The Top Three Burning Questions in Total Hip Arthroplasty.

Total hip arthroplasty (THA) for end-stage osteoarthritis is one of the most effective surgical treatments in medicine. Impressive outcomes have been well documented in the literature with patients gaining ambulation and recovery of hip joint function. Nevertheless, there are still debatable issues and controversies that the orthopedic community has not been able to provide a definitive answer for. This review is focused on the current three most debatable issues surrounding the THA procedure: (1) new cutting-edge technology, (2) spinopelvic mobility, and (3) fast-track protocols. The scope of the herein narrative review is to analyze the debatable issues surrounding the three aforementioned topics and conclude the best contemporary clinical approaches regarding each issue

Hand Compartment Syndrome

Compartment syndrome is defined by high pressures in a closed myofascial compartment, which affects initially the muscles and later the nerves and vessels. The hand is rarely affected, but if treated suboptimally, it results to a permanent loss of function. Eleven compartments are included in the hand and wrist. Diagnosis of compartment syndrome of the hand remains challenging. Pain out of proportion of injury and excessive swelling should raise suspicion towards a compartment syndrome. Intracompartmental pressure measurement contributes to the diagnosis, but it is not always reliable. Once the diagnosis of acute compartment syndrome has been made, decompression of all compartments is mandatory, in order to achieve a good outcome. Failing to manage this emergent condition properly leads to a significant hand disability. Our chapter includes the following sections: 1. Introduction. A brief description of the hand compartment syndrome is presented. 2. Anatomy. Special considerations regarding hand compartments are presented, 3. Etiology. 4. Diagnosis. Signs and symptoms are reported, as well as guidelines of the technique of intracompartmental pressure measurement. 5. Treatment. Faciotomies’ indications and operative technique are described in details. 6. Conclusion. Appropriate figures of the clinical image and surgical decompression are presented as well

Effect of C-Clamp Application on Hemodynamic Instability in Polytrauma Victims with Pelvic Fracture.

Background and Objectives: C-clamp application may reduce mortality in patients with unstable pelvic fractures and hemodynamic instability. Decreasing C-clamp use over the past decades may have resulted from concerns about its effectiveness and safety. The purpose of this study was to document effective hemodynamic stabilization after C-clamp application by means of vital parameters (primary outcome parameter), and the subsequent effect on metabolic indices and volume management (secondary outcome parameters). Materials and Methods: C-clamp application was performed between 2014 and 2021 for n = 13 patients (50 ± 18 years) with unstable pelvic fractures and hemodynamic instability. Vital parameters, metabolic indices, volume management, and the correlation of factors and potential changes were analyzed. Results: After C-clamp application, increases were measured in systolic blood pressure (+15 mmHg; p = 0.0284) and mean arterial pressure (+12 mmHg; p = 0.0157), and a reduction of volume requirements (p = 0.0266) and bolus vasoactive medication needs (p = 0.0081) were observed. The earlier C-clamp application was performed, the greater the effect (p < 0.05; r > 0.6). Heart rate, shock index, and end-tidal CO2 were not significantly altered. The extent of base deficit, hemoglobin, and lactate did not correlate with changes in vital parameters. Conclusions: In the majority of hemodynamically unstable trauma patients not responding to initial fluid resuscitation and severe pelvic fracture, early C-clamp application had an additive effect on hemodynamic stabilization and reduction in volume substitution. Based on these findings, there is still a rationale for considering early C-clamp stabilization in this group of severely injured patients

The ideal site of cement application in cement augmented sacroiliac screw fixation: the biomechanical perspective.

PURPOSE To compare construct stability of cement augmented sacroiliac screws using two different cementation sites in a biomechanical fragility fracture model of the pelvis. METHODS A fracture model with an incomplete fracture of the sacral ala and complete fracture of the anterior pelvic ring mimicking a FFP IIB fragility fracture of the pelvis was established in five fresh frozen human cadaveric pelvises. Sacral fracture stabilization was achieved with bilateral 7.3 mm fully threaded sacroiliac screws. Cement augmentation was performed at the tip of the screw (body of S1; Group A) on one side, and at the midshaft of the screw (sacral ala; Group B) on the contralateral side. Biomechanical testing was conducted separately on both sides comprising cyclic loading of axial forces transferred through the tested hemipelvis from L5 to the ipsilateral acetabulum. Combined angular displacement in flexion and internal rotation ("gap angle"), angular displacement of the ilium in relation to the screw ("screw tilt ilium"), and screw tip cutout were evaluated. RESULTS Relative interfragmentary movements were associated with significantly higher values in group A versus group B for "gap angle" (2.4° vs. 1.4°; p < 0.001), and for "screw tilt ilium" (3.3° vs. 1.4°; p < 0.001), respectively. No significant difference was indicated for screw tip cutout between the two groups (0.6 mm [Group A] vs. 0.8 mm [Group B]; p = 0.376). CONCLUSION The present study demonstrated less fragment and screw displacements in a FFP IIB fracture model under physiologic cyclic loading by cement augmentation of sacroiliac screws at the level of the lateral mass compared to the center of vertebral body of S1

Revision of a Failed Primary Total Hip Arthroplasty following Excessive Reaming with a Medial Cup Protrusion.

