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.

The purpose of this study was to illustrate the usefulness of ultrasound in the early diagnosis of occult scaphoid fractures. Forty-eight patients with clinical symptoms of scaphoid fracture and negative initial X-rays were examined. All patients underwent ultrasonography in the emergency room (ER). After 14 days, a computed tomography (CT) scan was performed, which confirmed or not the initial suspicion of fracture. Twenty-two patients were found with subperiosteal hematoma, while six also had cortical discontinuity. The sensitivity of ultrasound in the diagnosis of occult scaphoid fractures was 90% and the specificity was 85.7%. The positive prognostic value was 81.8%. The authors support the use of the scaphoid ultrasound only under strict circumstances. If subperiosteal hematoma or cortical discontinuity is present, there is a high likelihood of scaphoid fracture. On the contrary, if the ultrasound is negative and symptoms persist, the patient will require a CT scan or magnetic resonance imaging for definitive diagnosis. (Journal of Surgical Orthopaedic Advances 28(1):1-9, 2019).

The objective of this study is to analyze the kinetic and kinematic changes of the osteoarthritic knee after a mobile bearing total knee arthroplasty. Kinematic and kinetic gait analysis of level walking was performed in 15 patients (eight female and seven male) with knee ostoarthritis. All patients were free of any neurological diseases that could affect their normal gait. Mean age was 68.6 ± 5.2 years, mean height 159.8 ± 6.9 cm, and mean weight was 78.5 ± 10.1 kg. Full body gait analysis was performed using the BioKin three-dimensional (3D) motion analysis system preoperatively and 9 months after total knee arthroplasty. A single-step ascending kinetic analysis and a plantar pressure distribution analysis were also performed in all patients. An increased average cadence (mean 99.39 step/min preoperatively and 104.64 step/min postoperatively;  = 0.152), step length (0.44 m preoperatively and 0.52 m postoperatively;  < 0.001), stride length (0.89 m preoperatively and 1.0 m postoperatively;  < 0.007), and walking velocity (0.73 m/sec preoperatively and 0.90 m/sec postoperatively;  = 0.005) were noted postoperatively and postoperatively. A decrease in the stance duration percentage and the knee adduction moment was also reported postoperatively. All patients showed a significant improvement of knee kinetics and kinematics after a mobile bearing total knee arthroplasty. Statistically significant differences were found in the step length, stride length, and walk velocity postoperatively. The knee adduction moment was also significantly reduced. Further research is warranted to determine the clinical relevance of these findings. This study is a prospective comparative one and reflects level II evidence.

Longitudinal stability of the forearm is mainly provided by three structures: the radiocapitellar contact, which acts as the primary stabilizer, the central band of the interosseous ligamentous complex (IOLC) and the intact triangular fibrocartilage complex (TFCC). In an Essex-Lopresti lesion the forearm becomes fully destabilized, since all of these three components are injured. Fixation or replacement of the radial head with a metallic prosthesis along with repair of the TFCC and stabilization of the distal radioulnar joint (DRUJ) are well-established treatment goals. However the reconstruction of the central band of the IOLC remains to some extent controversial. The authors believe that the reconstruction of the central band, particularly in active patients, is crucial in order to restore normal load distribution through the forearm, thus ensuring both transverse and longitudinal stability. In this article, we present a case with an Essex-Lopresti lesion, which was effectively treated acutely with restoration of all three components of the injury (radial head prosthesis, DRUJ repair and reconstruction of the central band of the IOLC). A novel technique by rerouting the brachioradialis tendon is described in detail.

BACKGROUND: There are conflicting reports regarding the therapeutic effect of platelet-rich plasma (PRP) versus autologous whole-blood (platelet poor plasma, PPP) injections for plantar fasciitis. Therefore, this study was conducted to compare the effectiveness of a single ultrasound (US)-guided PRP versus PPP injection in patients with chronic plantar fasciitis. MATERIALS AND METHODS: 36 patients were recruited with clinical and sonographic evidence of chronic (>6 months) plantar fasciitis, refractory to analgesics and physical therapy in a double-blinded, randomized, prospective study. The patients were randomly allocated into two groups with a sealed envelope method. Group A included 18 patients who underwent a single US-guided PRP injection and group B included another 18 patients who underwent PPP injection with the same technique. Follow-up was set at 3 and 6 months; no patient was lost to follow-up. Pain, function and satisfaction were assessed using visual analogue scales, and occurrence of complications. RESULTS: All scores statistically significantly improved for both groups from baseline at the 3- and 6-month follow-up evaluation, without, however, any statistically significant differences between the two groups with respect to pain, function and satisfaction scores. Complications were not observed. CONCLUSIONS: A single US-guided PRP injection yields similar results with PPP injection in patients with chronic plantar fasciitis. Both treatments provide significant improvement at 3 and 6-month follow-up after the injection.

 BACKGROUND: The purpose of this study is to investigate the possible attenuating role of the intra-articular administration of Fetuin-A in post-traumatic secondary osteoarthritis in rats, and also its effect on the systematic levels of interleukins (ILs)-2,4,7, bone morphogenetic proteins (BMPs) 2, 4, 7, C-Reactive Protein (CRP) and Fetuin-A. METHODS: Thirty male Sprague Dawley rats were separated in two groups where post-traumatic osteoarthritis was induced surgically by Anterior Cruciate Ligament Transection and the transection of the Medial Collateral Ligament of the right knee. In the Control Group, only the surgical intervention took place. In Fetuin Group, along with the induction of osteoarthritis, a single dose of bovine fetuin was administrated intra-articularly, intra-operatively. Both groups were examined for 8 weeks. The levels of interleukins, bone morphogenetic proteins, Fetuin-A and C-Reactive Protein were evaluated by ELISA of peripheral blood in three time periods: preoperatively, 5 and 8 weeks post-operatively. Osteoarthritic lesions of the knee were classified according to the Osteoarthritis Research Society International Grading System and the Modified Mankin Score, by histologic examination. RESULTS: IL-2 levels were significantly decreased in the Fetuin Group. No statistical difference was signed on the levels of IL-7, BMP-2,4,7 and Fetuin-A between the two groups. CRP levels were significantly increased in the Fetuin Group in 5 weeks of the experiment. Fetuin Group signed better scores according to the OARSI classification system and Modified Mankin Score, without any statistical significance. CONCLUSIONS: Intra-articular administration of Fetuin-A restrictively affected the progression of post-traumatic arthritis in rats, as only the levels of IL-2 were decreased as well as limited osteoarthritic lesions were observed on the Fetuin Group.

PURPOSE: We aimed to evaluate the quantity and quality of current evidence concerning the outcomes of use of plastinated specimens in anatomy education. METHODS: We performed a narrative literature review, searching for papers dealing with the use of plastination in anatomy education. PubMed, Scopus, ERIC, Cochrane, Web of Science and CINAHL complete electronic databases were searched. The following data were extracted: author(s), year of publication, type of study (comparative or not), number of participants, evaluation of statistical significance, educational outcomes and their level according to Kirkpatrick hierarchy. RESULTS: Six studies were eligible for analysis. Five of them evaluated only students' reactions about plastination and one study also assessed their examinations results. There were four non-comparative and two comparative studies. Only a study evaluated statistical significance (p < 0.05) with higher score of perception in 2nd year undergraduate medical students, who were more familiar with plastination in comparison to 1st year students. Although the use of plastination was accompanied by positive outcomes in the majority of studies (five out of six), this method was not proved superior to traditional cadavers dissection. CONCLUSIONS: The existing evidence about the outcomes of the use of plastination in anatomy education is relatively limited and lacks comparative studies with statistical significant results. Positive students' reactions were generally noted, but further research is needed to clarify if plastination could be of benefit to students' attitude and anatomy knowledge.

Following publication of the original article [1], the authors opted to correct the middle initial of co-author Despina N. Perrea from S to N. The original article has been corrected.

BACKGROUND: Oxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA). METHODS: Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. "oxidized" AND "zirconium" AND "total" AND "hip" AND "arthroplasty"; b. "oxinium" AND "total" AND "hip" AND "arthroplasty". The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear. RESULTS: The vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants. CONCLUSION: OxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs. LEVEL OF EVIDENCE: Systematic review and meta-analysis of therapeutic studies I-III.

Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm.There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries.Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique another; however, they have shown special concerns with respect to the use of synthetic grafts.Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction. Cite this article: 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072.

Augmented reality (AR) comprises special hardware and software, which is used in order to offer computer-processed imaging data to the surgeon in real time, so that real-life objects are combined with computer-generated images. AR technology has recently gained increasing interest in the surgical practice. Preclinical research has provided substantial evidence that AR might be a useful tool for intra-operative guidance and decision-making. AR has been applied to a wide spectrum of orthopedic procedures, such as tumor resection, fracture fixation, arthroscopy, and component's alignment in total joint arthroplasty. The present study aimed to summarize the current state of the application of AR in orthopedics, in preclinical and clinical level, providing future directions and perspectives concerning potential further benefits from this technology.

Various systematic reviews have recently shown that intra-articular platelet-rich plasma (IA-PRP) can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb. A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III according to the Eaton and Littler classification) was conducted. Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval. Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient's subjective satisfaction. No significant differences between the baseline clinical and demographic characteristics of the 2 groups were identified. After 12 months' follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score ( P = 0.015), Q-DASH score ( P = 0.025), and patients' satisfaction ( P = 0.002). Corticosteroids offer short-term relief of symptoms, but IA-PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic TMJ arthritis.

The purpose of this study is to demonstrate whether and to what extent a single injection of platelet-rich plasma (PRP), under ultrasound guidance, can improve the clinical symptoms of patients with a mild to moderate carpal tunnel syndrome (CTS). We conducted a prospective, randomized, clinical study including 50 patients suffering from mild to moderate CTS for a minimum duration of 3 months. Patients were randomly divided into 2 groups: Group A (26 patients) received an ultrasound-guided PRP injection into the carpal tunnel, whereas Group B (24 patients) was injected with placebo (0.9% normal saline). The short- and mid-term outcomes were determined with the use of the Q-DASH questionnaire and the pain scale VAS administered at 0, 4, and 12 weeks follow-up. The success ratio was determined by the difference in the Q-DASH obtained pre-injection minus the final Q-DASH obtained after 12 weeks follow-up. Success was defined as a difference more than 25%. Group A patients demonstrated a 76.9% success as determined by the difference Q-DASH, whereas Group B patients demonstrated 33.3% success, which was significantly less than Group A (Χ , p = .011). The findings of this study suggest that a single PRP ultrasound-guided injection has positive effects in patients with CTS.

