Diabetes Mellitus and Poor Glycemic Control Are Associated With a Higher Risk of Lumbar Spinal Stenosis: An Analysis of a Large Nationwide Database

STUDY DESIGN

A large-scale retrospective case-control study.

OBJECTIVE

Examine diabetes as a risk factor for lumbar spinal stenosis (LSS) development and evaluate the impact of diabetes duration, glycemic control, and associated complications on this risk.

SUMMARY OF BACKGROUND DATA

Diabetes mellitus, a multiorgan disorder impacting various connective tissues, induces histological changes in spinal structures, particularly the ligamentum flavum. While clinical studies suggest a higher incidence of LSS in diabetic patients, substantial epidemiological research on the likelihood of LSS diagnosis in individuals with diabetes is scarce.

MATERIALS AND METHODS

Using nationwide data, a total of 49,576 patients diagnosed with LSS based on International Classification of Diseases-10 codes were matched with controls of the same number based on age and sex. Employing a multivariable logistic regression model, the study assessed for the association between spinal stenosis and diabetes, while adjusting for confounders.

RESULTS

We found a higher likelihood of LSS diagnosis in diabetic patients [odds ratio (OR) 1.39, 95% CI: 1.36 - 1.43, P <0.001]. Those with hemoglobin A1c ≥7% and ≥1 diabetes-related complication also had an elevated likelihood (OR: 1.19, 95% CI: 1.08-1.31, P =0.001). Prolonged diabetes exposure increased the risk. Diabetes diagnosis reduced median survival by around 4.5 years for both stenosis and nonstenosis patients; spinal stenosis diagnosis alone minimally impacted survival. Relative to individuals diagnosed with diabetes mellitus at the age of 65 or older, the OR for developing LSS were 1.22 (95% CI: 1.18-1.27, P <0.001) when DM was diagnosed at 50 to 65 years old and 1.67 (95% CI: 1.56-1.79, P <0.001) for those under 50 years old. Multivariate analysis revealed a significantly increased risk of all-cause mortality in patients with DM and spinal stenosis (hazard ratio: 1.36, 95% CI: 1.29-1.44, P <0.001) and those with DM without stenosis (hazard ratio: 1.49, 95% CI: 1.41-1.57, P <0.001) compared with controls.

CONCLUSIONS

Diabetic patients with prolonged disease, poor glycemic control, and diabetes-related complications face an elevated risk of developing LSS. Recognizing the reciprocal adverse relationship between these conditions is crucial in clinical practice and designing public health measures for managing both conditions.

LEVEL OF EVIDENCE

4.

Femoral neck shortening as a sequela of internal fixation for femoral neck fractures and its effect on the coronal alignment of the limb: a pilot study

INTRODUCTION

Femoral neck shortening is a common phenomenon following osteosynthesis for femoral neck fractures, which was shown to have a negative effect on hip function. There is paucity of literature on the effect of shortening on the ipsilateral limb mechanical axis and knee coronal alignment. We hypothesized that postoperative femoral neck shortening can alter the limb's mechanical axis into valgus.

METHODS

Of 583 patients screened, 13 patients with severe neck shortening (< 10 mm) following femoral neck fracture fixation, were found eligible and agreed to participate. A full-length lower limb radiographs were obtained and radiographic parameters (offset, neck-shaft angle, HKA, mLPFA, mDLFA, mMPTFA, MAD, MAD-r) as well as functional scores were obtained.

RESULTS

Statistically significant differences in mechanical axis deviation ratio (MAD-r) were found between the ipsilateral and the contralateral extremities (0.41 ± 0.16 versus 0.55 ± 0.11, p = 0.03). A correlation between femoral neck length differences and MAD was not statistically significant although a tendency towards lateral deviation of the mechanical axis was noted (r = - 0.5, p = 0.077). A negative correlation was found between a greater difference in the femoral neck length and the SF12 score, both in the physical and the mental parts (r = - 0.69, p = 0.008; r = - 0.58, p = 0.035, respectively).

CONCLUSION

We found a more lateralized mechanical axis in limbs that demonstrated post-operative ipsilateral femoral neck severe shortening. These findings may provide a possible explanation and rationale for knee pain and perhaps for the development of knee osteoarthritis as a sequalae of femoral neck shortening. Further investigation and larger cohort, long-term studies are needed to further explore this hypothesis.

Can nutritional and inflammatory indices predict 90-day mortality in fragility hip fracture patients?

INTRODUCTION

Hip fractures in the elderly are related to increased mortality. The identification of patients at risk is essential. Several nutritional and inflammatory parameters were investigated in an effort to find a prognostic indicator for mortality following fragility hip fractures (FHF) surgery. We aim to evaluate their utility and compare between the different factors.

METHODS

A retrospective cohort study of patients 65 years and older, who underwent surgery following fragility hip fractures between January 2012 and June 2020, was conducted. Patients who died within 90 days were matched at a 1:1 ratio with surviving controls, based on age, gender, fracture type, and comorbidities. Nutritional and inflammatory indices, including serum albumin, protein energy malnutrition (PEM), albumin-to-globulin ratio (AGR), prognostic nutritional index (PNI), the systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), and the neutrophile-to-lymphocyte ratio (NLR), were compared between groups.

RESULTS

304 patients were included, 152 in each group. Patients' demographics were similar. Among all indices evaluated, only the PLR significantly differed between the study groups (236.9 ± 193.5 for the study group vs. 186.6 ± 119.3 for the control group (p = 0.007). In patients who survived the initial hospitalization, the PEM was also found to be correlated with 90 days mortality.

DISCUSSION

The PLR was found to be correlated with mortality risk following FHF surgery. As it can be easily calculated from accessible blood tests, we recommend its' routine assessment as a screening tool for personalized management of patients at high risk for mortality.

Diabetes Mellitus Is a Possible Risk Factor for the Development of Trochanteric Bursitis-A Large-Scale Population-Based Study

BACKGROUND

Trochanteric Bursitis (TB) is a common reason to seek primary care, previously shown to be associated with female gender and obesity. Diabetes mellitus (DM) has several musculoskeletal manifestations, but was never found to be associated with TB.

