Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis

BACKGROUND

The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes.

STUDY METHODS

A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed.

RESULTS

The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars.

DISCUSSION

Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Pectoralis-major-pedicled bone window for revision of a shoulder arthroplasty

PURPOSE

The aim of this study is to review our experience with the pectoralis-major-pedicled bone window for the revision of shoulder arthroplasty.

METHODS

This study used the retrospective case series of six patients who underwent a pectoralis-major-pedicled bone window for revision of shoulder arthroplasty, with a minimum follow-up of 2 years. Demographic, clinical, and radiological data were analyzed.

RESULTS

The mean age of the included patients was 72.6 years old (standard deviation (SD) 4.7), and 83.3% were women (5/1). The mean follow-up was 36.6 months (range 25-48 months). Five patients had a shoulder hemiarthroplasty and one patient a reverse shoulder arthroplasty. The indications for revision were pain in five patients and recurrent dislocation in one patient. No intraoperative complications were found. One patient developed a wound infection that required debridement and a two-stage revision. Despite complications, 2 years after surgery, the range of motions and functional scores were improved from preoperative levels. The difference between preoperative and postoperative VAS pain scores was 7.1 points (p < 0.001). The difference between preoperative and postoperative CSS and ASES questionnaires were 32 and 31.6 points, respectively (p < 0.001). At the final follow-up, all radiographs showed bone union of the osteotomy, good fixation of all components, without evidence of prosthetic loosening or migration.

CONCLUSIONS

Revision of a shoulder arthroplasty using a pectoralis-major-pedicled bone window can be an effective treatment that can yield pain relief; however, improvements in motion and function were difficult to achieve.

Total calcaneal allograft reconstruction of an Ewing's sarcoma in a child: Outcome and review of the literature

BACKGROUND

Ewing's sarcoma rarely presents in bones of the feet. Surgical management usually includes amputation. Limb sparing surgery is anecdotal.

CASE

We report the case of a 13-year-old boy with an Ewing sarcoma in his calcaneus who had a calcaneal reconstruction with total calcaneus allograft after induction chemotherapy.

CONCLUSIONS

At 42 months of follow-up our patient remains disease free and functionally intact. A review of the exceptional limb salvage procedure options for malignant calcaneus tumor was performed.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly

PURPOSE

To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR).

METHODS

We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed.

RESULTS

Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality.

CONCLUSION

DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century?

BACKGROUND

Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening.

STUDY METHODS

We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed.

RESULTS

The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients.

DISCUSSION

Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.

Outcomes of Subcapital Femoral Fracture after a Fixation of an Intertrochanteric Fracture with a Proximal Femoral Nail: Case Report

Proximal femoral fractures are a common injury that represents an important cause of hospitalization, morbidity, and mortality in elderly patients. Subcapital femoral neck fracture after fixation of an intertrochanteric fracture with a proximal femoral nail is an extremely rare complication. However, because of the large and steadily increase in the number of patients undergoing to proximal femoral nail fixation in recent years, we believe that the number of these cases could increase over time. We present a 78-year-old woman with a subcapital femoral fracture 11 months after a fixation of intertrochanteric fracture with a proximal femoral nail in the same hip. Five years of follow-up was presented. Also through our case report a review of literature of these rare cases was done, trying to evaluate the associated risk factors, the difficulties in their treatment and the final follow-up of these patients.

Hip fractures in Spain: are we on the right track? Statistically significant differences in hip fracture management between Autonomous Communities in Spain

Although medicine is currently protocol-based, there are still differences in the management of the hip fracture in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations. This data will be of great value to assist stakeholders in formulating health policies.

PURPOSE

Analysis of demographic, clinical, surgical, and functional data of the Spanish National Hip Fracture National Registry (RNFC), during admission and at 1-month follow-up, by Autonomous Communities (ACs).

METHODS

Cross-sectional analysis in the framework of a RNFC cohort, from January 2017 to May 2018, including 15 ACs from Spain, with 1 month of follow-up. Sociodemographic, clinical, surgical, and outcome variables were analyzed.

