fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from calcaneal fractures and had been surgically treated for ORIF in our institution between January 2010 and January 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of PWCs, and a nomogram model was constructed to predict the risk of PWCs. The predictive performance and consistency of the model were evaluated by the Hosmer -Lemeshow (H-L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that smoking, limb swelling, angle of incision, and CRP were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.982 (95%CI 0.97-0.99). The H-L test revealed that the normogram prediction model had good calibration ability (P = .957). Finally, we found a correlation between PWCs and smoking, limb swelling, angle of incision, and CRP after ORIF for calcaneal fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high-risk patients, as interventions could be taken early to reduce the incidence of PWCs.