Orthopaedic trauma residency programs: Perspectives from different countries across the world

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Managing periprosthetic fractures: perspectives on periprosthetic pelvic fractures

Periacetabular periprosthetic fractures are rare but potentially disastrous for the longevity of the adjacent implants, leading to multiple revision surgeries. It is of paramount importance to identify and treat intraoperative fractures, which will lead to satisfactory results. Postoperative fractures may be managed operatively or nonoperatively depending on the patient's pain and function, the fracture pattern, and the stability of the acetabular component.

Homemade 3D mirror imaging models utility for surgical treatment of complex fractures of scapula

The treatment of complex articular scapular fractures requires obtaining an anatomic reduction. The experience of the surgeon and the surgical skills needed are still the most important aspect in this surgical field. 3D printed models at a 1:1 scale provides tactile and visual experience. We used a specular healthy scapula (reverse engineering) as a reliable template for preoperative planning. We pre-contour plates directly over a printed mold, for direct application, without further corrections during the surgical procedure. This reduces improvisation during surgery, the risks of complications and the total costs while improving the accuracy of the anatomical restoration of the native glenopolar angle derived from the indirect reduction of the fracture. Until recently, the use of RP (rapid prototyping) models for managing complex fractures required contracting the services provided by external companies, with the constraints posed on cost and time. We made the whole process ourselves in a DIY mode: from the post-processed radiological images to the 3D model printing, pre contoured plates and surgical simulation.

International trauma care: initial European approaches during the COVID 19 pandemic

The world was not prepared for the global of pandemic in early 2020 with the arrival of COVID 19. Europe has some of the most developed health care systems in the world and this article explains the initial response to the pandemic from an orthopaedic and trauma viewpoint from 8 nations. Italy reported the first cluster in February, which then rapidly spread around the continent, requiring a rapid reorganization of services. The reports highlight how elective surgery was universally stopped, surgical services were reconfigured, and new practices, such as the widespread use of telemedicine, may well become permanent. It also emphasizes how the pandemic has re-educated us on the importance of a consistent and central approach to deal with a global health crisis, and how medical services need to remain flexible and responsive to new ways of working.

In vitro chondral culture under compression and shear stimuli. From mesenchymal stem cells to hyaline cartilage

INTRODUCTION

The in vitro creation of hyaline joint cartilage is a challenge since, to date, the ex vivo synthesis of a structured tissue with the same biomechanical and histological properties of the joint cartilage has not been achieved. To simulate the physiological conditions we have designed an in vitro culture system that reproduces joint movement.

MATERIAL AND METHOD

We have developed a cell culture bioreactor that prints a mechanical stimulus on an elastin matrix, in which mesenchymal stem cells (MSC) are embedded. The first phase of study corresponds to the development of a bioreactor for hyaline cartilage culture and the verification of cell viability in the elastin matrix in the absence of stimulus. The second phase of the study includes the MSC culture under mechanical stimulus and the analysis of the resulting tissue.

RESULTS

After culture under mechanical stimulation we did not obtain hyaline tissue due to lack of cellularity and matrix destructuring.

CONCLUSION

The stimulus pattern used has not been effective in generating hyaline cartilage, so other combinations should be explored in future research.

Ultrasound-guided supra-acetabular pelvic external fixator (US-SA FIX)

BACKGROUND

Between the different options in pelvic external fixation, the supra-acetabular pin placement is considered the best option by many authors. The aim of this study is to describe the surgical technique of the ultrasound-guided supra-acetabular pelvic external fixator (US-SA FIX).

SURGICAL TECHNIQUE

Description of the steps to perform the US-SA FIX technique.

DISCUSSION

The supra-acetabular pin placement is considered the best option and it is the most wildly used because it combines three crucial qualities: safety, simplicity, and effectiveness. Notwithstanding, when a severely multiple injured patient arrives at the emergency room we need to perform an emergency external fixation, however trained x-ray technicians or pelvic surgeons are not always present, making it difficult to perform the surgery with the proper intra-operative imaging, increasing the surgical time with potentially serious repercussions, a case scenario where the ultrasound can be a very helpful tool. Ultrasound-guided supra-acetabular pelvic external fixator pin placement is feasible without compromising the reliability of its placement, and the application of this new technique in clinical practice in our centre brings encouraging results.

Ultrasound-guided supra-acetabular pin placement in pelvic external fixation: description of a surgical technique and results

INTRODUCTION

Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in the context of damage control surgery. Supra-acetabular pin offers the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study was to analyze our results for an ultrasound-guided supra-acetabular pinning.

