Strong association of meniscus tears with complete Anterior Cruciate Ligament (ACL) injuries relative to partial ACL injuries

BackgroundAnterior Cruciate Ligament (ACL) injuries are often associated with meniscus tears. These meniscus tears in long term may affect the functional outcomes after ACL reconstruction. The present study aims to identify the incidence and relative association of meniscus injuries in complete and partial ACL injuries.MethodsThis was a retrospective study. Patients were divided into 2 groups; group I: partial ACL tear and group 2: complete ACL tear. Both groups were assessed for meniscal tears; either isolated medial/lateral or combined and odds ratio was measured between two groups.ResultsA total of 43 and 219 patients were enrolled in group I and II respectively. The mean age (years) in group I and II were 25.32 ± 7.12 and 28.64 ± 10.84 respectively. There were a total of 5 and 28 females in group I and II respectively. Mean pre-injury Tegner score in group I and II was 7.02 ± 2.87 and 6.82 ± 3.14 respectively. Mean time from injury to surgery (months) in group I and II was 8.04 ± 6.43 and 7.62 ± 4.83 respectively. In group 1 There were a total of 6 with lateral meniscus tears, 9 with medial meniscus tears And 3 with combined meniscal tears in group 1 while in group 2, 47 had lateral meniscal tears, 71 had medial meniscal tears and 71 had combined tears. Group II patients had stronger association for isolated meniscal tears compared to group I, with an odds ratio of 5.05(p < 0.05). Combined meniscal tears had non-significant relation in two groups (p = 0.58).ConclusionPartial ACL injuries present with less risk of acquiring isolated meniscus tears, compared to complete ACL injuries.     

Severe hallux valgus can be treated using a distal metatarsal osteotomy: Results of 144 cases treated with the SERI technique

PurposeAim of this study is to analyze the clinical and radiographic results of the simple, effective, rapid and inexpensive (SERI) technique, a linear distal metatarsal osteotomy, for treating severe hallux valgus (HV).MethodsClinical outcomes were assessed pre- and postoperatively using the AOFAS, MOxFQ and VAS score. Pre and postoperative HV angle (HVA) and intermetatarsal angle (IMA) were measured.Results117 consecutive patients for a total of 144 feet were included. Pre and postoperatively, mean AOFAS changed from 44.8 ± 16.7 to 89 ± 10.3 (p < .001), mean MOxFQ changed from 76.2 ± 15.8 to 23.4 ± 7.9 (p < .001) and mean VAS score improved from 6.7 ± 2.1 to 1.5 ± 1.5 (p < .001). HVA diminished from 40.6° ± 6.9 preoperatively to 16.0° ± 7.3 postoperatively (p < .001). IMA decreased from 15.1° ± 2.8 preoperatively to 6.5° ± 2.4 postoperatively (p < .001). The main complication reported was stiffness (10.4 %).ConclusionSERI technique applied to severe HV showed positive clinical and radiological outcomes. A careful patient selection and a low grade first MTPJ arthritis are essential to obtain favorable results.Level of evidenceIV.     

Novel local anesthesia technique ‘NATURE ’ (Nerves And Transversalis-fascia Using RopivacainE) to improve outcomes during endo-laparoscopic inguinal hernia repair

BackgroundThe use of local anaesthesia infiltration techniques may attenuate pain following endo-laparoscopic inguinal hernia surgery. We aim to reduce post-operative pain and the subsequent need for analgesia using a novel technique of local anaesthesia infiltration ‘NATURE’ (Nerves And Transversalis-fascia Using RopivacainE).MethodsThis is a retrospective study of patients who underwent endo-laparoscopic inguinal hernia repair in two institutions in Singapore. Patients who received the local anaesthesia according to the new technique (intervention group) were compared to patients who received local anaesthesia only over their surgical incisions (control group).ResultsData on 97 patients were analysed. There were 50 (51.5%) patients in the intervention group and 47 (48.5%) patients in the control group. No significant differences were observed in the two patient population's baseline characteristics, operative time and cumulative need for medications. The intervention group reported lower pain levels immediately after surgery (1.4 ± 1.7 versus 2.4 ± 1.9, p<0.01) and at 4 hours post-surgery (0.9 ± 1.1 versus 1.4 ± 1.2, p = 0.02). They also had lower levels of post-operative complications (4% versus 21.3%, p = 0.03).ConclusionInfiltration of local anaesthesia at specific anatomical locations during endo-laparoscopic inguinal hernia surgery can be effective in minimising post-operative pain. Prospective randomised controlled trials are needed to further substantiate this technique.     

