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Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.

A thorough literature search was done in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of medicine and orthopedics. The philosophical ideas that emerged in ancient Greece served as a foundation for the development of medicine. In the 5th century BC, the schools of Knidos and Kos emerged as influential centers for the development of medical thinking. The field of orthopedics can be traced back to early human civilizations. Ancient Egyptians perpetuated the tradition of employing splinting techniques. Hippocrates provided insights for the diagnosis, correction and treatment of many musculoskeletal entities. The field of medicine experienced a period of limited advancement during the Middle Ages. The Renaissance provided for the foundation of modern orthopedics and important contributions to the understanding and implementation of antisepsis. The discovery of x-ray and advancements in infection control and anesthesia have shown substantial progress in the domain of orthopedics and have contributed to the development of orthopedic subspecialization. Orthopedic surgery holds a historical lineage deeply entrenched in ancient practices and early human civilizations. Physicians specializing in orthopedics should be aware of the historical origins of their discipline and continue to evolve through further subspecialization and enhanced research.

Pin site infections are the main complication of external fixators. The most common pathogens are Staphylococcus epidermidis and Staphylococcus aureus. The incidence of pin site infections ranges from 2% to 30%. Until now, no satisfactory prevention strategy exists. Therefore, we performed this study to assess the effect of a sucralfate gel 25% applied around the pins of external fixation systems in trauma patients with open tibia fractures. We prospectively studied two groups of patients with open tibia fractures treated with external fixators. In group A patients, pin site care was performed with the use of normal saline and plain dressings once a day. In group B patients, pin site care was performed with the use of sucralfate gel 25%. The incidence of pin site infections was 33.33% for patients of group A and 16.67% for patients of group B. Patients of group B showed significantly lower rate of pin site infections compared to patients of group A (p-value = 0.032). No patient experienced any complications related to the local application of the drug. Sucralfate significantly prevents pin site infections of external fixators in open tibia fractures. Therefore, it can be used as a preventive antimicrobial agent for pin site infections in patients with external fixators.

Ultrasound implementation for the facilitation of peripheral nerve blocks is well established. Ultrasound-guided lumbar plexus, femoral, fascia iliaca and supra-inguinal fascia iliaca compartment, pericapsular nerve group and quadratus lumborum nerve blocks have been employed for analgesia purposes in hip surgery. The combination of motor-sparing regional anesthesia strategies for optimal postoperative pain control with recovery protocols targeting to early and safe patients' mobilization constitute the current dogma of orthopedic surgery. Therefore, this editorial sets out to revisit the role of peripheral nerve blocks in postoperative pain management of hip surgery patients, under the prism of current orthopedic practice.

Hip fractures in the geriatric population are associated with high morbidity and mortality rate. Early surgical fixation is of major importance, as it is one of the factors that contribute to patient optimization. However, these patients usually present a high burden of comorbidities, including aortic stenosis that could affect their treatment. Despite major advances in anesthetic and surgical techniques, severe aortic stenosis remains an independent, important risk factor for patients undergoing anesthesia for noncardiac surgery. In these patients, general and/or neuraxial anesthesia should be avoided; peripheral nerve blockade is a viable option. This article presents a 96-year-old hip fracture patient with severe aortic stenosis and aspiration pneumonia that successfully underwent hip hemiarthroplasty under peripheral nerve blockade as sole anesthesia.

Ultrasound imaging of peripheral nerves is challenging in elderly population. In cases involving the lumbar plexus (LP), we have employed ultrasound imaging and neurostimulation guidance for successful localization and block of the LP. The postero-medial segment of the psoas muscle (PSM), superior to the vertebral body and anterior to the transverse process ("corner pocket") was used as an imaging landmark for the implementation of the LP block. By advancing the needle through the lateral abdominal wall into the "corner pocket" we were afforded a seamless advancement of the needle into the postero-medial segment of the PSM, which is the standard anatomic position of LP in the PSM. Forty-eight patients in whom ultrasound imaging of the LP was not feasible, but the "corner pocket" was clearly depicted were included in the study. LP block characteristics and adverse events were recorded. The LP was localized in 43/48 patients. The average imaging, needling, and performance times to complete the block were 51 sec (range, 6-180 sec), 81 sec (range, 16-236 sec), and 132 sec (range, 24-270 sec), respectively. The median number of needle redirections per patient was 5.5 (range, 1-13). The local anesthetic spread was visualized in the postero-medial segment of the PSM in 39/43 patients. No complications were recorded. The imaging, needling, and performance times, as well as the number of needle passes did not significantly differ between obese and non-obese patients. In conclusion, in cases with challenging ultrasound imaging of the LP, ultrasound-assisted LP block can be accomplished through the lateral abdominal wall by using as an imaging landmark the "corner pocket" at the postero-medial quadrant of the PSM.