MATERIAL AND METHODS

Cross-sectional study with cadaveric specimens. Ultrasound-guided pin placement assessed by fluoroscopy and dissection.

RESULTS

Fourteen ultrasound-guided supra-acetabular pins were placed in seven cadaveric specimens. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixation after dissection. One femoral cutaneous nerve was not found during anatomic dissection and was assumed injured.

CONCLUSION

Ultrasound-guided supra-acetabular pin placement is a feasible and effective technique. Our study indicates that pin placement without intraoperative fluoroscopy is feasible without compromising the reliability of its placement.

3D surgical printing and pre contoured plates for acetabular fractures

We describe the methodical and possibilities of 3D surgical printing in preoperative planning of acetabular fractures showing a case of a 45-year-old with an associated transverse fracture of the left acetabulum with posterior wall fracture, with multiple fragments, and posterior ipsilateral hip dislocation, defending the do it your-self mode.

Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to compare the outcomes of 1-mm ultra-minimally invasive ultrasound-guided carpal tunnel release and 2-cm blind mini-open carpal tunnel release.

METHODS

We conducted a single-center individual parallel-group controlled-superiority randomized control trial in an ambulatory office-based setting at a third-level referral hospital. Eligible participants had clinical signs of primary carpal tunnel syndrome and positive electrodiagnostic test results and were followed for 12 months. Independent outcome assessors were blinded. Patients were randomized by concealed allocation (1:1) by an independent blocked computer-generated list. The postoperative score on the Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was the primary variable. Grip strength and time for discontinuation of oral analgesics, complete wrist flexion-extension, relief of paresthesia, and return to normal daily activities (including work) were assessed.

RESULTS

Ninety-two of 128 eligible patients were randomly allocated and analyzed. QuickDASH scores were 2.2 to 3.3 times significantly lower in the ultra-minimally invasive group for the first 6 months: 23.6 [95% confidence interval (CI), 20.5, 27.4] versus 52.6 [95% CI, 49.4, 57.0] at the first week and 4.09 [95% CI, 1.5, 7.1] versus 13.0 [95% CI, 9.4, 18.9] at 6 months. Return to normal daily activities occurred significantly sooner in the ultra-minimally invasive group: 4.9 [95% CI, 3.2, 6.5] versus 25.4 [95% CI, 18.2, 32.6] days.

CONCLUSIONS

Ultra-minimally invasive carpal tunnel release provides earlier functional return and less postoperative morbidity with the same neurologic recovery as mini-open carpal tunnel release for patients with symptomatic primary carpal tunnel syndrome.

Retained Sponge: A Rare Complication in Acetabular Osteosinthesis

Retained sponges after a surgical treatment of polytrauma may cause a broad spectrum of clinical symptoms and present a difficult diagnostic problem. We report a case of retained surgical sponge in a 35-year-old man transferred from another hospital, that sustained a open acetabular fracture. The fracture was reduced through a limited ilio-inguinal approach. After 4 days, he presented massive wound dehiscence of the surgical approach. An abdominal CT scan showed, lying adjacent to the outer aspect of the left iliac crest, a mass of 10 cm, identified as probable foreign body. The possibility of this rare complication should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass.

Methods and Guidelines for Venous Thromboembolism Prevention in Polytrauma Patients with Pelvic and Acetabular Fractures

Sequential compression devices and chemical prophylaxis are the standard venous thromboembolism (VTE) prevention for trauma patients with acetabular and pelvic fractures. Current chemical pharmacological contemplates the use of heparins or fondaparinux. Other anticoagulants include coumarins and aspirin, however these oral agents can be challenging to administer and may need monitoring. When contraindications to anticoagulation in high-risk patients are present, prophylactic inferior vena cava filters can be an option to prevent pulmonary emboli. Unfortunately strong evidence about the most effective method, and the timing of their commencement, in patients with pelvic and acetabular fractures remains controversial.

[Total knee arthroplasty in a patient with meniscal transplantation]

BACKGROUND

The natural history of a knee subjected to total meniscectomy leads to poor outcomes, so we should be careful with these lesions. Meniscal transplantation may be a proper treatment for these patients as it involves a good medium-term survival.

MATERIAL AND METHOD

We report the case of a 52 year-old male who underwent meniscal transplantation and developed left gonarthrosis. The surgical approach consisted of medial longitudinal arthrotomy and implantation of a posterior stabilized prosthesis after releasing the soft tissues, which were very retracted.

RESULTS

At the one year follow-up the operated knee had an articular range of 0-110 degrees, with no gap and no pain; no external support was required for walking.