Recently, four different operative techniques, referring to the primary anterior cruciate ligament (ACL) repair, were described. These are the dynamic intraligamentary stabilization (DIS) with Ligamys™, the Bridge-enhanced repair (BEAR), the use of internal brace, and the refixation with suture anchors. The purpose of this study was to assess the already-published, clinical, and pre-clinical results of those techniques. A literature review was conducted and implemented by three independent researchers. Inclusion criteria were clinical or cadaveric or animal studies about patients suffering from ACL rupture, who were treated with one of those four different arthroscopic techniques of primary ACL repair. There were 10 clinical trials dealing with the different techniques of primary ACL repair and 12 cadaveric or animal studies. The majority of the published clinical trials investigated the dynamic intraligamentary stabilization (DIS), while only four studies referred to the three other surgical techniques. Most of the clinical trials suggested that primary ACL repair should be done during the first 14-21 days after a proximal ACL rupture and not later. Further clinical evidence is needed for the techniques of bridge-enhanced ACL repair, internal brace, and suture anchors ACL refixation in order to support the animal and cadaveric biomechanical studies. Till now, the existing clinical trials were not enough to establish the use of those techniques in the ACL-ruptured patients. On the contrary, the Dynamic intraligamentary stabilization with Ligamys™ device demonstrated very promising results in different types of clinical studies.

PURPOSE: The thorough knowledge of C2 lamina anatomy is essential for the avoidance of complications during screw fixation. We performed a review of the literature, aiming to detect what was found about anatomical feasibility of C2 translaminar fixation in different populations, along with possible recommendations for the avoidance of complications, and to detect whether factors such as race or gender could influence axis lamina anatomy and fixation feasibility. METHODS: We performed a search in PubMed and Cochrane database of systematic reviews for studies which correlated axis lamina anatomy with fixation feasibility. We extracted data concerning measurements on C2 lamina, the methods and conclusions of the studies. RESULTS: Twenty-six studies met our inclusion criteria. The studies mainly focused on Asian populations. Male gender was generally related to larger anatomical parameters of C2 lamina. The use of a C2 translaminar screw with a diameter of 3.5 mm was generally feasible, even in children, but there was disagreement about risk of vertebral artery injury. Computed tomography was most frequently recommended preoperatively. Three-dimensional reconstruction was suggested by some authors. CONCLUSION: C2 lamina anatomy generally permitted screw fixation in most studies, but there was disagreement about risk of vertebral artery injury. Preoperative computed tomography was generally recommended, while, according to some authors, three-dimensional reconstruction could be essential. However, there is a relative lack of studies about non-Asian populations. More research could further illustrate the anatomy of C2 lamina, clarify the safety of axis fixation for more populations and perhaps modify preoperative imaging protocols.

BACKGROUND: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. QUESTIONS/PURPOSES: We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup. METHODS: This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss' kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons. RESULTS: There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001). CONCLUSIONS: This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Fractures of the odontoid process seem to have an unclear and not well-understood behavior. This is well demonstrated in the literature as there is a disagreement in many fields, including the patterns of fractures, the percentage of pseudarthrosis or the appropriate treatment that is required. This situation makes the fracture itself a "challenging" one. Indeed, despite the existence of extensive literature, there are still many unresolved problems concerning these fractures. We recognize six main classification schemes of the odontoid process fractures which clearly demonstrate the presence of differences but, also, the disadvantages that these classifications are related to. The most important factors that render these fractures "enigmatic" are the anatomy of the odontoid, the diversity of fractures encountered, the radiological evaluation, the stability and the inability to incorporate the whole spectrum of fractures in one classification. The progress made the last decades in the field of the radiology and their follow-up permitted to better analyze these lesions and to extract useful conclusions.

Osteoarthritis is a slowly progressive disease which includes the intervention of several cytokines, macrophage metalleinoproteinases reaction, leading to the degradation of the local cartilage but also having an impact on the serum acute phase proteins (APPs). Subsequently, biomarkers seem to be essential to estimate its progression and the need for any surgical intervention such as total arthroplasty, but also can be used as therapeutic agents. Recently, among APPs, fetuin A drew attention regarding its possible anti-inflammatory role in animal models but also as a therapeutic agent in the inflammatory joint disease in clinical trials. In contrast with other APPs such as C-reactive protein, fetuin A appears to be lower in the serum of patients with degenerative joint disease in comparison with the healthy ones, and also acts as an antagonist of the anti-proliferative potential of transforming growth factor-β (TGF-β) cytokines. Because of its lower serum levels in arthritis, an unregulated binding of TGF-β and bone morphogenetic proteins takes place leading to further arthritic lesions. The purpose of the present review is to assess the current evidence regarding the multipotent role of the alpha-2-HS-glycoprotein or as also known Fetuin-a in animal models but also as a biomarker of the degenerative joint arthritis in clinical trials.

Osteochondral defects or injuries represent the most challenging entities to treat, especially when occur to young and active patients. For centuries, it has been recognized that such defects are almost impossible to treat. However, surgeons have never stopped the effort to develop reliable methods to restore articular cartilage and salvage the endangered joint function. Osteochondral allograft transplantation in human was first introduced by Eric Lexer in 1908. Since that era, several pioneers have been worked in the field of osteochondral allotransplantation, presenting and developing the basic research, the methodology and the surgical techniques. Herein we present in brief, the history and the early clinical results of osteochondral allograft transplantation in human.

AIM: To investigate the effectiveness of ultrasound-guided release of the first annular pulley and compare results with the conventional open operative technique. METHODS: In this prospective randomized, single-center, clinical study, 32 patients with trigger finger or trigger thumb, grade II-IV according to Green classification system, were recruited. Two groups were formed; Group A (16 patients) was treated with an ultrasound-guided percutaneous release of the affected A1 pulley under local anesthesia. Group B (16 patients) underwent an open surgical release of the A1 pulley, through a 10-15 mm incision. Patients were assessed pre- and postoperatively (follow-up: 2, 4 and 12 wk) by physicians blinded to the procedures. Treatment of triggering (primary variable of interest) was expressed as the "success rate" per digit. The time for taking postoperative pain killers, range of motion recovery, QuickDASH test scores (Greek version), return to normal activities (including work), complications and cosmetic results were assessed. RESULTS: The success rate in group A was 93.75% (15/16) and in group B 100% (16/16). Mean times in group A patients were 3.5 d for taking pain killers, 4.1 d for returning to normal activities, and 7.2 and 3.9 d for complete extension and flexion recovery, respectively. Mean QuickDASH scores in group A were 45.5 preoperatively and, 7.5, 0.5 and 0 after 2, 4, and 12 wk postoperatively. Mean times in group B patients were 2.9 d for taking pain killers, 17.8 d for returning to normal activities, and 5.6 and 3 d for complete extension and flexion recovery. Mean QuickDASH scores in group B were 43.2 preoperatively and, 8.2, 1.3 and 0 after 2, 4, and 12 wk postoperatively. The cosmetic results found excellent or good in 87.5% (14/16) of group A patients, while in 56.25% (9/16) of group B patients were evaluated as fair or poor. CONCLUSION: Treatment of the trigger finger using ultrasonography resulted in fewer absence of work days, and better cosmetic results, in comparison with the open surgery technique. It is a promising method that represents excellent results without major complications, so that it could be possibly be established as a first-line treatment in the trigger finger's disease.

PURPOSE: Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. METHODS: A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. RESULTS: The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups. CONCLUSIONS: When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

All orthopaedic fluoroscopic procedures performed using C-arm guidance were monitored for 1 y. The type of procedure, fluoroscopy time (T), kerma-area product (KAP) values and number of radiographs (F) were recorded. The two most often performed techniques were as follows: intramedullary nailing (IMN) of intertrochanteric/peritrochanteric (IP) fractures (101 cases, 49.3 %) and antergrade IMN of femur or tibia shaft (TS) fractures (28 cases, 13.7 %). For the remaining procedures, none accounted for >5 %, categorised as 'various' (76 cases, 37 %). Large variations in T, KAP and F were observed. For IMN of IP fractures, antergrade IMN of femur and TS fractures and for various procedures, respectively, median values were T--2.1, 2.2 and 0.6 min, KAP--6.3, 6.3 and 0.6 Gy cm(-2) and F--21, 2.2 and 6.7. The patient doses during fluoroscopically guided procedures are relatively low compared with other interventional procedures.

AIM: A morphometric analysis of the odontoid process of the A2 vertebra, in the Greek population, was conducted using CT scan. We aimed to determine the feasibility to use one or two screws when treating fractures of this anatomic element. PATIENTS AND METHODS: One hundred and fifteen patients (57 men) of a mean age of 48 years (16-95 years) underwent a cervical spine CT scan examination. The anterior-posterior and transverse diameters of the odontoid process were measured from the base, at 1-mm interval upward on axial CT images. The length from the tip of the odontoid process to the anterior-inferior angle of the body of the axis was calculated. Data concerning the height and weight of the examined patients were collected. RESULTS: The mean transverse and anterior-posterior distances were found to be 11.46 and 10.45 mm, respectively, for the upper end of the odontoid process. At the neck level of the odontoid process, the equivalent mean values were 11.12 and 8.73 mm, respectively, while at the base, these distances were found to be 13.84 and 12.3 mm, respectively. The mean distance from the tip of the odontoid to its base was 17.25 and 17.28 mm, respectively, while the mean distance from the tip of the dens to the anterior-inferior corner of the axis' body was 39.2 mm. Men showed greater values than women. CONCLUSIONS: In this study, it was shown that in the Greek population there is enough room for one 4.5-mm or one 3.5-mm cannulated screw to be used. The application of two 3.5-mm screws is feasible in 58.6 % of the male and 26.3 % of the female population. This confirms that the knowledge of the true dimensions of the odontoid process is of paramount importance before the proper management of fractured dens using the anterior screw technique.