Effectiveness of rapid response system in patients with hip fractures

IntroductionEven with preoperative screening and medical preparation, elderly hip fracture surgery (HFS) patients may have serious events including cardiopulmonary arrest (CPA) and death during the perioperative period. The rapid response system (RRS) that responds early to changes in the condition of patients is helping to improve the survival rate. To date, there have been no studies on the effectiveness of rapid response system in HFS patients.MethodsIn October 2012, our institution, a tertiary referral hospital, implemented an RRS. The system activated in heart rate <40/min or >140/min, systolic blood pressure <80mmHg, respiratory rate <10/min or >30/min, oxygen saturation <90%, sudden change in the level of consciousness, and seizure. We conducted before-and-after study using electronic medical records of patients older than 60 years, who underwent surgery during before implemented period (May 2003 to September 2012) and during after implemented period (October 2013 to December 2018). 1,483 pre-RRS patients and 1,315 post-RRS patients were enrolled in this study. We aimed to evaluate the effect of implementing the RRS on the management of patients undergoing HFS. We analysis 1) interval between the detection of abnormal vital sign and notification to attending physician; 2) interval between the detection of abnormal vital sign and adequate intervention; 3) incidence of CPA, 4) admission to intensive care unit 5) unexpected death; 6) duration of hospital stay; and 7) survival rate.ResultsThe interval between the detection of abnormal vital sign and notification to attending physician decreased from 23.9(±28.1) minutes to 11.4(±11.02) minutes (p<0.001). The interval between the detection of abnormal vital sign and intervention by the attending physician decreased from 67.3(±40.3) minutes to 15.8(±10.9) minutes (p<0.001). There were no significant differences in unexpected admission to intensive care unit (32/50 versus 20/88, p = 0.213) and in-hospital death (15 versus 16, p = 0.605) between the two groups. The duration of hospitalization decreased from 24.9 days to 15.4 days (p < 0.001). The 5-year survival rate was 57% in the pre-RRS group and 72% in the post-RRS group (hazard ratio = 0.73; 95% confidence interval = 0.61-0.87, p < 0.001).ConclusionsImplementation of RRS rendered early notification and prompt intervention of deteriorating patients undergoing HFS and reduced the duration of hospital stay.     

Comparison of clavicular hook plate with and without coracoclavicular suture fixation for acute acromioclavicular joint dislocation

ObjectiveThe aim of this study was to compare the clinical and radiographic outcomes of clavicular hook plate fixation with and without coracoclavicular (CC) tape augmentation for the treatment of acute unstable AC dislocation.MethodsWe treated 47 patients (31 men and 16 women; mean age: 47 years (range, 21–81)) with unstable acute AC dislocations (Rockwood III–V) and divided them into two groups according to the treatment modality, with hook plate fixation (hook plate group) or hook plate plus CC tape augmentation (combined group). We assessed radiologic findings, such as subacromial osteolysis and AC osteoarthritis. We also evaluated the clinical outcomes using a visual analogue scale (VAS) for pain, as well as the University of California at Los Angeles (UCLA) Shoulder Rating Scale and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score.ResultsWe found that the combined group had less subacromial osteolysis upon radiography, although the CC distance was similar in both groups (119 ± 29.7% of contralateral side CC distance in hook plate group versus 119 ± 34.8% in the combined group, p = 0.77). Compared with the hook plate group, the combined group had a lower VAS score (4.5 ± 2.3 in hook plate group versus 2.3 ± 1.4 in the combined group, p < 0.001), better UCLA scores (19.9 ± 4.9 in hook plate group versus 27.2 ± 4.0 in the combined group, p < 0.001) as well as better ASES scores (51.9 ± 17.8 in hook plate group versus 73.8 ± 13.1 in the combined group, p < 0.001) at 3 and 6 months after surgery.ConclusionHook plate fixation plus CC tape augmentation may prevent subacromial osteolysis and yield better short-term functional outcomes.Level of EvidenceLevel III, Therapeutic Study.     