CONCLUSIONS

Despite the fact that most case series report good short- and medium-term results, some patients do not have good results and need a total knee prosthesis.

Stoppa approach, an alternative for total hip arthroplasty in an intra-pelvic cup

Removal of an acetabular prosthesis that has migrated into the pelvis can be hazardous. We describe the preoperative planning and the surgical procedure for removing a severely displaced acetabular component in one patient and outline our recommendation for the use of Stoppa approach because it has advantages of simple dissection, a low complication rate, and may help in preventing life-threatening problems.

Cup-cage construct for acute fractures of the acetabulum, re-defining indications

Acetabular fractures in the elderly are challenging injuries. The use of a trabecular metal acetabular cage was investigated as the treatment option in a series of elderly patients with acetabular fractures. At a 2-year follow up, 6 elderly patients were found to have mimimum pain, increased function, and increased scores using the Merle d'Aubigné and Postel system modified by Charnley. Radiographically, the areas of morsellised autograft that surrounded the cups were seen to have incorporated uniformly well, and the acetabular fractures were healed within six months after surgery. No mechanical failure, screw breakage, loosening, or migration was noticed. This novel indication of the cup-cage construction that uses revision techniques, for selected patients and fractures, to achieve an acute stable reconstruction, should be considered as an alternative reconstruction option in elderly patients presenting with acetabular fractures.

[Trabecular metal box for acute acetabular fracture in an elderly patient]

BACKGROUND

We are currently observing an increase in the incidence of acetabular fractures in elderly patients due to the increase in this population age group. These fractures represent a challenge to the traumatologist because in some cases there is the surgical alternative of combining fixation with total acute hip arthroplasty. In this paper we explore the use of trabecular metal combining the stability provided by a cage with potential bone incorporation, applying the principles of revision surgery to speed-up the healing process without the limitations resulting from the restrictions in the load of the operated limb.

MATERIAL AND METHODS

We assessed the clinical and radiological results, with a 2-year follow-up, after total hip arthroplasty for the acute treatment of an acetabular fracture of the anterior column, with involvement of the quadrilateral lamina in an elderly 85 year-old patient.

RESULTS

Important pain relief occurred, with functional improvement and an appropriate range of motion using the Merle d'Aubigné system. Radiologically, the graft areas in the particles surrounding the acetabular component were uniformly integrated. No loosening, screw rupture or implant migration occurred.

CONCLUSIONS

This indication using a revision technique based on a trabecular metal reconstruction cage should be considered as an alternative to bear in mind in these patients.

Trends in incidence and outcomes of revision total hip arthroplasty in Spain: a population based study

Background

To analyze changes in incidence and outcomes of patients undergoing revision total hip arthroplasty (RTHA) over an 8-year study period in Spain.

Methods

We selected all surgical admissions in individuals aged ≥ 40 years who underwent RTHA (ICD-9-CM procedure code 81.53) between 2001 and 2008 from the Spanish National Hospital Discharge Database. Age- and sex-specific incidence rates, Charlson co-morbidity index, length of stay (LOS), costs and in-hospital mortality (IHM) were estimated for each year. Multivariate analyses were conducted to asses time trends.

Results

32, 280 discharges of patients (13, 391 men/18, 889 women) having undergone RTHA were identified. Overall crude incidence showed a small but significant increase from 20.2 to 21.8 RTHA per 100, 000 inhabitants from 2001 to 2008 (p < 0.01).

The incidence increased for men (17.7 to 19.8 in 2008) but did not vary for women (22.3 in 2001 and 22.2 in 2008). Greater increments were observed in patients older than 84 years and in the age group 75-84. In 2001, 19% of RTHA patients had a Charlson Index ≥ 1 and this proportion rose to 24.6% in 2008 (p < 0.001). The ratio RTHA/THA remained stable and around 20% in Spain along the entire period

The crude overall in-hospital mortality (IHM) increased from 1.16% in 2001 to 1.77% (p = 0.025) in 2008. For both sexes the risk of death was higher with age, with the highest mortality rates found among those aged 85 or over. After multivariate analysis no change was observed in IHM over time. The mean inflation adjusted cost per patient increased by 78.3%, from 9, 375 to 16, 715 Euros from 2001 to 2008.

After controlling for possible confounders using Poisson regression models, we observed that the incidence of RTHA hospitalizations significantly increased for men and women over the period 2001 to 2008 (IRR 1.10, 95% CI 1.03-1.18 and 1.08, 95% CI 1.02-1.14 respectively).