BACKGROUND: There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. One would expect surgeons to treat patients and themselves similarly based on best evidence and accounting for patient preferences. QUESTIONS/PURPOSES: (1) Are surgeons more likely to recommend surgery when choosing for a patient than for themselves? (2) Are surgeons less confident in deciding for patients than for themselves? METHODS: Two hundred fifty-four (32%) of 790 Science of Variation Group (SOVG) members reviewed 21 fictional upper extremity cases (eg, distal radius fracture, De Quervain tendinopathy) for which surgery is optional answering two questions: (1) What treatment would you choose/recommend: operative or nonoperative? (2) On a scale from 0 to 10, how confident are you about this decision? Confidence is the degree that one believes that his or her decision is the right one (ie, most appropriate). Participants were orthopaedic, trauma, and plastic surgeons, all with an interest in treating upper extremity conditions. Half of the participants were randomized to choose for themselves if they had this injury or illness. The other half was randomized to make treatment recommendations for a patient of their age and gender. For the choice of operative or nonoperative, the overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the number of cases they would operate on by the total number of cases (n = 21), where 100% is when every surgeon recommended surgery for every case. For confidence, we calculated the mean confidence for all 21 cases per surgeon; overall score ranges from 0 to 10 with a higher score indicating more confidence in the decision for treatment. RESULTS: Surgeons were more likely to recommend surgery for a patient (44.2% ± 14.0%) than they were to choose surgery for themselves (38.5% ± 15.4%) with a mean difference of 6% (95% confidence interval [CI], 2.1%-9.4%; p = 0.002). Surgeons were more confident in deciding for themselves than they were for a patient of similar age and gender (self: 7.9 ± 1.0, patient: 7.5 ± 1.2, mean difference: 0.35 [CI, 0.075-0.62], p = 0.012). CONCLUSIONS: Surgeons are slightly more likely to recommend surgery for a patient than they are to choose surgery for themselves and they choose for themselves with a little more confidence. Different perspectives, preferences, circumstantial information, and cognitive biases might explain the observed differences. This emphasizes the importance of (1) understanding patients' preferences and their considerations for treatment; (2) being aware that surgeons and patients might weigh various factors differently; (3) giving patients more autonomy by letting them balance risks and benefits themselves (ie, shared decision-making); and (4) assessing how dispassionate evidence-based decision aids help inform the patient and influences their decisional conflict. LEVEL OF EVIDENCE: Level III, diagnostic study.

Both in vitro and in vivo experiments have confirmed that platelet-rich plasma has therapeutic effects on many neuropathies, but its effects on carpal tunnel syndrome remain poorly understood. We aimed to investigate whether single injection of platelet-rich plasma can improve the clinical symptoms of carpal tunnel syndrome. Fourteen patients presenting with median nerve injury who had suffered from mild carpal tunnel syndrome for over 3 months were included in this study. Under ultrasound guidance, 1-2 mL of platelet-rich plasma was injected into the region around the median nerve at the proximal edge of the carpal tunnel. At 1 month after single injection of platelet-rich plasma, Visual Analogue Scale results showed that pain almost disappeared in eight patients and it was obviously alleviated in three patients. Simultaneously, the disabilities of the arm, shoulder and hand questionnaire showed that upper limb function was obviously improved. In addition, no ultrasonographic manifestation of the carpal tunnel syndrome was found in five patients during ultrasonographic measurement of the width of the median nerve. During 3-month follow-up, the pain was not greatly alleviated in three patients. These findings show very encouraging mid-term outcomes regarding use of platelet-rich plasma for the treatment of carpal tunnel syndrome.

Bone defects can be congenital or acquired resulting from trauma, infection, neoplasm and failed arthroplasty. The osseous reconstruction of these defects is challenging. Unfortunately, none of the current techniques for the repair of bone defects has proven to be fully satisfactory. Bone tissue engineering (BTE) is the field of regenerative medicine (RM) that focuses on alternative treatment options for bone defects that will ideally address all the issues of the traditional techniques in treating large bone defects. However, current techniques of BTE is laborious and have their own shortcomings. More recently, 2D and 3D bone printing has been introduced to overcome most of the limitations of bone grafts and BTE. So far, results are extremely promising, setting new frontiers in the management of bone defects.

Consecutive patients that had primary metal-on-metal (MoM) or metal-on-polyethylene (MoP) hip arthroplasty were prospectively enrolled to this study. All operated hips were evaluated with MRI by one radiologist who was blinded to the radiographic findings and clinical symptoms. Three groups of patients were formed: (1) thirteen MoM THRs in 13 patients with groin pain (Group 1), (2) ten MoM THRs in 10 patients with no pain (Group 2), (3) five MoP THRs in 4 patients without pain (control group). Abnormal MRI findings were distributed in all groups in a balanced way, irrespective of the patients' symptoms, prostheses, or metal ion levels. Two patients from Group 1 and one patient of Group 3 (control group) were diagnosed with a large periprosthetic mass (pseudotumor).

The purpose of our study was to summarize all the knowledge concerning the innovative pioneer in the field of orthopaedic surgery, Nicholas J. Giannestras (1908-1978). A thorough study of texts, medical books and reports, in the field of history of medicine, together with a review of the available literature in PubMed, was undertaken. Giannestras left his mark in the history of orthopaedics with his clinical work and his publications, mainly his treatise "Foot Disorders: Medical and Surgical Management" (1973), while his name lingers in Greece with the introduction of spine fusion with the use of metallic implants. He was an eminent university clinical professor of orthopaedics who had harmonically combined academic writing, teaching and clinical research in every field of orthopaedic surgery.

BACKGROUND: Besides the vast success and reliability of lower extremity joint replacement, deep and periprosthetic infection remains a serious complication of such operations. Many publications addressing periprosthetic infection have remarked about this "devastating" complication, with a risk around 1% after total hip arthroplasty and between 1% and 2% after total knee arthroplasty. The purpose of this study is to assess current trends in prevention of contamination with improved up-to-date pre-operative skin preparation methods and intra-operative draping. METHODS: A literature review was conducted in MEDLINE, Web of Science, and the Cochrane database, looking for high-quality papers summarizing the most widely held and up-to-date concepts of perioperative measures for reducing infection, focusing on the best available evidence concerning skin preparation for joint arthroplasty (THR and THR) and surgical draping. RESULTS: Current evidence suggests the use of alcohol solutions for pre-operative painting with emphasis on the use of chlorhexidine gluconate solutions beginning the night before surgery. Hair removal should be performed in the operating room with electric clippers, not razor blades. In order to enhance drape adhesion to the skin, the use of iodophor-in-alcohol solutions is recommended over the traditional scrub-and-paint technique. Disposable non-woven drapes are superior to reusable woven cotton/linen drapes in resisting bacterial penetration. Finally, the use of adherent plastic adhesive incision drapes for the prophylaxis of post-operative surgical site infections is considered not necessary in orthopedic surgery. CONCLUSIONS: The importance of skin preparation and adequate and reliable draping cannot be overemphasized for infection prevention, especially in clean operations such as THR and TKR. Thorough and strict protocols are mandatory for every department, as well as education curricula for operating room personnel. Further randomized studies are mandatory to specify the effect of the above measures, their pitfalls, and their improvement, along with further crucial details such as cost-benefit analysis of different pre-operative preparations in preventing infections.

PURPOSE: To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. METHODS: Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. RESULTS: Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. CONCLUSIONS: Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

INTRODUCTION: Distal radius fractures are very common upper limb injuries irrespective of the patient's age. The aim of our study is to evaluate the reliability of the three systems that are often used for their classification (AO - Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation, Fernandez and Universal) and to assess the need for computed tomography (CT) scan to improve inter- and intra-observer agreement. MATERIALS AND METHODS: Five orthopaedic surgeons and two hand surgeons classified radiographs and CT scans of 26 patients using the Fernandez, AO and Universal systems. All data were recorded using MS Excel and Kappa statistics were performed to determine inter- and intra-observer agreement and to evaluate the role of CT scan. RESULTS: Fair-to-moderate inter-observer agreement was noted with the use of X-rays for all classification systems. Intra-observer reproducibility did not improve with the addition of CT scans, especially for the senior hand surgeons. CONCLUSIONS: The agreement rates observed in the present study show that currently there is no classification system that is fully reproducible. Adequate experience is required for the assessment and treatment of these injuries. CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems.

BACKGROUND: This study was conducted to investigate the effects of intravenous thalidomide administration in an experimental model of musculoskeletal trauma. We hypothesized that because thalidomide inhibits secretion of tumor necrosis factor alpha (TNF-α), survival of animals that received thalidomide would be significantly prolonged. MATERIAL AND METHODS: After an open fracture of the right femur, 24 rabbits were randomly assigned to control and thalidomide groups. Intravenous therapy with thalidomide was started 30 min after fracture. Hemodynamic monitoring of all animals was performed for 4 h. Survival was recorded and bacterial growth in blood and organs was measured after animal death or sacrifice. Blood was sampled for TNF-α measurement and for isolation of peripheral blood mononuclear cells (PBMCs). Apoptosis of PBMCs was measured by flow cytometry. RESULTS: Survival was significantly prolonged in the thalidomide group. Apoptosis of PBMCs was increased in the control group compared with the thalidomide group at 24 h. There were no differences in vital signs, blood and tissue cultures, and serum TNF-α concentration between the two groups. CONCLUSIONS: Intravenous thalidomide prolonged survival in an experimental model of severe musculoskeletal injury in rabbits. Its mechanism of action did not involve TNF-α suppression but prevention of mononuclear apoptosis. In view of these promising results, further research is needed to clarify the immunomodulatory mechanism of action of thalidomide and its potential use for the management of severe trauma.

Adrenal hemorrhage (AH) is a rare but serious condition that is often diagnosed at autopsy. Unilateral adrenal hemorrhage (UAH) in adults is extremely rare and is often due to trauma or anticoagulation or is associated with systemic illness. The case of a 73-year-old man who was diagnosed with UAH several days after an elective total knee replacement is presented. The patient had an uncomplicated procedure and he was treated postoperatively with a prophylactic dose of subcutaneous low-molecular- weight heparin and compression sleeves. On postoperative day 8, he reported sustained epigastric and midback pain at the lower thoracic level. He had a temperature of 38.5°C. On clinical examination, the patient expressed only mild tenderness at the lumbar area. Abdominal ultrasound and computed tomography (CT) scan were inconclusive. On postoperative day 13, the patient experienced no pain but remained febrile. An abdominal CT scan revealed a high-density mass on the left adrenal gland suggestive of hemorrhage. The subcutaneous heparin as well as the antimicrobial therapy was discontinued and a serum cortisol examination was done. Serum levels were within normal values in the evening and the morning. On postoperative day 16, all laboratory values returned to normal and the patient was discharged in excellent condition. Patients who have abdominal pain, hypotension, or both soon after initiation of anticoagulation or patients who experience abdominal pain, fever, nausea, or confusion postoperatively should be screened for AH.

