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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. © 2022, Begell House Inc.. All rights reserved.

Purpose: Using serum biomarkers, this systematic review assessed soft tissue injury following different total hip arthroplasty surgical approaches. The purposes were to determine if there is any advantage between the standard and minimal invasive approaches, and to compare tissue damage of the respective surgical approaches using biomarkers such as creatine kinase, myoglobin, c-reactive protein, erythrocyte sedimentation rate, skeletal troponin and interleukins. Method: A search in Pubmed/MEDLINE, Scopus and Web of Science databases was conducted in October 2021 with the use of PRISMA guidelines. Search items were (“biomarkers” OR “markers” OR “tissue damage” OR “muscle damage”) AND “approach” AND (“total hip arthroplasty” OR “total hip replacement”). Inclusion criteria were prospective, randomized, controlled trials or prospective, comparative studies, comparing serum markers for muscle damage in two or more surgical approaches for primary total hip arthroplasty. Exclusion criteria were study protocols, case reports, systematic reviews, meta-analyses, studies in non-English language or without available full text, and studies not recording biomarkers of muscle damage. Results: Initial search revealed 508 studies; after subtraction of duplicates, and exclusion criteria, 31 studies remained for analysis. No advantage between different approaches was found when evaluating biomarkers, and no specific biomarkers had a distinct role in tissue damage in total hip arthroplasty. Anterior and minimally invasive approaches were associated with lower values of soft tissue (creatine kinase) and inflammation (c-reactive protein) biomarkers compared to the standard approaches. Conclusion: Measurement of serum biomarkers after primary total hip arthroplasty for the estimation of tissue damage has unclear or little clinical value. Trial registration: PROSPERO Registration: CRD42022303959. © 2022, The Author(s) under exclusive licence to SICOT aisbl.

Purpose: Pedicle or free-flap reconstruction is important in surgical sarcoma management. Free flaps are indicated only when pedicle flaps are considered inadequate; however, they are associated with a higher risk of flap failure, longer surgical times, and technical difficulty. To determine the skin defect size that can be covered by a pedicle flap, we investigated the clinical outcomes and complications of reconstruction using pedicle flaps vs. free flaps after sarcoma resection. Methods: We retrospectively studied the medical records of 24 patients with soft-tissue sarcomas who underwent reconstruction using a pedicle (n = 20) or free flap (n = 4) following wide tumour resection. Results: All skin defects of the knee, lower leg, and ankle were reconstructed using a pedicle flap. Skin defects of the knee, lower leg, and ankle were covered by up to 525 cm2, 325 cm2, and 234 cm2, respectively. The amount of blood loss was significantly greater in the free-flap group than in the pedicle flap group (p = 0.011). Surgical time was significantly shorter in the pedicle flap group than in the free-flap group (p = 0.006). Total necrosis was observed in one (25%) patient in the free-flap group; no case of total necrosis was observed in the pedicle flap group. Conclusion: Less blood loss, shorter surgical time, and lower risk of total flap necrosis are notable advantages of pedicle flaps over free flaps. Most skin defects, even large ones, of the lower extremities following sarcoma resection can be covered using a single pedicle flap or multiple pedicle flaps. © 2021, The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature.

Teratomas are a subtype of germ cell tumors composed of a variety of somatic tissues derived from more than one of the three germinal layers (ectoderm, endoderm and mesoderm). They can be classified as mature tumors and immature tumors. Teratomas most commonly arise at the sacrococcygeal region and the gonads. The occurrence of a teratoma outside the common gonadal and midline locations is exceptional. This review article lists the reported primary and metastatic malignant teratomas in extragonadal locations and discusses the possible explanation for the atypical location, their treatment and prognosis. © 2022, The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients’ comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients’ chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative. © 2022, The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.

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.

Purpose: To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology. Method: A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing. Results: The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients. Conclusion: Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications. © 2021, SICOT aisbl.

Approximately 2% to 9% of giant cell tumor of bone (GCTB) metastasizes systemically, mainly to the lungs. The biological behaviors and clinical courses of lung metastases are difficult to predict, and their treatment recommendations vary, including metastasectomy and non-metastasectomy with chemotherapy (denosumab, interferon-alfa, bisphosphonates), with radiation therapy, or with observation alone. However, it is unclear whether metastasectomy for GCTB lung metastases decreases the mortality rate of these patients. Therefore, the authors performed this systematic review to compare metastasectomy and non-metastasectomy for GCTB patients with operable lung metastasis. Of the 919 relevant studies, 16 studies (138 patients) were included for analysis; 61.6% of patients had metastasectomy and 38.4% had non-metastasectomy. Analysis showed that mortality rates were similar for the patients who had metastasectomy compared with those who did not; the proportion of patients who died of disease was 7.1% in the metastasectomy group and 17.0% in the non-metastasectomy group, with an overall pooled odds ratio of 0.64 (P=.36). Therefore, physicians should reconsider the potential risks and benefits of metastasectomy for patients with GCTB and lung metastasis, because metastasectomy does not reduce the mortality rate in these patients. © 2020 SLACK Incorporated.