RESULTS

In total, 13,839 patients were analyzed. There were significant differences (p <0.001) in median surgical delay and percentage of patients operated in less than 48 h. Mean surgical delay was 70.75 h, with a 12-h difference between the Communities of Madrid (71.22) and Catalonia (59.65). Only 43% of patients had less than 48-h delay. Overall, most patients received regional anesthesia (91.9%); however, there was a significant difference between ACs (p = 0.0001). There were also differences in inpatient stay, early mobilization, discharge destination, and mortality (p <0.001). Mortality 30 days after surgery was 7.8%, and highest in the Basque Country (12.5%).

CONCLUSIONS

The registry showed homogeneity among ACs regarding sociodemographic variables, fracture type, surgical treatment, ASA risk, and co-management with a geriatrician or an integrated internist. There were significant differences in hip fracture management between ACs in Spain, especially regarding surgical delay, type of anesthesia, early mobilization, and discharge destinations.

Rethinking Trauma Hospital Services in one of Spain's Largest University Hospitals during the COVID-19 pandemic. How can we organize and help? Our experience

INTRODUCTION

The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistribution of resources to meet hospitals' current service needs during this pandemic. The aim is to share our experiences and outcomes during the first month of the Covid-19 pandemic, based on the strategies recommended and strategies we have implemented.

METHODS

Our experience comes from our work at a referral hospital within the Spanish National Health System. Changes to clinical practice have largely been guided by the current evidence and four main principles: (1) patient and health-care worker protection, (2) uninterrupted necessary care, (3) conservation of health-care resources, (4) uninterrupted formation for residents. Based on these principles, changes in the service organization, elective clinical visits, emergency visits, surgical procedures, and inpatient and outpatient care were made.

RESULTS

Using the guidance of experts, we were able to help the hospital address the demands of the Covid-19 outbreak. We reduced to a third of our orthopaedics and trauma hospital beds, provided coverage for general emergency services, and five ICUs, all continuing to provide care for our patients, in the form of 102 trauma surgeries, 6413 phone interviews and 520 emergency clinic visits. Also in the third week, we were able to restart morning meetings via telematics, and teaching sessions for our residents. On the other hand, eight of the healthcare personnel on our service (10.8%) became infected with Covid-19.

CONCLUSIONS

As priorities and resources increasingly shift towards the COVID-19 pandemic, it is possible to maintain the high standard and quality of care necessary for trauma and orthopaedics patients while the pandemic persists. We must be prepared to organize our healthcare workers in such a way that the needs of both inpatients and outpatients are met. It is still possible to operate on those patients who need it. Unfortunately, some healthcare workers will become infected. It is essential that we protect those most susceptible to severer consequences of Covid-19. Also crucial are optimized protective measures.

How COVID-19 has affected emergent visits to a Latin-American trauma department: Experience at a Peruvian national trauma referral center

INTRODUCTION

By May 2020, Peru was the country with the third most COVID-19 cases in the Americas. The current study's overall aim was to examine the impact of the current COVID-19 outbreak on the number of non-COVID-related patient presentations to a major national emergency traumatology/orthopedics referral center in Latin America.

METHODS

An observational study was performed at one of Peru's main tertiary trauma referral centers, during the current COVID-19 pandemic. Numbers of non-follow-up patients presenting to the traumatology/ orthopedics service were counted and compared between January through April 2019 and January through April 2020; and between the month immediately prior to the Peruvian government's implementation of national lock-down measures (Feb 16-Mar 15; Period 1) and the month immediately following (Mar 16-Apr 15; Period 2). The number of surgery service hospitalizations also was compared pre- versus post lockdown initiation (Period 1 vs. 2), as were patient characteristics and outcomes, like age, sex, discharge disposition, mortality, indications for hospital admission, and COVID-19 status.

RESULT

Comparing 2019 and 2020, no appreciable differences were detected in the number of patients seen in either January or February. However, relative to March and April 2019, the numbers of patients seen in March and April 2020 (the two months after the first Peruvian case of COVID-19 was detected) were reduced by 55.8 and 88.6%, respectively. Comparing the months immediately pre and post lockdown, the number of service patients declined by 79.9% in April, while the number of hospitalizations declined by 30.9%. The number of admissions for various surgical indications either remained stable or declined in parallel with the overall decline in admissions for all indications except for osteoporotic hip fractures and diabetic foot ulcers (both of which increased proportional to the overall number of admissions) and for hand and foot fractures, both of which decreased.

CONCLUSION

At our hospital, not all indications for traumatology/orthopedics service utilization declined despite the national government's directive to reduce non-COVID-related consultations and admissions. Some disorders presented with even greater frequency, which must be considered when developing contingencies for the reallocation of healthcare resources during a pandemic.