Fractures of the lesser tuberosity of the humerus are typically met in combination with other injuries of the shoulder. Case reports of isolated lesser tuberosity fractures are particularly rare and, consequently, therapeutic protocols have not yet been completely clarified. Conservative as well as surgical treatment has been recommended, while several operative techniques have been applied. We present a case of a 39-year-old man with an isolated lesser tuberosity fracture who was treated surgically in our institution. Due to fracture comminution, a two-level reconstruction technique with headless screws and buttress plate was applied. As far as we know, this method of fixation of this type of fracture has not been previously described in the literature. The patient tolerated the procedure well and excellent results were obtained at the latest follow-up.

AIM: Posterior cervical spine fixation has undergone tremendous advancement in recent years. The purpose of this study is to present our experience with the Roy-Camille instrumentation for posterior cervical stabilization after injury in a long-term follow-up. PATIENTS AND METHODS: From 1985 to 1995, 76 patients with a lower cervical spine traumatic lesion were treated in a single institution by posterior plate stabilization using the Roy-Camille plates (R-C plates). Fifty-four men and 22 women with a mean age of 43.2 years were involved. In 59 patients the injuries were due to a road traffic accident, in 14 cases the fall from a high was responsible, while in two cases the injuries were due to sport activities. There were four bilateral dislocations, nine unilateral dislocations, 56 fracture dislocations, five fracture separations of a lateral mass and two burst fractures. Neurological lesions were present in 65 patients (9 ASIA A, 16 ASIA B, 22 ASIA C, 18 ASIA D and 11 ASIA E). All patients had minimum follow-up of 7 years. Fifty-nine patients were followed up for a mean period of 21 years (14-27 years). RESULTS: Stability was obtained in all but two cases. Reoperation was done in two cases: in one for the correction of the lost reduction and in a second for the reinsertion of a screw irritating a nerve root. No case in the ASIA A group showed neurological improvement, a fact observed in the other groups. CONCLUSIONS: The R-C plates were used in the last quarter of the last century. This technique showed good short-time results, and we have shown good results in a long-term follow-up as well. The literature referred to this technique was favorable, as far as the biomechanical behavior and also clinical application concern. The question about this plating system abundance still remains unanswered.

Purpose. The purpose of this paper is to present our technique for the treatment of periplate fractures. Methods. From 2009 to 2012 we treated three patients. In all cases the existing plate was left and the new one placed over the existing. Locking screws were placed through both plates. The other screws in the new plate were used as best suited the fracture. Results. In all cases less than 6 months had passed between fractures. None of the original fractures had healed. Mean followup was 2 years. All fractures proceeded to union within 7 months. No complications were recorded. All the patients returned to their normal activities and were satisfied with the results of their treatment. Conclusion. Our plate on plate technique is effective for the treatment of periplate fractures. A solid fusion can be achieved at the new fracture site without disturbing the previous fixation.

Total knee replacement (TKR) is a widely used operation that has radically improved the quality of life of millions of people during the last few decades. However, some technical details, concerning the surgical procedure and the rehabilitation following total knee arthroplasty, are still a matter of a strong debate. In this review of the literature, we have included the best evidence available of the last decade, in an effort to shed light on some of the most controversial subjects related to TKR surgery. Posterior-stabilized or cruciate-retaining prosthesis? To use a tourniquet during operation or not? Do patients need continuous passive motion for their post-surgery rehabilitation? To resurface patella or not? These are some of the most controversial topics that until now have been persistent dilemmas for the orthopedic surgeon. Results of this systematic review of the literature are highly controversial. These conflicting results are an indication that larger and more well conducted high quality trials are needed in order to gain more secure answers. At the same time, it is becoming apparent that a meticulous operative technique, respecting the soft tissue envelope and knowing the principles of alignment and soft tissue balancing, are some of the parameters that might contribute more to achieving the optimal results for the patients.

Vanishing bone disease (Gorham-Stout syndrome) is a rare entity of unknown etiology, characterized by destruction of osseous matrix and proliferation of vascular structures, resulting in destruction and absorption of bone. Despite the extensive investigation of the pathogenetic mechanisms of the disease, its etiology hasn't been clarified and several theories exist. The syndrome can affect one or multiple bones of the patient, including the skull, the upper and lower extremities, the spine and pelvis. The clinical presentation of a patient suffering from vanishing bone disease includes, pain, functional impairment and swelling of the affected region, although asymptomatic cases have been reported, as well as cases in which the diagnosis was made after a pathologic fracture. In this short review we summarize the theories regarding the etiology as well as the clinical presentation, the diagnostic approach and treatment options of this rare disease.

INTRODUCTION: It is our impression that many biomechanical studies invest substantial resources studying the obvious: that more and larger metal is stronger. The purpose of this study is to evaluate if a subset of biomechanical studies comparing fixation constructs just document common sense. METHODS: Using a web-based survey, 274 orthopaedic surgeons and 81 medical students predicted the results of 11 biomechanical studies comparing fracture fixation constructs (selected based on the authors' sense that the answer was obvious prior to performing the study). Sensitivity, specificity, and accuracy were calculated according to standard formulas. The agreement among the observers was calculated by using a multirater kappa, described by Siegel and Castellan. RESULTS: The accuracy of predicting outcomes was 80% or greater for 10 of 11 studies. Accuracy was not influenced by level of experience (i.e., time in practice and medical students vs. surgeons). There were substantial differences in accuracy between observers from different regions. The overall categorical rating of inter-observer reliability according to Landis and Koch was moderate (κ=0.55; standard error (SE)=0.01). CONCLUSION: The results of a subset of biomechanical studies comparing fracture fixation constructs can be predicted prior to doing the study. As these studies are time and resource intensive, one criterion for proceeding with a biomechanical study should be that the answer is not simply a matter of common sense.

Platelet-rich plasma (PRP) is defined as an autologous concentrated preparation of platelets and their associated growth factors in a small volume of plasma. The presence of these growth factors has stimulated the scientific community to search about possible benefits of the use of PRP in tissue regeneration. Provided that previously in vitro and animal research demonstrated that PRP could probably play an important role in the treatment of neural tissue disorders, we aimed to review the current literature, regarding the clinical studies that have been conducted to confirm this hypothesis. More specifically, we have reviewed the literature concerning the clinical application of PRP in peripheral neuropathies and investigated if there is strong evidence to establish the use of PRP in clinical practice as a therapeutic option. In contrast with animal studies, we have been able to identify only few clinical data concerning the use of PRP in peripheral neuropathies. We found five trials matched to our research that yields positive and promising results for the future for the application of PRP for the therapy of disorders of the peripheral nervous system. It is obvious that this interesting field of research gives to the scientists the ability to expand it extensively, in terms of both quality and quantity.

Background. Dysplasia epiphysealis hemimelica (DEH) is rare and its main characteristic is osteochondromas of the epiphysis of long bones. Methods. We report a case of DEH of the ankle in an 8-year-old boy that was resected in 2005. Additionally we collect all the reported cases of DEH. The literature is reviewed regarding the treatment, prognosis, long term function, and patterns and areas affected by DEH. Results. In our case no complications were noted and our patient remains asymptomatic. Reviewing the literature we found that 73 authors have reported 144 cases from 1926 to 2013. We propose and describe a new classification that correlates with prognosis. According to our classification DEH is classified as types 1 with single lower limb involvement, 2 with multiple lower limb, 3 with single upper limb, 4 with multiple upper limb, 5 with upper and lower limb, and 6 with spine. Conclusions. All single lesions should be followed up and if indicated a whole body nuclear bone scan can be useful in identifying the existence of multiple affected joints. Type 1 lesions have better prognosis than 2 and have less chances of developing OA even if not resected. Resection, even if partial, can be a successful treatment for DEH.

The congenital pseudarthrosis of the tibia (CPT) is one of the most challenging problems in pediatric orthopedics. The primary treatment goals are outlined as osteosynthesis, stabilization of the ankle mortise by fibular stabilization and lower-limb-length equalization. Despite the fact that each of the aforementioned goals is difficult to be achieved regardless the surgical option, the main biological consideration is the same: pseudarthrosis resection, biological bone bridging of the defect by stable fixation and the correction of any angular deformity. The external fixation method is suggested as valuable treatment of CPT because it can address not only pseudarthrosis but also all complex deformities associated with this condition. However, treatment of CPT is impaired with complications due to the complex nature of the disease thus failure is common. The most common of these are refracture, growth disturbance, poor foot and ankle function with stiffness. Of these, refracture is the most common and serious complication after primary healing and might result in the reestablishment of pseudarthrosis. Therefore, an effective, safe and practical treatment method that minimizes the residual challenges after healing and accomplishes the multiple goals of treatment is needed. In this article, we report a patient with CPT treated successfully with external fixation. Level of evidence IV retrospective.

STUDY DESIGN: Comparative biomechanical study. OBJECTIVE: To determine whether an angular mismatch between the vertebral body replacement (VBR) endplate and the simulated foam vertebral endplate leads to accelerated subsidence in a cyclic compression model of the VBR-vertebra interface. SUMMARY OF BACKGROUND DATA: One of the main complications of the VBR surgery is postoperative subsidence and collapse of the VBR implant into the adjacent vertebral bodies. Although numerous factors affecting intervertebral cage subsidence have been cited, few studies have proposed factors responsible for VBR cage subsidence. METHODS: Hardwood blocks at 0-30-degree angles and polyurethane foam blocs have been used as base for this experimental setting. One end of the Synex (Synthes) expandable cage was attached to a material testing machine. The endplate of the implant was placed at a similar spot on the block in such a manner that there was an exact match between the Synex endplate and the foam block at 0 degrees, subsequent angled blocks would tilt the foam endplates by the 10-, 20-, and 30-degree increments as needed. Cyclic axial loads were applied in 9 load-unload cycles. RESULTS: Five samples were tested at each mismatch angle (0, 10, 20, and 30 degrees), for a total of 20 trials. Implant subsidence significantly increased for each 10-degree increase in mismatch angle. This effect, however, did not follow a uniform trend at all angles. The curve appeared exponential at 0 degree of angular mismatch, became linear at 10-20 degrees of mismatch, and then demonstrated some ability to resist load at 30 degrees, leading to a plateau at the higher loads. CONCLUSIONS: Increasing mismatch angles are an important factor in leading to increased cage subsidence into polyurethane blocks. Consequently, the incidence of subsidence in the clinical setting could be reduced by paying careful attention to ensuring that both the prosthetic and bony endplates are well apposed at the end of surgery.