Introduction: Trauma-induced coagulopathy has been extensively investigated in the multitrauma setting, but only sparsely following moderate orthopedic trauma. The purpose of this study was to evaluate changes in the hemostatic profile of patients with hip fractures, using rotational thromboelastometry (ROTEM). Methods: 198 patients with hip fractures who underwent surgery were included in the study. A matched group of 52 healthy individuals was also enrolled. Demographics, conventional laboratory assays, and ROTEM parameters were recorded and compared between patients and healthy adults. The preoperative and postoperative ROTEM values of fractured patients were also compared. Results: The conventional coagulation assays were similar for the 2 groups. However, several ROTEM parameters including EXTEM MCF (P

Differentiation of malignant from benign soft tissue tumors is challenging with imaging alone, including that by magnetic resonance imaging and computed tomography. However, the accuracy of this differentiation has increased owing to the development of novel imaging technology. Detailed patient history and physical examination remain essential for differentiation between benign and malignant soft tissue tumors. Moreover, measurement only of tumor size based on Response Evaluation Criteria In Solid Tumors criteria is insufficient for the evaluation of response to chemotherapy or radiotherapy. Change in metabolic activity measured by 18F-fluorodeoxyglucose positron emission tomography or dynamic contrast enhanced-derived quantitative endpoints can more accurately evaluate treatment response compared to change in tumor size. Magnetic resonance imaging can accurately evaluate essential factors in surgical planning such as vascular or bone invasion and “tail sign”. Thus, imaging plays a critical role in the diagnosis and treatment of soft tissue tumors. © 2021 Bentham Science Publishers.

Fluid-fluid levels result from the separation of two fluids of differing densities within a cavernous space with the boundary between the two layers running in a horizontal plane at 90 de-grees to the direction of gravity. Magnetic resonance imaging is the most sensitive imaging modali-ty to identify fluid-fluid levels. Although the most common bone lesions containing fluid-fluid levels are aneurysmal bone cyst and telangiectatic osteosarcoma, fluid-fluid levels can be observed in a wide variety of bone and soft tissue lesions. Therefore, fluid-fluid levels cannot be considered diagnostic of any particular type of tumor and the diagnosis should be made on the basis of other clin-ical, radiological and pathological findings. This article summarizes the pathophysiology and imaging characteristics of fluid-fluid levels and discusses the differential diagnosis of tumors with this imaging sign. © 2021 Bentham Science Publishers.

Background: Medulloscopy refers to the visualization of the intramedullary canal with an arthroscope, providing access to the infection site without the need for an extensive approach therefore not compromising the surrounding soft tissue. It provides information regarding the extent of the infected endosteal surface of bone, and it allows a thorough debridement of the intramedullary canal in a controlled manner. Therefore, it can be used as an adjunct to traditional open surgical techniques, to perhaps help to visualize hard to see intramedullary areas. Materials and methods: This article reports a patient with chronic osteomyelitis of the distal metaphysis of the femur that was treated successfully with intramedullary debridement through medulloscopy. The sinus tract reaching down to the femoral bone and communicating with the intramedullary canal was excised, and a cortical window was formed through which the arthroscope was inserted and thorough irrigation of the intramedullary canal and excision of necrotic and infected bone was done. A second medulloscopy through the same approach was necessary 3 months later because of persistent infection. Re: sults: At 3-year follow-up, the patient was well without any clinical or radiographic evidence of recurrent infection. Conclusion: Medulloscopy can be very useful in localized osteomyelitis as an adjunct to traditional surgical techniques; it helps to visualize hard to see intramedullary areas and adequately addresses the infection, while the damage to surrounding soft-tissue is limited. © 2020, Springer-Verlag France SAS, part of Springer Nature.

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine. More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord. As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely. Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization. This article summarizes the clinical findings of echinococ-cosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients’ outcomes. The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. © 2021. The author(s) This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.

