The management of closed mid shaft tibia fractures remains reamed intramedullary statically locked nailing 1,2. Since the first description of intramedullary tibia nails by Gerhard Küntscher 3,4 and through the subsequent introduction of the locked nails by Grosse and colleagues 5,6, infrapatellar and parapatellar access routes have been utilized. The discussion on the correlation between different entry points and the incidence of anterior knee pain has been extensive 7-10. Nailing of a proximal tibia fracture can be complicated by malalignment, typically an apex anterior with valgus angulation, coupled with posterior displacement of the distal fragment 11. The insertion of an intramedullary nail in the tibia utilizing a suprapatellar percutaneous entry point, with the knee in semi extension, appears to mitigate the establishment of malreduction 12,13. Because the suprapatellar route does not interfere with the patellar tendon, it consequently appears to lead to reduced incidence of knee pain and rapid rehabilitation. Originally indicated for proximal tibia fractures, this modification of the classical tibial nailing has been proven effective in all tibial fracture locations. It allows for fast setup of the operating room, with the patient in a supine position on a translucent table. It simplifies the treatment in polytrauma patients with injuries to the soft tissue surrounding the patellar tendon area fractures. It is coupled by excellent and unobstructed intra-operative radiological projections, allowing the maintenance of fracture reduction with minimal manual longitudinal traction and/or percutaneous clamps. Furthermore, the implementation of a reamed, locked intramedullary nail with no Herzog curve, designed specifically for the suprapatellar insertion, with ad hoc instrumentation, cannulas, and trochars, allowing protected passage under the patella in the trochlear femoral groove, is paramount in the nailing of proximal, mid-diaphyseal and distal tibial fractures.
The obesity epidemic afflicting the Western world leads to an increase in orthopedic pro-cedures on such patients. Primary concerns relate to peri-operative complications and a more challenging surgical technique, even in the most common fracture patterns. The aim of this manuscript is to describe a supracondylar femur fracture in morbidly obese patient (BMI > 69), from arrival at the Emergency Department to post-operative follow-up. This particular case prompted the authors wonder about possible complications that will arise in the near future, and thus the need for more awareness. A supracondylar femur fracture is a testing procedure for surgeons, especially in an obese patient; it requires careful pre-operative planning to minimize the operative time and, subsequently, the complication rate. In our patient, a double plating with an endomedullary allograft was performed to withstand the weight and provide adequate fixation to a comminuted fracture. The aim of this case report is to describe a rare case which will most likely be more frequent in the near future. Furthermore, the obese population faces more post-operative complications due to multiple comorbidities, coupled with more challenging fracture fixation and longer operative time
Introduction. Femoral stem fracture is a rare cause of revision total hip replacement. Nonmodular extensively porous coated stems, well-fixed and non-cemented, have significant bone adhesion. Case report. A 56-year-old patient presented to the emergency room with a proximal fracture of a nonmodular stem in the portion of the neck, in absence of trauma or fall. The femoral stem was well fixed without any signs of osteolysis, with the result that the extraction instrumentation was ineffective to remove it. A transfemoral Wagner osteotomy was deemed necessary for removal of the femoral stem, and implantation of a Wagner revision stem. At 3 months of follow-up the patient walked without the aid of crutches and X-rays showed a correct integration of the implant. Conclusions. No cases of atraumatic fracture of the proximal region of the nonmodular stem not associated with risk factors have been described in the literature. With a perfect integration of the proximal and distal prosthetic implant, a transfemoral osteotomy is necessary.
This review examines the current state-of-the-art of ultrasound-guided lumbar facet joint injections (FJI), highlighting its emergence as a novel and increasingly successful approach. The literature underscores its growing popularity owing to practical advantages such as low cost, absence of radiation, real-time needle visualisation and tracking, and a low rate of complications. The procedure serves a dual purpose: as a diagnostic test for facet joint syndrome-related low back pain and as a therapeutic intervention for pain alleviation. Ultrasound guidance is particularly advantageous when coupled with needle guidance systems, ensuring precise needle direction for deep structure penetration with heightened accuracy. In conclusion, ultrasound-guided lumbar FJI is a non-invasive, cost-effective, and radiation- free alternative to intrarticular injections guided by fluoroscopy and computed tomography. This comprehensive review aims to serve as an insightful resource for practitioners, providing valuable insights into the procedural nuances and clinical benefits of this procedure.
