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Elena Gálvez-Sirvent, Aitor Ibarzábal-Gil, and E Carlos Rodríguez-Merchán

  • Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis.

  • The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA.

  • Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection.

  • In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage).

  • Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

Abdul-ilah Hachem, Andres Molina-Creixell, Xavier Rius, Karla Rodriguez-Bascones, Francisco Javier Cabo Cabo, Jose Luis Agulló, and Miguel Angel Ruiz-Iban

  • Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality.

  • Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure.

  • A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory.

  • Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface.

  • Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way.

  • An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.

Qiushi Bai, Yuanyi Wang, Jiliang Zhai, Jigong Wu, Yan Zhang, and Yu Zhao

  • Tandem spinal stenosis (TSS) is defined as the concomitant occurrence of stenosis in at least two or more distinct regions (cervical, thoracic, or lumbar) of the spine and may present with a constellation of signs and symptoms. It has four subtypes, including cervico-lumbar, cervico-thoracic, thoraco-lumbar, and cervico-thoraco-lumbar TSS. The prevalence of TSS varies depending on the different subtypes and cohorts.

  • The main aetiologies of TSS are spinal degenerative changes and heterotopic ossification, and patients with developmental spinal stenosis, ligament ossification, and spinal stenosis at any region are at an increased risk of developing TSS.

  • The diagnosis of TSS is challenging. The clinical presentation of TSS could be complex, concealed, or severe, and these features may be confusing to clinicians, resulting in an incomplete or delayed diagnosis. Additionally, a consolidated diagnostic criterion for TSS is urgently required to improve consistency across studies and form a basis for establishing treatment guidelines.

  • The optimal treatment option for TSS is still under debate; areas of controversies include choice of the decompression range, choice between simultaneous or staged surgical patterns, and the order of the surgeries.

  • The present study reviews publications on TSS, consolidates current awareness on prevalence, aetiologies, potential risk factors, diagnostic dilemmas and criteria, and surgical strategies based on TSS subtypes. This is the first review to include thoracic spinal stenosis as a candidate disorder in TSS and aims at providing the readers with a comprehensive overview of TSS.

Geovanny Ruiz, Norberto J Torres-Lugo, Pablo Marrero-Ortiz, Humberto Guzmán, Gerardo Olivella, and Norman Ramírez

  • Early-onset scoliosis (EOS) is defined as any spinal deformity that is present before 10 years old, regardless of etiology.

  • Deformity must be evaluated based on the intercorrelation between the lungs, spine, and thorax.

  • Curvatures of early-onset have increased risk of progression, cardiorespiratory problems, and increased morbidity and mortality.

  • Progression of the deformity may produce thoracic insufficiency syndrome, where a distorted thorax is unable to support normal respiratory function or lung growth.

  • Management and treatment of EOS should pursue a holistic approach in which the psychological impact and quality of life of the patient are also taken into consideration.

  • Growth-friendly surgical techniques have not met the initial expectations of correcting scoliotic deformity, promoting thoracic growth, and improving pulmonary function.

A Frodl, N Geisteuer, A Fuchs, T Nymark, and H Schmal

Purpose

  • Incisional negative pressure wound therapy (iNPWT) has shown effectiveness in the treatment of high-risk surgical wounds. Especially patients with diabetes-induced peripheral arterial disease undergoing major limb amputation have a high intrinsic risk for post-surgical wound infections. While normal gauze wound dressings do not cause stimulation of microvasculature, iNPWT might improve wound healing and reduce wound complications. The purpose of this study was to systematically review the literature for rates of wound complications and readmissions, as well as post-surgical 30-day mortality.

Methods

  • We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score >60, non-traumatic major limb amputation, and adult patients. Traumatic amputations and animal studies were excluded. Relevant articles were reviewed independently by referring to the title and abstract. In a meta-analysis, we compared 3 studies and 457 patients.

Results

  • A significantly overall lower rate of postoperative complications is associated with usage of iNPWT (odds ratio (OR) = 0.52; 95% CI: 0.30–0.89; P = 0.02). There was no significant improvement for 30-day mortality, when iNPWT was used (OR= 081; 95% CI: 0.46 – 1.45; P = 0.48). Nevertheless, we did not note a significant difference in the readmission rate or revision surgery between the two groups.

Conclusion

  • Overall, the usage of iNPWT may reduce the risk of postoperative wound complications in major lower limb amputations but does not improve 30-day mortality rates significantly. However, to anticipate surgical-site infection, iNPWT has shown effectiveness and thus should be used whenever applicable.

Elisa Pala, Alberto Procura, Giulia Trovarelli, Antonio Berizzi, and Pietro Ruggieri

Purpose

  • The aim of this study is to compare titanium vs carbon fiber intramedullary (IM) nailing in terms of response to radiotherapy, local control of the disease, time of surgery, fluoroscopy exposure, and complications.

Methods

  • From 2015 to 2021, 52 impending or pathologic fractures were treated with IM nailing in 47 patients: 18 males and 29 females with a mean age of 73. Titanium nails were used in 27 cases: femur (17 cases), humerus (8 cases), and tibia (2 cases). Carbon fiber nails were used in 25 cases: femur (17 cases), humerus (7 cases), and tibia (1 case).