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, hyperlip-idemia, 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. © 2021 by Begell House, Inc. www.begellhouse.com.

Purpose: To compare and discuss the gender disparities in the Orthopaedic specialty. Methods: We reviewed the literature to find the rates of women applying for an orthopaedic residency, fellowship, and academic career program, to understand the causes of the disparities in women in orthopaedics, and how this relates to orthopaedic surgical practice. Results: The idea that men and women are different and have different working styles and skills and the belief that males are more dominant and more status-worthy than females leads to gender barriers and stereotypes that restrict women from entering male-dominated specialties. It is important to mention that equivalent barriers restrict men from pursuing female-dominated specialties such as Gynecology. Economic disparities and gender stereotypes that divide medical specialties into masculine and feminine, creating a gender gap in health care are major concerns. However, the number of women in the health sector is expected to increase due to the growing amount of female students that are expected to soon graduate. A leadership gender gap also exists; although women consist of 70% of the health care workforce they occupy only 25% of leadership positions. Conclusion: The existence of gender-based disparities in healthcare is multifactorial. The explanation behind the existence of a so-called gender gap lies in organizational and individual factors. Early development and family relations, the decision between work and life balance, personal choices and interests, as well as working conditions, absence of role models and mentorship and institutional policies make gender disparities even more evident. © The Authors, published by EDP Sciences, 2021.

Background: Double ipsilateral femoral fractures account for 1–9% of femoral fractures. There is no clear advantage between single or double implant osteosynthesis. We present a series of patients with double ipsilateral femoral fractures, to address the challenges in treatment, namely the implants for osteosynthesis and complications of treatment. Materials and methods: We retrospectively studied 16 patients (7 men, 9 women; mean age, 51 years) treated from January 2015 to December 2018. Motor vehicle accidents were the leading cause of injury. Types of fractures were pertrochanteric and shaft (6), pertrochanteric and distal (2), double shaft (3), neck and shaft (2), neck and distal (1), shaft and distal (1), and triple fracture including a pertrochanteric, shaft and distal (1). In five patients, two different implants were used (plate and screws, cannulated hip screws, femoral nail), whereas in 11 patients a long femoral nail was used. Results: Fourteen patients experienced union at a mean of 3 months (2–6 months). Two patients experienced nonunion: both had plate and screws osteosynthesis. One patient died 15 days after admission from polytrauma and another patient experienced central venous catheter thrombosis and pneumonia. Surgical complications (2 patients) included a thigh skin necrosis, and external fixator pin tract infection/infected non-union. Weight-bearing was delayed in all patients; full weight-bearing was allowed in 11 patients at 4 months postoperatively, and in four patients at 5 months. Conclusion: Due to the rarity and the difficulty of standardization of double ipsilateral femoral fractures, there is variable information on the optimal osteosynthesis of the fractures and the outcome of the patients. It seems that closed reduction and long hip nailing is the treatment of choice, with few complications. © 2021, The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature.

Background: Diffuse tenosynovial giant cell tumors (TGCT) are more likely to occur in the hindfoot and tend to recur after surgical excision. We performed a pooled analysis of hindfoot TGCT cases to identify factors associated with local recurrence and functional outcomes. Methods: We retrospectively reviewed medical records of 33 patients diagnosed with TGCT (15, localized cases; 18 diffused cases) of the hindfoot between 1998 and 2017. Median follow-up was 32 months. Multivariable Cox proportional hazards regression analysis was conducted to estimate the hazard ratios for risk factors for local failure. Generalized linear regression models were used to assess whether resection status, tumor size, tumor type or bone involvement correlated with the Musculoskeletal Tumor Society (MSTS) score. Results: Local failure was reported in 30% (10/33) patients. Multivariable analysis showed that macroscopically incomplete resection was the only independent prognostic factor for poor local failure-free survival (P =.001). Incomplete resection significantly decreased MSTS score and negatively affected functional outcome (P =.047). Conclusions: Incomplete resection increases the risk of local recurrence and negatively affects functional outcome in patients with TGCT of the hindfoot. © 2019 European Foot and Ankle Society

Multifocal, extraosseous, and surface aneurysmal bone cysts are rare variants of the primary lesions. The clinicopathological features are similar, and the optimal treatment is surgical. Although local recurrences may occur, the prognosis is excellent. This review article introduces the readers to a rare diagnosis which they may have been previously unfamiliar with, presents the clinicopathological and imaging features of these rare aneurysmal bone cyst variants, and discusses their diagnosis and treatment. The clinicians who treat patients with aneurysmal bone cysts should be familiar with these uncommon entities and their differential diagnosis. © 2020, Springer-Verlag France SAS, part of Springer Nature.