Objectives. Knee dislocation is an uncommon injury. This study aims to describe the treatment of a postero-lateral knee dislocation. Case presentation. We report on a 71-year-old man, who accessed the emergency department for direct-rotational trauma to his left knee. X-rays showed a postero-lateral knee dislocation associated with multiple traction fractures. Results. Under fluoroscopy a closed reduction was performed in the operating room by flexing the knee to 120°, internal rotation of the lower extremity and valgus stress at the distal thigh. Due to the instability, a knee-spanning external fixation at 30° of flexion was performed. Post-operatively the patient fell, causing disassemblation of the external fixator and recurrence of medial knee dislocation. Only a partial re-alignment was obtained with a second closed reduction and spanning. The knee was later reconstructed with hinged knee prosthesis and the deformity was corrected. Conclusions. This case report is the third instance of closed reduction for a postero-lateral knee dislocation. Furthermore, this case report highlights possible complications of the treatment of this rare injury and how definitive treatment must be tailored to the patient’s age, function, clinical conditions, radiological findings and joint stability.
Objective. The objective of this article is to describe how to manage the humeral shaft fractures with neurological involvement in emergency trauma. Traumatic humeral fractures can be associated with neurological palsy in 11.6-23% 1 of cases and the most frequent involvement is the radial nerve. The median and ulnar nerves are usually damaged directly from trauma with an open humeral fracture. In contrast, the radial nerve is associated with closed fractures and the palsy is caused from dislocation of bone fragments. Methods. We report our protocol for management of humeral shaft fractures with neurological involvement that consists in early nerve exploration, reduction, and bone fixation. In the presence of an open fracture, this approach is mandatory as soon as possible, and within six hours from the trauma, and is performed by stabilization with an external fixator. In case of a closed fracture with neurological palsy, the operation can be performed within 12 hours and involves internal fixation with a plate. Surgically treatment of these humeral shaft fracture should be early together with nerve exploration because it can be entrapped or skewered in the fracture site. Very rarely have we observed complete or incomplete dissection of the radial nerve. Conclusions. In open fractures with neurological deficits, early stabilization with an external fixator is mandatory, as well as repair of the vascular damage when present with a vascular surgeon and careful exploration of the affected nerve with a plastic surgeon or micro surgeon. In closed fractures with radial nerve paralysis, we believe that immediate exploration, within 12 hours, and rigid osteosynthesis with a plate is the correct approach.
Objective. Suboptimal fixation of the tibial component is one of the main factors leading to aseptic loosening in unicompartmental knee arthroplasty (UKA). Improvements in primary fixation in cemented UKA have been suggested to be a key issue for long-term survival. In this context, it has been questioned whether specific implant design features influence interface strength, lowering aseptic loosening and post-operative pain rates. The aim of this study is to compare two different tibial tray designs in cemented UKA in terms of clinical outcome, failures, implant survival, and complications. Materials and methods. This is a prospective consecutive study of two different tibial component fixation in 100 cemented UKA. 50 patients received a flat cemented tibial tray design, and 50 a two-peg cemented tibial component UKA. Both groups were similar in terms of age, sex, comorbidities, and BMI. Results. No significant difference was found in clinical outcomes and overall failure rates. In the flat tray group, the mean preoperative KSS was 57.2, which increased at 1-year follow-up after surgery to 92.28, and remained stable at the 3 and 6 year control visits. In parallel, the mean pre-operative KOOS of 59 increased to 87.20. The mean preoperative KSS score in the 2 pegs group was 56.8 and the mean KOOS 58.1. At 1-year follow-up the KSS score increased to 94.1 and the KOOS score to 89.22, remaining stable at the 3- and 6-year follow-ups. Two-peg tibial component showed a significantly lower rate of persistent pain on the tibial side, 8% of patients at 1 year follow-up and 2% at 2 years, compared to 20% at 1 year and 6% at 2-year follow-up in the flat tray group (p < 0.05). In both groups, patients with pain at the 2-year control, 4 patients in total, still complained of mild and intermittent pain, VAS 1 to 2, at the 6 year visit. There was also a lower incidence of radiolucent lines compared to flat design prosthesis, none versus 6 at 3-yeas radiographic control. Radiolucent lines were not related to pain. No difference was detected regarding range of motion between the two groups. Conclusions. This study reveals that the clinical results and failure rates arising from the use of two different tibial components, one flat and one with 2 pegs, are similar. However, a lower rate of pain and radiolucent lines are detected on the tibial side with the use of a two-peg tibial component design. This outcome could denote a better fixation of the 2 peg metal-backed tibial component implant.
