Is it really advantageous to operate proximal femoral fractures within 48 h from diagnosis? – A multicentric retrospective study exploiting COVID pandemic-related delays in time to surgery

Objectives: Hip fractures in the elderly are common injuries that need timely surgical management. Since the beginning of the pandemic, patients with a proximal femoral fracture (PFF) experienced a delay in time to surgery. The primary aim of this study was to evaluate a possible variation in mortality in patients with PFF when comparing COVID-19 negative versus positive. Methods: This is a multicentric and retrospective study including 3232 patients with PFF who underwent surgical management. The variables taken into account were age, gender, the time elapsed between arrival at the emergency room and intervention, pre-operative American Society of Anesthesiology score, pre-operative cardiovascular and respiratory disease, and 10-day/1-month/6-month mortality. For 2020, we had an additional column, “COVID-19 swab positivity.” Results: COVID-19 infection represents an independent mortality risk factor in patients with PFFs. Despite the delay in time-to-surgery occurring in 2020, no statistically significant variation in terms of mortality was detected. Within our sample, a statistically significant difference was not detected in terms of mortality at 6 months, in patients operated within and beyond 48 h, as well as no difference between those operated within or after 12/24/72 h. The mortality rate among subjects with PFF who tested positive for COVID-19 was statistically significantly higher than in patients with PFF who tested. COVID-19 positivity resulted in an independent factor for mortality after PFF. Conclusion: Despite the most recent literature recommending operating PFF patients as soon as possible, no significant difference in mortality was found among patients operated before or after 48 h from diagnosis