The spinal column represents the third most common site for metastases after the lungs and the liver, and the most common site for metastatic bone disease. With life-extending advances in the systemic treatment of cancer patients, the surgical procedures performed for spinal metastases will increase, and their related complications will increase unavoidably. Furthermore, considering the high complication rates reported in the spinal literature regarding spine surgery overall, it becomes clear that a better understanding of complications that the cancer patients with spinal metastases may experience is necessary. This article aims to summarize and critically examine the current evidence for complications after spine surgery for metastatic spinal disease, in both the perioperative and postoperative period. This paper would be useful for the treating physicians of these patients in their clinical practice. © 2019, Springer-Verlag France SAS, part of Springer Nature.

Background: The outcomes of patients with lung metastases from giant cell tumor of bone (GCTB) vary from spontaneous regression to uncontrolled growth. To investigate whether observation is an appropriate first-line management approach for patients with lung metastases from GCTB, we evaluated the outcomes of patients who were initially managed by observation. Methods: We retrospectively reviewed the data of 22 patients with lung metastases from histologically confirmed GCTB who received observation as a first-line treatment approach. The median follow-up period was 116 months. Results: Disease progression occurred in 12 patients (54.5%). The median interval between the discovery of lung metastases and progression was 8 months. Eight patients underwent metastasectomy following initial observation. The median interval between the discovery of lung metastases and treatment by metastasectomy was 13.5 months. None of the patients experienced spontaneous regression. Of the 22 patients, 36.4% needed a metastasectomy, and 9.1% required denosumab treatment during the course of the follow-up period. Disease progression occurred in 45.5% of the 11 patients with lung nodules ≤ 5 mm, while all five of the patients with lung nodules > 5 mm experienced disease progression. Progression-free survival was significantly worse in the group with lung nodules > 5 mm compared to the group with lung nodules ≤ 5 mm (p = 0.022). Conclusions: Observation is a safe first-line method of managing patients with lung metastases from GCTB. According to radiological imaging, approximately half of the patients progressed, and approximately half required a metastasectomy or denosumab treatment. However, patients with lung nodules > 5 mm should receive careful observation because of the high rate of disease progression in this group. © 2020, The Author(s).

We reviewed the files of 203 patients with extremities GCTB treated with curettage as first surgery from 1990 to 2013. Median follow-up was 84.2 months. We evaluated whether the years of practice and training in orthopaedic oncology are associated with local recurrences, function and complications after curettage as first surgery for giant cell tumour of bone (GCTB). Local recurrences were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Function was not significantly different between orthopaedic oncology trained and non-trained surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. The only important univariate and multivariate predictor for local recurrence was PMMA adjuvant. Complications were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Curettage may be effectively performed as first surgery for GCTB by early-career (< 10 years of practice) non-trained orthopaedic oncology orthopaedic surgeons. PMMA adjuvant is recommended after appropriate curettage. © 2019, Springer-Verlag France SAS, part of Springer Nature.

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. © 2020 by Begell House, Inc. www.begellhouse.com.

