Cephalomedullary nailing of unstable intertrochanteric fractures has been established as a fruitful surgical approach with relatively limited complications. Anatomic fracture reduction and proper implant positioning are vital to attaining a favorable long-term surgical outcome. Appropriate intraoperative fracture compression augments stability and invigorates healing. The amount of compression permitted by cephalomedullary nails cannot always adequately reduce large fragment gaps. This paper presents a novel technical trick of double compression of the fracture site, in order to achieve the essential extra compression and reduction when required, thus decreasing the risk of postoperative implant cut-out. The technique was used in 14 out of 277 peritrochanteric fractures treated with cephalomedullary nailing in our trauma center for 12 months, with satisfactory outcomes regarding both fracture site union and postoperative functional capacity.
Pediatric acetabular dysplasia is common in orthopedic practice. Femoral de-rotational varus osteotomy (FDVO) is one of the surgical options suggested for treatment. In this article, we describe a simplified surgical technique of performing FDVO percutaneously using a pediatric Limb Reconstruction System external fixator, and we discuss the advantages and disadvantages of the technique.
Background: Navigation in total hip arthroplasty has been shown to improve acetabular positioning and can decrease the incidence of mal-positioned acetabular components. This study aimed to assess two surgical guidance systems by comparing intra-operative measurements of acetabular component inclination and anteversion with a post-operative CT scan.
Methods: We prospectively collected intra-operative navigation data from 102 hips receiving conventional THA or hip resurfacing arthroplasty through either a direct anterior or posterior approach. Two guidance systems were used simultaneously: an inertial navigation system (INS) and an optical navigation system (ONS). Acetabular component anteversion and inclination were measured on a post-operative CT.
Results: The average age of the patients was 64 years (range: 24-92) and the average BMI was 27 kg/m2 (range 19-38). 52% had hip surgery through an anterior approach. 98% of the INS measurements and 88% of the ONS measurements were within 10° of the CT measurements. The mean (and standard deviation) of the absolute difference between the postoperative CT and the intra-operative measurements for inclination and anteversion were 3.0° (2.8) and 4.5° (3.2) respectively for the ONS, along with 2.1° (2.3) and 2.4° (2.1) respectively for the INS. There was a significantly lower mean absolute difference to CT for the INS when compared to ONS in both anteversions (p < 0.001) and inclination (p = 0.02).
Conclusions: We found that both inertial and optical navigation systems allowed for adequate acetabular positioning as measured on postoperative CT, and thus provide reliable intraoperative feedback for optimal acetabular component placement.
Level of evidence: Therapeutic Level II.
Introduction: The Tibial Tubercle Osteotomy (TTO) technique, by lifting the distal bony attachment of the extensor mechanism, allows efficient knee exposure while preserving soft tissues and tendinous attachments. The surgical technique seems essential to obtain satisfying outcomes with a low rate of specific complications. Several tip sand tricks can be used to improve this procedure during the revision of total knee arthroplasty (RTKA).
Technique: The osteotomy should be at least: 60 mm in length and 20 mm in width to allow fixation with 2 screws; and 10-15 mm thick to resist to screw compression. The proximal cut of the osteotomy must keep a proximal buttress spur of 10 mm to get primary stability and avoid the tubercle ascension. A smooth end of the TTO distally reduces the risk of a tibial shaft fracture. The strongest fixation is obtained using two bicortical 4.5 mm screws slightly ascendant.
Results: From January 2010 to September 2020, 135 patients received an RTKA with concomitant TTO and a mean follow-up of 51 ± 26 months [24-121]. The osteotomy was healed in 95% of patients (n = 128) with a mean delay of 3.4 ± 2.7 months [1.5-24]. However, there are some specific and significant complications related to the TTO. Twenty complications (15%) related to the TTO were recorded, with 8 (6%) requiring surgery.
Conclusion: Tibial tubercle osteotomy in RTKA is an efficient procedure to improve knee exposure. To avoid tibial tubercle fracture or non-union, a rigorous surgical technique is primordial with a sufficient length and thickness of the tibial tubercle, a smooth end, a proximal step, a final good bone contact, and a strong fixation.
Purpose: Graft diameter in anterior cruciate ligament reconstructions has been shown to influence the risk of failure. It is therefore important to be able to adjust the graft configuration to modify the diameter. To measure the impact of a 6-strand (6S) hamstring autograft configuration on graft diameter compared to the standard 4-strand (4S) configuration.
Methods: Cadaveric study on 33 knees, using the usual hamstring graft harvesting technique. Semitendinosus and gracilis tendons were harvested and their length, width, and diameter were measured in 4S and 6S configurations separately by three evaluators.
Results: 6S configuration leads to a median increase of 1.5 (range: 0.0-2.0) mm in diameter compared to 4S (p < 0.001). A graft diameter of more than 8 mm is attained in less than a third of 4S grafts within this population in comparison to 84% when the 6S configuration is used.
Discussion: The 6S hamstring graft configuration increases the graft diameter by a median of 1.5 millimeters compared to the traditional 4S configuration. It can reliably be used to obtain an 8.5 mm graft diameter or more in cases where the semitendinosus measures at least 270.5 mm and the 4S configuration has a diameter of 7.5 mm or 8 mm. This information helps to better delineate the impact of a 6S configuration in a pre-operative or intra-operative setting to optimize the decisional process and surgical flow and to easily adapt the graft diameter.
Level of evidence: V (cadaveric study).
Introduction: Nitride-based ceramic coating was introduced into surgical implants to improve hardness, reduce abrasion, and decrease the risk of metal-induced adverse reactions, especially for patients with suspected or identified metal hypersensitivity. The study aimed to evaluate the effectiveness and safety of a titanium nitride (TiN) coated prosthesis with a mobile bearing design.