Patient outcomes after humeral fracture surgery during the COVID-19 outbreak in Spain

BACKGROUND

The global spread of the 2019 novel coronavirus (COVID-19) has profoundly affected the way we conduct our health care practices. The goal of this paper is to report the outcomes of 11 patients who underwent humeral fracture surgery in the first few weeks of the COVID-19 outbreak in Spain.

METHODS

This was a retrospective case series of 11 patients who underwent humeral fracture surgery during the first weeks of the COVID-19 outbreak in Spain, between March 10 and April 25, 2020. The clinical outcomes of these operative patients were monitored up to May 12, 2020, the final date of follow-up, a minimum of 15 days after all patients were discharged from the hospital. COVID-19 infection, mortality, demographic, clinical, and laboratory data were analyzed.

RESULTS

Thirty-six humeral fractures were recorded between March 10 and April 25, 2020. During this period, humeral fracture fixation was the third most common surgery for fracture in our institution after hip fracture and ankle fracture surgery. Eleven patients underwent surgery (30.5%), of whom 7 were women (63.3%). The mean age was 64.8 years (standard deviation, 13.5). Nine operated cases had a proximal humerus fracture and 2 had a humeral shaft fracture. One of the 11 patients was positive for SARS-CoV-2 on the basis of the quantitative reverse transcription polymerase chain reaction of throat swab samples. The overall median surgical time was 101.2 minutes (standard deviation, 28.4). The overall median hospital length stay for the patient discharged was 2.2 days (range, 1-4 days). No COVID-19 nosocomial intrahospital infection occurred, and no patient reported COVID-19 infection during the 15 days after hospital discharge. No intrahospital mortality was recorded. Furthermore, no COVID-19 infection was reported in the shoulder surgeons who performed the surgeries.

CONCLUSIONS

Although humeral fractures were not the most frequent fractures during this outbreak, some required surgery. With good preoperative management that included reverse transcription polymerase chain reaction for COVID-19 and chest radiographs, protective measurements for the surgical team, and rapid discharge of the patients, we were able to operate on 11 humeral fractures with no COVID-19 nosocomial intrahospital infection in the patients or in the shoulder surgeons who performed the surgeries.

Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain

INTRODUCTION

The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistribution of resources to meet hospitals' current service needs during this pandemic. The aim of this study was to provide an overview of the impact of the pandemic, and its corresponding State of Emergency, on a tertiary traumatology emergency service.

METHODS

An observational study was performed at a tertiary hospital within the Spanish National Health System. Four different periods were studied, including the first 20 days of Spain's current State of Emergency, from March 14 to April 02, 2020 (Period 4). This period was compared to the 20-day period prior to the State of Emergency (Period 3), and to matching periods in the two previous years (Periods 1 and 2). A total of 6,565 patient visits were analyzed: 1909 in Period 1 (29.1%), 2161 in Period 2 (32.9%), 1983 in Period 3 (30.2%), and 512 in Period 4 (7.8%). Variables collected included patient age and sex, insurance type, discharge destination and reason for hospital admission.

RESULTS

The patients' mean age was 55.1 years old (Standard Deviation (SD): 22.1), and 51.8% were women (3495/6565). During the COVID-19 pandemic, there were significant reductions in total visits to the trauma emergency department, workplace accidents, traffic accidents and number of hospital admissions, particularly during Period 4. However, no statistically-significant differences were found in the number of osteoporotic hip fractures admitted between the four periods. The numbers of hospital admissions for osteoporotic hip fracture were 42 during Period 1, 41 during Period 2, 43 during Period 3 and 36 during Period 4.

CONCLUSIONS

While most traumatological presentations decreased in frequency over the course of the outbreak, the number of osteoporotic hip fractures remained stable. Thus, contingency plans in times of crisis need to be carefully targeted, and to keep in mind certain public health issues that do not decrease, despite a State of Emergency, like osteoporotic hip fractures.

COVID-19 Infection After a Total Knee Arthroplasty in a Patient with Hemophilia A: A Case Report

CASE

Minimal information is available regarding coronavirus disease-19 (COVID-19) patients with hemophilia A. Coagulopathy is a major pathophysiological characteristic of COVID-19; however, because of a paucity of data, it is not clear whether these patients with hemophilia are more or less prone to the severe form of the COVID-19 disease. We report the case of a hemophilic patient with confirmed COVID-19 after total knee arthroplasty.