BackgroundDenosumab, a monoclonal antibody that binds to receptor activation of nuclear factor-kappa ß ligand (RANKL), has been used as a drug to treat aggressive giant cell tumors of bone. It is unclear whether preoperative denosumab therapy is associated with the local recurrence risk in patients with giant cell tumors of bone treated with curettage. Early evidence suggests that denosumab treatment is associated with a reduction in local recurrence, but other studies have questioned that premise. Curettage after a short course of denosumab (3 to 4 months) has been recommended, especially for large, aggressive giant cell tumors in which complete curettage is difficult to achieve. No randomized studies have documented the benefit of this approach, and some investigators have reported higher local recurrence after denosumab treatment. Due to this confusion, we performed a systematic analysis of existing reports to attempt to answer this question and determine whether the appropriate preoperative denosumab therapy duration could be established.Questions/purposes(1) Is the use of preoperative denosumab associated with local recurrence risk in patients with giant cell tumors of bone treated with curettage compared with those treated with curettage alone? (2) Is the preoperative denosumab therapy duration associated with local recurrence after curettage?MethodsWe searched the PubMed, EMBASE, and CENTRAL databases on April 26, 2019 and included both randomized and non-randomized studies that compared local recurrence between patients who had giant cell tumors of bone and were treated with curettage after preoperative denosumab and patients treated with curettage alone. Two authors independently screened the studies. There were no randomized studies dealing with denosumab in giant cell tumors of bone, and generally, denosumab was used for more aggressive tumors. We assessed the quality of the included studies using the Risk of Bias Assessment tool for Non-randomized Studies, with a moderate overall risk of bias. We registered our protocol in PROSPERO (registration number CRD42019133288). We selected seven eligible studies involving 619 patients for the final analysis.ResultsThe proportion of patients with local recurrence ranged from 20% to 100% in the curettage with preoperative denosumab group and ranged from 0% to 50% in the curettage-Alone group. The odds ratio of local recurrence ranged from 1.07 to 37.80 in no more than 6 months of preoperative denosumab duration group and ranged from 0.60 to 28.33 in more than 6 months of preoperative denosumab duration group.ConclusionsThe available evidence for the benefit of denosumab in more aggressive giant cell tumors is inconclusive, and denosumab treatment may even be associated with an increase in the proportion of patients experiencing local recurrence. Because there are no randomized studies and the existing studies are of poor quality due to indication bias (the most aggressive Campanacci 3 lesions or those where even a resection would be difficult and result in morbidity are generally the patients who are treated with denosumab), the evidence to suggest a disadvantage is weak. Denosumab treatment should be viewed with caution until more definitive, randomized studies documenting a benefit (or not) have been conducted. Furthermore, we could not find evidence to suggest an appropriate length of preoperative denosumab before curettage. © 2020 Lippincott Williams and Wilkins. All rights reserved.

Cervical plexus nerve blocks have been employed in various head and neck operations. Both adequate anaesthesia and analgesia are attained in clinical practice. Nowadays, ultrasound imaging in regional anaesthesia is driven towards a certain objective that dictates high accuracy and safety during the implementation of peripheral nerve blocks. In the cervical region, ultrasound-guided nerve blocks have routinely been conducted only for the past few years and thus only a small number of publications pervade the current literature. Moreover, the sonoanatomy of the neck, the foundation stone of interventional techniques, is very challenging; multiple muscles and fascial layers compose a complex of compartments in a narrow anatomic region, in which local anaesthetics are injected. Therefore, this review intends to deliver new insights into ultrasound-guided peripheral nerve block techniques in the neck. The sonoanatomy of the cervical region, in addition to the cervical plexus, cervical ganglia, superior and recurrent laryngeal nerve blocks are comprehensively discussed. © 2020 The Authors. Published by the British Institute of Radiology

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 (

Purpose: To summarize the available information from mythology, archeology, and classical literature aiming to compose the image of Asclepieia, Asclepius, and the Asclepiads, and to depict the atmosphere of medicine in its infancy. Method: A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the pharmacies and pain practices used for trauma in ancient Greece. Results: The antiquity of medicine is confirmed by the worship of God Apollo and Asclepius, who were the persons who possessed the knowledge of medicine and surgery, and delivered it to mortals. The available archaeological data, stone offerings, and inscriptions from Asclepieia were the first testimonies of divine and human knowledge and provide insights on individual cases of patients cured by the Asclepiads. Sparse descriptions offer a first glimpse of the methods and means used by the first priests-physicians for wound healing and diseases treatment. Conclusion: Asclepieia established the roots of medicine and the first step of human knowledge, and contributed to the field of surgery and pharmacology that gave birth to the rational medicine. With Hippocrates and his research, the circle of Asclepieia ended, and the era of the organized medical schools with theories and experiments on every aspect of medicine begun. © 2020, SICOT aisbl.

Background: Surgical site infection (SSI) following spinal surgery is a frequent clinical problem with significant clinical and socio-economic consequences. Malnutrition has been linked with SSI in various other surgical procedures. Aim: To investigate whether malnutrition is a risk factor for SSI following spinal surgery. Methods: Two electronic databases (PUBMED and SCOPUS) and the Cochrane Library were searched systematically from inception to May 2019. Cohort and case–control studies assessing malnutrition as a risk factor for SSI in patients undergoing spinal procedures were considered eligible. Μalnutrition was defined according to laboratory measurements or by relevant International Classification of Diseases-9 codes. SSI was the outcome of interest. Two reviewers independently abstracted study data and assessed the risk of bias for each study. Pooled effect estimates were calculated using random effects models. Findings: In total, 22 studies (20 retrospective cohort and two case–control) with over 175,000 participants (of whom 2.14% developed postoperative SSI) were analysed. SSIs were more likely to develop in malnourished patients [odds ratio (OR) 2.31, 95% confidence interval (CI) 1.75–3.05]. While pre-operative malnutrition was significantly associated with SSI in patients undergoing thoracolumbar spinal and sacral surgery, no significant difference was seen in patients undergoing cervical spinal surgery. In subgroup analyses, similar results were observed for both hospital-based (OR 3.16, 95% CI 1.84–5.43) and population-based (OR 2.00, 95% CI 1.63–2.46) studies. Conclusions: Malnutrition is associated with increased risk of developing SSI after spinal surgery. Further high-quality research is warranted to investigate whether improvement of pre-operative nutritional status can decrease SSI rates. © 2019 The Healthcare Infection Society