Methods: This was a retrospective matched-cohort study from a single center, comparing clinical outcomes between patients receiving either a TiN-coated versus an uncoated cobalt-chromium-molybdenum (CoCrMo) prostheses for primary total knee replacement. Seventeen patients received the TiN prosthesis between 2015 and 2019. These were matched 1:2 with patients receiving uncoated mobile-bearing knee prostheses with the same design manufacturer.
Results: Fourteen patients in the TiN group had complete 5-year follow-up data and were compared with 34 patients from the CoCrMo group. The Knee Society Score was 170.6 ± 28.0 (Function subscore 83.7 ± 17.5 and Knee subscore 86.9 ± 13.8) in the TiN group and 180.7 ± 49.4 (Function subscore 87.5 ± 14.3 and Knee subscore 93.2 ± 9.6) in CoCrMo group, with no statistically significant difference (p = 0.19). One patient underwent a revision for instability requiring the removal of the implant in the TiN group and none in the CoCrMo group. The survival rates were 92.9% (CI95% 77.3-100.0) and 100.0% in the TiN group and CoCrMo group respectively (p = 1.0).
Discussion: TiN-coated TKA with mobile bearing resulted in satisfactory clinical outcomes, and a low revision rate, and there was no complication related to the coated implant. The use of TiN-coated prostheses in case of confirmed or suspected metal allergy provides satisfactory short-term clinic outcomes.
Background: Nonunion in scaphoid fractures may be considered a devastating problem. Union failure results in scaphoid deformity, resorption, and bone loss. Failed previous fixation decreases remaining bone stock and makes it more difficult to achieve union. Free vascularized graft represents a good option to achieve scaphoid union with revision fixation. Our study aims at the assessment of the management of scaphoid fractures non-union after failed previous fixation with the use of a free vascularized graft from the medial femoral condyle.
Methods: This is a retrospective study including 16 cases with persistent scaphoid nonunion after previous fixation managed by vascularized medial femoral condyle grafts. The mean follow-up was 24 months. Previous surgical attempts and nonunion duration were noted. We evaluated the union rate, together with ROM, Scapholunate angles and pain scores.
Results: the union was achieved in 13 of 16 cases. Pain improved in all patients (10/16 complete relief). Wrist ROM at follow-up was an average of 50° flexion 48° extension. There was no change in the relationship between lunate and scaphoid with an average angle of 37.5° preoperative and 38° postoperative.
Conclusion: Free vascularized MFC grafts are considered a reliable method to treat persistent nonunion of scaphoid fractures after failed previous operations. Short-term follow-up data showed considerable union rates with adequate pain relief and satisfactory ROM.
Introduction: The Direct Superior Approach (DSA) is a muscle-sparing hip approach that does not protect the piriformis and the other short external rotators. We present a DSA modification we named STAR (Superior Transverse Atraumatic Reconstruction), which has DSA advantages but always preserves piriformis. Our study compared the early postoperative, radiological, and functional results of patients undergoing primary total hip arthroplasty (THA) through the STAR approach with a matched DSA group performed by a senior surgeon.
Methods: Each group, DSA, and STAR included 200 elective primary unilateral THAs performed by the surgeon between 2016-2017 and 2020-2021, respectively. Patients were included in both groups using the same inclusion criteria. Both groups were matched for age and sex. The same postoperative pain management, chemoprophylaxis, and physiotherapy protocols were followed in both groups. Two independent orthopaedic surgeons performed the clinical and radiological follow-up.
Results: The STAR group had significantly lower mean incision length (p = 0.042) and hospital stay (p = 0.002) than the DSA group. The mean intraoperative blood loss (p = 0.085) and the need for blood transfusion (p = 0.228) were less for the STAR than the DSA group. The mean postoperative functional scores improvement was significantly higher for the STAR than the DSA group at the end of the first and third postoperative months.
Conclusions: The STAR approach offers earlier functional improvement, shorter hospital stay and less transfusion need than DSA for patients undergoing primary THA. Both approaches showed a limited complication risk and an outstanding acetabular and femoral access enabling the procedure.
Objective: To determine the frequency, clinical presentation, and etiological factors of cauda equina syndrome (CES).
Materials and method: This retrospective study was done on 256 participants, and aimed to analyze the frequency and patterns of clinical presentation in suspected cases of CES. The inclusion criteria included participants aged 18 or older with medical records available for review and having red-flagged symptoms for CES. The study collected information on various factors such as age, gender, confirmation of CES on MRI, neurological deficits, etiological factors, duration of symptoms, and more. The data collected was analyzed using descriptive statistics and logistic regression to identify significant variables between MRI-proven CES and suspected CES.
Results: The mean age was 58.05 ± 19.26 years, with 151 females (58.98%) and 105 males (41.02%). The majority (50.78%) had a neurological deficit, while other symptoms included difficulty initiating micturition or impaired sensation of urinary flow (17.58%), loss of sensation of rectal fullness (3.12%), urinary or faecal incontinence (35.16%), bilateral sciatica (21.88%), neurological symptoms in the lower limbs (25.00%), anaesthesia or any leg weakness (24.22%), and bilateral sciatica as the predominant symptom (21.88%). Symptoms were chronic in 47.27% and acute in 21.88%. The odds of MRI-proven CES increase by 3% per year of age. Neurological deficit was strongly associated with MRI-proven CES (OR = 14.97), while loss of sensation of rectal fullness increased the odds by 10-fold (OR = 10.62).
Conclusion: CES can present with various symptoms, including the bilateral neurological deficit, urinary and faecal incontinence, and bilateral sciatica, with age, severe bilateral neurological deficit, and loss of sensation of rectal fullness being associated with MRI-proven CES. Early diagnosis and treatment are crucial for better outcomes.
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