PURPOSE

To explore the association between DM and TB, based on a large database. The secondary aim was to explore the influence of gender and insulin usage on the occurrence of TB.

STUDY DESIGN

cross-sectional study.

METHODS

A population-based cohort consisting of 60,610 patients (55,428 without DM and 5182 with DM), of whom 5418 were diagnosed with TB. A logistic regression model was applied to estimate propensity scores.

RESULTS

The odds of individuals with DM being diagnosed with TB were 55.8% higher compared to the odds of patients without DM (OR: 1.558, 95% CI: [1.429, 1.70], p < 0.0001). We found that insulin users had a lower risk of TB than patients not using insulin (log-rank p < 0.0001). Females are 3.3 times more likely to have TB than males (RR: 3.337, 95% CI: [3.115, 3.584], p < 0.0001).

CONCLUSIONS

DM is a risk factor for developing TB. Insulin had a protective effect against TB, suggesting that better glycemic control might prevent this painful infliction.

Nutritional and Inflammatory Indices and the Risk of Surgical Site Infection After Fragility Hip Fractures: Can Routine Blood Test Point to Patients at Risk?

Background: Surgical site infection (SSI) after fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality. We aim to utilize several established nutritional and inflammatory indices to characterize patients at risk. Patients and Methods: A retrospective cohort study of patients 65 years and older, who underwent surgery following FHFs between January 2012 and June 2020. Those patients who presented with post-operative infection in the year after surgery were compared with patients who did not. The primary outcomes were serum albumin, protein energy malnutrition (PEM), albumin to globulin ratio, prognostic nutritional index (PNI), the systemic immune inflammation index, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, and body mass index. Results: A total of 1,546 patients, ages 82.4 ± 7.7, were included; 55 of whom presented with SSI. Demographics and comorbidities were similar. Anticoagulation treatment was more prevalent in the infected group (32.7% vs. 13.9%, p < 0.001) as were intra-capsular fractures (60% vs. 42.9%, respectively; p = 0.012). Of all indices estimated, only the PNI and the PEM were found to differ significantly (44.7 ± 9.6 and 26.1% vs. 49.4 ± 17.3 and 13.6% for the study and control groups respectively; p = 0.002 and 0.027). A logistic regression model was calculated to evaluate the contribution of fracture type and anticoagulation treatment as possible confounders. Both indices were found to be significant for infection after regression odds ratio, 2.25 for PEM; (95% confidence interval [CI], 1.089-4.344) and odds ratio, 0.97 for PNI (95% CI, 0.937-0.996). Conclusions: The PNI and the PEM were found to correlate with infection risk after FHF surgery. As both can be easily calculated from an accessible blood test, we recommend their routine use as a screening tool for tailored management of patients at risk for SSI.

Risk Factors Associated With de Quervain Tenosynovitis in Postpartum Women

BACKGROUND

De Quervain (DQ) disease is caused by stenosis of the first dorsal compartment containing the abductor pollicis longus and extensor pollicis brevis. This condition affects women 6 times more than men and is also commonly reported in pregnant and lactating women. The natural course of the disease and associated risk factors are not well understood. In this study, we described the gestational risk factors associated with postpartum DQ.

METHODS

Sixty-three postpartum women with DQ were included in final study population. Medical records were reviewed for patient characteristics, including age, comorbidities, and body mass index (BMI), and gestational information, including length of pregnancy, gestation number, single or twin birth, and weight at birth. Odds ratio (OR) for developing DQ tenosynovitis were calculated with the control group of 630 postpartum women without DQ who gave birth between 2012 and 2020 in the same district.

RESULTS

Length of pregnancy (>40 weeks, OR = 5.81 [3.29-10.28]), first childbirth (OR = 2.23 [1.32-3.77]), and weight (BMI > 25, OR = 2.08 [1.14-3.81]) were all statistically significant risk factors associated with developing DQ. Number of fetuses > 1 (OR = 0.98 [0.29-3.33]) and birth weight more than 3.5 kg (OR = 0.60 [0.30-1.21]) were not associated with higher risk of DQ.

CONCLUSIONS

Gestational risk factors associated with developing postpartum DQ include first pregnancy and long pregnancy of more than 40 weeks. Interestingly, child's birthweight and number of fetuses, both factors that might increase load on the first dorsal compartment while holding the child, were not shown to increase the risk of postpartum DQ.

The quality of immediate postoperative radiographs, performed after total hip replacement in the operating room versus in the post-anesthesia care unit: is there a difference?

INTRODUCTION

Currently, there are no clear guidelines regarding the optimal settings for immediate postoperative imaging following total hip arthroplasty (THA). Authors' primary aim was to determine the preferred setting for postoperative radiographs by comparing a technical quality of imaging performed in postanesthesia care unit (PACU) versus operating room (OR).

MATERIALS AND METHODS

Our study is a retrospective comparison of quality of postoperative radiographs following THAs, performed in PACU versus OR. The evaluated factors included a technical quality (penetration, collimation and presence of foreign bodies), proper patient positioning, and clinical significance of the imaging expressed in number of decisions to perform immediate revision surgery that were based on postoperative imaging.

RESULTS

267 radiographs of patients who underwent primary unilateral THA were evaluated (139 performed in PACU and 128 in OR). In terms of technical quality, PACU radiographs were characterized by better penetration (69.1% vs 27.3%, p < 0.001) and less foreign bodies in the field (95.7% vs 83.6%, p < 0.001), but less adequate collimation (41.7% vs 79.7%, p < 0.001). There was a significant difference in the number of radiographs obtained without any noteworthy technical errors - 24 (17.3%) in PACU group vs 10 (7.8%) in OR group.

CONCLUSION

Postoperative X-rays performed in the PACU were characterized by better technical quality compared to postoperative radiographs performed in OR. We, therefore, suggest to perform immediate postoperative evaluation in PACU to provide baseline radiographs of higher quality for future follow-up.