Limb salvage in patients with tumors of the shoulder girdle

Introduction: The shoulder girdle is the second most common location for primary musculoskeletal malignancies and a common location of metastatic lesions. The evolution of therapeutic agents and surgical techniques improved radically the life expectancy of these patients. Nowadays, amputations have been replaced from limb sparing surgeries, and 95% of the patients with shoulder girdle tumors can undergo limb-salvage surgery. However, shoulder is a very complex articulation, and, in many cases, limb salvage surgery is associated with functional limitation. Purpose: There are many reconstructive options after wide excision of shoulder girdle tumors. The purpose of this PhD thesis is to assess the clinical, oncological, and functional outcome of the patients, who undergo endoprosthetic reconstruction of the shoulder, after tumor excision. For this aim, the patients were divided into two subgroups: patients with proximal humerus tumors and patients with glenoid tumors. Patients and methods: A retrospective, comparative study was performed, including patients with proximal humerus malignancies, who underwent endoprosthetic reconstruction, using two different prosthesis types. Forty patients were included in the study. Proximal humeral endoprosthesis (PHE) was used for 21 patients, and reverse shoulder arthroplasty (RSA) was used for 19 patients. Clinical results, oncologic outcomes, and complication rates were assessed. The functional outcomes of the patients were assessed with the Musculoskeletal Tumor Society scoring system (MSTS), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and shoulder range of motion. For the patients with glenoid tumor, 3-D printed custom-made glenoid component with reverse shoulder arthroplasty were used. Four patients were included in the study. We retrospectively reviewed the clinical and functional outcome, using MSTS and DASH score, as well as complications’ rate. Results: For the patients diagnosed with proximal humerus tumor, the mean follow-up was 62±15 months. Shoulder dislocations occurred among 8 patients with PHE and 1 patient with RSA (P=.021). The other complication rates were similar for the 2 groups (P<.05). At the latest follow-up, the mean MSTS score was 68±10.3 for those with PHE and 76±7.7 for the patients with RSA (P=.72). However, the QuickDASH score was significantly better (P=.031) for those with RSA (mean, 19±6.3) compared with patientswith PHE (mean, 30±4.8). Additionally, shoulder active abduction and forward flexion were significantly greater for the RSA group (P=.04 and P=.03, respectively). Five patients had local recurrence. In glenoid tumor patients’ group, Wide excision was achieved in all patients. No local recurrence or distant metastasis were diagnosed at the follow-up period. The mean MSTS score was 80,5% and DASH score was 15,2%. According to Henderson’s’ classification, there were no postoperative complications. Conclusions: Prosthetic reconstruction after oncologic re-section of the proximal humerus is associated with significant limitation of shoulder range of motion and a high rate of revision surgery. However, in this study, RSA was associated with fewer dislocations, improved Quick-DASH score, and greater abduction and forward flexion compared with PHE. The use of 3-dimensional printed implants can be a very reliable solution with satisfying clinical and functional outcomes for reconstruction, in patients with musculoskeletal malignancies of the glenoid.