Effectiveness of Ilizarov external fixation in elderly patients with pilon fractures

BackgroundPilon fractures are associated with soft tissue complications such as skin necrosis, and deep infections have been reported very often. This study retrospectively compared the treatment effects of Ilizarov external fixation and of internal fixation methods in elderly patients with pilon fractures.MethodsA total of 37 patients >60 years old with pilon fractures (AO classification type 43) were investigated. Patients were treated either with internal fixation (n = 15) or Ilizarov external fixation (n = 22). The patients' mean age was 74.2 (range, 60–78) years in the internal fixation group and 76.1 (range, 60–82) years in the Ilizarov external fixation group. Many patients in the internal fixation group received toe-touch to 1/3 partial weight-bearing at 2–4 weeks postoperatively and full weight-bearing by 6–8 weeks postoperatively. Many patients in the Ilizarov external fixation group received partial weight-bearing (as tolerated) 1 day postoperatively, 1/2 partial weight-bearing at 2 weeks postoperatively, and full weight-bearing at 4 weeks postoperatively.ResultsThe mean duration of hospitalization was 79.1 ± 30.1 days for the internal fixation group and 29.1 ± 18.8 days for the Ilizarov external fixation group (p < 0.05). Bone mineral density (T-score) was 2.6 ± 0.7 for the internal fixation group and 3.6 ± 1.2 for the Ilizarov external fixation group (p < 0.05). The incidence of skin disorders that required additional surgical treatment was 33.3% (5/15 patients) in the internal fixation group and 0% (0/22 patients) in the Ilizarov external fixation group (p < 0.05).ConclusionsIn elderly patients with periarticular fractures of the ankle, those who underwent Ilizarov external fixation had a shorter duration of hospitalization and fewer complications than those who underwent internal fixation.     

Goal-directed fluid therapy guided by Plethysmographic Variability Index (PVI) versus conventional liberal fluid administration in children during elective abdominal surgery: A randomized controlled trial

BackgroundPVI has been shown to be an accurate predictor of fluid responsiveness in paediatric patients. Evidence regarding the role of PVI to guide intraoperative fluid therapy in paediatric abdominal surgery is lacking. We aimed to assess the effect of PVI-guided fluid therapy on the volume of intraoperative fluids administered and post-operative biochemical and recovery profile in children undergoing elective abdominal surgery.Methods42 children, 6 months-3 years scheduled for elective open bowel surgery were randomised to receive either ‘conventional liberal intraoperative fluids’ (liberal group) or ‘goal-directed intraoperative fluids’ (GDT group). PVI <13 was targeted in the GDT group. The primary outcome was the volume of intraoperative fluids administered. Postoperative serum lactate, base excess, hematocrit, recovery of bowel function and duration of postoperative hospital stay were the secondary outcomes.ResultsThe mean fluid administered intra-operatively was significantly lower in the GDT group as compared to the liberal group (24.1 ± 9.6 mL/kg vs 37.0 ± 8.9 mL/kg, p < 0.001). The postoperative hemoglobin concentration (g%) was significantly lower in the liberal group as compared to the GDT group (8.1 ± 1.3 vs 9.2 ± 1.4, p = 0.008). Recovery of bowel function (hours) was significantly delayed in the liberal group as compared to the GDT group (58.2 ± 17.9 vs 36.5 ± 14.1, p < 0.001).ConclusionIntraoperative PVI-guided fluid therapy significantly reduces the volume of intravenous crystalloids administered to children undergoing open bowel surgery. These children also had faster recovery of bowel function and less hemodilution in the immediate postoperative period, compared to those who received liberal intraoperative fluid therapy.Type of study: Randomized Clinical Trial.Level of evidence: Treatment Study (LEVEL 1).     

Outcomes of modified chevron osteotomy for hallux valgus

PurposeThis study aimed to detect the effect of a modified chevron osteotomy on hallux valgus (HV) deformity at five-year follow up.MethodsTwenty patients with symptomatic HV who underwent modified chevron osteotomy between June 2014 and January 2016 were included in the present study. The minimum follow-up duration was five years. Each patient was evaluated preoperatively, six weeks postoperatively and five years postoperatively using the visual analog scale (VAS) pain score, the American Orthopedic Foot & Ankle Society (AOFAS) score and cosmetic and radiological outcomes.ResultsThe AOFAS score improved from 54.40 ( ± 4.58) preoperatively to 94.30 ( ± 2.15) six weeks postoperatively (p < 0.001) and 96.95 ( ± 1.54) five years postoperatively (p < 0.001). The VAS scores decreased from 6.30 ( ± 1.17) preoperatively to 0.15 ( ± 0.37) five years postoperatively (p < 0.001). The mean intermetatarsal angle improved from 16.00° ( ± 2.20°) preoperatively to 4.15° ( ± 1.22°) six weeks postoperatively (p < 0.001) and 4.40° ( ± 1.39°) five years postoperatively (p < 0.001). The mean HV angle also improved, from 32.70° ( ± 5.34°) preoperatively to 4.80° ( ± 1.40°) six weeks postoperatively (p < 0.001) and 5.20° ( ± 1.32°) five years postoperatively (p < 0.001). The cosmetic results were either excellent or good in 19 patients (95%). There was no recurrence in this study during the five postoperative years.ConclusionA modified chevron osteotomy can achieve successful correction of moderate-to-severe HV, with excellent outcomes at five-year follow up.     