The effect of patient body mass index and sex on the magnification factor during pre-operative templating for total hip arthroplasty

INTRODUCTION

Pre-operative templating prior to hip arthroplasty has traditionally used implant-company-provided acetates, which assumed a magnification factor between 115% and 120%. In recent years, pre-operative planning has been performed with digital calibration devices, in order to calculate the magnification factor. However, these devices are not without their limitations and are not readily available at many institutions. As previous reports suggest a wide range of magnification factors, the determination of an optimal magnification factor is currently unclear. We investigated the relationship between obesity and gender on the magnification factor in order to improve the accuracy of pre-operative templating.

PATIENTS AND METHODS

Ninety-seven consecutive pre-operative calibrated pelvic radiographs using the KingMark calibration were analyzed using the TraumaCad templating software. The magnification factor calculated by the software was considered the true magnification factor and analysis was made in order to assess the effect of sex and body mass index (BMI) on the magnification factor. A linear regression analysis was utilized to create a predictive model for optimal magnification factor value.

RESULTS

Magnification factor was significantly affected by sex (male, 120.0% vs. female 121.2%, p < 0.01) and by categorized BMI (obese 121.8% vs. non-obese 119.9%, p < 0.001). A positive linear association was found between BMI and the magnification factor (r = 0.544). The magnification factor was significantly different between the following sub-groups: obese female, non-obese female, obese male, and non-obese male (p < 0.001). When applying the model formulated by the linear regression analysis, the calculated magnification factor was within 2% of the true magnification factor for the majority of patients (n = 83, 85.6%).

CONCLUSIONS

BMI and gender have a significant effect on the magnification factor. Future determination of the magnification factor should consider the influence of these variables in order to improve the accuracy of pre-operative templating in THA.

Single Surgeon versus Co-Surgeons in Primary Total Joint Arthroplasty: Does "Two Is Better than One" Apply to Surgeons?

BACKGROUND

As the demand for total joint arthroplasties (TJA) increases steadily, so does the pressure to train future surgeons and, at the same time, achieve optimal outcomes. We aimed to identify differences in operative times and short-term surgical outcomes of TJAs performed by co-surgeons versus a single attending surgeon.

METHODS

A retrospective analysis of 597 TJAs, including 239 total hip arthroplasties (THAs) and 358 total knee arthroplasties (TKAs) was conducted. All operations were performed by one of four fellowship-trained attending surgeons as the primary surgeon. The assisting surgeons were either attendings or residents.

RESULTS

In 51% of THA and in 38% of TKA, two attending surgeons were scrubbed in. An additional scrubbed-in attending was not found to be beneficial in terms of surgical time reduction or need for revision surgeries within the postoperative year. This was also true for THAs and for TKAs separately. An attending co-surgeon was associated with a longer hospital stay (p = 0.028). Surgeries performed by fewer surgeons were associated with a shorter surgical time (p = 0.036) and an increased need for blood transfusion (p = 0.033). Neither the rate of intraoperative complications nor revisions differed between groups, regardless of the number of attending surgeons scrubbed in or the total number of surgeons.

CONCLUSION

A surgical team comprised of more than a single attending surgeon in TJAs was not found to reduce surgical time, while the participation of residents was not related with worse patient outcomes.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function.

METHODS

A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB.

RESULTS

Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups.

CONCLUSIONS

Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA.

TRIAL REGISTRATION

The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711.

LEVEL OF EVIDENCE

level I randomized controlled trial.

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.

Thickness of the Subcutaneous Fat as a Risk Factor for Surgical Site Infection Following Fragility Hip Fracture Surgery

INTRODUCTION

Surgical site infection (SSI) following fragility hip fracture (FHF) surgery is associated with increased morbidity and mortality.

SIGNIFICANCE

Prediction of patients at risk for SSI is fundamental. We aimed to determine whether subcutaneous radiographic fat measurement (SRM) is associated with increased SSI risk.

METHODS

A retrospective case-control comparison of SRMs at 3 locations around the hip. Patients diagnosed with SSI in the first post-operative year were matched with age, gender, surgical year, Charlsons' co-morbidity index score, and surgical type controls, not diagnosed with SSI, at a 1:2 ratio. Measurements included the distance between (1) the sourcil to skin surface (SS), (2) the tip of the greater trochanter to skin surface (TGTS), and (3) the most prominent lateral aspect of the greater trochanter to skin surface.

RESULTS

1430 patients were operated during the study period, of whom 45 patients presented with a diagnosis of SSI and compared to 90 controls. Infections occurred 27.4 ( ± 24.8) days following surgery. SRM significantly differed between groups, and all were higher in the study group; SS, 86.8 ± 25.5 cm vs 74.2 ± 15.3 cm; TGTS, 59.8 ± 26.3 cm vs 47.0 ± 15.8 cm; and LGTS, 45.4 ± 25.1 cm vs 33.2 ± 15.1 cm (P = .003, .004, and .004, respectively). Intraclass correlation coefficients (intra-rater) were high for all measurements (.999 for all). Intraclass correlation coefficients (inter-rater) for SS, TGTS and LGTS were high, .749 (.663.815), .792 (.719.847) and .817 (.751.866), respectively.

CONCLUSIONS

SRMs were found to be a valid and reproducible tool for predicting high risk of SSI in geriatric patients sustaining FHFs.

LEVEL OF EVIDENCE

III.

Medium-term outcome and classification of traumatic anterior hip dislocations

INTRODUCTION

Traumatic anterior hip dislocations are subdivided to obturator (inferior) and pubic (superior) dislocations by Epstein's descriptive classification. This rare injury is thought to have favourable clinical outcomes. The incidence of associated femoral head and acetabular injuries has been low in past case series. We sought to revisit this injury and classification in the era of advanced imaging and contemporary surgical techniques.

MATERIALS AND METHODS

A retrospective study of 15 patients treated for anterior hip dislocation was performed. Medical records were reviewed for demographic and surgical data. Imaging studies were revisited to determine direction of dislocation and associated fractures. Patients were assessed for pain, hip function using the modified Harris Hip Score (mHHS), hip range of motion and radiographic changes. Mean follow-up time was 3 years.