CONCLUSION

This case highlights the idea that patients with a congenital hypocoagulability stated as haemophilia may be protected against COVID-19 hypercoagulability-related adverse effects. Thromboprophylaxis with low-molecular-weight heparin should be evaluated in patients with hemophilia and COVID-19 disease.

Validation of the concavity-convexity quotient as a new method to measure the magnitude of scoliosis

Objectives

We propose a novel and simple method to determine the magnitude of the curve in scoliosis and its correlation with the Cobb angle.

Methods

Using multiple rounds of nominal group technique and an established consensus-building methodology, a multidisciplinary research group identified a simple method to value the curve deformity based on the vertebral pedicles.

Measurements

A mathematical study was performed to determine the relationship between the Cobb angle and the concavity-convexity quotient (CCQ). To evaluate the clinical correlation between the Cobb angle and CCQ, spine surgeons measured 48 curves (before and after follow-up) of congenital scoliosis.

Results

This quotient reflects the ratio between the distance from the upper end of the most inclined upper vertebra to the lower end of the most inclined lower vertebra on the concave side (A-distance) and the corresponding distance on the convex side of the curve (B-distance). The existing mathematical relationship is based on changing the explicit coordinates to polar coordinates. Finally, the clinical correlation between the Cobb angle and CCQ was statistically significant (r = -0.688; P < 0.001 in first measure and r = -0.789; P < 0.001 in the second measure).

Conclusions

Our study provides Level III evidence that CCQ represents a promising alternative or a complementary method to the traditional Cobb angle due to its simple and reliable ability to measure the magnitude of the curve.

Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip

Backgroud

Untreated osteonecrosis of the femoral head ultimately leads to secondary coxarthrosis. The aim of this study was to determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. We also sought to determine whether this treatment improved clinical outcomes and reduced the need for total hip arthroplasty.

Methods

Eighteen hips were included in the present study. All of them underwent core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate between 2007 and 2012. The cell concentrate was obtained from the posterior iliac crest and processed and implanted during the same surgical procedure. Patient demographic data, clinical data including modified Harris hip score, and radiological data were collected preoperatively, postoperatively, and during the follow-up period. Also, survival endpoints were analyzed: time of femoral head collapse and need for total hip arthroplasty.

Results

The mean age of patients was 37.8 years (standard deviation [SD], 9.31 years). The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months).

Conclusions

The results obtained in this study suggest that core decompression combined with implantation of autologous bone marrow concentrate and tricalcium phosphate will not prevent radiographic progression of early stage osteonecrosis of the hip. These finding also suggest that the absence of indications for hip replacement alone is not an indicator of good response to the treatment, and it is important to note the radiological results.

Safety of Romosozumab in Osteoporotic Men and Postmenopausal Women: A Meta-Analysis and Systematic Review

Sclerostin is a protein synthesized mainly by osteocytes whose function is to inhibit bone formation. A recent monoclonal antibody, Romosozumab, is able to block sclerostin. The aim of this meta-analysis is to compare the safety of Romosozumab with placebo and alendronate. Five randomized controlled trials that described the safety of Romosozumab in healthy men and postmenopausal women were analyzed. The measures to be compared were the number of adverse events and the number of serious adverse events. Specific results included injection site reaction, arthralgia, nasopharyngitis, and back pain. A total of 11,741 patients were included in this meta-analysis, in three different groups: Romosozumab, alendronate, and placebo. Significant differences were seen between the groups with regard to injection site reaction: 5.88% in the Romosozumab group versus 3.62% in the placebo group (Mantel-Haenszel [M-H] 1.54, confidence interval [95% CI] 1.22-1.96; p < 0.001) and 2.62% in the alendronate group (M-H 1.8, 95% CI 1.32-2.60; p < 0.001). In addition, patients treated with Romosozumab had significantly fewer total adverse events than the alendronate group (M-H 0.85, 95% CI 0.74-0.98; p < 0.05). In conclusion, Romosozumab may have lower adverse effects compared to alendronate and comparable to a placebo, except injection site reactions. Injection site reactions were more with romosozumab compared to alendronate and compared to the placebo as well. Romosozumab appears to have a similar safety profile to bisphosphonates.

Newcastle approach for the treatment of supra-intercondylar fractures in children

Purpose

The aim of this study is to evaluate the functional results of open reduction using the Newcastle approach and internal fixation for complex intra-articular distal humeral fractures in children through the report of cases.

Material and methods

A retrospective case series of patients who underwent open reduction and internal fixation surgery because of a complex intra-articular distal humeral fracture using the Newcastle approach were reviewed. Minimum follow-up was 2 years. Demographic, clinical, and radiological data were analyzed. Also, Mayo Elbow Performance Score and four-point Likert scale were evaluated.

Results

2 children were included in the final analysis. In both fractures, the approach was sufficient for accurate reduction and the functional outcome on both elbows was satisfactory. The Mayo elbow score was 95 points (excellent results) and the five-point Likert scale, both patients were very satisfied with the outcomes. In the radiographic study, no necrosis or secondary deformities were observed.

Conclusions

Our study provides evidence that the Newcastle approach is an alternative to perform open reduction in those children supra-intercondylar fractures that cannot be reduced using a close reduction. To our knowledge, there is not previous paper that has reported the used of this approach in the treatment in this kind of fractures.

A meta-analysis of bone morphogenetic protein-2 versus iliac crest bone graft for the posterolateral fusion of the lumbar spine

The impact of autologous iliac crest bone graft versus BMP-2 to improve fusion rates for posterolateral fusion (PLF) of the lumbar spine remains unanswered. Single-institution-centered data dominate the literature, providing results that may be contradictory or inconclusive. The aim of this paper is to analyze data pooled from multiple well-controlled studies that examined both ICBG and BMP-2 for use in PLF. This meta-analysis also provides details of success in different subsets of patients with variable risk factors for delayed and non-unions. Six high-quality randomized clinical trials were selected. Efficacy, morbidity, quality of life, and safety were compared between the BMP-2 group and the ICBG group. A total of 908 patients were included in the study. At 24 months, 94% of patients achieved fusion in the BMP-2 group and 83% in the ICBG group. At 6 and 12 months, the fusion was also greater in the BMP-2 group (86% vs. 60% and 88% vs. 80%, respectively). Surgical time, intraoperative blood loss, and hospitalization days also showed significant differences in favor of the experimental group (p < 0.01). There were no differences between two groups in the Oswestry Disability Index, 36-Item Short Form Health Survey and Back Pain Score, whereas a greater number of additional surgical procedures were performed in the ICBG group (p = 0.001). In conclusion, the use of BMP-2 in PLF reduced the surgical morbidity and had more beneficial effects on the fusion rate. The quality of life based on clinical scores was the same in both groups.

Shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in the elderly

PURPOSE

The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up.

MATERIAL AND METHODS

Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated.

RESULTS

All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results.

CONCLUSIONS

Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.

Frequency and characteristics of congenital intraspinal abnormalities in a cohort of 128 patients with congenital scoliosis

OBJECTIVES

The aims of this study were to determine the incidence and main characteristics of associated intraspinal anomalies in patients with congenital scoliosis (CS) and to analyze the different factors that influence the curve progression.

DESIGN

This was a retrospective comparative study.

METHODS

This was a retrospective study of 128 patients with CS.

MAIN OUTCOME MEASUREMENTS

The incidence of the patients with intraspinal anomalies and their demographic, clinical, and radiological values was described.

RESULTS

Intraspinal anomalies were present in 13.3% of the patients. Among them, the most frequent anomaly was syringomyelia. The most frequent curve was the thoracic curve. The main deformity based on McMaster classification was formation failure. The curve progression during follow-up did not show significant differences between vertebral anomalies, syringomyelia, presence of thoracic anomalies, and gender (P > 0.05).

CONCLUSIONS

Our study showed a lower percentage of spinal anomalies compared to other series. As other studies, the progression of the scoliosis curve in patients with spinal anomalies seems primarily to be determined by the type of vertebral malformation.

LEVEL OF EVIDENCE

Level II.

Surgical Treatment of Cervical Spine Fibrous Dysplasia: Case Report and Literature Review

Background

Fibrous dysplasia (FD) is an uncommon benign intramedullary fibro-osseous lesion. Cervical spine compromise is rare with only cases reported. Currently, the natural history of cervical FD is poorly understood, and its treatment remains controversial.