Εισαγωγή: Η ωμική ζώνη αποτελεί τη δεύτερη συχνότερη θέση εντόπισης πρωτοπαθών όγκων του μυοσκελετικού. Επίσης, στην περιοχή συχνά εντοπίζονται δευτεροπαθείς μεταστατικές βλάβες. Η εξέλιξη της φαρμακευτικής θεραπείας των σαρκωμάτων σε συνδυασμό με την εξέλιξη των χειρουργικών τεχνικών εκτομής των όγκων της ωμικής ζώνης, έχουν βελτιώσει θεαματικά το προσδόκιμο επιβίωσης των ασθενών. Οι ακρωτηριαστικές επεμβάσεις σταδιακά αντικαταστάθηκαν από επεμβάσεις διάσωσης μέλους. Σήμερα, το 95% των ασθενών με κακοήθεις όγκους του ώμου μπορούν να υποβληθούν σε επέμβαση διάσωσης μέλους. Ο ώμος αποτελεί μια εξαιρετικά πολύπλοκη άρθρωση με πολύ μεγάλο εύρος κίνησης. Συνεπώς, οι επεμβάσεις διάσωσης μέλους δε συνοδεύονται πάντα από πλήρη αποκατάσταση της κινητικότητας. Σκοπός: Στη σύγχρονη ορθοπαιδική ογκολογία έχουν περιγραφεί πολυάριθμες επεμβάσεις διάσωσης μέλους σε ασθενείς με όγκους της ωμικής ζώνης. Σκοπός αυτής της διδακτορικής διατριβής αποτελεί η αξιολόγηση των ογκολογικών, κλινικών και λειτουργικών αποτελεσμάτων, των ασθενών, οι οποίοι υποβάλλονται σε επεμβάσεις διάσωσης μέλους, με χρήση ενδοπροθέσεων. Για το σκοπό αυτό οι ασθενείς ταξινομήθηκαν σε δύο υποομάδες: τους ασθενείς με όγκους εγγύς βραχιονίου και τους ασθενείς με όγκους της ωμογλήνης. Ασθενείς και μέθοδοι: Για τους ασθενείς με κακοήθεις όγκους εγγύς βραχιονίου πραγματοποιήθηκε μια αναδρομική μελέτη σύγκρισης των κλινικών, λειτουργικών και ογκολογικών αποτελεσμάτων από τη χρήση δυο διαφορετικών τύπων ενδοπροθέσεων. Συνολικά, μελετήθηκαν 40 ασθενείς με κακοήθεις όγκους εγγύς βραχιονίου. Στους 21 χρησιμοποιήθηκε ενδοπρόθεση εγγύς βραχιονίου (proximal humerus endoprosthesis, PHE) για την αποκατάσταση μετά την εκτομή του όγκου, ενώ σε 19 ασθενείς χρησιμοποιήθηκε ενδοπρόθεση εγγύς βραχιονίου με ανάστροφη αρθροπλαστική ώμου (reverse shoulder arthroplasty, RSA). Διενεργήθηκε συγκριτική αξιολόγηση των κλινικών, ογκολογικών και λειτουργικών αποτελεσμάτων μεταξύ των δύο ομάδων ασθενών, καθώς και σύγκριση του ποσοστού επιπλοκών μεταξύ των δυο μεθόδων αποκατάστασης. Για την αξιολόγηση των λειτουργικών αποτελεσμάτων χρησιμοποιήθηκε το MSTS score (Musculoskeletal Tumor Society score), η σύντομη εκδοχή του DASH score (Disabilities of the Hand Shoulder and Hand score). Για τη μελέτη και την κατηγοριοποίηση των επιπλοκών χρησιμοποιήθηκε η ταξινόμηση κατά Henderson. Οι ασθενείς με όγκο στην ωμογλήνη, υπεβλήθησαν σε επέμβαση διάσωσης μέλους και αποκατάσταση με ειδική πρόθεση τρισδιάστατης εκτύπωσης με ανάστροφη αρθροπλαστική ώμου. Διενεργήθηκε αναδρομική μελέτη παρατήρησης, σε συνολικά 4 ασθενείς. Αξιολογήθηκε το κλινικό και ογκολογικό αποτέλεσμα, ενώ για την αξιολόγηση του λειτουργικού αποτελέσματος και των επιπλοκών χρησιμοποιήθηκε η ίδια μεθοδολογία. Αποτελέσματα: Το μέσο διάστημα μετεγχειρητικής παρακολούθησης, στους ασθενείς με όγκο εγγύς βραχιονίου ανήλθε σε 62 ± 15 μήνες. Οκτώ ασθενείς με PHE και ένας με RSA (p=0.021) διαγνώστηκαν με εξάρθρημα ώμου. Σε ότι αφορά στις υπόλοιπες επιπλοκές το ποσοστό επιπλοκών ήταν παρόμοιο, χωρίς να παρουσιάζει στατιστικά σημαντική διαφορά μεταξύ των δυο ομάδων. Το MSTS score στους ασθενείς με PHE ομάδα με RSA εμφάνισε σημαντικά καλύτερο quick DASH score, το οποίο υπολογίστηκε σε 30 ± 4,8% (p=0,031). Επιπλέον, η απαγωγή του ώμου και η πρόσθια κάμψη ήταν σημαντικά καλύτερη στους ασθενείς με RSA (p=0,04 και p=0,03 αντίστοιχα). Τοπική υποτροπή διαγνώστηκε σε 5 ασθενείς συνολικά. Στους ασθενείς με όγκο της ωμογλήνης, το μετεγχειρητικό διάστημα παρακολούθησης κυμαίνεται από 12-28 μήνες. Ευρεία εκτομή με ελεύθερα χειρουργικά όρια επιτεύχθηκε σε όλους τους ασθενείς. Το μέσο MSTS score υπολογίστηκε σε 80,5% και το QuickDASH σε 15,2%. Σύμφωνα με την ταξινόμηση του Henderson, δεν παρατηρήθηκαν μετεγχειρητικές επιπλοκές. Συμπεράσματα: η αποκατάσταση του εγγύς βραχιονίου με ενδοπρόθεση μετά την εκτομή μυοσκελετικών όγκων αποτελεί αξιόπιστη επιλογή, η οποία όμως μπορεί να συνοδεύεται από επιπλοκές και περιορισμό της κινητικότητας του ώμου. Η ανάστροφη αρθροπλαστική φαίνεται να προσφέρει, στατιστικά σημαντικά, χαμηλότερο ποσοστό επιπλοκών και βελτιωμένο λειτουργικό αποτέλεσμα. Η αποκατάσταση του ώμου μετά την εκτομή όγκων της ωμογλήνης με πρόθεση τρισδιάστατης εκτύπωσης, φαίνεται να αποτελεί μια πολλά υποσχόμενη μέθοδο, που προσφέρει ικανοποιητική αποκατάσταση της λειτουργικότητας της άρθρωσης και χαμηλό ποσοστό επιπλοκών