RESULTS

Anterior dislocation occurred in an obturator (inferior), pubic (superior) or central direction. 9 patients had concomitant femoral head impaction and 7 patients suffered from acetabular fractures. 8 patients with an anterior hip dislocation underwent surgical treatment. This therapy, along with early range of motion and weight bearing, produced favourable clinical outcomes with 9 patients reporting no pain and an average mHHS of 83.8. 6 patients had heterotopic ossification at latest follow-up.

CONCLUSIONS

Traumatic anterior hip dislocation is commonly associated with femoral head impaction and acetabular injuries which should be addressed operatively when appropriate to produce favourable results. In this paper, we propose a revision to the commonly used descriptive classification system.

Lateral Column Lengthening for Flexible Flat Foot: Was It Short to Begin With?

BACKGROUND

Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column.

OBJECTIVES

To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter.

METHODS

The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio.

RESULTS

All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not.

CONCLUSIONS

Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter.

The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery

BACKGROUND

Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied.

OBJECTIVES

To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years.

METHODS

A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts.

RESULTS

During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups.

CONCLUSIONS

LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.

C5 Palsy Following Cervical Spine Decompression

BACKGROUND

Cervical spinal surgery is considered safe and effective. One of the few specific complications of this procedure is C5 nerve root palsy. Expressed primarily by deltoid muscle and biceps brachii weakness, it is rare and has been related to nerve root traction or to ischemic spinal cord damage.

OBJECTIVES

To determine the clinical and epidemiological traits of C5 palsy. To determine whether C5 palsy occurs predominantly in one specific surgical approach compared to others.

METHODS

A retrospective study of patients who underwent cervical spine surgery at our medical center during a consecutive 8-year period was conducted. The patient data were analyzed for demographics, diagnosis, and surgery type and approach, as well as for complications, with emphasis on the C5 nerve root palsy.

RESULTS

The study group was comprised of 124 patients. Seven (5.6%) developed a C5 palsy following surgery. Interventions were either by anterior, by posterior or by a combined approach. Seven patients developed this complication. All of whom had myelopathy and were older males. A combined anteroposterior (5 patients) and posterior access (2 patients) were the only approaches that were associated with the C5 palsy. None of the patients who were operated via an anterior approach did develop this sequel.

CONCLUSIONS

The incidence of the C5 root palsy in our cohort reached 5.6%. Interventions performed through a combined anterior-posterior access in older myelopathic males, may carry the highest risk for this complication.

The Reliability of Classifying the Morphology of Anterior Cruciate Ligament Remnants during Surgery

Arthroscopic classification of the torn anterior cruciate ligament (ACL) morphology is fundamental for clinical studies on emerging techniques such as repair and preservation. At present, the most acknowledged classification is Crain description of four morphological patterns. The purpose of the study was to analyze the intra- and interobserver reliability of Crain classification in patients undergoing ACL reconstruction surgeries. The study included 101 patients who had ACL reconstruction surgery between the years 2014 and 2017. The morphological pattern of ACL remnant scar formation during surgery was observed and classified according to Crain by three orthopaedic surgeons. Inter- and intraobserver reliabilities were measured using kappa statistics. Intraobserver reliability for the Crain classification ranged from 0.63 to 0.83 (substantial to almost perfect agreement). Interobserver reliability was 0.51 (moderate agreement). In almost a third of the cases, observers reported on additional morphological pattern of scar formation that was not well defined by Crain. A modified classification of four patterns was suggested: (A) without scar tissue, (B) with adhesion to the femoral notch (wall or roof), (C) with adhesion to the notch and posterior cruciate ligament (PCL), and (D) with adhesion to the PCL. Reanalysis of these four morphological configurations resulted in interobserver reliability of 0.82 (almost perfect agreement). In conclusion, the Crain classification of torn ACL remnant morphology has moderate interobserver reliability; however, a suggested classification with modified and additional configurations has almost perfect reliability and may be useful for studies on ACL repair and preservation.

Efficacy of Anti-inflammatory Treatment Versus Rescue Analgesia After Arthroscopic Partial Meniscectomy in Nonarthritic Knees: A 3-Arm Controlled Study

Background

There is currently no consensus regarding the appropriate treatment for postoperative pain after arthroscopic partial meniscectomy (APM). Prescribing a mild non-anti-inflammatory protocol of rescue analgesia may be sufficient to avoid the side effects of opioids or anti-inflammatories.

Purpose/Hypothesis

The purpose was to compare the efficacy of pain reduction after APM in nonarthritic knees using betamethasone or celecoxib as anti-inflammatory analgesics versus acetaminophen or tramadol as rescue analgesics. The hypothesis was that there is no advantage for anti-inflammatories in achieving postoperative immediate pain relief after APM in nonarthritic knees compared with a simple nonopioid treatment.

Study Design

Cohort study; Level of evidence, 2.

Methods

This 3-arm controlled study evaluated postoperative pain levels and analgesic consumption in patients who underwent primary APM (under general anesthesia) at a single institution from December 2018 to December 2019. Patients were prospectively divided into 3 treatment groups: (1) betamethasone injection at the end of the procedure, (2) oral celecoxib prescription, or (3) neither treatment (control). All groups were instructed to take supplementary acetaminophen as needed. Patients were also allowed to take tramadol as needed to evaluate the need for opioids. At postoperative weeks 1, 2, and 3, patients completed the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, and results were compared between time points and groups.

Results

A total of 99 patients were included in the treatment groups: betamethasone group (32 patients), celecoxib group (30 patients), and control group (37 patients). At baseline, there were no statistically significant differences between the groups in age, sex, body mass index, level of activity, comorbidities, or surgical findings. KOOS Pain scores improved at every time point for all 3 groups (P < .001), and no differences in scores were observed among groups. The consumption of acetaminophen or tramadol as rescue analgesia throughout the follow-up period was negligible among groups.