We aimed to investigate the effect of metal ions on the semen of males of child fathering age with metal-on-metal (MM) total hip arthroplasty (THA). Semen was collected form 11 patients with MM THA and 5 control of comparable age. Cobalt and chromium concentrations were measured in both the seminal plasma and in the blood of patients. Results showed that cobalt level was higher in the seminal plasma of MM THA patients (2.89 μg/L) compared to control patients (1.12 μg/L) (P = .011). The ejaculate volume, the sperm density, the total sperm count, the pH, and the percentage of cells with normal morphology were in the range of the World Health Organization criteria for fertile population.

PURPOSE: To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. METHODS: We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." RESULTS: According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. CONCLUSIONS: Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. CLINICAL RELEVANCE: Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

AIM: To present the 18 year survival and the clinical and radiological outcomes of the Müller straight stem, cemented, total hip arthroplasty (THA). METHODS: Between 1989 and 2007, 176 primary total hip arthroplasties in 164 consecutive patients were performed in our institution by the senior author. All patients received a Müller cemented straight stem and a cemented polyethylene liner. The mean age of the patients was 62 years (45-78). The diagnosis was primary osteoarthritis in 151 hips, dysplasia of the hip in 12 and subcapital fracture of the femur in 13. Following discharge, serial follow-up consisted of clinical evaluation based on the Harris Hip Score and radiological assessment. The survival of the prosthesis using revision for any reason as an end-point was calculated by Kaplan-Meier analysis. RESULTS: Twenty-four (15%) patients died during the follow-up study, 6 (4%) patients were lost, while the remaining 134 patients (141 hips) were followed-up for a mean of 10 years (3-18 years). HSS score at the latest follow-up revealed that 84 hips (59.5%) had excellent results, 30 (22.2%) good, 11 (7.8%) fair and 9 (6.3%) poor. There were 3 acetabular revisions due to aseptic loosening. Six (4.2%) stems were diagnosed as having radiographic definitive loosening; however, only 1 was revised. 30% of the surviving stems showed no radiological changes of radiolucency, while 70% showed some changes. Survival of the prosthesis for any reason was 96% at 10 years and 81% at 18 years. CONCLUSION: The 18 year survival of the Müller straight stem, cemented THA is comparable to those of other successful cemented systems.

Inflammatory masses or cysts occurring in the pelvis, thigh, and gluteal regions, often mimicking infection, occasionally arise after total hip arthroplasty procedures. Inflammatory pseudotumors comprise a subgroup of these lesions. Pseudotumors have been associated with pain, rashes, instability, neuropathy, and premature loosening of prosthetic components, often leading to early and difficult revision surgery. The association between such pseudotumors and metal-on-metal bearings has led to questions regarding the performance of these bearings in hip arthroplasty. We present a case of pseudotumor requiring revision surgery, which occurred uniquely around a metal-on-highly cross-linked polyethylene bearing.

PURPOSE: We performed a prospective study to document, by intra-operative manipulation under anaesthesia (MUA) of the pelvic ring, the stability of lateral compression type 1 injuries that were managed in a Level-I Trauma Centre. The documentation of the short-term outcome of the management of these injuries was our secondary aim. METHODS: A total of 63 patients were included in the study. Thirty-five patients (group A) were treated surgically whereas 28 (group B) were managed nonoperatively. Intraoperative rotational instability, evident by more than two centimetres of translation during the manipulation manoeuvre, was combined with a complete sacral fracture in all cases. RESULTS: A statistically significant difference was present between the length of hospital stay, the time to independent pain-free mobilisation, post-manipulation pain levels and opioid requirements between the two groups, with group A demonstrating significantly decreased values in all these four variables (p < 0.05). There was also a significant difference between the pre- and 72-hour post-manipulation visual analogue scale and analgesic requirements of the group A patients, whereas the patients in group B did not demonstrate such a difference. CONCLUSION: LC-1 injuries with a complete posterior sacral injury are inheritably rotationally unstable and patients presenting with these fracture patterns definitely gain benefit from surgical stabilisation.

The ideal bearing surface for young patients undergoing total hip replacement (THR) remains controversial. We report the five-year results of a randomised controlled trial comparing the clinical and radiological outcomes of 102 THRs in 91 patients who were < 65 years of age. These patients were randomised to receive a cobalt-chrome on ultra-high-molecular-weight polyethylene, cobalt-chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic bearing. In all, 97 hip replacements in 87 patients were available for review at five years. Two hips had been revised, one for infection and one for peri-prosthetic fracture. At the final follow-up there were no significant differences between the groups for the mean Western Ontario and McMaster Universities osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness, p = 0.99), Short Form-12 (physical component, p = 0.878; mental component, p = 0.818) or Harris hip scores (p = 0.22). Radiological outcomes revealed no significant wear in the ceramic group. Comparison of standard and highly cross-linked polyethylene, however, revealed an almost threefold difference in the mean annual linear wear rates (0.151 mm/year versus 0.059 mm/year, respectively) (p < 0.001).

We have undertaken a meta-analysis of the English literature, to assess the component alignment outcomes after imageless computer assisted (CAOS) total knee arthroplasty (TKA) versus conventional TKA. We reviewed 23 publications that met the inclusion criteria. Results were summarised via a Bayesian hierarchical random effects meta-analysis model. Separate analyses were conducted for prospective randomised trials alone, as well as for all randomised and observational studies. In 20 papers (4,199 TKAs) we found a reduction in outliers rate of approximately 80% in limb mechanical axis when operated with the CAOS. For the coronal femoral and tibial implants positions, the analysis included 3,058 TKAs. The analysis for the femoral implant showed a reduction in outliers rate of approximately 87% and for the tibial implant a reduction in outliers rate of approximately 80%. Imageless navigation when performing TKA improves component orientation and postoperative limb alignment. The clinical significance of these findings though has to be proven in the future.

The aim of this double-blind, randomized control trial was to compare the effectiveness of intra-articular ropivacaine alone or with morphine or ketoprofen for controlling pain after arthroscopic knee surgery. One hundred fifty-six patients scheduled for elective knee arthroscopy were recruited. All patients received general anesthesia and were randomly assigned to 4 groups to receive intra-articular ropivacaine 40 mg (group R), ropivacaine 24 mg plus morphine 8 mg (group R+M), ropivacaine 36 mg plus ketoprofen 100 mg (group R+K), or normal saline (group N/S). Pain, sedation, orientation, nausea, vomiting, and urine retention were recorded at 0, 1, 2, 4, 8, 12, and 24 hours postoperatively. Pain was evaluated by a 10-cm visual analog scale (VAS). When the pain was >2, a suppository of 400 mg paracetamol plus 10 mg codeine plus 50 mg caffeine was given. Results showed that at 4 hours postoperatively, pain differed significantly among the 4 groups (P<.001), with less pain recorded in the R+M group. Similarly, the number of suppositories administered postoperatively to the R+M group was significantly less (P<.001) vs the other groups. Patients who received ropivacaine and morphine or normal saline had a higher incidence of nausea and vomiting vs the other groups (P=.001 and P=.036, respectively). The combination of intra-articular ropivacaine and morphine is associated with less pain after knee arthroscopy during early recovery but with a higher incidence of nausea and vomiting. However, the addition of ketoprofen to ropivacaine provides relatively satisfactory pain relief, but with fewer side effects compared to morphine.

For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated heparins or vitamin K antagonists, have been used as anticoagulants for prevention of venous thromboembolism following major lower limb surgery. However, these regiments have limitations that rendered the quest for new anticoagulants mandatory. Recently, research has been focused on the development of orally active small molecules that directly target thrombin or activated factor X (FXa). These regiments exhibit a number of characteristics that an "ideal" anticoagulant should possess. Currently, two agents, dabigatran etexilate and rivaroxaban, which inhibit thrombin and FXa, respectively have been approved in the European Union and Canada for venous thromboprophylaxis in patients undergoing elective hip- or knee-replacement surgery. Other agents are at an early or late stage of clinical evaluation. In this study, we summarize the current evidence for these new developed or under development drugs regarding their applications in the filed of lower limb orthopaedic surgery.

Thromboembolic disease remains one of the most devastating and potentially lethal complications after elective total knee replacement (TKR) surgery. Studies have shown that 40-85% of patients undergoing TKR will develop venographically confirmed deep vein thrombosis (DVT) if they are not given any type of post-operative thromboprophylaxis and approximately 0.1 to 1.7% will suffer fatal pulmonary embolism (PE). Consequently, there is a general consensus that patients undergoing elective TKR require adequate antithrombotic prophylaxis. The following article reviews current evidence regarding chemical thromboprophylaxis after total knee replacement. Clinical guidelines as described by the American Academy of Orthopaedic Surgeons (AAOS), the American College of Chest Physicians (ACCP) and the UK's National Institute for Health and Clinical Excellence (NICE) are summarized along with the differences between the recommendations. The results of the new oral anticoagulants are reviewed as well as the most recent developments in the search for the most effective venous thromboembolism (VTE) prophylaxis after TKR surgery.

Between 2004 and 2009, 60 patients with proximal tibial fractures were included in this prospective study. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, IN, USA). Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and fracture union were analysed. The mean follow-up was 14 (12-36) months. According to the Orthopaedic Trauma Association (OTA) classification, there were five 41-A, 28 41-B and 27 41-C fractures. Fractures were treated percutaneously in 30% of cases. Double-plating was used in 11 cases. All but three fractures progressed to union at a mean of 3.2 (2.5-5) months. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was one case of lateral joint collapse (>10°) in a patient with open bicondylar plateau fracture. The mean Knee Society Score at the time of final follow-up was 91 points, and the mean functional score was 89 points. The polyaxial locking-plate system provided stable fixation of extra-articular and intra-articular proximal tibial fractures and good functional outcomes with a low complication rate.