Clinical Outcome after Surgical Treatment of Sacral Chordomas: A Single-Center Retrospective Cohort of 27 Patients

Introduction: The aims of our study were (1) to determine disease-specific and disease-free survival after the en-bloc resection of sacral chordomas and (2) to investigate potential risk factors for tumor recurrence and major postoperative wound-related complications. Methods: We retrospectively analyzed 27 consecutive patients with sacral chordomas who were surgically treated in our institution between 2004 and 2022. Three patients (11.1%) had a recurrent tumor and four patients (14.8%) had history of a second primary solid tumor prior to or after their sacral chordoma. A combined anterior and posterior approach, colostomy, plastic reconstruction, and spinopelvic instrumentation were necessitated in 51.9%, 29.6%, 37%, and 7.4% of cases, respectively. The mean duration of follow-up was 58 ± 41 months (range= 12–170). Death-related-to-disease, disease recurrence, and major surgical site complications were analyzed using Kaplan–Meier survival analysis, and investigation of the respective risk factors was performed with Cox hazard regression. Results: The estimated 5-year and 10-year disease-specific survival was 75.3% (95% CI = 49.1–87.5%) and 52.7% (95% CI = 31–73.8%), respectively. The estimated 1-year, 5-year, and 10-year disease-free survival regarding local and distant disease recurrence was 80.4% (95% CI = 60.9–91.1%), 53.9% (95% CI = 24.6–66.3%), and 38.5% (95% CI = 16.3–56.2%), respectively. The mean survival of the recurred patients was 61.7 ± 33.4 months after their tumor resection surgery. Conclusions: Despite the high relapse rates and perioperative morbidity, long-term patient survival is not severely impaired. Positive or less than 2 mm negative resection margins have a significant association with disease progression

Neuromuscular activity of the lower‐extremities during running, landing and changing‐of‐direction movements in individuals with anterior cruciate ligament reconstruction: a review of electromyographic studies

Abstract Purpose Running, jumping/landing and cutting/change of direction (CoD) are critical components of return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR), however the electromyographic (EMG) activity patterns of the operated leg during the execution of these tasks are not clear. Methods A systematic review was conducted to retrieve EMG studies during running, jumping/landing and cutting/(CoD) in ACLR patients. MEDLINE, PubMed, SPORTDiscus and Web of Science databases were searched from 2000 to May, 2022 using a combination of keywords and their variations: “anterior cruciate ligament reconstruction” OR “ACLR”, “electromyography” OR “EMG”, “running”, “jumping” OR “landing”, “cutting” OR “change‐of‐direction” OR “CoD”. The search identified studies comparing EMG data during running, landing and cutting/(CoD) between the involved limb and contralateral or control limbs. Risk of bias was assessed and quantitative analyses using effect sizes were performed. Results Thirty two studies met the inclusion criteria. Seventy five percent (24/32) of the studies reported altered EMG activity pattern of the ACLR leg during running, jumping/landing and cutting/(CoD) when compared with either the healthy control leg or the contra‐lateral leg. Twelve studies showed decreased, delayed or earlier onset and delayed peak in quadriceps EMG activity with small to large effect sizes and 9 studies showed increased, delayed or earlier onset and delayed peak in hamstrings EMG activity with small to large effect sizes. Four studies showed a “hamstrings‐dominant” strategy i.e. decreased quadriceps coupled with increased hamstrings EMG activity in both running and jumping/landing irrespective of graft type. One study reported that on the grounds of decreased quadriceps activity, lower hamstrings EMG activity was predictive of ipsilateral re‐injury in ACLR patients. Conclusion This systematic review of Level III evidence showed that the ACLR leg displays decreased quadriceps or increased hamstrings EMG activity or both despite RTS. Simultaneous decreased quadriceps and increased hamstrings EMG activity was shown for both running and jumping/landing. From a clinical perspective this “hamstrings dominant” strategy can serve as a protective mechanism against graft re‐injury. Level of evidence III

The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study

Simple Summary Tranexamic acid can be an effective and safe way to reduce perioperative bleeding following an endoprosthetic reconstruction of a lower limb after a bone tumor resection. Tranexamic acid does not result in a complete shutdown of the fibrinolysis, supporting its safe use without increasing the risk of thromboembolic complications. Background: An endoprosthetic reconstruction in musculoskeletal oncology patients is associated with significant blood loss. The purpose of this study is to evaluate the safety and efficacy of tranexamic acid (TXA) for these patients and to assess any changes in their hemostatic profile using rotational thromboelastometry (ROTEM). Methods: A retrospective observational study was performed including 61 patients with primary or metastatic bone tumors who underwent surgery. Group A (n = 30) received both intravenous and local TXA whereas Group B (n = 31) was the control group. The primary outcomes were perioperative blood loss and blood unit transfusions and the secondary outcomes included the incidence of thromboembolic complications and a change in blood coagulability as reflected by ROTEM parameters. Results: The median difference in blood loss between the two groups was 548.5 mL, indicating a 29.2% reduction in the 72 h blood loss following TXA administration (p &lt; 0.001). TXA also led to a reduced transfusion of 1 red blood cell (RBC) unit per patient (p &lt; 0.001). The two groups had similar rates of thromboembolic complications (p = 0.99). The antifibrinolytic properties of TXA were confirmed by the significantly higher INTEM, FIBTEM and EXTEM LI60 (p &lt; 0.001, p = 0.005 and p &lt; 0.001, respectively) values in the TXA group. Conclusion: Tranexamic acid was associated with a significant reduction in perioperative blood loss and transfusion requirements without a complete shutdown of the fibrinolysis. Larger studies are warranted to assess the frequency of these outcomes in musculoskeletal oncology patients