Low body mass index is a risk factor for increased post-operative mortality and poor functional improvement in distal femur fractures among patients aged over 65: A multicentre (TRON) study

BackgroundDistal femur fractures have been reported to have a mortality rate comparable to hip fractures, but the risk is still unknown. Recent studies have reported that low body mass index (BMI) is a risk factor for mortality in the elderly. We investigated the efficacy of low BMI for predicting the risk of mortality in distal femur fractures in patients aged over 65 within 18 months after injury and its impact on postoperative clinical outcomes and mortality.MethodsData from patients followed for more than six months were obtained from our trauma research group's database. We investigated risk factors for increased mortality using Cox proportional hazards models. We divided the analysed cases into low (<18.5 kg/m²) and high (>18.5 kg/m²) BMI groups. We adjusted the background characteristics of the groups by patient matching, and evaluated the postoperative mortality, complication rate, and knee society score (KSS).ResultsWe identified 216 patients, including 58 (26.9%) with low BMI values. Low BMI was an independent risk factor for mortality in all models (Hazard Ratio: 2.9, p = 0.011). The overall survival rate of the low BMI group at 18 months was significantly lower than that of the high BMI group (70.7% vs. 89.1%; p = 0.003). The complication rates of the low BMI and high BMI groups were not significantly different (33.3% vs. 22.2%; p = 0.283). The mean KSS values at 3, 6, and 12 months in the low BMI group was significantly worse than that in the high BMI group (78.7 ± 16.2 vs. 84.8 ± 13.1; p = 0.035, 82.2 ± 16.9 vs. 89.7 ± 8.9; p = 0.005, 86.4 ± 13.0 vs. 91.4 ± 8.4; p = 0.020, respectively).ConclusionsOur study indicated that low BMI was independent associated with increased mortality and impaired postoperative functional recovery in distal femur fractures of the elderly patients.     

Effects of preoperative oral carbohydrate administration combined with postoperative early oral intake in elderly patients undergoing hepatectomy with acute-phase inflammation and subjective symptom burden: A prospective randomized controlled study

BackgroundEnhanced recovery after surgery (ERAS) has received increasing attention. Preoperative oral carbohydrate and postoperative early oral feeding (POC-PEOF) as the basic nutrition administration in the ERAS program suffers from low adherence. The role and benefits of administering POC-PEOF in elderly patients with hepatocellular carcinoma (HCC) are unclear. Therefore, the randomized controlled trial evaluated the effects of POC-PEOF in elderly patients with HCC undergoing hepatectomy with inflammation and patient self-reported symptom burden compared with the corresponding outcomes of traditional fasting protocols.MethodsElderly patients with HCC (n = 126) were randomly assigned to two groups using the sealed envelope technique. Sixty-three patients were included in the intervention (POC-PEOF) group and received POC-PEOF administration, whereas the 63 patients in the control (FAST) group underwent conventional fasting. Acute-phase inflammation markers, patient self-reported symptom burdens, and postoperative outcomes were compared between the two groups.ResultsThe average age was 69.60 ± 5.00 years in the POC-PEOF group and 70.44 ± 6.15 years in the FAST group. Compared to prolonged fasting, POC-PEOF achieved significant positive results, including lower overall levels of inflammatory response mediators (CRP, IL-6) on postoperative day (POD) 1, POD 3, and POD 5 (P < 0.05), lower patient self-reported symptom burdens of thirst, hunger, anxiety and nausea (P < 0.05), faster gastrointestinal function return with shortened times to first flatus and first defecation (48.31 ± 13.24 h vs. 96.26 ± 23.12 h and 72.87 ± 21.12 h vs. 144.34 ± 23.31 h, and P = 0.034 and P = 0.013, respectively). Furthermore, the average postoperative hospitalization duration in the POC-PEOF group was shorter than that in the FAST group (6.93 ± 0.98 d vs. 8.12 ± 1.15 d, P = 0.042). There was no significant difference of total complications between the groups (25.39 % vs 36.51 %, RR 0.696, 95 % CI 0.408–0.187, P = 0.177).ConclusionPOC-PEOF helps lessen acute-phase inflammation and relieves the subjective symptom burden, which can ensure better positive postoperative outcomes in elderly HCC patients undergoing hepatectomy.     