OBJECTIVES: To investigate the hypothesis that specific fracture patterns in patients with femoral shaft fractures can predict the likelihood of associated injuries. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive patients treated because of a traumatic diaphyseal femoral fracture. MAIN OUTCOME MEASUREMENT: We studied the association between the Orthopaedic Trauma Association (OTA) fracture classification (derived from initial radiographs) and concomitant injuries of the head, spine, chest, abdomen, and pelvis with a severity of two or more points according to the Abbreviated Injury Scale by logistic regression analysis. RESULTS: One hundred forty-three of 203 patients (80 men, 63 women; mean age 54 ± 26 years) met the inclusion criteria. All patients had unilateral diaphyseal fractures, 64 OTA 32.A (45%), 46 OTA 32.B (32%), and 33 OTA 32.C (23%). In addition, 134 associated injuries were identified in 52 patients. Increasing fracture severity, as expressed by the OTA classification (ie, A, B, C), was significantly associated with a higher likelihood of thoracic (odds ratio [OR], 5.89; 95% confidence interval [CI], 2.59-13.40), pelvic (OR, 4.55; 95% CI, 2.01-10.28), upper (OR, 2.38; 95% CI, 1.27-4.48), and lower extremity injuries (OR, 3.12; 95% CI, 1.78-5.46). Fracture severity explained between 70% and 86% of the probability of having accompanying injuries. CONCLUSION: Radiographic grading of the severity of a femoral shaft fracture may signal the presence of accompanying injuries and should contribute to the clinical decision-making process in severe trauma.

We prospectively studied 110 consecutive patients with intertrochanteric hip fractures treated with the 130 degree angle, 10-mm short IMHS intramedullary hip screw (IMHS, Smith & Nephew, Richards, Memphis, TN). Surgery was performed within 36 hours from admission; all patients were mobilized immediately postoperatively. Fracture union, pre- and post-operative mobility status and complications were evaluated. Eighty patients were included in the postoperative evaluation for a mean followup of 14 (range, 9 to 25) months. Mortality was 19%. Union occurred in 79 fractures within 6 months from surgery; there was one case of screw cut-out and one case of deep venous thrombosis. Periprosthetic femoral shaft fractures were not observed. At the latest examination, the mean mobility score decreased from 8.4 +/- 1.6 to 7.1 +/- 2.1 (p = 0.0001); 26 patients (32%) fully achieved the preoperative mobility score and 54 patients (68%) achieved more than 90% of the preoperative mobility score. The IMHS intramedullary hip screw represents a reliable method for the treatment of patients with intertrochanteric hip fractures, and provides for early mobilization and rehabilitation of the patients with acceptable complications.

BACKGROUND: The effectiveness of a new delivery system consisting of polymerized dilactide (PLA) with incorporated linezolid was investigated in a rabbit model as a means of treating methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis. METHODS: The PLA-linezolid system was prepared after thorough stirring of PLA with linezolid at a 10:1 ratio. Experimental osteomyelitis was established in 40 rabbits by a modification of the Norden model with MRSA as the test isolate. After a hole had been drilled in the upper right femur, the isolate was inoculated using a thin needle working as a foreign body. At three weeks, the needle was removed and cultured, and the PLA-linezolid system was implanted in half the animals (group B); the remaining half was the control group (group A). Animals were sacrificed at regular intervals; tissue around the site of implantation was examined for pathologic changes and cultured quantitatively. RESULTS: The prepared system eluted linezolid in vitro at concentrations much greater than the minimum inhibitory concentration (MIC) of the test pathogen for 11 days. At three weeks after inoculation of the test isolate, all animals had osteomyelitis. By the sixth week, bacterial growth from cancellous bone of group B was significantly lower than that in group A. However, this effect was not maintained until the end of the study (weeks 8 and 10), when the differences in bacterial growth in the two groups were not significant. CONCLUSION: Polymerized dilactide mixed with 10% linezolid achieved partial arrest of the offending pathogen in an experimental model of osteomyelitis caused by MRSA.

Metal-on-metal (MoM) total hip arthroplasty (THA) has been introduced in an attempt to reduce the wear rate and the consequent osteolysis around implants. The aim of this study was to present the intermediate to long-term clinical and radiological outcomes and to investigate the metal ion levels in the blood of patients who had undergone primary uncemented MoM THA in our institution. Between July 1997 and November 2003, 166 patients (193 hips), with a mean age of 50 years (range, 18-65 years), underwent primary MoM THA. Clinical data, radiographs, and blood samples were obtained at regular follow-up visits. Cobalt (Co), chromium (Cr), and molybdenum (Mo) ions were measured by inductively coupled plasma-mass spectrometry (ICP-MS) from the patient's whole blood. All patients were prospectively followed for a minimum of 5 years (mean, 7 years; range, 5-11 years). The mean Harris hip score (HHS) and the University of California at Los Angeles (UCLA) activity score at the latest follow-up was 88 ± 11 and 7 ± 1.8 points, respectively. Thirteen hips have been revised. Ten acetabular components had early failure, due to factory manufacturing problems. All other implants have been found stable, with no signs of aseptic loosening. The probability of survival at 11 years, if the hips that were revised due to manufacturing problems were excluded, was 98.4%. The Co and Cr metal ion levels, after increasing significantly during the first 4 to 5 years post-surgery, remained stable, with a tendency to decrease thereafter, but not significantly. During the same follow-up period, Mo ion levels remained stable. In this 5-to-11 year follow-up study of MoM THA patients, excellent survivorship, with low complications rates, was found. Results of longer follow-up studies are necessary to clarify the possible long-term effects of metal ion release.

Numerous studies have been published concerning the characteristics and the behaviour of the intramedullary devices in the treatment of the intertrochanteric hip fractures. However, there is still room for further exploration and exploitation concerning the implant behaviour with respect to the parts of the implant assembly (nail, lag screw and distal screw). Towards this direction, the present paper aimed at revealing the effect of the position of the distal screw on the mechanical behaviour of the fixation device. For this purpose, a simplified model was developed and analysed with the finite element method. In total, five different locations for the distal screw were examined. In all cases, the bone was fixed at its distal end while the external load was applied at the tip of the lag screw towards the hip and in the form of orthonormal force components applied individually. The results of the FE analyses were illustrated in appropriately formed plots revealing the sensitivity of the behaviour of the implant with respect to the location of the distal screw. The main conclusion derived from the present investigation was that moving the distal screw apically decreases the stresses on the distal screw but increases the stresses on the lag screw. In turn, this indicates the existence of a location for the distal screw that compromises these two effects in an optimum way.

OBJECTIVES: This study aims to assess whether elderly patients (>65 years) with open tibial shaft fractures (OFs) have increased mortality rates than those with closed fractures (CFs). PATIENTS AND METHODS: Patients admitted during 2003-2005 with open/closed diaphyseal (AO 42) fractures of the tibia were eligible to participate. EXCLUSION CRITERIA: Pathological and peri-prosthetic fractures. RESULTS: A total of 54 patients (38 females) met the inclusion criteria. Twenty-six patients had sustained CF and 28 OF (Gustilo grade I (11), grade II (five), grade IIIa (two) and grade IIIb (10)). The OF group was statistically significantly different with higher injury severity score, secondary procedures and length of hospital stay (p<0.05). A higher rate of admission/length of stay to intensive care unit and complication rate was noted in the OF group. Mortality rate between the two groups was comparable (CF=2/26, OF=3/28). CONCLUSIONS: Elderly patients with OFs of the tibial shaft have similar mortality rate to those with CFs.

The parameter of health economics in the use of any contemporary medical module plays a dominant role in decision making. A prospective nonrandomised comparative study of the direct medical costs on the first attempt of treating aseptic nonunions of tibial fractures, with either autologous-iliac-crest-bone-graft (ICBG) or bone morphogenetic protein-7 (BMP-7), is presented. Twenty-seven consecutive patients, who were successfully treated for fracture nonunions, were divided into two groups. Group 1 (n = 12) received ICBG and group 2 (n = 15) received BMP-7. All patients healed their nonunions, and the financial analysis presented represents a best-case scenario. Three out of 12 of the ICBG group required revision surgery while just one out of 15 required it in the BMP-7 group. Average hospital stay was 10.66 vs. 8.66 days, time-to-union 6.9 vs. 5.5 months, hospitals costs pound2,133.6 vs. pound1,733.33, and theatre costs were pound2,413.3 vs. pound906.67 for the ICBG and BMP-7 groups, respectively. The BMP-7 cost was pound3002.2. Fixation-implant was pound696.4 vs. pound592.3, radiology pound570 vs. pound270, outpatient pound495.8 vs. pound223.33, and other costs were pound451.6 vs. pound566.27 for the ICBG and BMP-7 groups, respectively. The average cost of treatment with BMP-7 was 6.78% higher (P = 0.1) than with ICBG, and most of this (41.1%) was related to the actual price of the BMP-7. In addition to the satisfactory efficacy and safety of BMP-7 in comparison to the gold standard of ICBG, as documented in multiple studies, its cost effectiveness is advocated favourably in this analysis.

We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.

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.

A review of prospectively collected data in our trauma unit for the years 1998-2003 was undertaken. Adult patients who suffered multiple trauma with an Injury Severity Score (ISS) of >/=16, admitted to hospital for more than 72 hours and with sustained blunt chest injuries were included in the study. Demographic details including pre-hospital care, trauma history, admission vital signs, blood transfusions, details of injuries and their abbreviated injury scores (AIS), operations, length of intensive care unit and hospital stays, Injury Severity Score (ISS) and mortality were analysed. Fulfilling the inclusion criteria with at least one chest injury were 1,164 patients. The overall mortality reached 18.7%. As expected, patients in the higher AIS groups had both a higher overall ISS and mortality rate with one significant exception; patients with minor chest injuries (AIS(chest) = 1) were associated with mortality comparable to injuries involving an AIS(chest) = 3. Additionally, the vast majority of polytraumatised patients with an AIS(chest) = 1 died in ICU sooner than patients of groups 2-5.

Tibial stress fractures are not rare--they have been extensively studied in young athletes and soldiers and in elderly people with rheumatoid arthritis, osteoporosis, Paget's disease, pyrophosphate arthropathy, and hyperparathyroidism--but they seldom occur in patients with severe primary degenerative knee osteoarthritis. The etiology, diagnosis, and optimal treatment of these fractures remain a challenge. In this article, we review the English-language literature on the symptoms, diagnosis, treatment options, and final outcomes of these fractures, and we report 2 new cases of proximal tibial stress fractures in elderly women with severe primary degenerative knee osteoarthritis.