Rotational Thromboelastometry Findings Are Associated with Symptomatic Venous Thromboembolic Complications after Hip Fracture Surgery

Background Venous thromboembolism is a common complication after hip fractures. However, there are no reliable laboratory assays to identify patients at risk for venous thromboembolic (VTE) events after major orthopaedic surgery. Question/purposes (1) Are rotational thromboelastometry (ROTEM) findings associated with the presence or development of symptomatic VTE after hip fracture surgery? (2) Were any other patient factors associated with the presence or development of symptomatic VTE after hip fracture surgery? (3) Which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE? Methods This retrospective study was conducted over a 13-month period. In all, 354 patients with femoral neck and peritrochanteric fractures who underwent hip hemiarthoplasty or cephallomedullary nailing were assessed for eligibility. Of those, 99% (349 of 354) were considered eligible for the study, 1% (3 of 354) of patients were excluded due to coagulation disorders, and another 1% (2 of 354) were excluded because they died before the postoperative ROTEM analysis. An additional 4% (13 of 354) of patients were lost before the minimum study follow-up of 3 months, leaving 95% (336 of 354) for analysis. A ROTEM analysis was performed in all patients at the time of their hospital admission, within hours of the injury, and on the second postoperative day. The patients were monitored for the development of symptoms indicative of VTE, and the gold standard tests for diagnosing VTE, such as CT pulmonary angiography or vascular ultrasound, were selectively performed only in symptomatic patients and not routinely in all patients. Therefore, this study evaluates the association of ROTEM with only clinically evident VTE events and not with all VTE events. ROTEM results did not affect the clinical surveillance of the study group and the decision for further work up. To determine whether ROTEM findings were associated with the presence or development of symptomatic VTE, ROTEM parameters were compared between patients with and without symptomatic VTE. To establish whether any other patient factors were associated with the presence or development of symptomatic VTE after hip fracture surgery, clinical parameters and conventional laboratory values were also compared between patients with and without symptomatic VTE. Finally, to determine which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE, the area under the curve (AUC) for certain cut off values of ROTEM parameters was calculated. Results We found several abnormal ROTEM values to be associated with the presence or development of symptomatic VTE. The preoperative maximum clot firmness was higher in patients with clinically evident VTE than in patients without these complications (median [interquartile range] 70 mm [68 to 71] versus 65 mm [61 to 68]; p &lt; 0.001). The preoperative clot formation time was lower in patients with clinically evident VTE than those without clinically evident VTE (median 61 seconds [58 to 65] versus 70 seconds [67 to 74]; p &lt; 0.001), and also the postoperative clot formation time was lower in patients with clinically evident VTE than those without these complications (median 52 seconds [49 to 59] versus 62 seconds [57 to 68]; p &lt; 0.001). Increased BMI was also associated with clinically evident VTE (odds ratio 1.26 [95% confidence interval 1.07 to 1.53]; p &lt; 0.001). We found no differences between patients with and without clinically evident VTE in terms of age, sex, smoking status, comorbidities, and preoperative use of anticoagulants. Lastly, preoperative clot formation time demonstrated the best performance for detecting the association of hypercoagulability with symptomatic VTE (AUC 0.89 [95% CI 0.81 to 0.97]), with 81% (95% CI 48% to 97%) sensitivity and 86% (95% CI 81% to 89%) specificity for clot formation time &lt;= 65 seconds. Conclusion ROTEM’s performance in this preliminary study was promising in terms of its association with symptomatic VTE. This study extended our earlier work by demonstrating that ROTEM has a high accuracy in detecting the level of hypercoagulability that is associated with symptomatic VTE. However, until its performance is validated in a study that applies a diagnostic gold standard (such as venography, duplex/Doppler, or chest CT) in all patients having ROTEM to confirm its performance, ROTEM should not be used as a regular part of clinical practice