Results

  • At a mean follow-up of 8.4 months, most patients died from the disease (63.4%). Fracture healing without osteolysis progression was present in 52% of titanium nailing at a mean time of 6 months and in 53% of carbon fiber nails at a mean time of 4.6 months. No statistically significant difference has been shown in terms of healing (P = 0.5), intraoperative fluoroscopy (P = 0.7), and time of surgery in femoral nailing (P = 0.6), while a significantly lower surgical time for carbon fiber humeral nailing (P  = 0.01) was found. Two breakages of carbon fiber femoral nails were observed, and both were treated with revision with modular tumor megaprosthesis.

Conclusions

  • Our results suggest that surgical time and fluoroscopy exposure are not longer for carbon fiber nails compared to titanium ones. Healing seems to be faster in carbon fiber nails. Further clinical studies are needed to clarify the long-term outcomes of these implants.

Claudio Legnani, Andrea Parente, Franco Parente, and Alberto Ventura

Purpose

  • It is debatable whether or not previous high tibial osteotomy (HTO) has negative effects on the results of subsequent medial unicompartmental knee replacement (UKR). The purpose of this study is to report, through a systematic review of the literature, the outcomes of medial UKR after failed HTO. It was hypothesized that this procedure would be safe and effective in providing satisfactory postoperative functional outcomes.

Methods

  • A systematic review was performed by searching Pubmed/MEDLINE, Embase and CINAHL. Only studies in English pertaining to all levels of evidence reporting on subjects undergoing UKR following HTO were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications, surgical technique and associated procedures, type of prosthesis, clinical and functional outcomes, rate of complications, revision surgery and failure rate.

Results

  • Overall, six studies met all the inclusion criteria for this review. All were published between 2006 and 2021. The search resulted in one prospective comparative study, four retrospective comparative cohort studies, and one retrospective cohort study. Average follow-up periods ranged from 1 to 13 years. From these studies, 115 patients (117 knees) were identified. Overall, most studies reported satisfying postoperative clinical and functional outcomes. Implant survivorship ranged from 66 to 97.6%. In 15 patients, revision surgery was performed due to persistent pain.

Conclusions

  • Medial UKR performed after failed HTO appears as a feasible procedure providing satisfying outcomes and limited complications in most cases. Further prospective comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are lacking.

David González-Martín, José Luis Pais-Brito, Sergio González-Casamayor, Ayron Guerra-Ferraz, Jorge Ojeda-Jiménez, and Mario Herrera-Pérez

  • There is currently a debate on whether all Vancouver B2 periprosthetic hip fractures should be revised.

  • The aim of our work was to establish a decision-making algorithm that helps to decide whether open reduction and internal fixation (ORIF) or revision arthroplasty (RA) should be performed in these patients.

  • Relative indications in favour of ORIF are low-medium functional demand (Parker mobility score (PMS) <5), high anaesthetic risk (American Society of Anesthesiologists score (ASA) ≥ 3), many comorbidities (Charlson Comorbidity Index (CCI) ≥ 5), 1 zone fractured (VB2.1), anatomical reconstruction possible, and no prior loosening (hip pain).

  • Relative indications in favour of RA are high functional demand (PMS ≥6), low anaesthetic risk (ASA< 3), few comorbidities (CCI<5), fracture ≥ 2 zones (VB2.2), comminuted fractures, and prior loosening (hip pain).

  • In cemented stems, those fractures with fully intact cement–bone interface, no stem subsidence into the cementraliser, cement mantle anatomically reducible, and some partial stem-cement attachment can be safely treated with ORIF.

Pieter Bas de Witte, Christiaan J A van Bergen, Babette L de Geest, Floor Willeboordse, Joost H van Linge, Yvon M den Hartog, Magritha (Margret) M H P Foreman-van Drongelen, Renske M Pereboom, Simon G F Robben, Bart J Burger, M Adhiambo Witlox, and Melinda M E H Witbreuk

Background and purpose

  • Diagnostics and treatment of developmental dysplasia of the hip (DDH) are highly variable in clinical practice. To obtain more uniform and evidence-based treatment pathways, we developed the ‘Dutch guideline for DDH in children < 1 year’. This study describes recommendations for unstable and decentered hips.

Materials and methods

  • The Appraisal of Guidelines for Research and Evaluation criteria (AGREE II) were applied. A systematic literature review was performed for six predefined guideline questions. Recommendations were developed, based on literature findings, as well as harms/benefits, patient/parent preferences, and costs (GRADE).

Results

  • The systematic literature search resulted in 843 articles and 11 were included. Final guideline recommendations are (i) Pavlik harness is the preferred first step in the treatment of (sub) luxated hips; (ii) follow-up with ultrasound at 3–4 and 6–8 weeks; (iii) if no centered and stable hip after 6–8 weeks is present, closed reduction is indicated; (iv) if reduction is restricted by limited hip abduction, adductor tenotomy is indicated; (v) in case of open reduction, the anterior, anterolateral, or medial approach is advised, with the choice based on surgical preference and experience; (vi) after reduction (closed/open), a spica cast is advised for 12 weeks, followed by an abduction device in case of residual dysplasia.

Interpretation

  • This study presents recommendations on the treatment of decentered DDH, based on the available literature and expert consensus, as Part 2 of the first official and national evidence-based ‘Guideline for DDH in children < 1 year’. Part 1 describes the guideline sections on centered DDH in a separate article.

Mario Herrera-Pérez, Victor Valderrabano, Alexandre L Godoy-Santos, César de César Netto, David González-Martín, and Sergio Tejero

  • Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients.

  • Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active.

  • The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA.

  • Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms.

  • After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures.

  • In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease.

  • Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.