Developmental dysplasia of the hip (DDH) is the most common musculoskeletal disorder of the infant age. Its incidence ranges from 0.06/1000 to 76.1/1000 live births and is more frequent in female infants. Breech position, family history and firstborn children are the main risk factors for DDH and this disorder is also associated with the presence of other congenital deformities. Anatomically, the acetabulum remains shallow and the femoral head grows in a wrong position. Clinical examination is important and tests such us Barlow and Ortolani give indications only for a part of the spectrum of this entity. Nowadays the sonographic examination is the most accurate option for the diagnosis. Graf classification categorizes the DDH cases in four types, from normal to dislocated hip, by description and measuring specific angles in sonographic examination. The wide usage of ultrasonography has decreased the non-diagnosed or neglected cases; treatment begins immediately in young age and is usually conservative with the usage of devices such as Pavlik harness and hip spica. To enhance the literature, we searched for published studies on DDH, to summarize the pathogenesis and the diagnosis and to discuss the treatment and outcome of the patients with this disorder.

Infection after anterior cruciate ligament reconstruction is a rare but devastating complication resulting in a deleterious impact on knee function as well as an increased related cost for treatment and rehabilitation for the patients. There are conflicting reports regarding the rate of infection between bone patellar tendon bone (BPTB) and hamstrings tendon (HT) autografts for anterior cruciate ligament reconstruction. Therefore, we performed this review to summarize all the available data regarding the risk of infection after ACL reconstruction, to provide insight on the infection risk between BPTB and HT autografts, and to discuss current recommendations for the diagnosis and treatment of these infections. The incidence and risk of infection after ACL reconstruction with HT graft is higher compared with BPTB grafts. The most commonly subacute and late infections, quadruple type, need for cannulated instruments for harvesting, size and shape and fixation of the extra-tunnel material of the HT are important risk factors for infection. Combined antibiotics administration and adequate arthroscopic lavage and debridement are the optimal treatments for ACL reconstruction infection. Early diagnosis and treatment is the most important predictor for graft retention, which accounts more commonly for BPTB grafts. The treating physicians should be aware of the higher incidence of infection after ACL reconstruction with HT graft, as well as for the need for a high clinical suspicion for early diagnosis of the infection. These will increase the possibility of eradication of the infection and retention of the graft.

Fourier transform infrared spectroscopy was used to evaluate the molecular structure of bone tissues of patients who underwent revision of total hip and shoulder arthroplasty. The intensity increase of the spectral bands in the region of 3000-2850 cm-1 provided information about the increase of the lipophilic environment, which supported the formation of aggregates and amyloid protein formation. The appearance and the intensity increase of the "marker band" at 1744 cm-1 suggested protein peroxidation and inflammation progression. The shift of the amide I and amide II absorption bands from 1650 cm-1 and 1550 cm-1, respectively, to lower frequencies was related to changes of collagen conformation structure from α-helix to β-sheet and random coil. The appearance and shifts of the new bands in the region 1200-900 cm-1 were related with the increasing of glycosylation upon inflammation. Important was also the disappearance of the hydroxyapatite vPO43- absorption bands at the spectral regions 1200-900 cm-1 and 550-650 cm-1 indicated the osteolysis development. Moreover, the formation of corrosive metallic implants confirmed the effect of oxidative stress on the development of periprosthetic joint infection.

Low back pain (LBP) is a common problem, affecting 11% of the population in Greece. Pain can last upwards of 6 wk and impact functional ability and quality of life. Treating LBP often includes the use of alternative methods, such as relaxation techniques. We tested whether relaxation techniques could reduce stress and pain and improve quality of life. Patients engaged in methods such as diaphragmatic breathing, progressive muscular relaxation, autogenic training, and guided imagery. The treatment group consisted of 31 randomized patients and the control group had 33. The treatment group followed an 8-wk relaxation program with weekly sessions and practiced techniques every day by listening to a compact disk at home (2×/d). The control group did not follow relaxation techniques. No statistically significant differences were present regarding the Perceived Stress Scale, body-mass index, and satisfaction with functional ability. However, statistically significant differences were found in the Brief Pain Inventory score and multidimensional locus of control. We also found decreases in all three cortisol measurements for the treatment group. Relaxation techniques provide positive results in pain reduction and cortisol decrease and must therefore be incorporated into rehabilitation protocols.

We prospectively studied 51 patients (38 men and 13 women; mean age, 52 years) with upper extremity infections. Body mass index (BMI), smoking habits, and comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, thyroid disease, and the site and type of infection were recorded. The 0-10 point Visual Analogue Scale (VAS) was used to evaluate the pain of the affected limb, and the Quick DASH Score was used to assess the severity of upper limb injury. ESR, CRP, and WBC, as well as serum levels of IL-1β, IL-17A, and IL-17F were measured. The serum levels of IL-1β and IL-17F were not elevated in the majority of the patients. In contrast, 14 patients (27.4%) had elevated levels of IL-17A. However, serum levels of IL-17A were not correlated with sex, age, BMI, comorbidities, fever, VAS score, WBC, CRP, ESR, and IL-17F. A trend to significance was observed between IL-17A and DASH score, and a strong association was observed between IL-17A and IL-1β. No correlation was detected between serum levels of IL-17A and type of isolated bacteria, Gram stain, site and type of infection. After controlling the impact of sex, age, and BMI, a trend to significance was observed between IL-17A and VAS score, and a marginal significance was observed between IL-17A and DASH score.

The aim of the present study is to control the hypothesis that the rib hump deformity can be adequately corrected when applying vertebral derotation. We retrospectively studied patients treated with full pedicle screw systems (group A), hybrid constructs (group B), and Harrington rod instrumentation (group C). No costoplasties were performed in the patients included in our study. Derotation was applied in groups A and B. The rib hump deformity was assessed on lateral radiographic studies by rib index (RI). Of the 72 patients that were finally included in our study, 30 patients (24 females and 6 males; mean age, 14.5 ± 2.2 years) were treated with a full pedicle screw system, 23 patients (19 females and 4 males; mean age, 13.8 ± 1.9 years) were treated with a hybrid construct, and 19 patients (16 females and 3 males; mean age, 14.3 ± 2 years) received the Harrington rod instrumentation. In all groups RI was significantly corrected after surgery. Before surgery no difference in RI was found among groups; however, after surgery RI was found significantly higher in group C as compared to groups A and B. The between-group analysis revealed that the correction of RI, and thereby the rib hump deformity correction, did not significantly differ among the three patient groups. In conclusion, it cannot be suggested based on the present study that vertebral derotation alone can offer an adequate correction of the rib hump deformity. Further, the development of rib cage deformity and its degree of interdependence with the scoliotic spinal deformity has to be further investigated and assessed, as it seems that it may not necessarily result directly from the primary vertebral deformity.

Posterior dislocation of the sternoclavicular joint is a rare and emergent injury. Diagnosis is often missed or delayed. Treatment is challenging because of the joint's inherent instability. This article presents a 15-year-old adolescent who experienced a traumatic posterior dislocation of his right sternoclavicular joint that was treated successfully with open reduction and joint reconstruction using the ipsilateral subclavius tendon autograft. At one-year follow-up, the patient was asymptomatic, with a stable sternoclavicular joint and full range of motion of his right shoulder.

Tibial tubercle avulsion fractures are uncommon injuries that are seen mostly in adolescent male patients during athletic activities. The mechanism of injury usually involves a strong eccentric contraction of the quadriceps femoris muscle when the proximal tibial physis is closing, leading to failure of the physis at the patellar tendon insertion. The treatment of patients with tibial tubercle avulsion fractures depends on the fracture pattern; it can be conservative with immobilization in a long leg cast in extension for 6 weeks with minimal displacement (< 2 mm) and/or acceptable displacement after closed reduction/cast application. Or it can be surgical. This article presents a 14-year-old boy with an Ogden type IIIB tibial tubercle avulsion fracture that was misdiagnosed on radiographs at presentation as type IB. Open reduction and cannulated screw osteosynthesis was done. The outcome was excellent after a 12-week rehabilitation protocol.

Piriformis syndrome (PS), first described by Yeoman in 1928, is a general term referring to low back pain, sciatica, and instability. PS has a 6% incidence rate worldwide. In this study, we aim to retrospectively evaluate the effectiveness of computed tomography (CT)-guided percutaneous infiltration in a series of consecutive PS patients who have symptoms that are refractory to conservative therapies. An institutional database search identified 20 such consecutive patients who underwent infiltration with a mixture of long-acting corticosteroid and local anesthetic. Preoperational evaluation included physical examination and magnetic resonance imaging. The correct position of the 22-gauge spinal needle was verified with CT scan after contrast medium injection. Pain measured before the procedure and at 1 wk and 1, 6, and 12 mo after the procedure was compared by means of a numeric visual scale (NVS) questionnaire. The mean pain score before CT-guided percutaneous infiltration was 8.95 ± 1.432 NVS units. This score was reduced to a mean value of 0.85 ± 0.933 units at 1 wk, 0.90 ± 0.852 at 1 mo, 1.10 ± 1.165 at 6 mo, and 1.20 ± 1.399 at 12 mo follow-up (p < 0.001). Two patients of 20 (10%) underwent a second infiltration that was performed at 7 and 10 d after the first, respectively. No complications were observed. CT-guided infiltration seems to be a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic PS.