The Hypercoagulable Profile of Patients with Bone Tumors: A Pilot Observational Study Using Rotational Thromboelastometry

Introduction: A detailed evaluation of the malignancy-associated coagulopathy (MAC) in surgical patients with bone tumors may allow for more effective thromboprophylactic measures. The purpose of this study was to assess the perioperative hemostatic changes in patients with bone tumors, using rotational thromboelastometry (ROTEM). Methods: An observational study was performed, including 50 patients with bone tumors who underwent oncologic resection and 30 healthy controls, matched for age and gender. The preoperative and postoperative laboratory evaluation of coagulation in both groups included conventional coagulation tests and a ROTEM analysis. The results of the conventional coagulation tests and the ROTEM analysis were compared between the two groups. Results: The results of the conventional coagulation tests were comparable between the tumor patients and the healthy controls. However, compared to the healthy adults, the tumor patients had lower CT (p &lt; 0.001) and CFT (p &lt; 0.001) values suggesting a rapid induction of the coagulation cascade, elevated A10 (p &lt; 0.001) and MCF (p &lt; 0.001) values indicating a higher clot strength and platelet activation, and elevated LI60 (p &lt; 0.001) values indicating hypofibrinolysis in patients with bone tumors. The multiple linear regression analysis (controlling for potential confounding factors) confirmed the independent association of bone tumors with these hemostatic changes. Conclusions: Our results support the advantageous use of a ROTEM in patients with bone tumors over conventional coagulation tests because the qualitative changes in the hemostatic profile of these patients that can be detected by a ROTEM analysis cannot be identified by conventional tests. The ROTEM results indicate that the hypercoagulable state in patients with bone tumors is caused by the malignancy-associated activation of the coagulation cascade, platelet activation, and hypofibrinolysis

The Prognostic Performance of Rotational Thromboelastometry for Excessive Bleeding and Increased Transfusion Requirements in Hip Fracture Surgeries

Background Hip fracture surgeries are associated with considerable blood loss, while the perioperative coagulopathy is associated with the bleeding risk of these patients. We aimed to evaluate the ability of rotational thromboelastometry (ROTEM) to detect patients at high risk for excessive bleeding and increased transfusion requirements. Methods We conducted a prospective observational study of 221 patients who underwent hip fracture surgeries. ROTEM analysis was performed preoperatively and immediately postoperatively. Blood loss parameters including blood loss volume, number of transfused red blood cell (RBC) units, and drop in hemoglobin levels were recorded. ROTEM parameters were compared between patients with and without excessive bleeding, and between patients with and without increased transfusion requirements (i.e., &gt;= 2 RBC units). Results The postoperative FIBTEM MCF value &lt;= 15mm had 66.6% (95% confidence interval [CI]: 59.7-74.1%) sensitivity and 92.0% (95% CI: 80.7-97.7%) specificity to prognose excessive bleeding, and preoperative FIBTEM MCF value &lt;= 15mm had 80.4% (95% CI: 73.5-86.2%) sensitivity and 91.2% (95% CI: 80.7-97.0%) specificity to prognose increased transfusion requirements. Preoperative FIBTEM MCF &lt;= 11mm and postoperative FIBTEM MCF &lt;= 15mm were associated with considerably increased risks of excessive bleeding (odds ratio [OR]: 44.8, 95% CI: 16.5-121.3, p &lt;0.001; and OR: 23.0, 95% CI: 7.8-67.0, p &lt;0.001, respectively). Conclusion ROTEM parameters demonstrated high prognostic accuracy for excessive bleeding and increased transfusion requirements. This can enable implementation of blood sparing strategies in high-risk patients, while blood banks could be better prepared to ensure adequate blood supply