Objective. The aim of this study is to describe and evaluate clinical and subjective outcomes of our mini-invasive technique: the “BarTur technique”, and to consider it as a viable surgical treatment option for Achilles tendon rupture (ATR). Methods. We included 69 patients who underwent the Bartur technique from January 2019 to December 2022. We analyzed the rate of satisfaction, quality of life and functional clinical outcomes with a minimum of 6 months of follow-up. Results. The final study population consisted of 69 patients with a mean age of 49 years and a mean follow-up of 16.5 months. During follow‐up no complications were observed, and no workers changed their job. They returned at work after a mean of 3.2 months. Only 27 patients returned to practice sport after a mean of 8.8 months; 21 of these changed the type of sport. Our population had good results in clinical scores (92.6% AOFAS, 92.6% FAAM, 4.7% FFI, 91.4 ATRS); their satisfaction was 8.5 and they had a good quality of life (95 EQ-5L).Conclusions. The BarTur method is a simple, inexpensive and good option for surgical treatment of ATR. This treatment offers a lower risk of complications, high rate of satisfaction, good clinical outcomes and a few limitations in sports.
Healthcare-associated infections (HAIs) are a significant problem in healthcare facilities, resulting in longer hospital stays, additional costs and inconvenience for patients. Surgical site infections are one of the most common types of HAIs. In this context, orthopaedics appears to be the surgical area that is most involved in claims for HAIs. This narrative review explores the landscape of HAIs, their prevalence, associated adverse events, preventive measures and overall impact by providing an overview of infections in elective orthopaedic surgery. In summary, a significant proportion of surgical site infections can be prevented by a comprehensive, multidisciplinary approach.
Objective. Periprosthetic tibial fractures are rare injuries with few studies in the literature. With an increasing number of total knee arthroplasties performed, these injuries are expected to become more common. These fractures are difficult to treat due to complex fracture morphology, high proportions of injuries associated, and the variability of injury patterns. The aim of this work is to report our experience and results in the fixation of Felix type IIIA periprosthetic tibial fractures. Methods. We treated by osteosynthesis three patients who sustained a Felix type IIIA periprosthetic tibial fracture using three different devices. Patients were clinically and radiographically followed up at 1, 3, 6, and 12 months from the surgery. Results. All patients had a good clinical and radiographic outcome with almost complete recovery of joint function. Complete bone healing was radiographically seen on average 6 months after surgery. No signs of infection were observed. Conclusions. Although the incidence of periprosthetic tibial fractures is growing, evidence- based guidelines for their treatment are still lacking. We report our experience in the treatment of these complex fractures, but larger studies in this area are needed to better guide our knowledge and choices of treatment.
Total hip arthroplasty is a popular procedure for treatment of osteoarthritis of the hip, aseptic necrosis of femoral head and femur neck and head fractures. It is a highly successful procedure with high satisfaction of the patients, however sometimes the success rate might be limited by the development of heterotopic ossification around the hip. This narrative review aims to analyse the peri-operative modifiable risk factors for heterotopic ossification formation to help especially young surgeons in choosing the correct way to prevent this problematic complication. The search was conducted on PubMed and the final set includes 32 academic articles. Results are grouped in five paragraphs: nonsteroidal anti-inflammatory drugs and radiation therapy, surgical approach, surgical time and use of drainage and type of implant. In light of this narrative review, we suggest the systematic use of NSAIDs as preventive therapy, the adoption of minimally invasive surgical approaches aiming to reduce both surgical time and soft tissue damage and we discourage the use of drainage and short stems in total hip arthroplasty.
The recommended treatment of a subamputation or amputation of the lower limb (with a severe combined osteo-articular, vascular and nerve lesions) is a combined orthopedic and plastic approach with revascularization/replantation/reconstruction of the segment. The indications for reconstruction of mangled lower limbs are more selective than for the upper limb due to the possibilities to return to satisfactory walking given by prosthesis. For this reason, some scoring systems have been created to aid in decision making. If a reconstruction is decided, timing is crucial as we have to consider if all structures will be reconstructed immediately (all-in-one approach) or to apply the rules of damage control, and delay the reconstruction. In few cases, loss of tissues may be resolved on emergency. Secondary reconstructions need the expertise of using sophisticated flaps (simple fasciocutaneous up to complex combined free flaps) and/or well-established orthopedic techniques (bone transport with Ilizarov technique, massive free grafts according to Masquelet, etc.). The choice of the technique and timing (one stage – two stages) needs a clear plan which will not exclude traditional techniques, but has to take into account the possibility to use microsurgical reconstructions.