Acute respiratory distress syndrome (ARDS) is a potentially life-threatening condition for a many patients. The associated mortality rate may exceed 50% in some cases. The etiopathogenesis of the syndrome remains unclear, and in Greece the exact number of people suffering or dying of ARDS each year is unknown. In this study, we sought to record the clinical characteristics and outcomes of all patients with laboratory confirmed ARDS. This is a retrospective single-center observational study, conducted in mixed, closed-type ICU with 12 beds at a Greek public health system hospital. The medical records of patients admitted to the ICU from January 1, 2015, until December 31, 2016, were retrospectively studied, and statistical analyses were performed using SPSS version 22.0 software. Patients were assessed using the Fisher exact test assuming variances. All tests were two-tailed. In total, 15 patients developed ARDS (5.4%). According to the existence of radiographic pulmonary edema image with bilateral infiltrates, 12 patients were classified in the early phase of the syndrome described by the term exudative phase and 3 patients were classified in the third stage of final fibrosis (fibrotic stage). According to the Fisher test, there is a significant correlation between age and outcome. The incidence of the syndrome among hospitalized patients in ICU is in line with the current literature, while the main predisposing factor in this study was acute pancreatitis.

Nerve injuries around the shoulder are common. They usually occur as a result of motor vehicle accidents, gunshot or athletic injuries, or overuse and chronic repetitive stress often observed in sports involving repetitive overhead or throwing activities. The mechanisms of nerve injury include direct pressure, repetitive microtrauma, and compression- or stretch-induced ischemia. The severity and extent of compression is related to the degree of the nerve injury. Several nerve injury grading systems have been developed, allowing for the correlation between microscopic changes occurring after the injury and the patient's symptoms; recovery and prognosis is related to the type and severity of the injury. Distinct clinical syndromes involving the shoulder joint area can develop after injuries to the axillary, musculocutaneous, suprascapular, long thoracic, and spinal accessory nerves, as well as the proximal brachial plexus trunks and the lower cervical nerve roots. When a patient complains of pain, weakness, or paresthesia in the absence of known bone, soft tissue, or vascular injury, nerve injury must be suspected. This article summarizes the most common nerve injuries around the shoulder and discusses the classification, mechanism, treatment, and prognosis for these injuries.

Clinical studies and experimental research have described therapeutic hypothermia for patients suffering from traumatic brain injury (TBI), cardiac arrest, and neonatal hypoxic ischemic encephalopathy. This procedure is implemented by intensive care unit (ICU)-trained nurses. The aim of the present study was to compare cold compresses/ ice packs, cooling blankets, and heat-exchange systems via intravascular catheters used in the ICU for therapeutic hypothermia from a nursing perspective with respect to ease of application, additional workload, ease of temperature monitoring, and effectiveness. A questionnaire was completed by ICU nurses to evaluate these techniques for therapeutic hypothermia. The results were calculated and a score of 1 to 5 was obtained, where 1 = very bad, 2 = bad, 3 = moderate, 4 = good, and 5 = very good. Overall, heat exchange via intravascular catheters had the best score for implementation of therapeutic hypothermia. Regarding ease of the application, cold compresses/ice packs had the best score. Regarding additional workload, cold compresses/ice packs had the worst score, whereas the heat-exchange system via intravascular catheters scored the best. Regarding ease of temperature monitoring, the heat-exchange system via intravascular catheters had the best score and, regarding effectiveness, cold compresses/ice packs scored the best.

Arthroscopic and prosthetic hip and knee joint infection are uncommon; however, devastating complications in adult reconstruction surgery. An acute onset of pain combined with effusion, erythema, warmth and fever are the typical signs of early infection. Hypersensitivity or allergic reactions to arthroplasty components, concerning mainly metal-to-metal bearings and metal-on-plastic total knee arthroplasties have also been reported. Inflammation associated with allergic reaction to any of these materials (metallic and/or acrylic bone cement) can plausibly cause a number of similar manifestations to infection such as loosening, instability, stiffness, arthrofibrosis, swelling, warmth, and pain. This article presents a patient without known polymethylmethacrylate (PMMA) bone cement allergy who experienced a prosthetic joint infection after a cemented total knee arthroplasty. The diagnosis of infection was misled by the wrong timing of cultures with respect to antibiotics cessation, and the documentation of PMMA cement allergy with allergiologic examination and patch testing.

Parkinson's disease is a degenerative disorder of the central nervous system affecting the substantia nigra in the midbrain. It accounts for 1.5% of the population in Europe over 60 years of age. Recent advances in the medical treatment of Parkinson's disease have improved the quality of life and life expectancy of the patients. However, it remains a debilitating disease. Spinal disorders are frequent in these patients, and as the population ages, more patients with Parkinson's disease are expected to require spinal surgery. Spinal surgery in patients with Parkinson's disease has been associated with an exceptionally high rate of complications; failures and reoperations are common, and patient outcomes are dismal.

A 17-yr-old male patient was admitted with a transverse sharp transection caused by broken glass at the volar aspect of his left wrist. Clinical examination showed loss of sensation at the distribution of the median nerve to the thumb, index, and middle finger and an inability to flex the middle finger. Under regional anesthesia and a high humerus tourniquet, surgical exploration of the wound with binocular loupe magnification showed a bifid median nerve with a persistent thin median artery running between the two nerve trunks. The bifid median nerve was sharply and transversely transected, slightly proximal to the transverse carpal ligament. The palmaris longus tendon and the flexor digitorum superficialis tendon of the middle finger were also cut. The flexor digitorum tendon was sutured with a two-strand technique augmented with a running epitendinous suture. The two trunks of the bifid median nerve were repaired separately using microsurgical technique and 8-0 nylon epineural sutures. Postoperatively, the hand was immobilized in a palmar short-arm splint that was removed at 40 d. A progressive Tinel sign was evident 30 d postoperatively. At 3 mo, the patient experienced light touch sensation at the tip of the index and middle fingers. At the last follow-up, 2.5 yr after his injury, the patient has complete nerve functional recovery without atrophy of the thenar muscles and with strong thumb opposition.

Angiosarcoma of bone is a rare high-grade malignant vascular tumor accounting for <1% of malignant bone tumors. Tumor location in the distal radius is very rare. Complete surgical resection with limb salvage surgery or amputation is essential for the outcome of the patient. However, the literature is vague regarding the best surgical approach for resection of the distal radius and the optimal reconstruction option after a bone tumor resection. Several reconstruction techniques have been described, varying from arthrodesis to arthroplasties. In this article, we present a report of a patient with angiosarcoma of the distal radius treated with complete resection and reconstruction with a distal radius osteoarticular allograft. We discuss the advantages and the limitations of this surgical technique for the distal radius.

Although radiation therapy is an essential treatment of cancers, it is associated with unwanted complications. The purpose of this review is to summarize the current knowledge regarding the side effects of radiation in bone and articular cartilage and to recommend Fourier transform infrared spectroscopy to monitor the differences in infrared spectra between healthy and irradiated bone and cartilage.

Lower-extremity angular deformities are among the most common non-traumatic conditions in children being referred to pediatric orthopedists. Understanding of this abnormality and knowledge of current treatment is essential for pediatricians and primary caregivers. A development in the surgical management of these problems has improved the quality of care of affected children and adolescents. Traditionally, angular deformities are treated by means of osteotomy. In patients who are skeletally immature, this major intervention can be avoided by influencing or guiding the growth of the affected physis using hemiepiphysiodesis techniques. Recently, alternative surgical techniques and implants have been described for improved control of the guided growth.

Although computer-assisted navigation has been used in clinical practice for more than 15 years, it has only recently started to gain acceptance in a variety of orthopedic procedures. Different types of computer-assisted navigation are available, which allow the surgeon to obtain real-time feedback and offer him the potential to decrease intraoperative errors. However, its increased cost and lacking evidence of long-term superiority have made many surgeons skeptical about its clinical usefulness. The scope of this article is to review the clinical applications of computer-assisted navigation in orthopedic surgery of the knee joint.

Hip fractures are associated with significant mortality and morbidity for the patients, more dependent residual status, and increased socio-economic cost. Many hip-fracture patients experience severe functional impairment, and most never recover their pre-fracture level of function. Current research has sought to identify the most effective treatments to reduce the incidence of hip fractures, improve survival and quality of life, and minimize complications and disability. The treatment of these fractures in the elderly aims to return these people to their pre-fracture mobility and functional level. This article reviews the surgical treatment options for extracapsular hip fractures and discusses their associated advantages, disadvantages, and complications. Two types of implants are currently available: the dynamic hip screw (DHS), and the intramedullary hip nail with one or two sliding screws. In this review, no clear advantage of one implant over another for the treatment of extracapsular hip fractures was evident. Both the DHS and hip nails can be used successfully for the treatment of stable hip fractures; for unstable fractures and low subtrochanteric fractures, hip nails are preferred. Although hip nails are associated with limited exposure, lower blood loss and transfusion requirements, and shorter operative time, complications are more common with hip nails. Long-term survival and function are similar in the two approaches. Hip nails with two sliding screws do not seem to make the difference in clinical practice that is reported in biomechanical studies.