Background and Objectives: Atraumatic intrapelvic protrusion of the acetabular component following excessive reaming of the acetabulum with a far medial positioning of the cup is a rare, but serious complication of a total hip arthroplasty (THA). This study analyzes the factors contributing to this uncommon complication and presents the outcome after the revision surgery using the Ganz reinforcement ring combined with a bone graft and plating of the posterior column and/or screws for the anterior column. Materials and Methods: A retrospective case series study with seven patients (four males, mean age 76 ± 10 years (60-86)) that underwent a revision THA within 24 ± 17 days (5-60) after an atraumatic periprosthetic acetabular fracture with a medial cup protrusion was performed. All fractures were reconstructed with a Ganz reinforcement ring and bone graft with a mean follow-up of 1.7 ± 1.7 years (0.5-5). Radiographs were evaluated for the following: (i) cup positioning immediately after the primary THA and the revision surgery, (ii) cup migration in the follow-up, and (iii) fracture healing. Results: The position of the acetabular component as assessed on the postoperative radiographs after the index surgery and before the complete medial cup protrusion showed a cup placement beyond the ilioischial line indicative of a fracture of the medial wall. The revision surgery with the reconstruction of the medial wall with a Ganz reinforcement ring combined with a bone graft restored in the presented cases the center of rotation in the horizontal direction with a statistical significance (p &lt; 0.05). During the follow-up, there was no aseptic loosening with the relevant cup migration or significant change in the position of the acetabular cup at the final follow-up (p &gt; 0.05) after the revision. All seven fractures and bone grafts realized a bone union until the latest follow-up. Conclusions: Following excessive reaming, the acetabular component was placed too far medially and resulted in an intrapelvic cup protrusion. An unstable cup following a fracture of the medial wall was evident on the immediate postoperative radiographs. In the case of the medial wall perforation with an intrapelvic cup protrusion after the primary THA, the reconstruction with a Ganz reinforcement ring was a successful treatment option resulting in the fracture healing and a stable cup positioning. Surgeons should be aware of that rare and probably underreported complication and restore the anatomic center of rotation by treating the defect intraoperatively

The importance of sympathetic innervation, adrenergic receptors, and local catecholamine production in the long head of the biceps brachii tendinopathy

Στην παρούσα έρευνα έγινε προσπάθεια να μελετηθούν οι δομές και να εξηγηθούν οι μηχανισμοί που πιθανώς εμπλέκονται στην δημιουργία του άλγους του τένοντα του δικέφαλου βραχιονίου μυός. Η μελέτη αυτή επικεντρώθηκε στην διερεύνηση της συμπαθητικής νεύρωσης, των αδρενεργικών υποδοχέων και της τοπικής παραγωγής κατεχολαμινών της μακράς κεφαλής του δικέφαλου βραχιονίου μυός σε περιπτώσεις οξείας (περιπτώσεις καταγμάτων) και χρόνιας (τενοντοπάθεια δικέφαλου με συνυπάρχουσα ρήξη του μυοτενοντίου πετάλου του ώμου) παθολογίας του. Η μελέτη έγινε με την χρήση των μεθόδων της κλασσικής ιστολογίας καθώς επίσης και της ανοσοϊστοχημείας. Παράλληλα έγινε προσπάθεια να συσχετιστούν τα ιστολογικά και ανοσοϊστοχημικά χαρακτηριστικά του τένοντα του δικέφαλου, με την παραγωγή του άλγους. Μέχρι σήμερα και σύμφωνα με την ελληνική αλλά και διεθνή βιβλιογραφία, αυτή η μελέτη αποτελεί την πρώτη συστηματική προσπάθεια ανάλυσης αυτών των δεδομένων σε βλάβες του συγκεκριμένου τένοντα. Συμπερασματικά στην παρούσα διδακτορική διατριβή, μελετήθηκαν τα ιστολογικά χαρακτηριστικά που σχετίζονται με παθολογία του τένοντα σε συνάρτηση με τα ανοσοϊστοχημικά χαρακτηριστικά που υποδηλώνουν διαδικασία παραγωγής άλγους. Η συσχέτιση αυτή έγινε σε υγιείς τένοντες, σε τένοντες με οξεία παθολογία (μετά από κατάγματα) και σε τένοντες με χρόνια παθολογία (τενοντοπάθεια δικέφαλου). Κατόπιν διενεργήθηκε σύγκριση των ανωτέρω ομάδων. […

The role of “cell therapy” in osteonecrosis of the femoral head

<div><p><b>Background and purpose —</b> The value of core decrompression for treatment of osteonecrosis of the femoral head (ONFH) is unclear. We investigated by a literature review whether implantation of autologous bone marrow aspirate, containing high concentrations of pluripotent mesenchymal stem cells, into the core decompression track would improve the clinical and radiological results compared with the classical method of core decompression alone. The primary outcomes of interest were structural failure (collapse) of the femoral head and conversion to total hip replacement (THR).</p><p><b>Patients and methods —</b> All randomized and non-randomized control trials comparing simple core decompression with autologous bone marrow cell implantation into the femoral head for the treatment of ONFH were considered eligible for inclusion. The methodological quality of the studies included was assessed independently by 2 reviewers using the Cochrane Collaboration tool for assessing risk of bias in randomized studies. Of 496 relevant citations identified, 7 studies formed the basis of this review.</p><p><b>Results —</b> The pooled estimate of effect size for structural failure of the femoral head favored the cell therapy group, as, in this treatment group, the odds of progression of the femoral head to the collapse stage were reduced by a factor of 5 compared to the CD group (odds ratio (OR) = 0.2, 95% CI: 0.08–0.6; p = 0.02). The respective summarized estimate of effect size yielded halved odds for conversion to THR in the cell therapy group compared to CD group (OR = 0.6, 95% CI: 0.3–1.02; p = 0.06).</p><p><b>Interpretation —</b> Our findings suggest that implantation of autologous mesenchymal stem cells (MSCs) into the core decompression track, particularly when employed at early (pre-collapse) stages of ONFH, would improve the survivorship of femoral heads and reduce the need for hip arthroplasty.</p></div

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes.

PURPOSE To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated. METHODS PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted. RESULTS Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively. CONCLUSION A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve