Reconstructive osteotomy of fibular malunion: review of the literature

The treatment of ankle fractures has a primary goal of restoring the full function of the injured extremity. Malunion of the fibula is the most common and most difficult ankle malunion to reconstruct. The most frequent malunions of the fibula are shortening and malrotation resulting in widening of the ankle mortise and talar instability, which may lead to posttraumatic osteoarthritis. The objective of this article is to review the literature concerning the results of osteotomies for correcting fibular malunions and to formulate recommendations for clinical practice. Based on available literature, corrective osteotomies for fibular malunion have good or excellent results in more than 75% of the patients. Reconstructive fibular osteotomy has been recommended to avoid or postpone sequela of posttraumatic degeneration, an ankle arthrodesis or supramalleolar osteotomy. The development of degenerative changes is not fully predictable; therefore, it is advisable to reconstruct a fibular malunion soon after the diagnosis is made and in presence of a good ankle function. Recommendations were made for future research because of the low level of evidence of available literature on reconstructive osteotomies of fibular malunions

The value of radiographic markers in the diagnostic work-up of rotator cuff tears, an arthroscopic correlated study

Objective To evaluate the value of radiographs during the diagnostic work-up of rotator cuff tears, using arthroscopy as reference standard. Materials and methods This retrospective study included 236 shoulders of 236 patients. All radiographs were evaluated for inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, greater tubercle cysts, and subacromial space calcifications. Predictive value of these radiographic signs in predicting rotator cuff tears was determined with arthroscopy as reference standard. Results According to arthroscopy, 131 shoulders were diagnosed with rotator cuff tears. Seventy-two out of 131 shoulders (55%) had inferior cortical acromial sclerosis, 37 (28%) lateral acromial spur, 21 (16%) superior migration of the humeral head, 7 (5%) greater tubercle cysts and 15 subacromial space calcifications (11%). Inferior cortical acromial sclerosis (P = 0.001), lateral spur (P = 0.001), superior migration (P = 0.002), and cysts (P = 0.03) were significantly and independently associated with rotator cuff tears, whereas subacromial calcifications (p = 0.21) was not. Inferior cortical acromial sclerosis, superior migration, lateral acromial spur, and cysts combined have a positive predictive value of 78%. Conclusions The combination of inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, and greater tubercle cysts has a high positive predictive value for the presence of full-thickness rotator cuff tears. In patients with a high suspicion for having a rotator cuff tear based on radiographic findings, MRI can be performed directly without the delay and costs caused by an additional ultrasound exam

The Zagreb indices of graphs with a given clique number

AbstractFor a (molecular) graph, the first Zagreb index M1 is equal to the sum of squares of the degrees of vertices, and the second Zagreb index M2 is equal to the sum of the products of the degrees of pairs of adjacent vertices. Let Wn,k be the set of connected n-vertex graphs with clique number k. In this work we characterize the graphs from Wn,k with extremal (maximal and minimal) Zagreb indices, and determine the values of corresponding indices

Evidence-based treatment of open ankle fractures

Fractures of the ankle are fairly common injuries. Open ankle fractures are much less common and associated with severe injuries to surrounding tissues. We have performed a systematic review of the literature concerning the clinical results and complication rates in the treatment of open ankle fractures. We conducted a search limited to the following databases: Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register and Embase. These were searched from 1968 to April 2010 to identify studies relating to the treatment of open ankle fractures. Fifteen articles concerning 498 patients with treatment of an open ankle fracture were identified. The number of included patients varied from 11 to 64. There were 2 prospective and 13 retrospective studies. All articles were case series and classified as Level IV evidence. In 373 cases, open ankle fractures were treated by immediate internal fixation. In 125 cases, a conservative treatment or delayed/other fixation treatment was followed. Of those patients treated by immediate internal fixation, 81% had satisfactory result. Poor results (15%) were most commonly due to non-anatomic reductions, articular surface damage or deep infection. When conservative treatment was followed, 76% had satisfactory results. The most reported complications after immediate internal fixation were deep infection (8%) and skin necrosis (14%). There is a lack of high quality literature concerning the (operative) treatment of patients with open ankle fractures. Remarkable is that most authors reported satisfactory results after performance of their treatment protocol. Based on the available literature, we formulated guidelines regarding: timing of operative treatment, wound irrigation, the role of internal fixation, wound coverage and closure, the use of antibiotics and additional therapies

Triceps Insufficiency After Total Elbow Arthroplasty:A Systematic Review.

Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.BACKGROUND: The incidence of triceps insufficiency after total elbow arthroplasty (TEA) varies in the literature, and a consensus on treatment strategy is lacking. We review the incidence, the risk factors, the clinical presentation, and the diagnosis and treatment of triceps insufficiency after TEA. Based on this information, we have formulated recommendations for clinical practice. METHODS: We performed a systematic review of the literature from January 2003 to April 2020 to identify studies that investigated triceps function following TEA by searching the PubMed, Cochrane, and Embase databases. Eligible studies (1) reported on triceps function following primary or revision TEA for every indication, regardless of technique (e.g., bone grafts), (2) included ≥6 adult patients, (3) had the full-text article available, and (4) had a minimum follow-up of 1 year. RESULTS: Eighty studies with a total of 4,825 TEAs were included. The quality was low in 15 studies, moderate in 64 studies, and high in 1 study. The mean incidence of triceps insufficiency was 4.5%. The rates were highest in patients after revision TEA (22%), in those with posttraumatic arthritis as an indication for surgery (10.2%), and after a triceps-reflecting approach (4.9%). Most studies used the Medical Research Council scale to score triceps function, although cutoff points and the definition of triceps insufficiency differed among studies. Surgical treatment showed favorable results with anconeus tendon transfer and Achilles allograft repair when compared with direct repair. CONCLUSIONS: The incidence of triceps insufficiency varies greatly, probably due to a lack of consensus on the definition of the term. Therefore, we recommend the guidelines for clinical practice that are presented in this article. These guidelines assist clinicians in providing the best possible treatment strategy for their patients and help researchers optimize their future study designs in order to compare outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