The media play a key role in promoting public health and influencing debate regarding health issues; however, some topics seem to generate a stronger response in the public, and this may be related to how the media construct and deliver their messages. Mass media coverage of COVID-19 epidemic has been exceptional with more than 180,000 articles published each day in 70 languages from March 8 to April 8, 2020. One may well wonder if this massive media attention ever happened in the past and if it has been finally proven to be beneficial or even just appropriate. Surgical site and implant-related infections represent a substantial part of health care-associated infections; with an estimated overall incidence of 6% post-surgical infection, approximately 18 million new surgical site infections are expected each year globally, with 5 to 10% mortality rate and an astounding economic and social cost. In the current mediatic era, orthopaedic surgeons need to refocus some of their time and energies from surgery to communication and constructive research. Only raising mediatic awareness on surgical site and implant-related infections may tune up the volume of silent epidemics to a level that can become audible by governing institutions. © 2020, SICOT aisbl.

We report the case of a 40 year-old male with Staphylococcus aureus osteomyelitis of the proximal humerus after open reduction and internal fixation of a fracture from motor vehicle accident. Removal of the osteosynthesis, extensive debridement and intravenous antibiotics administration was done followed by external fixation stabilization and reconstruction with a combined pedicled flap using the serratus anterior reversed flap and the 6th rib. At the last follow-up, healing of the bone flap was observed; the patient experienced useful motion of his upper extremity without any evidence of recurrent infection. © 2020 Elsevier Ltd

Reconstruction of the interosseous membrane has the potential to re-establish a normal loading pattern through the forearm and enhance stability after an Essex-Lopresti lesion. The aim of our study was to assess the capacity of three different techniques, which all use a regionally harvested autograft, to restore longitudinal stability. Simulation of the Essex-Lopresti lesion was done by excising the radial head and sectioning the interosseous membrane in seven cadaveric specimens. Each technique was used in each specimen consecutively, using the pronator teres, the brachioradialis and the flexor carpi radialis tendons, respectively. The specimens were submitted to mechanical testing by applying proximally migratory forces to the radius and radioulnar displacement was assessed fluroscopically at wrist level. The pronator teres tendon achieved the greatest reduction (94% correction with respect to the intact interosseous membrane/radial head out state, followed by brachioradialis (92%) and flexor carpi radialis (85%). However, no statistically significant differences in displacement data or strength were detected between the techniques. © The Author(s) 2019.

Approximately one-fourth of osteosarcoma patients have metastases at presentation. The best treatment options for these patients include chemotherapy, surgery, and radiotherapy; however, the optimal scheme has not yet been defined. Standard chemotherapy for osteosarcoma metastatic at presentation is based on high-dose methotrexate, doxorubicin, and cisplatin (the MAP regimen), with the possible addition of ifosfamide. Surgical treatment continues to be fundamental; complete surgical resection of all sites of disease (primary and metastatic) remains essential for survival. In patients whose tumors do not respond to neoadjuvant chemotherapy, early surgical resection of the primary tumor with limb-salvage surgery or amputation and multiple metastasectomies, if feasible, after the completion of adjuvant chemotherapy is a reasonable option, as the reduction of the tumor volume could probably increase the effect of chemotherapy. Advanced radiotherapy techniques, such as carbon ion radiotherapy and stereotactic radiosurgery, and molecular targeted chemotherapy with drugs such as pazopanib or apatinib have improved the dismal prognosis, especially for patients who are medically inoperable or who refuse surgery. Given that the presence of metastatic disease at diagnosis of a patient with osteosarcoma is a poor prognostic factor, a multidisciplinary approach by surgeons, medical oncologists, and radiotherapists is important. © 2020 Slack Incorporated. All rights reserved.