Conclusion

During the first 3 postoperative weeks after APM in nonarthritic knees, pain was efficiently controlled by betamethasone or celecoxib; however, pain was also efficiently controlled by minimal consumption of acetaminophen with negligible use of tramadol. Therefore, acetaminophen could be prescribed as an effective first-line postoperative analgesic after APM.

Patient outcomes and survival following surgery for spinal metastases

Context: There is no consensus on the preferred treatment for patients with spinal metastases. Little is known about the outcomes of surgery for this population. The objectives of this paper are to examine the outcomes of surgery among patients with spinal metastases suffering from cord compression (CC) or intractable pain (IP).Design: Retrospective, descriptive (level 4) case series.Setting: Rabin Medical Center, Israel.Participants: 61 patients undergoing surgery for spinal metastasis in a tertiary care hospital. Patients were divided into two groups: those with spinal CC and those with IP only.Interventions: Surgery due to CC or IP among patients with spinal metastases.Outcome measures: Frankel scale to assess neurological status, ambulatory and incontinence status, which were examined before surgery, at discharge and at last follow-up. Endpoints were death or latest follow-up visit. Survival and postoperative complications were documented.Results: There was no significant difference in Frankel score before and after surgery among patients with CC (mean score 3.5 and 3.4 respectively, P = 0.62). Complete incontinence rates significantly increased in patients with CC between preoperative and last follow-up examinations (13.6% vs. 20%, respectively, P = 0.05). Median survival of CC and IP groups was 201 and 402 days, respectively (P = 0.32). Complication rate was 41.4%.Conclusion: In our cohort, Frankel score and walking capability of patients with CC did not change postoperatively, but continence status deteriorated over time. Surgeons should advise patients on expected surgical outcomes, especially in non-ambulatory and incontinent patients.

Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture

INTRODUCTION

Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery.

MATERIALS AND METHODS

A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year.

RESULTS

Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson's co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar.

CONCLUSIONS

Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.

Morphological and Histological Changes in the Human Anterior Cruciate Ligament after Rupture

BACKGROUND

Injuries to the anterior cruciate ligament (ACL) are common and complete tears often fail to heal. ACL reconstruction is considered the surgical gold standard of care for ACL injuries in young active patients.

OBJECTIVES

To determine the corresponding morphological and histological features of the torn ACL in different time periods after injury.

METHODS

The study included 28 remnant specimens of torn ACLs from patients who had ACL reconstruction surgery of the knee. The remnant pathology was evaluated by its morphology during arthroscopy and by histopathologic measurements.

RESULTS

At surgery there were three progressive and distinct morphological tear patterns. The first pattern was noticed within the first 3 months from injury and showed no scar tissue. The second pattern appeared later and was characterized by the appearance of scar tissue with adhesion to the femoral wall. The third pattern was characterized by adhesion of the ACL remnant to the posterior cruciate ligament. The histological changes of the first morphological pattern showed abundance of blood vessels and lymphocytes at the torn femoral end with few irregular collagen fibers. The second and third tear patterns showed decrement in the number of blood vessels and lymphocytes with longitudinally oriented collagen fibers.

CONCLUSIONS

The morphological features of the ACL remnant in the first 3 months after injury showed no scar tissue and its histological features had the characteristics of a reparative phase. This phase was followed by a prolonged remodeling phase that ended with attachment of the remnant to the posterior cruciate ligament.

The quality of informed consent obtained for orthopedic surgeries-elective versus trauma: A prospective interview-based study

BACKGROUND

Orthopedic surgeons routinely obtain informed consent prior to surgery. Legally adequate informed consent necessitates a thorough discussion of treatment options and risks and proper documentation. However, the quality of informed consent in orthopedic trauma patients is an under-researched area.

PURPOSE

To assess the quality of the informed consent process in trauma compared with elective orthopedic patients and to assess patients' emotional state at the time of signing consent form.

METHODS

Sixty-two consecutive patients undergoing either elective total joint arthroplasty ( N = 32) or orthopedic trauma surgery ( N = 30) were included. The data were collected through personal interviews using a proposed informed consent score. The interviews were held after obtaining the informed consent and before the index procedure. Patients were asked to describe their diagnosis, the surgical procedure, its' benefits, and risks as well as alternative treatments.

RESULTS

Mean age differed significantly between elective and trauma group patients (66.1 vs. 51.6, respectively, p < 0.01), while gender and education level were comparable ( p = 0.075, p = 0.55, respectively). The quality of consent was significantly better for patients with post-high-school education compared to elementary education level (consent score: 16.9 ± 4.1 vs. 12.2 ± 5.5, p = 0.021). Patients in the elective group showed an overall higher quality of consent, as reflected by a mean score of 17.03 ± 4.2 versus a mean score of only 13.73 ± 4.7 in the trauma group ( p = 0.005, 95% CI: 1.02-5.57). Specifically, trauma patients demonstrated a lower comprehension of the diagnosis, the benefits of surgical treatment, the possible complications, and the expected postoperative course.

CONCLUSION

Patients undergoing trauma surgery are significantly more likely to have an inadequate understanding of the proposed treatment. These findings raise questions concerning the validity of consent from trauma patients.

Denosumab treatment for giant-cell tumor of bone: a systematic review of the literature

BACKGROUND

Denosumab is a human monoclonal antibody (mAb) that specifically inhibits tumor-associated bone lysis through the RANKL pathway and has been used as neoadjuvant therapy for giant-cell tumor of bone (GCTB) in surgical as well as non-surgical cases. The purpose of this systematic review of the literature, therefore, is to investigate: (1) demographic characteristics of patients affected by GCTBs treated with denosumab and the clinical impact, as well as, possible complications associated with its use (2) oncological outcomes in terms of local recurrence rate (LRR) and development of lung metastasis, and (3) characteristics of its treatment effect in terms of clinical, radiological, and histological response.

METHODS

A systematic review of the literature was conducted using PubMed, EMBASE, and COCHRANE search including the following terms and Boolean operators: "Denosumab" AND "primary bone tumor", "denosumab" AND "giant cell tumor", "denosumab" AND "treatment", and finally, "denosumab" AND "giant cell tumor" AND "treatment" since 2000. After applying inclusion and exclusion criteria, a total of 19 articles were included. The quality of the included studies was assessed using STROBE for the assessment of observational studies.

RESULTS

A total of 1095 patients were included across all 19 studies. Across all the studies included, there were 615 females and 480 males. The mean patient age was 33.7 ± 8.3 years when starting the denosumab treatment. The pooled weighted local recurrence rate was 9% (95% CI 6-12%) and the pooled weighted metastases rate was 3% (95% CI 1-7%). The most common adverse event was fatigue and muscular pain. Radiologic response was estimated to occur in 66-100% of the patients. A significant reduction in pain under denosumab treatment was reported in seven studies and additional improvement in function and mobility was reported by several authors. Only two studies reported musculoskeletal tumor society (MSTS) scores which were better after denosumab treatment.

CONCLUSIONS

The use of denosumab as an adjuvant treatment of GCTB has shown a positive but variable histological response with consistent radiological changes and several types of adverse effects. There is a positive clinical response in terms of pain relief with decrease on the morbidity of surgical procedures to be performed. Finally, oncological outcomes are disparate with neither effect on metastatic disease nor local recurrence rates.

LEVEL OF EVIDENCE

IV.

The Role of 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography in the Diagnosis of Postoperative Hardware-Related Spinal Infections

BACKGROUND

Implant-related spinal infections are a surgical complication associated with high morbidity. Due to infection, hardware removal may be necessary, which could lead to pseudarthrosis and the loss of stability and alignment.

OBJECTIVES

To evaluate the accuracy and diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) in the workup of patients with suspected implant-related infections of the spine and to assess the clinical impact of PET/CT results on the management of these infections.

METHODS

The study included nine consecutive patients with a history of spinal surgery who underwent PET/CT for evaluation of suspected spinal implant related infection. All imaging studies were performed between January 2011 and December 2013. All 18F-FDG PET/CT scans were performed on an 8 slice PET/CT following an 18F-FDG injection. Images were scored both visually and semi-quantitatively by a radiology expert. Results were compared to additional imaging studies when available, which were correlated to clinical and bacteriological findings allowing calculation of sensitivity, specificity and accuracy.

RESULTS

Among the patients, five experienced hardware-related spinal infection. 18F-FDG PET/CT sensitivity was 80%, specificity 100%, and accuracy 88.9%. One scan produced a false negative; however, a second PET/CT scan revealed an infection.

CONCLUSIONS

PET/CT was found to be valuable for the diagnosis of postoperative hardware-related spinal infection, especially when other imaging modalities were uninformative or inconclusive. As such, PET/CT could be useful for management of infection treatment.

The detached stump of the torn anterior cruciate ligament adheres to the femoral notch wall and then to the posterior cruciate ligament within 6 months from injury

PURPOSE

To evaluate the progressive changes in the morphology of traumatic ruptures of the anterior cruciate ligament (ACL) over time. A secondary objective was evaluating their correlation with meniscal tears or chondral lesions.

METHODS

The study included one hundred and one patients who underwent ACL reconstruction surgery of the knee after a definite date of injury. The torn ACL remnant morphological pattern was assessed and classified during arthroscopy. A correlation analysis was performed between the pathological features of the remnant and the time length from injury. In addition, correlation between ACL remnant subtypes and meniscal tears or chondral lesions was evaluated.

RESULTS

At surgery there were four distinct ACL tear morphological patterns that were correlated to the time span from injury (r = 0.61, p < 0.001) and ended with scarring of the femoral remnant to the posterior cruciate ligament. The early pattern was noticed within median time of 2.6 months from injury and appeared as a separate stump with no scar tissue. The following two patterns appeared within 6 months from injury and were characterized by adhesion of scar tissue to different locations in the femoral notch. The last morphological pattern appeared as adherence of the ACL stump to the posterior cruciate ligament. This pattern was seen in some patients within 6 months from injury but was the dominant pattern later on and was also correlated with meniscal tears.

CONCLUSIONS

During the first 3 months from injury the gross morphological features of the torn ACL remnant showed no scar. This phase was followed by scarring of the femoral remnant at first to the femoral notch, and eventually to the posterior cruciate ligament within 6 months from injury and later on. Therefore, further research on the healing potential of the human ACL stump and its biological environment should be focused on the first 3 months from injury.

STUDY DESIGN

Case series; Level of evidence, 4.

Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population

INTRODUCTION

With the aging of the population the rate of fragility hip fractures increases. While medical recommendations are for hasten surgical treatment, for some older patients burdened with severe comorbidities, this might be risky.

AIMS

To compare the outcomes of patients treated non-surgically to those of the most fragile patients treated surgically.

PATIENTS AND METHODS

A retrospective cohort study, of individuals aged ≥65 years who presented with fragility hip fractures between 01.01.2011-30.06.2016, to a primary trauma center. Patients treated surgically were stratified according to their age-adjusted Charlsons' comorbidity index (ACCI) score. Patients in the upper third of ACCI score, representing the more fragile population, were compared to patients treated non-surgically.

RESULTS

847 patients presented with fragility fractures. 94 (11%) were treated non-surgically and 753 (89%) underwent surgery. Medical reasons were the leading cause for non-surgical treatment (61.7%). Surgically-treated patients were stratified according to their ACCI and 114 patients with ACCI > 9 were chosen for comparison. While both groups were comparable in terms of age, the non-surgical treatment group had more female patients (p. = 0.026) and a smaller proportion of independent walkers (p < 0.001). The ACCI was higher for the surgical treatment group (p < 0.001). In-hospital mortality was similar (14.9% and 18.1% for the operative and non-surgical groups respectively, P. = 0.575). However, one-year mortality was significantly higher for the non-surgical group (48.2% vs. 67.0%, P. = 0.005). The rates of in-hospital complications and 1-year readmissions were similar.

CONCLUSIONS

Operative treatment for fragility hip fracture reduces long-term mortality rates even in the more fragile patients, compared to non-surgical treatment.

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or "spare parts technique") has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the "spare parts". The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap. The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound. In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.

The Association Between Scholarly Impact and National Institutes of Health Funding in Orthopaedic Surgery

The assessment of scholarly productivity assumes a strong role in evaluating faculty in academic orthopaedic surgery. The investigators examine the association between scholarly impact, as measured by the h-index, and National Institutes of Health (NIH) funding in orthopaedic surgery. Orthopaedic surgery faculty from 20 randomly chosen departments that received NIH-funding were compared to non-NIH funded faculty from the same departments. Faculty members in orthopaedic surgery departments who received NIH funding had higher scholarly impact as measured by h-index than their non-funded peers (h = 11.98 versus 4.45; p < 0.0001). This relationship holds across academic ranks, terminal degrees, and institutions. Investigators with higher academic rank had higher scholarly impact (h = assistant 3.29 versus associate 5.12 versus full professor 7.94; p < 1 x 10-7) as well as higher NIH-funding (assistant $16,580 versus associate $26,368 versus full professor $113,129; p < 1 x 10-7). Increasing individual NIH funding is correlated with elevated scholarly impact (β = 4.64; p < 0.0001). Increasing total departmental NIH funding is correlated to increased departmental scholarly impact (β = 1.04; p < 0.0001). The h-index is strongly associated with NIH funding, academic rank, and sole PhD holding faculty. Increasing scholarly impact is also correlated with higher NIH funding. The h-index is an objective and easily calculable measure of assessing individual research productivity.

Skeletal muscle metastasis from the most common carcinomas orthopedic surgeons deal with. A systematic review of the literature

INTRODUCTION

There is scarce information in the literature dealing with the clinical presentation, management and oncologic outcomes of skeletal muscle metastases (SMM). We sought to perform a systematic review of the literature to investigate: (1) tumor characteristics of SMM, (2) therapeutic approach, and (3) oncological outcomes.

METHODS

A systematic review of the literature was performed using PubMed and EMBASE search engines. A total of 3231 references were reviewed and 49 studies were included. Demographic data, presentation characteristics, and oncological outcomes were recorded. Statistical analysis was performed using SPSS 22.0 software (IBM; Armonk, New York) and Comprehensive Meta-Analysis software version 3 (Biostat, Inc.), with p < 0.05 as statistically significant.

RESULTS

A total of 231 patients were included. These tumors presented more commonly on males 58.4% (135/231), with a mean age of 60.08 ± 10.6 years, and in the axial area 39.6% (88/222). The most common carcinoma type was lung 41.1% (95/231). Resection of a single metastases did not change survival significantly (p = 0.992). LRR was higher within the group of patients that underwent WLE compared with non-WLE [31.3% (23/74) vs. 8.7% (2/23), p ≤ 0.001]. Kaplan-Meier survival analysis for the entire cohort showed an estimate of 15.3 months [95% confidence interval (CI) 11.6-19; standard error (SE) 0.432], with lung carcinoma carrying the worst prognosis 6.7 months (95% CI 5.4-8.07; SE 0.68). Patients with a single SMM showed a worse estimate mean survival time compared to patients with multiple metastases limited to muscles [8.6 months (95% CI 4.7-12.5; SE 2.0) vs 25.4 months (95% CI 19.8-31.05; SE 2.8; p ≤ 0.001)].

CONCLUSIONS

Overall survival is poor and is driven mainly by the type of carcinoma. An Increased LRR might be present due to the systemic nature of the condition, and degree of control of the primary carcinoma.

The value of 18-FDG PET/CT in the diagnosis and management of implant-related infections of the tibia: a case series

BACKGROUND

Positron emission tomography (PET) combined with Computerised Tomography (CT) is gaining ground in clinical settings due to its added value of combined metabolic and anatomical imaging. PET/CT has shown promising results in diagnosing both acute and chronic infection of the axial and appendicular skeleton. PET imaging has an advantage in patients with metallic implants because FDG uptake, in contrast to magnetic resonance imaging (MRI) and standard computed tomography (CT), is not hampered by metallic artifacts. The role of PET/CT in the evaluation of implant-related infections involving the tibia in particular has not been thoroughly studied.

PURPOSE

To investigate the usefulness of 18-FDG PET/CT in the diagnosis and treatment of implant-related infections of the tibia following osteosynthesis.

METHODS

We reviewed 10 patients who underwent internal fixation to the tibia following trauma (4 open fractures, 6 closed fractures) and presented later with clinical signs of a possible implant-related infection. In evaluating the patients we used standard work-up methods (standard radiographs, lab tests) as well as advanced imaging techniques (PET/CT) in order to confirm the diagnosis and decide upon the preferred treatment. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were then calculated for PET/CTs ability to predict presence of infection using intraoperative cultures as the gold standard.

RESULTS

PET/CT validated our working diagnosis 9 out of 10 patients. In particular, it helped distinguish between: infected nonunion (n=4), aseptic nonunion (n=1), soft tissue infection (n=2) and chronic osteomyelitis (n=3). The overall sensitivity and specificity of PET/CT for identifying an osseous infection were 85.7% and 100%, respectively. The PPV and NPV were 100% and 75%, respectively.

CONCLUSION

PET/CT is a promising imaging modality that can aid in the work up of patients with suspected implant-related infections of the tibia following osteosynthesis, and may be used as a supportive measure in clinical decision making.

Extended Paratricipital Approach for Intra-articular Fractures of the Distal Humerus

This article describes an extensile surgical exposure to the distal humerus that is suitable for complex fractures involving the articular surface and extending into the humeral diaphysis proximal to the radial nerve. This method combines 2 approaches: olecranon osteotomy and the lateral paratricipital approach. This combination allows an appropriate exposure of both the articular surface and the humeral diaphysis up to the level of the deltoid tuberosity, while maintaining the extensor mechanism unharmed.

A Novel Non-Invasive Adjuvant Biomechanical Treatment for Patients with Altered Rehabilitation after Total Knee Arthroplasty: Results of a Pilot Investigation

BACKGROUND

Many factors contribute to suboptimal results after total knee arthroplasty (TKA) but little is known regarding the value of postsurgical rehabilitation after TKA. We examined the effects of an enhanced closed kinematic chain exercises program (AposTherapy) on gait patterns and clinical outcomes among patients with a lack of progress in their postsurgical rehabilitation.

METHODS

Twenty-two patients were prospectively followed during the study. Gait spatiotemporal parameters were measured at the initial evaluation, after 15 minutes of therapy, and after 3 months of therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the short form (SF) 36 health survey were completed by patients before treatment and after 3 months of treatment.

RESULTS

The WOMAC and SF-36 scores improved significantly after 3 months of treatment. Gait velocity, single limb support, and step length of the operated leg improved significantly even after a single 15 minutes treatment. Normal gait velocity was observed in 36% of patients after 3 months of treatment.

CONCLUSIONS

A physiotherapy program that included enhanced closed kinematic chain biomechanical therapy was beneficial for patients who experienced a suboptimal rehabilitation course after TKA.

[Posterolateral rotatory instability of the elbow]

The term posterolateral rotatory instability (PLRI) was coined in 1991 by O'Driscoll to describe the instability of the elbow caused by injury to the lateral ulnar collateral ligament (LUCL). This condition, which is usually preceded by a traumatic dislocation of the elbow, is the most common type of chronic instability of the elbow. In this type of instability, the radius and ulna rotate externally in relation to the distal humerus, leading to posterior displacement of the radial head relative to the capitellum. lateral elbow pain, clicking, popping and snapping are possible symptoms. The diagnosis of PLRI relies on a high index of suspicion and on a detailed physical examination. Several tests have been described including apprehension tests and examination under anesthesia. Surgical treatment with reconstruction of the lateral collateral ligament complex yields successful results. In this review we summarize the current knowledge of the pathoanatomy, presentation, physical examination, diagnostic tests and management of chronic posterolateral rotatory instability of the elbow.

Intramedullary nailing without curettage and cement augmentation for the treatment of impending and complete pathological fractures of the proximal or midshaft femur

Metastases in the proximal femur and in the femoral diaphysis are usually treated with either cephalomedullary or intramedullary nailing. The benefit of curettage and augmentation of the nail with methyl methacrylate remains controversial. The authors retrospectively studied the outcomes with cephalomedullary and intramedullary nailing without curettage and methyl-methacrylate augmentation for lytic metastases of the proximal/diaphyseal femur. Twenty-one complete (11) or impending (10) pathological fractures in 19 consecutive patients were treated between January 2006 and August 2013. There were 11 women and 8 men. Their mean age was 62 years (range, 38 to 87). All patients received adjuvant chemotherapy or radiotherapy.The average postsurgical survival was 9.7 months (range 1-36 months). A single deep infection was debrided. Seventeen out of 19 patients were ambulatory, with or without a walking aid. No implant failure was noted. In other words, patients succumbed to the disease prior to hardware failure. Femoral nail insertion without curettage and cement augmentation provided satisfactory stabilization of proximal and diaphyseal femur fractures, impending or complete, even when there was massive bone destruction.

Plastic cylindrical cement mold in the treatment of long bone metastatic fractures

Presented here is a simple and practical surgical technique for creating a cement spacer in the cement-metal composite fixation of pathological fractures. This technique has been effectively used in several of our patients for fixation of pathological fractures due to metastatic disease of long bones.

Septic arthritis of the knee following intraarticular injections in elderly patients: report of six patients

BACKGROUND

Intraarticular injections for the local treatment of osteoarthritis are widely used in the office or hospital setting. Septic arthritis is a potential catastrophic complication of intraarticular injection, as bacterial arthritis of any cause is associated with up to 15% mortality and residual impairment of joint function in up to 50% of survivors. There is lack of evidence regarding the precautions that should be taken to avoid such a complication, as well as how often it is encountered.

OBJECTIVES

To report our experience with the clinical presentation, diagnosis and treatment of knee septic arthritis following intraarticular injections.

METHODS

We followed six patients who were admitted to the hospital and underwent surgery for the treatment of pyogenic arthritis following injection to the knee joint in outpatient clinics.

RESULTS

All but one patient were over 70 years old with comorbidities. Three patients were injected with steroid preparations and three with hyaluronic acid several days before admission. In all six patients the infection was treated surgically and three of them had undergone more than one operation during their hospitalization. Four of the six patients were treated by means of an open arthrotomy and synovectomy, and the other two were treated successfully with arthroscopic lavage and synovectomy. One patient underwent an above-knee amputation due to septic shock and died after several days.

CONCLUSIONS

Despite the rarity of this complication, surgeons must be aware of the possibility of pyogenic arthritis when administering injections, especially in elderly patients with serious underlying medical conditions.

Overexpression of cytosolic malate dehydrogenase (MDH2) causes overproduction of specific organic acids in Saccharomyces cerevisiae

Saccharomyces cerevisiae accumulates L-malic acid through a cytosolic pathway starting from pyruvic acid and involving the enzymes pyruvate carboxylase and malate dehydrogenase. In the present study, the role of malate dehydrogenase in the cytosolic pathway was studied. Overexpression of cytosolic malate dehydrogenase (MDH2) under either the strong inducible GAL10 or the constitutive PGK promoter causes a 6- to 16-fold increase in cytosolic MDH activity in growth and production media and up to 3.7-fold increase in L-malic acid accumulation in the production medium. The high apparent Km of MDH2 for L-malic acid (11.8 mM) indicates a low affinity of the enzyme for this acid, which is consistent with the cytosolic function in the enzyme and differs from the previously published Km of the mitochondrial enzyme (MDH1, 0.28 mM). Under conditions of MDH2 overexpression, pyruvate carboxylase appears to be a limiting factor, thus providing a system for further metabolic engineering of L-malic acid production. The overexpression of MDH2 activity also causes an evaluation in the accumulation of fumaric acid and citric acid. Accumulation of fumaric acid is presumably caused by high intracellular L-malic acid concentrations and the activity of the cytosolic fumarase. The accumulation of citric acid may suggest the intriguing possibility that cytosolic L-malic acid is a direct precursor of citric acid in yeast.