We present a report of nine patients (eight women and one man; mean age 37 years) from 2010 to 2012 with septic pseudarthrosis of the tibia treated with bone transport over an intramedullary nail using a circular external fixator. The mean follow-up was 15 months (range: 10-21 months). A two stage approach was used. At the first stage, removal of the primary osteosynthesis and extensive bone debridement to healthy, bleeding bone margins was performed. The bone defect was packed with antibiotic loaded cement beads, and stabilization of the tibia was done with a unilateral external fixator or with a long leg posterior splint. The mean size of bone defect was 4 cm (range: 3.5-5.5 cm). At the second stage, two consecutive negative wound cultures and normal values of blood cell count, C-reactive protein (CRP), and estimated sedimentation rate (ESR) were obtained. Then we reamed and locked the intramedullary nailing of the tibia, applied a circular external fixator, and performed percutaneous corticotomy of the tibia opposite the site of the bone defect. Bone distraction over the nail was initiated at the eighth postoperative day at a rate of 1 mm/day. At the last follow-up, union was achieved in all cases without recurrence of bone infection. All patients experienced excellent (n=3) or good (n=6) knee and ankle function, as well as complete return to their daily activities. Two patients experienced pin-tract infection, and one patient experienced anterior knee pain at the entry point of the nail.

Spinal instrumentation constructs are frequently necessary for the surgical management of patients with variable spinal pathology. However, surgical complications may appear. These should be detected early and managed to achieve recovery and good functional outcome for the patient. This article provides an in-depth analysis of the most common instrumentation-related complications of spine surgery as well as a diagnostic plan and treatment options for the management of these challenging entities once they occur.

Radiation-induced sarcomas are rare, high-grade sarcomas that may arise within the radiation volume at a mean latency period of 3-55 years after radiation therapy, doses of which range from 45 to 60 Gy. Radiation-induced osteosarcomas, fibrosarcomas, and malignant fibrous histiocytomas are the most common. Extensive surgery with microscopically negative-margin resection, or amputation is recommended for improved survival. Adjuvant radiation therapy and chemotherapy have not been shown to improve survival rates significantly. The prognosis is poor.

Osseointegration or osteointegration refers to a direct bone-to-metal interface without interposition of non-bone tissue. The long-term clinical success of bone implants is critically related to wide bone-to-implant direct contact. However, only poor bone formation or even host bone resorption have been shown where bone is in tight contact with the implant surface. It has been suggested that an appropriate space between implant and host bone may be useful for early peri-implant bone formation. Additionally, osseointegration depends on the topographical and chemical characteristics of the implant surface. Cobalt-chrome (Co-Cr) is a metal alloy of cobalt and chromium. Because of its high strength, temperature endurance and wear resistance, it is commonly used in dental and orthopedic implants. In orthopedic implants it is usually composed of cobalt with chromium, molybdenum, and traces of other elements. Co-Cr alloys are especially useful where high stiffness or a highly polished and extremely wear-resistant material is required. This article reviews the Co-Cr alloy orthopedic implants in terms of their properties, porous coating, osseointegration, outcome, and failure.

Controversy exists regarding the optimal method of internal fixation in femoral neck fractures. Biomechanical data suggest that calcar fixation is superior to central screws placement. We propose a divergent technique for placing 3 cannulated stainless steel screws engaging the calcar femorale. Fifty two patients admitted to our institution for a femoral neck fracture were treated with the divergent screw technique, over a 7-year period. Four patients were deceased and 4 were lost to follow-up. Of the remaining 44 patients there were 10 males and 34 females, aged from 33 to 78 years (mean, 58 years). All patients were operated on by the same surgeon and were followed-up for a minimum of 2 years (mean: 33.6 months, range: 2-6 years). Twenty four patients sustained a non-displaced fracture (Garden I-II) and 20 sustained a displaced fracture (Garden III-IV) of the femoral neck. Mean Harris hip score (HHS) was 89.6 points. Avascular necrosis was evident in 4 patients (9%) with displaced fractures. Non-unions or failed internal fixations were not encountered. There was a significant difference in the HHS, in favor of the divergent group (P = 0.006), while more complications were encountered in the parallel group including 6 cases with non-union. In conclusion, parallel screw placement is not critical for an excellent clinical outcome. Our proposed fixation method using 3 screws that diverge and lie in different coronal planes (1 engaging the calcar femorale) with a free-hand technique may offer enhanced fixation. Biomechanical data along with larger clinical studies are needed to establish our proposed method.