Conclusions

The crude incidence of RTHA in Spain showed a small but significant increase from 2001 to 2008 with concomitant reductions in LOS, significant increase in co-morbidities and cost per patient.

Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 2: randomized comparative study of the economic impact of 3 surgical models

OBJECTIVES

Trigger digit surgery can be performed by an open approach using classic open surgery, by a wide-awake approach, or by sonographically guided first annular pulley release in day surgery and office-based ambulatory settings. Our goal was to perform a turnover and economic analysis of 3 surgical models.

METHODS

Two studies were conducted. The first was a turnover analysis of 57 patients allocated 4:4:1 into the surgical models: sonographically guided-office-based, classic open-day surgery, and wide-awake-office-based. Regression analysis for the turnover time was monitored for assessing stability (R(2) < .26). Second, on the basis of turnover times and hospital tariff revenues, we calculated the total costs, income to cost ratio, opportunity cost, true cost, true net income (primary variable), break-even points for sonographically guided fixed costs, and 1-way analysis for identifying thresholds among alternatives.

RESULTS

Thirteen sonographically guided-office-based patients were withdrawn because of a learning curve influence. The wide-awake (n = 6) and classic (n = 26) models were compared to the last 25% of the sonographically guided group (n = 12), which showed significantly less mean turnover times, income to cost ratios 2.52 and 10.9 times larger, and true costs 75.48 and 20.92 times lower, respectively. A true net income break-even point happened after 19.78 sonographically guided-office-based procedures. Sensitivity analysis showed a threshold between wide-awake and last 25% sonographically guided true costs if the last 25% sonographically guided turnover times reached 65.23 and 27.81 minutes, respectively. However, this trial was underpowered.

CONCLUSIONS

This trial comparing surgical models was underpowered and is inconclusive on turnover times; however, the sonographically guided-office-based approach showed shorter turnover times and better economic results with a quick recoup of the costs of sonographically assisted surgery.

Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 1: clinical efficacy and safety

OBJECTIVES

For trigger digits, intrasheath sonographically guided first annular (A1) pulley release has shown safety and effectiveness in cadavers. This clinical study describes sonographically guided A1 pulley release results in terms of resolution of symptoms, safety, and functional recovery.

METHODS

Sonographically guided A1 pulley release (11-MHz probe) was used in 48 digits of 48 patients prospectively followed for 11.3 months and examined 1, 3, and 6 weeks, 3 and 6 months, and 1 year later. Resolution of triggering (primary variable of interest) was expressed as the "success rate" per digit. The time for taking postoperative pain killers, range of motion recovery, grip strength, QuickDASH test scores, return to normal activities (including work), cosmetic results, satisfaction, and complications were assessed.

RESULTS

The success rate was 100%, and no cases recurred. Mean times were 1.9 days for taking pain killers, 6.6 days for returning to normal activities, and 9.9 and 3.8 days for complete extension and flexion recovery, respectively. Mean QuickDASH scores were 39.8 preoperatively and 7.8, 1.7, and 0 after 6 weeks, 6 months, and 1 year postoperatively. Grip strength reached greater than 90% of the individual's normal strength by the sixth week in men and by the third month in women (P < .001). Radial digital nerve numbness developed in 1 finger, which disappeared by the third week. No other complications were noted. All wounds were cosmetically excellent, and final satisfaction was excellent or good in 98%.

CONCLUSIONS

With adequate anatomic knowledge, technical training, and a basic ultrasound machine, sonographically guided A1 pulley release can be performed safely and successfully, offering an alternative to classic open surgery in the ambulatory setting.

[Bilateral avascular necrosis after resurfacing hip arthroplasty. A case report]

Resurfacing hip arthroplasty is an alternative to conventional arthroplasty and it is indicated in young and active patients. Good results and the prevention of complications stem from a meticulous surgical technique and proper patient selection. We present herein the case of a 43 year-old patient who, after undergoing bilateral hip replacement with resurfacing prostheses, sustained a non-simultaneous fracture of both femoral necks due to avascular necrosis. He was treated by placing a metaphyseal anchoring stem. Postoperative X-rays showed proper implant placement without femoral notching, with a discrete 7 degrees valgus alignment of the femoral component. Both passive and active mobility was painful. X-rays showed cervical fracture of the right femur. The femoral head was attached to the implant, with no metallosis nor loosening of the femoral or acetabular components, but the bone had a fragmented and friable appearance that histopathologically was defined as avascular necrosis. Femoral neck fracture is the main complication after resurfacing hip arthroplasty. The effect of other factors like bone necrosis due to cement is unknown.