Methods

A review of the literature was performed to analyze and discuss the management of cervical FD through a case report and literature review.

Results

Cervical FD is a rare benign pathology. Clinical presentation is usually casual or only clinical pain. Computed tomography (CT)-guided percutaneous biopsy is a safe and effective technique for evaluation of spinal lesions; however, the accuracy of the preoperative biopsy findings has been disappointing. Although all treatments are valid, no one has been demonstrated to be better. Our proposed treatment, a corpectomy and fixation with a titanium mesh cage filled with allograft bone and an anterior cervical plate, showed good results.

Conclusions

The rarity of cervical FD and the lack of detailed reports with long-term follow-up periods complicate the research on the optimal treatment approach in these cases, but apparently all are valid for pain control. In our case, a corpectomy and fixation with a titanium mesh cage filled with allograft bone and an anterior cervical plate was carried out and showed good results. We submit this surgery option to be considered in these rare type of injuries.

Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament

Background

Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment.

Methods

A historical cohort of patients who underwent arthroscopic total or partial excision of the anterior cruciate ligament due to mucoid degeneration between 2011 and 2014 were reviewed. The minimum follow-up was 3 years. Demographic, radiological, and histological findings, type of surgery, and clinical pre- and postoperative data were analyzed. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period.

Results

Seventeen females (67%) and eight males (33%) were included in the final analysis. The mean age at the time of surgery was 57 years (range, 31 to 78 years). Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. No reconstruction was performed at the same time. A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Anterior cruciate ligament reconstruction was required in only one young patient due to disabling instability. At last follow-up, the mean visual analogue scale score, International Knee Documentation Committee score, and Tegner Lysholm Knee score improved (p < 0.01).

Conclusions

Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. However, young patients should be forewarned about the risk of instability, and an anterior cruciate ligament reconstruction could be necessary.

Ischiofemoral Impingement Syndrome: Outcomes of Endoscopic Resection of the Lesser Trochanter

Ischiofemoral impingement syndrome is a rare clinical entity characterized by chronic groin, buttock or hip pain associated with radiographic evidence of narrowing of the space between the lesser femoral trochanter and the ischial tuberosity. Introduction of magnetic resonance imaging to the clinical practice as well as the establishment of the radiological definition of the abnormal ischiofemoral distance has led to an increasing interest in this condition. Ischiofemoral impingement syndrome is a poorly understood disorder of chronic pain, especially regarding its treatment. The authors present two cases of primary ischiofemoral impingement syndrome successfully treated with a minimally invasive surgical technique. With this endoscopic technique, it was possible to resect the lesser trochanter and restore the ischiofemoral space. Immediate clinical and functional improvement was reported by both patients.

Bilateral insufficiency hip fractures after bariatric surgery

Bariatric surgery is one of the most common surgeries within developed countries due to the increase in morbid obesity that has been observed in the past decades. The short-term alterations in the metabolism of calcium and vitamin D are well known after these procedures; however, the clinical and biochemical consequences may not be detected for years or even remain undiagnosed. We present the first case of bilateral insufficiency hip fracture after years of bariatric surgery. Although this is a long-term and rare complication, with the high number of gastric bypass performed in the past years, the number of these cases could increase with time. Moreover, it is important as an undiagnosed hip fracture can cause a displacement that could need an arthroplasty, with all the complications that entails. For that reason, this long-term complication highlights the need to reevaluate the optimal follow-up of these patients and the importance to continue monitoring metabolic bone diseases in the prevention of insufficiency fractures.

Simultaneous bilateral atypical femoral fracture in a patient receiving denosumab: case report and literature review

Osteoporosis remains a chronic and common disease associated with high medical costs. Pharmacological therapy has shown to be a good strategy to significantly reduce fracture risk. While literary evidence for bone protection in the short and medium term is strongly in it's favor, there are concerns about long-term treatment with antiresorptive drugs. Increased risk of atypical femoral fractures (AFFs) have been demonstrated in several studies following the long-term use of bisphosphonate. Denosumab offers an alternative approach to the treatment of osteoporosis, however, it is also an antiresorptive drug. We present a case of simultaneous bilateral atypical femoral fractures in a patient with denosumab treatment. These findings highlight the need to reevaluate the optimal antiresorptive therapy duration, as well as the safety of transition from bisphosphonates to denosumab and the need for continued monitoring in the prevention of AFFs.