AIM: In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed. PATIENTS AND METHODS: Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis. RESULTS: In all group A patients Singh score < or =4 and CBR>0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score > or =5 and CBR<0.48. Fractures of group A healed in 19.38+/-5.9 weeks (12-30) and in group B 16.19+/-5.07 weeks (10-28), P=0.02. CONCLUSIONS: Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process.

We describe a patient in whom an initially intact sciatic nerve became rapidly encased in heterotopic bone formed in the abductor compartment after reconstruction of the posterior wall of the acetabulum following fracture. Prompt excision and neural release followed by irradiation and administration of indometacin resulted in a full neurological recovery and no recurrence 27 months later.

Thirty New Zealand white rabbits underwent anterior cruciate ligament (ACL) reconstruction in their right knees; 15 animals underwent a double-bundle anatomic ACL reconstruction using the medial third of the patellar tendon and the semitendinosus tendon. Additionally, 15 animals underwent ACL reconstruction, using a single-bundle semitendinosus tendon autograft. The knees of both groups were evaluated with a device similar to the KT1000 arthrometer onto which a dial indicator was attached (Mitutoyo dial indicator 2050) in 30 degrees and 90 degrees of flexion, preoperatively, after ACL resection and 3 months postoperatively. Statistical analysis of the results revealed that for 90 degrees of knee flexion, the mean estimated anterior shift for the double-bundle technique was 1.92 mm lesser than that of the single-bundle technique (P = 0.006). For 30 degrees of knee flexion, the mean anterior shift was again lesser than that of the single-bundle technique by 0.66 mm, but this difference was not statistically significant. The described double-bundle ACL reconstruction technique resulted in a more stable knee as far as the anterior tibial shift was concerned as compared to a single-bundle ACL reconstruction. This animal model may be potentially useful in the future for the study of other parameters influencing the outcome of the double-bundle ACL reconstruction.

UNLABELLED: Although acute management of pelvic fractures and their long-term functional outcome have been widely documented, important information regarding malunion and nonunion of these fractures is sparse. Despite their relative rarity, malunions and nonunions cause disabling symptoms and have major socioeconomic implications. We analyzed the factors predisposing a pelvic injury to develop malunion/nonunion, the clinical presentation of these complications, and the efficacy of the reported operative protocols in 437 malunions/nonunions of 25 clinical studies. Treatment of these demanding complications appeared effective in the majority of the cases: overall union rates averaged 86.1%, pain relief as much as 93%, patient satisfaction 79%, and return to a preinjury level of activities 50%. Nevertheless, the patient should be informed about the incidence of perioperative complications, including neurologic injury (5.3%), symptomatic vein thrombosis (5.0%), pulmonary embolism (1.9%), and deep wound infection (1.6%). For a successful outcome, a thorough preoperative plan and methodical operative intervention are essential. In establishing effective evidence-based future clinical practice, the introduction of multicenter networks of pelvic trauma management appears a necessity. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Hip resurfacing has recently been offered as an attractive alternative to conventional total hip arthroplasty. This report evaluated the short-term functional outcome and longevity of a newer generation resurfacing device and includes the results of 228 consecutive hip resurfacing in 209 patients at a minimum of two-year follow-up. All resurfacing were performed by a single surgeon using a posterior approach. Excluding infections, there were only three failures (1.3%). The overall survival at 4.6 years was 96.9%. The survival of resurfacing in this study was comparable to that of other published studies of hip resurfacing. Surface hip arthroplasty appears to be an effective alternative to conventional total hip arthroplasty in patients suffering from osteoarthritis.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

We present a case of a 53-year-old woman with recurrent intra-articular osteoid osteoma of the hip 6 months after initial treatment with percutaneous radiofrequency ablation. En bloc surgical excision of the osteoid osteoma and prophylactic internal fixation for impending stress fracture was performed. The patient is pain free, has returned to normal function and there is no sign of recurrence at the one-year follow-up. Intraarticular osteoid osteoma, present a diagnostic challenge and often they are misdiagnosed. Minimally invasive ablation techniques can fail in significant percentage and then surgical excision with histological confirmation remains the definitive treatment of choice.

Evaluation and treatment of pain following hip resurfacing arthroplasty can be challenging, even for the most experienced arthroplasty surgeon. As in any total hip replacement, there are a number of investigative tools at the disposal of orthopaedic surgeons to elicit the underlying causes of pain for diagnosis and treatment. A detailed history and physical examination are the most important first steps in the differential diagnosis of the intrinsic and extrinsic etiologies of hip pain. Serial radiographs from the time of surgery also should be reviewed and compared for changes indicative of loosening, migration, and osteolysis, in combination or alone. Diagnostic injections with local anesthetic agents additionally can be performed to localize the origin of pain. Bone scintigraphy, hip joint aspiration, and laboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), should be requested routinely to exclude an occult infection. The use of ultrasound (US), magnetic resonance imaging (MRI), and even hip arthroscopy has been suggested as potential diagnostic tools when metal sensitivity is suspected. Relative to cause, femoral neck fractures and the possibility of metal hypersensitivity as sources of persistent groin pain should always be considered in metal-on-metal hip resurfacing. Additionally, iliopsoas tendinopathy and anterior impingement of the femoral neck are well-recognized causes of pain and should be included in the differential diagnosis. Surface arthroplasty is becoming an acceptable alternative to standard total hip replacement in young patients. It is increasingly essential to recognize the different causes of pain following resurfacing in order to make an accurate diagnosis and initiate timely, appropriate treatment.

Patients with lower limb and pelvic trauma, or undergoing major orthopaedic surgery represent one of the highest risk groups for the development of venous thromboembolism (VTE). A significant number of pharmacological and mechanical agents have been used for the prophylaxis and treatment of VTE. Fondaparinux is a relative new pharmacological agent that selectively binds to antithrombin, and represents a new class of synthetic selective inhibitors of activated factor X. Eleven percent of the fondaparinux-related English language literature, between 2001 and 2007, refers to orthopaedic trauma, and was the sample assessed for this critical analysis review. The clinical studies evaluating the safety, efficacy, and financial implications associated with lower limb orthopaedic trauma show that fondaparinux has comparable results with the well-established use of enoxaparin. However, the scientific community has raised several issues regarding mostly fondaparinux's safety, timing of its 1(st) dose, bleeding side effects, duration of administration and lack of a reliable reversing agent. Further trials are necessary focusing on the safety and efficacy of this drug mostly in relation to clinical relevant outcomes and to different fields of trauma surgery (pelvis, long bone fractures and polytrauma patients).

SUMMARY: Fracture healing constitutes a complex and delicate physiological process. Local vascularity at the site of the fracture has been identified as one of the most significant parameters influencing the healing procedure. VEGF is the most important component of the regeneration of the vascular system at the fracture site. The aim of this review is to determine the evidence supporting the direct role of VEGF in the enhancement of fracture healing and the possible clinical use of VEGF for non-unions. The literature search was performed via the internet using the Medline. The key words which were searched in the abstracts were the terms "VEGF", "angiogenesis", "fracture", "bone" and "healing". Twenty-five articles were relevant to the topic of interest. A total of 11 articles were excluded from our research due to non conformity of their content to the inclusion criteria. Evidence retrieved suggests that VEGF could be extremely valuable for the treatment of critical size bone defects and that VEGF could have a direct effect on osteoprogenitor cells, mainly by promoting the differentiation of osteoblasts and by increasing the mineralisation of the regenerated bone. The former observation could have very interesting repercussions for the field of non-unions and the latter for the field of osteoporosis.

Posterior wall fractures are the commonest type of acetabular fracture. Nonoperative management is associated with significant complications and poor outcome. Consequently, open reduction and internal fixation has become increasingly common. In this article, inaugurating the new section of "how do I do it", we present our current approach to the treatment of posterior wall fractures of the acetabulum, including the preoperative planning, the details of the operative procedure in terms of patient's positioning and draping, surgical approach, osteosynthesis and wound closure.

BACKGROUND: Many surgeons tend to believe that MRI is an accurate, non invasive diagnostic method, enough to lead to decisions for conservative treatment and save a patient from unnecessary arthroscopy. We conducted a retrospective study to investigate the accuracy of the MRI of the knee for the detection of injuries of the meniscus, cruciate ligaments and articular cartilage, in comparison with the preoperative clinical examination and intraoperative findings. Between May 2005 and February 2006 102 patients after clinical examination were diagnosed with meniscal or cruciate injury and underwent definitive treatment with arthroscopy. 46 of these patients fulfilled the inclusion criteria. The accuracy, sensitivity, specificity, negative and positive predictive values of the MRI findings were correlated with the lesions identified during arthroscopy. The diagnostic performance of the initial clinical examination was also calculated for the meniscal and cruciate ligament injuries. RESULTS: The accuracy for tears of the medial, lateral meniscus, anterior and posterior cruciate ligaments and articular cartilage was 81%, 77%, 86%, 98% and 60% respectively. The specificity was 69%, 88%, 89%, 98% and 73% respectively. The positive predictive value was 83%, 81%, 90%, 75% and 53% respectively. Finally, the clinical examination had significant lower reliability in the detection of these injuries. CONCLUSION: MRI is very helpful in diagnosing meniscal and cruciate ligament injuries. But in a countable percentage reports with false results and in chondral defects its importance is still vague. The arthroscopy still remains the gold standard for definitive diagnosis.

The authors examined the effectiveness of the local anti-microbial treatment on methicillin resistant Staphylococcus aureus (MRSA) experimental osteomyelitis. Thirty-six rabbits with chronic MRSA osteomyelitis of the right femur were treated with local grepafloxacin delivery system prepared by a mixture of acrylic bone cement (polymethyl methacrylate, PMMA) plus 4% grepafloxacin. Osteomyelitis was induced by inoculating MRSA (100 microl of cultured bacteria; 10(7)) and the local insertion of a needle, serving as a foreign body, at the upper third of the femur. The course of the infection was followed by clinical, radiographic and microbiological examination. In the third week, all animals were re-operated, needles were removed, and antibiotic containing acrylic cement was implanted. Thereafter, one control and five treated animals were sacrificed per week, within 6 weeks. Osteomyelitis was found in all rabbits. In vitro grepafloxacin levels remained high throughout the 6 weeks of the experiment. Histologically tissue reaction against the cement was not observed. Osteomyelitis lesions and bone structure were progressively repaired after cement implantation. Biomechanical analysis showed no significant influence on the mechanical properties of acrylic cement due to grepafloxacin. The above mixture could prove to be an important supplementary method for the treatment of bone infections. Such a system could replace the use of gentamycin PMMA beads in the treatment of patients with chronic osteomyelitis due to MRSA. Furthermore, the proposed method could be used as a spacer after removal septic loosened prostheses in combination with systemic administration of antibiotics.