There are conflicting reports regarding the outcome and effect of denosumab for distal radius giant cell tumor of bone (GCTB). The authors performed this study to evaluate the behavior of distal radius GCTB in relation to the type of treatment and the administration of denosumab. The files of 72 patients with distal radius GCTB treated from 1984 to 2018 were reviewed. Fourteen patients were administered denosumab. Surgical treatment consisted of curettage (25 patients) or resection (47 patients) and allograft or vascularized fibular head graft reconstruction. Median follow-up was 63.1 months (interquartile range [IQR], 35.5-107.1 months). The authors evaluated local recurrences, metastasis, function, and complications. The local recurrence rate was 30.6% at a median of 14.0 months (IQR, 10-19 months), with no difference between curettage and resection. The local recurrence rate was significantly higher in the patients who received denosumab. The metastasis rate was 9.7% at a median of 41.0 months (IQR, 15-114 months), with no difference regarding denosumab administration. Function was significantly better in patients after curettage. The complication rate was 25%; vascularized fibular graft reconstruction was associated with fewer complications. This study found that denosumab increases the risk of local recurrence after curettage, function is better after curettage, and vascularized fibular graft is the optimal reconstruction after resection of distal radius GCTB. COPYRIGHT © SLACK INCORPORATED

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. © 2020 by Begell House.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Its diagnosis is based on clinical symptoms and neurophysiological evaluation. Recently, ultrasonography has been introduced as a promising noninvasive diagnostic alternative. In this study, the authors compared ultrasonography with neurophysiological findings for the diagnosis of CTS in 96 patients/hands with clinical symptoms of CTS. The latency, amplitude, distance, and velocity of the median and ulnar nerves were measured. Needle electromyography was performed in the abductor pollicis brevis, in addition to muscles of the arm and forearm, to exclude proximal median nerve, brachial plexus, or radicular abnormalities. Ultrasonography was based on the morphologic/anatomic changes of the median nerve crosssectional area in the sagittal plane of the wrist at the level of the pisiform bone, the changes of its regional echogenicity, and the identification of coexisting pathologies, such as tenosynovitis, space-occupying lesions, supplementary muscles, and vessels, that may provoke indirectly an increase of the pressure in the carpal tunnel. Eighty-seven (90%) of the 96 patients/hands with clinical symptoms of CTS showed positive findings in both ultrasonography and nerve conduction studies. Six (6%) patients showed positive findings only in nerve conduction studies, and 3 (3%) patients showed positive findings only in ultrasonography; the difference was not statistically significant. The sensitivity and the specificity of nerve conduction studies compared with ultrasonography was 97% and 89% compared with 94% and 55%, respectively. A positive correlation and proportional increase of the ultrasonography measurements compared with the increase of the nerve conduction studies severity was observed. Copyright © SLACK Incorporated.

Please note that the full listing for the ESCMID Study Group for Implant-Associated Infections (ESGIAI) is as follows: Collaborators: Jaime Esteban-Moreno, Department of Clinical Microbiology, IISFundación Jiménez Díaz, Joaquín García Cañete, Madrid, Spain, and Bone and Joint Infection Unit, IIS-Fundación Jiménez Díaz, Madrid, Spain; Raúl Parrón, Bone and Joint Infection Unit, Department of Emergency Medicine, IIS-Fundación Jiménez Díaz Hospital, Madrid, Spain; David Lye, Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore; Rahmet Guner, Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Yildirim Beyazit University, Ankara Ataturk Education and Research Hospital, Ankara, Turkey; Laura Morata, Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain; Ernesto Muñoz-Mahamud and Luis Lozano, Department of Orthopedics, Hospital Clínic, Barcelona, Spain; Ibai Los-Arcos, Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Pablo S. Corona, Department of Orthopedic Surgery (Reconstructive Surgery and Septic Division), Hospital Universitari Vall d'Hebron, Barcelona, Spain; Maily Lung, Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Taiana Cunha Ribeiro and Giselle B. Klautau, Division of Infectious Diseases, Department of Internal Medicine, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil; Salvatore Cardaci, Infectious Diseases Unit, University of Perugia, Perugia, Italy; Yolanda Borrego Izquierdo, Infectious Diseases Unit, Hospital Universitario Virgen Macarena, Seville, Spain; Isabel Mur, Unit of Infectious Diseases, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Xavier Crusi, Marcos Jordán and José Carlos González, Department of Orthopedics, Hospital de la Santa Creu i Sant Pau, Institut d'InvestigacióBiomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Pere Coll and Alba Rivera, Department of Clinical Microbiology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Marie Ghéno, Enora Ouamara-Digue, Anne Jolivet-Gougeon and Cédric Arvieux, Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; Gyula Prinz, Joined Saint Stephan and Saint Ladislaus Hospital, I Department of Internal Medicine, Budapest, Hungary; Botond Lakatos, Joined Saint Stephan and Saint Ladislaus Hospital, Department of Infectious Diseases, Budapest, Hungary; Nikolaos Antonakos, George Siakalis, Alice Dourou, Eleni Aggelou, Paraskevas Nikou and Sofia Athanasia, Fourth Department of Internal Medicine, University General Hospital ‘ATTIKON’, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; and Vasilios G. Igoumenou, First Department of Orthopaedics, University General Hospital ‘ATTIKON’, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; Oscar Murillo and, Joan Gómez-Junyent, Infectious Diseases Department, Hospital Universitari de Bellvitge, Barcelona; Jacier Cabo, Orthopaedic Surgery Department, Hospital Universitari de Bellvitge, Barcelona; Fe Tubau, Microbiology Department, Hospital Universitari de Bellvitge, Barcelona. The authors would like to apologise for this error. © 2019 Elsevier Ltd