There are several total knee arthroplasty designs available with wide variation in features. The long-term results of total knee replacement with a fixed bearing design have shown a high degree of clinical success. However, implant loosening and polyethylene wear became recognized as long-term causes of late failure. Mobile bearing knee replacements were designed to create a durable surface articulation by using a polyethylene insert that articulates with a metallic femoral component and a metallic tibial tray. The purpose of this article is to review clinical and basic scientific studies comparing the clinical results, the biomechanical features, and the kinematic patterns of fixed versus mobile bearing knee designs. Beside the fact that in vitro kinematic studies have shown reduced polyethylene wear in mobile bearings due to increased implant conformity and reduced polyethylene contact stresses, which should hypothetically prolong polyethylene life, various independent studies for both mobile bearing and fixed bearing prostheses have documented results that are comparable in terms of survival and performance.

With recent advances in medical and orthopedic oncology, radiation therapy and single- or multiple-agent perioperative chemotherapy are currently applied as an essential part of the multidisciplinary treatment to improve disease-free and overall survival of patients with primary and metastatic bone and soft tissue tumors. However, these treatments have led to unwanted complications. A better understanding of the effects of various antineoplastic agents on bone, soft tissue, and organs may provide the basis for the more efficacious use of antiproliferative drugs when fracture healing or allograft incorporation is required. This knowledge may also provide a rationale for concurrent treatment with drugs that protect against or compensate for adverse effects in osseous repair resulting from chemotherapy.

Radiation therapy is applied for systemic effects to patients with bone and soft tissue tumors and for local effects that facilitate the surgical procedure. However, while it remains an essential treatment of cancers, radiation therapy is associated with unwanted complications. The purpose of this review is to summarize information regarding the complications of radiation in musculoskeletal oncology and their management. Because preoperative radiotherapy is associated with an increased risk of wound complications and postoperative radiation is associated with an increased risk of postradiation fractures, the physician requires additional information in deciding on the best method of treatment, and such information is provided in this review.

Classifications have been previously reported and biomechanical studies have been performed, but the management of humeral fractures between implants remains problematic. At the time of arthroplasty, planning of the optimum length of the prostheses is required, especially for patients being considered for a second arthroplasty in the ipsilateral elbow or shoulder. Current treatment may be conservative if reduction can be obtained and the prostheses are stable, or it may be surgical using internal fixation with plates, strut grafts, double plates, or a plate and strut graft construct if the fracture extends around the components of the prosthesis and autogenous bone grafting.

We present the clinical and radiographic outcomes of the cementless low-contact-stress (LCS) rotating-platform total knee arthroplasty. Overall, 423 prostheses were implanted in 393 consecutive patients (30 patients had bilateral total knee replacement) for primary varus gonarthrosis (381 patients) and rheumatoid arthritis (12 patients). There were 81 men and 312 women with a mean age of 73 years (range, 58-85 years). Patella replacement was not performed in any case. Clinical and radiographic evaluation was performed using the Knee Society Score (KSS) and the Knee Society Assessment Form, respectively. The mean follow-up was 10 years (range, 5-15 years). Three patients were lost to follow-up. Survival of the prostheses was 98% at 10 years; three prostheses required revision for deep infection, bearing dislocation, and periprosthetic fracture. The mean KSS improved significantly, from 42 and 44 points preoperatively to 90 and 79 points, respectively, at the latest evaluation (P < 0.001); results were excellent in 278 cases, good in 106, fair in 27, and poor in nine. Radiolucent lines were observed in 80 cases; revision arthroplasty was not performed in any of these cases. Complications included deep infection in one patient, bearing dislocation in one, skin necrosis in four, and a supracondylar fracture in one. The cementless LCS rotating-platform total knee arthroplasty is associated with excellent mid- and long-term results for patients with osteoarthritis and rheumatoid arthritis of the knee.