The incidence of proximal femoral fractures has increased significantly in recent years, and is expected to continue to rise with increasing life expectancy. However, the optimal method of treatment of these fractures is still debated. This article summarises current evidence concerning the most controversial issues in the treatment of intracapsular and extracapsular proximal femoral fractures. Despite initial enthusiasm, many new treatment options have been proved inferior to older, traditional methods, and physicians should be cautious when it comes to managing these fractures. It seems that meticulous surgical technique and implant selection according to fracture pattern and the characteristics of the individual patient offer the best route to optimal final outcome.

INTRODUCTION: Osteoid osteoma is a benign tumor of the growing skeleton. It presents with pain, which is usually worse at night. The radiographic features consist of a central oval or round nidus surrounded first by a radiolucent area followed by another area of sclerotic bone. In the hand, osteoid osteoma is more commonly located in the phalanges and carpal bones. The metacarpals are the least common sites for osteoid osteoma. CASE PRESENTATION: We present a case of an osteoid osteoma of the left third metacarpal bone in a 36-year-old woman. The clinical and radiographic findings along with the surgical management of the lesion are presented. The pain disappeared immediately after the operation. At the 2-year follow-up, the patient was pain-free and there was no evidence of recurrence. CONCLUSION: Physicians should be aware of the unusual presence and the atypical clinical presentation of this benign lesion in the metacarpal bones of the hand.

Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.

A 52-year-old man presented with a 3-week history of right knee pain, significant enough to prevent weight bearing. There was no history of knee injury or disease. On knee examination, an effusion and medial joint line tenderness was noted. Knee range of motion was full, but painful. Radiographs revealed minor osteoarthritic changes. Laboratory values were within normal limits, including those associated with infection. Magnetic resonance imaging showed decreased signal intensity on T1-weighted images within the medial femoral condyle and corresponding increased signal intensity on T2-weighted consistent with bone marrow edema as well as edema to the adjacent soft tissues. Bone scanning showed increased uptake of radioisotope in the medial femoral condyle. The patient was diagnosed with bone marrow edema syndrome, and managed medically with analgesics and continued non weight-bearing status. At the 1-month follow-up, his symptoms had improved significantly. The patient progressively increased weight bearing as tolerated over the subsequent weeks. At 12-week follow-up, symptoms had completely resolved. Magnetic resonance imaging showed no signal abnormalities in the affected knee. Transient osteoporosis is an uncommon and typically self-limiting condition that can be challenging to diagnose and treat. The clinician must be aware of this entity, as well as its typical course, to prevent unnecessary testing and invasive intervention.

The purpose of this study was to evaluate the histologic changes that occur between 3 and 12 weeks in an intra-articular, semitendinosus autograft, which was harvested without detachment of its tibial insertion and was placed through tibial and femoral drill holes, in a rabbit model. About 30 New Zealand white rabbits underwent ACL replacement using a semitendinosus tendon autograft. The normal ACL was transected at its femoral and tibial insertions. The tendon graft was harvested without detachment of its tibial insertion and its free end was secured with sutures. The graft was then passed through one tibial and one femoral tunnel and secured at the lateral femoral condyle. All animals were divided into three groups and were killed at 3, 6 and 12 weeks after surgery. Nine more animals underwent ACL reconstruction using a free semitendinosus tendon autograft. These animals were used as controls. The intra-articular portion of the graft and the interface between the bone tunnel and the graft was evaluated postoperatively for gross morphology and histological appearance. Results of this study showed that in a rabbit model the semitendinosus tendon autograft retained its viability when harvested without detachment of its peripheral insertion. On contrary, at the control group, necrosis of the graft was observed 3 weeks after surgery and progressively revascularization and maturation occurred 6 and 12 weeks after surgery. Retaining the tibial insertion of the semitendinosus autograft seems to preserves its viability and bypasses the stages of avascular necrosis and revascularization that occurs with the use of a free tendon autograft.

Despite the long lasting research the ideal method of reconstructing the ACL has not been found so far. The last year's attention has shifted to the use of the multistrand hamstring tendon grafts. High ultimate tensile load, multiple-bundle replacement that better approximates the anatomy of the normal ACL and low donor site morbidity are the main advantages of this ACL replacement graft. These theoretical advantages have been multiplied when surprisingly studies have shown that semitendinosus and gracilis tendons actually regenerate after harvesting for use as ACL autografts. In this review article we summarize the current knowledge concerning the hamstring regeneration and we focus on issues that have clinical relevance or issues that have not been answered so far.

We report a randomised prospective study comparing two implants, the Gamma trochanteric nail and the ACE trochanteric nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and twelve patients were randomised on admission into two treatment groups. Fifty-six patients were treated with Gamma nail implants, and 56 were treated with ACE trochanteric nail. The average age of these patients was 78 years. Twenty fractures were stable and 92 unstable. The mean follow-up time was 8 months (6 -12). Regular clinical and radiological review was done 1, 3 and 6 months postoperatively. Operation time, fluoroscopy time, blood transfusion and complications were recorded. The mobility score was used to assess the pre-injury and postoperative mobility status. All the patients were treated within 36 h of their accident. There were no complications during surgery. All the patients were mobilised in the first 24 h postoperatively, regardless of the fracture type, and weight bearing was permitted as tolerated. Union of the fracture was achieved in all patients. There was no statistically significant difference between the two groups with regard to the studied parameters. There was no mechanical failure of the implants despite the early patient mobilisation. Early operation and early mobilisation resulted in a good functional outcome in all patients. Both the trochanteric gamma nail and ACE trochanteric nail provide effective methods of treatment for intertrochanteric fractures in elderly patients.

Inflammatory leiomyosarcoma is a rare morphologic expression of smooth muscle tumor, which is more often found in the trunk, extremities, and retroperitoneoum. We present a case of inflammatory leiomyosarcoma arising near the ankle joint, superior to the medial malleolus, in a 55-year-old man. Immunohistochemistry, electron microscopy, and cytogenetics were used in the differentiation of this rare morphologic expression of leiomyosarcoma. As in all soft tissue leiomyosarcomas, the accurate prediction of the clinical behavior of this morphologic expression often proves to be difficult. Age, vascular invasion, depth, grade, tumor disruption, size, and stage have prognostic value. Nevertheless, prognosis of inflammatory leiomyosarcoma seems to be favorable when treated early with wide excision of the tumor as in the case presented. Sixteen months after excision of the tumor the patient is doing well with no signs of recurrence.

The objective of this study was to investigate the occurrence of apoptosis of monocytes in an experimental model of multiple trauma and its probable correlation to bacterial translocation. Thirty-two rabbits were applied in three groups: A, controls; B, myotomy of the right femur; and C, myotomy and fracture of the right femur. Blood was sampled for the estimation of endotoxins [lipopolysaccharide (LPS)], tumour necrosis factor (TNF)-alpha, malondialdehyde (MDA) and isolation of peripheral blood mononuclear cells (PBMCs). PBMCs, derived after centrifugation over Ficoll, were incubated in flasks and apoptosis of non-adherent lymphocytes and adherent monocytes was estimated after staining for Annexin-V and flow cytometry. TNF-alpha of supernatants of cultured monocytes was also determined. Tissue segments were cultured after death. Median survival of groups A, B and C was > 14, > 14 and 9.00 days, respectively. Apoptosis of lymphocytes in group C was higher than group A at 2, 4 and 48 h and of monocytes in group C higher than group A at 2 and 4 hours. LPS in group C was higher than group A at 2, 4 and 48 h. Apoptosis of lymphocytes and monocytes was correlated positively with serum TNF-alpha and negatively with TNF-alpha of monocyte supernatants. Cultures of organ segments of group A were sterile. Pseudomonas aeruginosa was isolated from liver, lung and spleen in five animals in group B (45.45%) and in six in group C (54.54%). Early apoptosis of blood monocytes supervened after multiple trauma; the phenomenon was accompanied by apoptosis of blood lymphocytes and subsequent bacterial translocation.

Immunonutrition with diets enriched in polyunsaturated fatty acids (PUFAs) are becoming mandatory for multiple trauma patients. Solutions containing single n-6 PUFAs were administered intravenously in an experimental model of trauma. Thirty-five rabbits were studied; 13 controls; 10 administered gamma-linolenic acid (GLA) 30 min after fracture of the right femor; and 12 arachidonic acid (AA). Systolic, diastolic and mean arterial pressures and heart rate were recorded; serum levels of tumor necrosis factor-alpha (TNFalpha), malondialdehyde (MDA) and nitrate were estimated before and after therapy. Mean survival of controls, of animals treated with GLA and of animals treated with AA was 0.80, 1.41 and 3.60 days, respectively. Administration of PUFAs induced higher levels of blood pressure; that of AA decreased serum TNFalpha and tissue bacterial load compared to controls. Intravenous administration of n-6 PUFAs conferred hemodynamic stability and increased survival in a model of trauma rendering further research mandatory.

To assess the effectiveness of calcium phosphate as a delivery system of teicoplanin, methicillin-resistant Staphylococcus aureus osteomyelitis was induced in 36 rabbits. Osteomyelitis was induced by inoculating 10 cfu of methicillin-resistant Staphylococcus aureus isolate into a 2-mm hole at the upper 1/3 of the femur for 3 weeks, when all animals had reoperations, and calcium phosphate cement with 3% teicoplanin was implanted. Animals were divided into six groups of six animals each, sacrificed at Weeks 1, 2, 3, 4, 5, and 6, respectively, after implantation. One rabbit in each group was used as a control. Substantial clinical improvement of the rabbits was observed after implantation, accompanied with sterile cultures of bone after the second week of treatment. Throughout the same period, 10 to 10 cfu/g of methicillin-resistant Staphylococcus aureus isolate was cultured from the control samples. Bacterial eradication signified a considerable decrease of the total histologic scores of osteomyelitis compared with controls, accompanied with newly growing host bone. The calcium phosphate with teicoplanin delivery system seems promising for treatment of bone infection attributable to methicillin-resistant Staphylococcus aureus. In addition, this mixture allows filling of bone defects by new host bone.