Functional outcomes of total knee arthroplasty in patients with Parkinson's disease: A case control study

BackgroundParkinson's disease is a neurodegenerative condition causing coordination loss in musculoskeletal system. Many studies suggest that total knee arthroplasty in patients with Parkinson's disease has unfavorable treatment results and high complication rates. Our hypothesis was that total knee arthroplasty might be an effective procedure in patients with Parkinson's disease.MethodsParkinson's disease patients who underwent total knee arthroplasty between 2006 and 2018 were retrospectively evaluated. Patients who had Parkinson's disease diagnosis before surgery and who had a minimum follow-up duration of 12 months were included. Secondary knee osteoarthritis patients were excluded. A matched control group was randomly formed. Outcome measures were evaluated by preoperative and postoperative Knee Society Score and joint range of motion values. Comparison was made by means of increase in Knee Society Score and range of motion values. Study group patients were reviewed according to Columbia Classification System to determine disease severity. Stages I-II were accepted as “low-grade” and III-IV-V as “high-grade” disease. Another comparison was made between “low-grade” and “high-grade” patients. Patient who showed disease progression after surgery were also compared to patients without progression.ResultsThere were 13 patients in both groups. In study group, mean preoperative and postoperative Knee Society Score values were 45.4 (±16.8) and 85.6 (±7.60); range of motion values were 93.9° (±17.0°) and 99.5° (±9.37°) respectively with a mean follow-up of 64.5 (±44.7) months. In control group, mean preoperative and postoperative Knee Society Score values were 38.8 (±11.5) and 86.1 (±10.0); range of motion values were 100.4° (±14.6°) and 109.2° (±10.2°) respectively with a mean follow-up of 51.8 (±13.6) months. No significant difference was observed between 2 groups (p > 0.05). Mean preoperative KSS and ROM values were significantly lower in high-grade patients (30.0 (±17.0) and 78.8° (±11.8°) respectively) compared to low-grade patients (52.2 (±11.9) and 100.6° (±14.7°) respectively) (p < 0.05). However, mean increase in KSS and ROM values were significantly higher for high-grade patients (p < 0.05). Mean increase in Knee Society Score and range of motion was 32.4 (±10.9) and 1.00° (±9.46°) respectively in patients with progression, 45.4 (±16.8) and 8.63° (±8.00°) in patients without progression (p > 0.05).ConclusionTotal knee arthroplasty is a successful treatment of knee osteoarthritis in Parkionson's disease patients with similar outcomes compared to general population despite disease severity and progression.     

Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery

IntroductionSpinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost.MethodsThe authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality.ResultsA total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225).Discussion/conclusionTo our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.     

Ankylosing spondylitis substantially increases health-care costs and length of hospital stay following total hip arthroplasty – National in-patient database study

IntroductionThe outcome following major arthroplasty surgeries in patients with ankylosing spondylitis (AS) has tremendously improved over the past decades, due to substantial amelioration in the medical therapies and sophistication of available surgical modalities. Although various studies have already demonstrated the complication rates and challenges faced in AS patients undergoing THA, there is a substantial paucity of data on the actual healthcare burden associated with this disease, and the diverse factors which may affect it.MethodsUsing the National Inpatient Sample (NIS) database (on the basis of ICD-10 CMP codes), patients undergoing THA between the years 2016 and 2019 were identified. These patients were then classified into two categories: group A: patients with a known diagnosis of AS; and group N: those without. The details regarding demographical information, associated co-morbidities, data pertaining to patients’ hospital admissions including expenditure incurred, length of stay and complications encountered, were compared. In addition, propensity-score matching was performed to identify a 1:1 matched sample of THA patients without AS.ResultsOverall, 367,890 patients underwent THA; among whom, 501 (0.14%) were known AS patients (group A). Group A included a substantially higher proportion of patients belonging to younger age group (58.6 ± 13.4 versus 65.9 ± 11.4 years; p < 0.001), male sex (67.1% in group A vs 44.1% in group N; p < 0.001), and Asian ethnicity (p < 0.001). Group A patients had a substantially higher risk for longer duration of hospital stay (p < 0.03) and higher overall healthcare expenditure incurred (p < 0.001). As compared to group N, AS patients had a significantly higher risk for developing post-operative anemia [21.8% (group A) vs 11.8% (group N); p < 0.02]; and higher rate of periprosthetic infections [2.4% (group A) vs 1.0% (group N); p < 0.007].ConclusionPatients with AS require a significantly longer duration of hospital stay and higher admission-related expenditure following THA, as compared to the general population. These enhanced early health care-associated costs can be attributed to higher complication rates in AS patients. AS patients are prone to higher rates of anemia and peri-prosthetic infections during the early post-THA period.     