Fifty consecutive patients with posterior thoracolumbar spine fusion were included in a prospective study to determine the accuracy of intraoperative neurophysiological monitoring (IONM) for safe pedicle screw placement using postoperative computed tomography (CT). The patients were allocated into two equal groups. Pedicle screw placement was evaluated intraoperatively by using the image intensifier. In group A, the integrity of the pedicle wall was evaluated intraoperatively with monopolar stimulation of each screw head with a hand-held single-tip stimulator; the compound muscle action potentials were recorded. A constant current threshold of 7 mA was considered indicative of pedicle breach; < 7 mA was considered as direct contact with neural elements, and > 7mA was considered normal. In group B, pedicle screw placement was performed without IONM. Overall, 306 pedicle screws were inserted in both groups. Postoperatively, all patients underwent CT scans of the spine to evaluate pedicle screw placement. Intraoperatively, five screws in respective group A patients had to be repositioned after IONM (threshold of < 7 mA); in these patients, postoperative CT scans showed proper screw placement. Postoperative CT scans showed eight misdirected screws; two screws (1.26%) in group A patients and six screws (4%) in group B patients. Two screws were misdirected through the medial pedicle wall and six screws were misdirected through the lateral pedicle wall. Both medially misdirected screws were observed in group B patients (1.35%); these patients developed neurologic symptoms postoperatively and underwent revision surgery, with redirection of the misdirected screws and subsequent resolution of the neurologic symptoms. Two of the six laterally misdirected screws were observed in group A patients (1.26%); the remaining four laterally misdirected screws were observed in group B patients (2.7%). None of these patients had neurologic sequelae; no revision surgery was required. The cut-off value of 7 mA had a 98.73% (> 95%) positive predictive value for accurate pedicle screw placement.

Limb salvage surgery and reconstruction of bone defects is challenging in orthopaedic oncology. Allogenic and autologous bone grafting are well-recognized methods for bone reconstruction. Custom-made and modular, cemented and cementless, mega-prostheses provide the modular options needed intraoperatively to bridge variable bone defects. However, these mega-prostheses have worse long-term results compared to conventional total joint replacements. Mechanical failure, aseptic loosening, infection, dislocation, skin necrosis, extensor mechanism ruptures and periprosthetic fractures are acknowledged complications of orthopaedic oncology procedures. These complications are due to the large defects that need to be bridged with a more difficult fixation in the diaphysis of the native bone, the more complex restoration of joint biomechanics, the extensive soft-tissue resection, the lengthy surgical operations, and the need for chemotherapy and radiation therapy. Because of the difficulties and the high rate of complications associated with the implantation of such highly modular systems, the treatment of patients with malignant bone tumors should only be carried out in specialized centers.

Six patients underwent segmental bone resection and limb salvage surgery for primary or metastatic bone tumors involving the diaphysis of the femur, the tibia, and the humerus using a modular intramedullary diaphyseal segmental defect fixation system. There were four men and two women with a mean age of 62 years (range: 40-77 years). Histological diagnosis included adamantinoma, synovial sarcoma, multiple myeloma, metastatic renal cell carcinoma, myeloid carcinoma of the thyroid gland, and adenocarcinoma of the stomach. The mean follow-up was 17 months (range: 11-28 months). At the latest examination, five patients were free of local or distant disease and one patient had deceased with distant disease, without evidence of local recurrence. Revision surgery was necessary in one patient because of mechanical loosening of the proximal fixation of the prosthesis at 24 months. The mean postoperative increase of the Enneking rating score was 87.8%. The intramedullary diaphyseal segmental defect fixation system used herein is associated with a satisfactory functional and oncological outcome after wide resection of diaphyseal bone tumors.

We reviewed the medical files of 32 patients with degenerative disc disease, spinal stenosis, and spondylolisthesis who underwent posterior lumbar interbody fusion using the B-Twin system. In 12 of these patients, posterior lumbar interbody fusion has been supplemented with posterior lumbar-instrumented fusion (circumferential fusion) because of spinal instability. Clinical and functional outcomes were assessed. The quality of fusion and disc height were recorded. The mean follow-up was 36 months (range, 18 to 42 months). At the latest examination, clinical improvement and fusion were statistically significant in both groups; the mean Oswestry disability index improved from 55% to 24%, and to 22% in the patients with more than 20 months follow-up; the mean Rolland-Morris disability questionnaire improved from 52% to 29% (p < 0.001); 95.6% (22/23) of the levels managed with the B-Twin system alone and 92.9% (13/14) of the levels managed with circumferential fusion showed solid fusion; and the intervertebral disc height increased from 8.1 +/- 0.74 mm to 11.4 +/- 0.93 mm in the B-Twin group and from 7.7 +/- 0.75 mm to 10.6 +/- 0.91 mm in the circumferential fusion group. However, in comparing the two groups there was no statistical significant difference. The B-Twin system is safe and effective for the management of degenerative disc disease as a stand-alone device. The combination with posterior lumbar-instrumented fusion systems for circumferential fusion yields statistically significant differences in fusion rate and functional outcome.