Prospective cohort study comparing a triceps-sparing and triceps-detaching approach in total elbow arthroplasty:a protocol

BACKGROUND: New surgical approaches have been developed to optimise elbow function after total elbow arthroplasty (TEA). Currently, there is no consensus on the best surgical approach. This study aims to investigate the functional outcomes, prosthetic component position and complication rates after a triceps-sparing and a triceps-detaching approach in TEA. METHODS AND ANALYSIS: A multicentre prospective comparative cohort study will be conducted. All patients with an indication for primary TEA will enrol in either the triceps-sparing or the triceps-detaching cohort. Primary outcome measure is elbow function, specified as fixed flexion deformity. Secondary outcome parameters are self-reported and objectively measured physical functioning, including triceps force, prosthetic component position in standard radiographs and complications. DISCUSSION: The successful completion of this study will clarify which surgical approach yields better functional outcomes, better prosthetic component position and lower complication rates in patients with a TEA. ETHICS AND DISSEMINATION: The Medical Ethics Review Board of University Medical Center Groningen reviewed the study and concluded that it is not clinical research with human subjects as meant in the Medical Research Involving Human Subjects Act (WMO), therefore WMO approval is not needed (METc2019/544). TRIAL REGISTRATION NUMBER: NTR NL8488

Comparison of intra-articular injections of Hyaluronic Acid and Corticosteroid in the treatment of Osteoarthritis of the hip in comparison with intra-articular injections of Bupivacaine. Design of a prospective, randomized, controlled study with blinding of the patients and outcome assessors

<p>Abstract</p> <p>Background</p> <p>Although intra-articular hyaluronic acid is well established as a treatment for osteoarthritis of the knee, its use in hip osteoarthritis is not based on large randomized controlled trials. There is a need for more rigorously designed studies on hip osteoarthritis treatment as this subject is still very much under debate.</p> <p>Methods/Design</p> <p>Randomized, controlled trial with a three-armed, parallel-group design. Approximately 315 patients complying with the inclusion and exclusion criteria will be randomized into one of the following treatment groups: infiltration of the hip joint with hyaluronic acid, with a corticosteroid or with 0.125% bupivacaine.</p> <p>The following outcome measure instruments will be assessed at baseline, i.e. before the intra-articular injection of one of the study products, and then again at six weeks, 3 and 6 months after the initial injection: Pain (100 mm VAS), Harris Hip Score and HOOS, patient assessment of their clinical status (worse, stable or better then at the time of enrollment) and intake of pain rescue medication (number per week). In addition patients will be asked if they have complications/adverse events. The six-month follow-up period for all patients will begin on the date the first injection is administered.</p> <p>Discussion</p> <p>This randomized, controlled, three-arm study will hopefully provide robust information on two of the intra-articular treatments used in hip osteoarthritis, in comparison to bupivacaine.</p> <p>Trial registration</p> <p>NCT01079455</p

Predictors of functional outcome following femoral neck fractures treated with an arthroplasty: limitations of the Harris hip score

Introduction To study the association between potential prognostic factors and functional outcome at 1 and 5 year follow-up in patients with femoral neck fractures treated with an arthroplasty. To analyze the reliability of the Harris hip score (HHS). Materials and methods A multicenter analysis which included 252 patients who sustained a femoral neck fracture treated with an arthroplasty. Functional outcome after surgery was assessed using a modified HHS and was evaluated after 1 (HHS1) and 5 (HHS5) years. Several prognostic factors were analyzed and reliability of the HHS was assessed. Results After 1 year the presence of co-morbidities was a significant (p = 0.002) predictor for a poor functional outcome (mean HHS1 71.8 with co-morbidities, and 80.6 without co-morbidities). After 5 years none of the potential prognostic factors had significant influence on functional outcome. Internal consistency testing of the HHS showed that when pain and function of the HHS were analyzed together, the internal consistency was poor (HHS1 0.38 and HHS5 0.20). The internal consistency of the HHS solely in function (without pain) improved to 0.68 (HHS1) and 0.46 (HHS5). Analyzing the functional aspect exclusively, age and the existence of co-morbidities could be defined as predictors for functional outcome of femoral neck fractures after 1 and 5 years. Conclusion After using the HHS in a modification, age and the existence of pre-operative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. The HHS, omitting pain, is a more reliable score to estimate the functional outcome, than HHS analyzing pain and function in one scoring syste

Routine versus on demand removal of the syndesmotic screw; A protocol for an international randomised controlled trial (RODEO-trial)

Background: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. Design: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. Discussion: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. Trial registration: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov (NCT02896998) on July 15th 2016