Outcomes of medial patellofemoral ligament reconstruction and tibial tubercle osteotomy in syndromic adolescents with patellar dislocation

BackgroundTreatment of congenital and habitual dislocation of the patella in syndromic adolescents can be difficult due to accompanying soft-tissue and/or osseous abnormalities often present in the knee. The aim of this study was to report the results of surgical treatment of congenital and habitual patellar dislocation with medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy (TTO) in adolescents with an underlying syndrome.MethodsSyndromic adolescent patients with congenital or habitual patellar dislocation treated with MPFL reconstruction and TTO between 2005 and 2019 with a minimum of one year of follow-up were identified. Demographic, clinical, radiographic, and surgical data were recorded, and any complications were noted. Kujala and Lysholm scores were used to quantitate knee function.ResultsSeventeen knees in 11 patients met the criteria for inclusion. The mean age at operation was 14.8 years (range, 13.3–18.3 years). Patients were identified as having Ehlers-Danlos (four), Down (two), trichorhinophalangeal (one), McCune-Albright (one), Klippel-Feil (one), and generalized joint hypermobility (two) syndromes. The mean follow-up was 2.2 years for each individual knee (range, 1–5.9 years). The mean Kujala score increased from 56 ± 10 preoperatively to 86 ± 6 at the most recent postoperative visit (p < 0.001). The mean Lysholm score increased from 53 ± 10 preoperatively to 85 ± 7 at the most recent postoperative visit (p < 0.001). Knee flexion increased significantly from 117° ± 15° preoperatively to 154° ± 13° postoperatively (p < 0.001). However, knee extension was no different pre- and postoperatively (4° ± 8° vs. 1° ± 4°, respectively, p = 0.2).ConclusionsCongenital and habitual patellar dislocation in adolescent-aged patients with an underlying syndromic diagnosis can be successfully treated with MPFL reconstruction combined with TTO.     

Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls

BackgroundWhile it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis.MethodsA retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years).ResultsThe valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031).ConclusionOur findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.     

Drainage decreases the seroma incidence in laparoscopic transabdominal preperitoneal (TAPP) hernia repair for large inguinoscrotal hernias

BackgroundSeroma is a common and inevitable postoperative complication in transabdominal preperitoneal (TAPP) hernia repair, especially in patients with large inguinoscrotal hernias. However, studies have rarely reported drainage in TAPP for large inguinoscrotal hernias.MethodsSixty-five patients with 78 large indirect inguinoscrotal hernias who underwent TAPP procedure with drainage between September 2016 and December 2019 were enrolled in this study. 181 patients with Type Ⅲ indirect inguinal hernias (European Hernia Society (EHS) classification, hernia defect >3 cm) who underwent TAPP without drainage (no-drainage group) between January 2019 and December 2019 were included for a comparison. In the drainage group, a 12-Fr drainage tube was inserted into the distal hernia sac via the preperitoneal space to decrease the incidence of seroma.ResultsThere was no conversion to open procedures in all the patients. The operative time (56.5 ± 8.4 VS 54.8 ± 9.6 min, unilateral; 95.8 ± 10.4 VS 92.1 ± 13.9 min, bilateral), blood loss (5.9 ± 1.9 VS 5.6 ± 1.7 mL), visual analogue scale score on postoperative day 1 (2.3 ± 0.5 VS 2.2 ± 0.5) and postoperative hospital stay (1.1 ± 0.3 VS 1.0 ± 0.2 days) in the drainage group were equivalent to those in the no-drainage group (p > 0.05). The mean length of drainage was 5.2 ± 1.3 days. The drainage group had a significantly lower incidence of seroma than the no-drainage group (1.5% VS 9.4%, p = 0.037). The postoperative complications including haematoma, recurrence and chronic pain were comparable in the two groups.ConclusionDrainage with appropriate duration is a feasible, safe and effective measure to decrease the incidence of seroma in TAPP for patients with large inguinoscrotal hernias.     

