经舟骨月骨周围脱位的诊断和治疗

目的 探讨经舟骨月骨周围脱位的诊断和治疗。方法 回顾性分析17例经舟骨月骨周围脱位病例，背侧型13例，掌侧型4例；新鲜损伤组10例中8例行撬拨复位成功，仅2例因舟骨对位不良接受手术治疗；陈旧性组7例中均接受手术，4例行开放复位内固定，3例行近排腕骨切除术。结果 采用Cooney评价标准，优11例，良3例，可1例，差2例，优良率82．35％。结论 经舟骨月骨周围脱位的早期治疗简单且疗效较好，而一旦误诊，则多数需手术治疗，且残留不同程度的功能障碍。提高对本病损伤机制、腕部体征和影像学特点的认识和了解，减少误诊。是提高本病预后的关键因素之一。     

Male with type II autosomal recessive cutis laxa

A 5-year-old boy, who had pre- and postnatal growth retardation, delayed motor development, cutis laxa, delayed closure of large fontanels, congenital hip dislocation and characteristic facies, is described. Disorders with cutis laxa are now divided into five types. The patient had clinical manifestations very similar to those of cutis laxa with bone dystrophy (type II autosomal recessive cutis laxa). Eighteen patients have been reported, the ratio of males to females being 5 to 14. This is the fifth case of this disorder occurring in a male, which provides further evidence for autosomal recessive inheritance.     

Ectopia lentis in Loeys‐Dietz syndrome type 4

Loeys‐Dietz syndrome is a heritable disorder of the connective tissue leading to multisystem involvement including craniofacial features, skeletal abnormalities, cutaneous findings and early‐onset and aggressive disease of the aorta and its branches. There are multiple types of Loeys‐Dietz syndrome related to pathogenic variants in TGFBR1, TGFBR2, SMAD3, TGFB2, and TGFB3. Individuals with Loeys‐Dietz syndrome may be misdiagnosed as having Marfan syndrome due to shared phenotypic features and aortic root dilation. However, ectopia lentis has been an important discriminating feature, being unique to Marfan syndrome and not reported to be associated with Loeys‐Dietz syndrome. We report the case of a 46‐year‐old woman with Loeys‐Dietz syndrome type 4 due to a pathogenic variant in TGFB2 who was diagnosed with ectopia lentis at age 44. The patient underwent whole exome sequencing and no other pathogenic variants were found to explain the ectopia lentis. Our findings indicate that ectopia lentis may be an uncommon finding in Loeys‐Dietz syndrome type 4 and emphasize the importance of genetic testing in familial thoracic aortic aneurysm disease.     

Prevalence of Risk Factors for Adverse Spinopelvic Mobility Among Patients Undergoing Total Hip Arthroplasty

BackgroundPatients with adverse spinopelvic mobility have higher complication rates following total hip arthroplasty (THA). Risk factors include a stiff lumbar spine, standing posterior pelvic tilt ≤ ?10°, and a severe sagittal spinal deformity (pelvic incidence minus lumbar lordosis mismatch ≥20°). The purpose of this study is to define the spinopelvic risk factors and quantify the prevalence of risk factors for pathologic spinopelvic mobility.MethodsA retrospective cohort analysis from January 2014 to February 2020 was performed on a multicenter series of 9414 primary THAs by 168 surgeons, all with preoperative spinopelvic measurements in the supine, standing, and flex-seated positions. All patients were included. The prevalence of adverse spinopelvic mobility and frequency of each spinopelvic risk factor was calculated.ResultsThe cohort was 52% female, 48% male, with an average age of 65 years. Thirteen percent of patients exhibited adverse spinopelvic mobility and 17% had one or more of the 3 risk factors. Adverse mobility was found in 35% of patients with at least 1 risk factor, 47% with at least 2 risk factors, and 57% with all 3 risk factors.ConclusionForty-six percent of patients had spinopelvic pathology driven by one or more of the risk factors. Number of risk factors present and risk of adverse spinopelvic mobility were positively correlated, with 57% of patients with all 3 risk factors exhibiting adverse spinopelvic mobility. Although this study defines the prevalence of these risk factors in this highly selected cohort, it does not report incidence in a general THA population.Level of EvidencePrognostic Level IV.     

Mortality After Revision Total Hip Arthroplasty

BackgroundIn counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA.MethodsAn institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision.ResultsThe overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate.ConclusionThe overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.     

The Effect of Functional Pelvic Tilt on the Three-Dimensional Acetabular Cup Orientation in Total Hip Arthroplasty Dislocations

BackgroundAnterior and posterior pelvic tilt appears to play a role in total hip arthroplasty (THA) stability. When changing from the standing to the sitting position, the pelvis typically rotates posteriorly while the hips flex and this affects the femoro-acetabular positions. This case-control study compares changes in 3-D acetabular cup orientation during functional pelvic tilt between posterior THA dislocations vs stable THAs.MethodsStanding and sitting 3-D cup orientation was compared between fifteen posterior dislocations vs 233 prospectively followed stable THAs. 3-D cup orientation was calculated using previously validated trigonometric algorithms on biplanar radiographs. Those algorithms combine the angles in the three anatomical planes (coronal inclination, transverse version, and sagittal ante-inclination) in the standing position with the change in sagittal pelvic tilt from standing to sitting to calculate the 3-D orientation in the sitting position.ResultsThe standing cup orientation of the dislocated THAs was only characterized by a lower coronal inclination (P = .039). Compared with the controls, from standing to sitting, they showed less posterior pelvic tilt (P < .001). This led to a significant lower coronal inclination (P < .001) and sagittal ante-inclination (P < .001) in the sitting position but similar transverse version (P = .366).ConclusionsComparing posterior THA dislocations to stable THAs, there is a lower increase of all three orientation angles from standing to sitting. This leads to a decreased sitting coronal inclination and sagittal ante-inclination which may lead to an increased risk of impingement ensued by THA instability. By contrast, the transverse version was not significantly different in both positions. This confirms the importance of biplanar data on functional cup orientation.Level of EvidenceDiagnostic, Level III.     

Dorsal Chopart’s fracture dislocation – A rare injury

A rare case of Dorsal Chopart’s fracture dislocation after a fall from height is presented. It combines the features of pure dorsal Chopart’s dislocation and the longitudinal swivel variant described by Main and Jowett presenting as dorsomedial fracture dislocation of the medial three fourths of the navicular, crushing the lateral one fourth. The possible mechanism of injury has been described. It has been successfully treated with closed reduction and percutaneous k-wire fixation. At two-year follow-up the patient was asymptomatic, back to his moderately active work.     

Neglected medial swivel dislocation of talonavicular joint with calcaneus,cuboid and 5th metatarsal fractures – A case report

Talonavicular dislocation is a rare injury. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a rare case of neglected medial swivel dislocation with concomitant calcaneus, cuboid and 5th metatarsal fracture, which was managed with open reduction and fixation of talonavicular joint with k-wires and an external distractor. At 1 year follow up the patient was mobilizing full weight bearing without any pain or deformity, the radiographs showing well located talonavicular joint and healed calcaneus, cuboid and 5th metatarsal fractures. This is the first reported case of medial swivel talonavicular dislocation with associated calcaneum, cuboid and 5th metatarsal fracture to the best of our knowledge. This case report highlights the importance of maintaining high level of suspicion for diagnosing midfoot injuries in a polytraumatized patient as well as need of accurate and timely reduction of dislocation for good functional outcome.Level of clinical evidenceLevel 4.