A series of clinical trials focused on the use of ultrasound-guided platelet-rich plasma (PRP) infusions for the treatment of patients with carpal tunnel syndrome (CTS) were published over the last few years. However, the role of PRP for CTS remains unclear. We performed a systematic review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently conducted the search using multiple databases: MEDLINE/PubMed, SCOPUS, Cochrane Database, and Web of Science. These databases were searched using terms “platelet” AND “rich” AND “plasma” AND “carpal” AND “tunnel”. To maximize the search, backward chaining of references from retrieved papers was also undertaken. From the initial 19 studies, only five met our eligibility criteria. These articles included one randomized controlled double-blind study, one randomized controlled single-blind study, one randomized controlled non-blind study, one case–control study, and one case report. The vast majority of the included studies supported that PRP infusion improved the clinical condition of the patients and that PRP infusion was beneficial for patients with mild-to-moderate CTS. Therefore, PRP seems to be an interesting alternative for the treatment of mild-to-moderate CTS which, still, has not been thoroughly investigated. However, despite the promising results of the present studies, PRP has to be further tested before we reach to a definite conclusion regarding its therapeutic value. © 2018, Springer-Verlag France SAS, part of Springer Nature.

Purpose: To highlight the most important innovations and milestones in the historical evolution of amputation and disarticulation surgery through the ages, from the early antiquity until the modern era. Method: A thorough search of the literature was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize current and classic literature on the hallmarks of the history of amputation surgery in the course of medical history. Results: Amputation of a limb is one of the oldest surgical procedures. Initially, it was fraught with complications and dismal outcome of the patients because of hemorrhage and infection. Due to lack of analgesics and narcotics the operation had to take only a few minutes. Obtaining experience, the surgeons evolved the operative technique and refined the procedure, anesthesia and perioperative analgesia was introduced, instruments were developed, and rehabilitation has enabled functional and social reintegration of amputees. Conclusion: From the Hippocratic era until currently, the surgical approach to amputation has changed little. However, the indications for amputations have changed a lot and had been refined, especially in diabetic patients and in those with severe chronic peripheral vascular disease. An exponential decrease in mortality for an operation once fraught with complications was due to the development of the tourniquet, proper vessel ligation and repair, antisepsis, and anesthesia. © 2018, SICOT aisbl.

Purpose: To summarize pharmacies for pain and trauma in ancient Greece, to present several pharmaceutical/therapeutical methods reported in myths and ancient texts, and to theorize on the medical explanation upon which these pharmacies were used. Method: A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the pharmacies and pain practices used for trauma in ancient Greece. Results: Archeological findings and historical texts have revealed that humans have always suffered from diseases and trauma that were initially managed and healed by priests and magicians. In early Greek antiquity, the term pharmacy was related to herbal inquiries, with the occupants called charmers and pharmacists. Additionally, apart from therapeutic methods, ancient Greeks acknowledged the importance of pain therapy and had invented certain remedies for both acute and chronic pain management. With observations and obtaining experience, they used plants, herbs, metals and soil as a therapeutic method, regardless of the cultural level of the population. They achieved sedation and central and peripheral analgesia with opium and cold, as well as relaxation of smooth muscle fibers and limiting secretions with atropina. Conclusion: History showed a lot of experience obtained from empirical testing of pain treatment in ancient people. Experience and reasoning constructed an explanatory account of diseases, therapies and health and have provided for the epistemology of medicine. © 2018, SICOT aisbl.

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach. © 2019