After failed radial head arthroplasty,what are the options? Risk factors and results of revisions in a multicenter study

IntroductionFew multicenter studies have analyzed the outcome of revision surgery of radial head arthroplasties (RHA) in the medium term follow up. The objective is twofold: to determine the factors associated with revision of RHAs and to analyze the results of revision with 2 surgical techniques: isolated removal of the RHA or revision with a new RHA (R-RHA).HypothesisThere are associated factors of RHA revision and RHA revision results in satisfactory clinical and functional outcomes.MethodsTwenty-eight patients were included in this multicenter retrospective study, with all surgical indications for initial RHA being traumatic/post-traumatic. The mean age was 47 ± 13 years with a mean follow-up of 70 ± 48 months. This series included two groups: the isolated RHA removal group (n = 17) and the revision RHA with new radial head prosthesis (R-RHA) group (n = 11). Evaluation was clinical and radiological with univariate and multivariate analysis.ResultsTwo factors associated with RHA revision were identified: a pre-existing capitellar lesion (p = 0.047) and a RHA placed for a secondary indication (<0.001). Revision for all 28 patients resulted in improved pain (pre-op Visual Analog Scale 4.7 ± 3 vs. post-op 1.57 ± 2.2, p < 0.001), mobilities (pre-op flexion 118 ± 20 vs. post-op 130 ± 13, p = 0.03; pre-op extension −30 ± 21 vs post-op −20 ± 15, p = 0.025; pre-op pronation 59 ± 12 vs post-op 72 ± 17, p = 0.04; pre-op supination 48 ± 2 vs post-op 65 ± 22, p = 0.027) and functional scores. Mobility and pain control were, for stable elbows, satisfactory in the isolated removal group. When the initial or revision indication was instability, the DASH (Disabilities of the Arm, Shoulder and Hand = 10 ± 5) and MEPS (Mayo Elbow Performance score = 85 ± 16) scores were satisfactory in the R-RHA group.DiscussionIn the case of a radial head fracture, RHA is a satisfactory first-line solution without pre-existing capitellar injury, its results being much weaker in the case of ORIF failure and fracture sequelae. In case of RHA revision, isolated removal or R-RHA adapted according to the pre-operative radio-clinical exam.Level of evidenceIV.     

97 HINTEGRA ankle prostheses: Results and survival at more than 5 years’ follow-up

BackgroundIn Europe, fixed-bearing implants predominate again in total ankle replacement (TAR). The present single-center single-surgeon study assesses the Hintegra® mobile-bearing implant (NEWDEAL).MethodsBetween November 2008 and November 2015, 97 Hintegra® were implanted in 94 patients: mean age, 62.4±10.9 years (26?83); 59% (57/97) male; normal mean body-mass index (BMI), 27.5 ± 4.3 kg/m². Indications mainly comprised posttraumatic (40.2%), instability (29.9%) and primary osteoarthritis (16.5%). 17.5% of patients had prior surgery during the previous 6 months (9 fusions, 8 ligament reconstructions, and 4 osteotomies); in 59.8%, other procedures were associated to TAR. Functional, clinical and radiological follow-up was conducted at 1 year, 2 years and last follow-up (>5 years).ResultsNinety-four TARs were analyzed at a mean 81 ± 21.6 months (19?124). Revision-free survival was 76% (95% confidence interval (95%CI): 0.66–0.8), and explantation-free survival 92% (95%CI: 0.85–1) with 10 cases of curettage and 5 explantations.Mean AOFAS score improved from 41.8 ± 12.5 (21?69) to 77.5 ± 16.5 (24?100) up (p < 0.001); 75% of patients had no or only mild pain (p < 0.001). Clinical ranges of motion were 8.0 ± 7.1° dorsiflexion (p < 0.001) and 35.1 ± 9.4° plantar flexion (preoperatively, 34.1 ± 7.9°) (p = 0.71).Radiologically, tibial components were well-positioned; 87% of talar components were well-centered. Global ankle range of motion was 23.5 ± 10.2° (5?48) (p = 0.17). 54.6% of TARs showed posterior tibial calcification at follow-up. Risk of severe cyst (>1 cm) on CT was 36% (95%CI: 23–47) at a mean 77 ± 21.9 months (18?123).ConclusionHintegra® TAR incurred a low risk of revision, and is a reliable option for ankle osteoarthritis.Level of evidenceIV     

Role of serum and synovial procalcitonin in differentiating septic from non-septic arthritis- a prospective study

IntroductionSeptic arthritis is a serious orthopaedic emergency that must be diagnosed and managed early to prevent devastating complications. The current gold standard for diagnosing septic arthritis is synovial fluid culture, but results are delayed by 48–72 h, and the sensitivity of the test is very low. Differentiating Septic from non-septic arthritis is vital to prevent unnecessary use of antibiotics and prevent complications. Serum Procalcitonin (PCT) is a useful marker in differentiating septic from non-septic arthritis but there are very few studies that have studied the role of synovial PCT for the same.AimTo determine the role of serum and synovial PCT in differentiating acute Septic from non-septic arthritis.Materials and methodsProspective clinical study in which 60 patients presenting with acute inflammatory arthritis (<2 weeks duration) were enrolled from May 2018 to May 2020. Serum and synovial fluid samples were drawn at presentation and routine blood investigations, synovial fluid culture sensitivity, and Procalcitonin levels were measured. Patients were divided into 3 groups, with group-1 having confirmed pyogenic, group-2 having presumed pyogenic, and group-3 having non –pyogenic patients, respectively. All data was tabulated and statistically analysed using appropriate tests.ResultsMean serum PCT values in groups 1, 2 and 3 were 1.06 ± 1.11, 0.85 ± 0.74, and 0.11 ± 0.24, respectively. Patients in the Pyogenic group (group1 and group 2) had significantly higher mean serum PCT as compared to group3 (p < 0.0001). Group 1 had higher serum PCT as compared to group 2, but the difference was not significant (p = 0.58). Mean synovial PCT in group 1, 2 and 3 were 2.42 ± 1.98, 1.89 ± 1.18, and 0.22 ± 0.40, respectively. Patients in the Pyogenic group (Group1 and Group2) had significantly higher mean synovial PCT as compared to Group 3 (p < 0.0001). Group 1 had higher mean synovial PCT as compared to group 2, but the difference was not significant (p = 0.54). The area under the ROC curve of the serum levels of PCT was 0.0.895, and the area under the ROC curve of the synovial fluid levels of PCT was 0.914, which was higher than the serum PCT level.ConclusionSerum and synovial Procalcitonin may be used as a diagnostic marker in differentiating septic from inflammatory arthritis and can help in reducing unnecessary use of antibiotics and early diagnosis and management of septic arthritis, thereby preventing complications.     

Operative treatments compared with nonoperative treatment of displaced midshaft clavicular fractures

BackgroundFew reports on external fixation to treat displaced midshaft clavicular fractures exist. We sought to compare the clinical effects of external fixation, plate fixation, and nonoperative treatment for treating displaced midshaft clavicular fractures in adults.Material and methodsEighty-nine patients with a displaced midshaft fracture of the clavicle were selected (according to inclusion criteria) for a retrospective analysis and assigned to either operative treatment with external fixation (29 patients), plate fixation (30 patients) or nonoperative treatment with a sling (30 patients). The average follow-up period is 32 months. Outcome analysis included: Constant shoulder score (CSS); disabilities of the arm, shoulder and hand score (DASH); nonunion rate; satisfaction of shoulder appearance.ResultsEighty-five cases were successfully followed up. No significant difference was observed between external fixation and plate fixation (p > 0.05 and p = 0.132, respectively). The operative groups achieved better effects (p < 0.001) compared to the nonoperative treatment. The healing time of the three groups were: 10.4 ± 2.3 weeks for external fixation; 12.1 ± 2.5 weeks for plate fixation; and 15.7 ± 2.2 weeks for nonoperative treatment. In the follow-up, patients in the external fixation group (96%) and plate fixation group (93%) were more likely to be satisfied with the appearance of the shoulder than were those in the nonoperative group (77%).ConclusionThe external fixation and plate fixation are overall better than the nonoperative treatment. As to choose between the two, it depends on the local soft tissue condition, surgeon's techniques, communication between doctor and patients and so on.