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1.  Treatment Options for Brachial Plexus Injuries 
ISRN Orthopedics  2014;2014:314137.
The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.
doi:10.1155/2014/314137
PMCID: PMC4045367  PMID: 24967125
2.  Brachial Plexus Injuries in Adults: Evaluation and Diagnostic Approach 
ISRN Orthopedics  2014;2014:726103.
The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries.
doi:10.1155/2014/726103
PMCID: PMC4045362  PMID: 24967130
3.  Management bone loss of the proximal femur in revision hip arthroplasty: Update on reconstructive options 
World Journal of Orthopedics  2014;5(5):614-622.
The number of revision total hip arthroplasties is expected to rise as the indications for arthroplasty will expand due to the aging population. The prevalence of extensive proximal femoral bone loss is expected to increase subsequently. The etiology of bone loss from the proximal femur after total hip arthroplasty is multifactorial. Stress shielding, massive osteolysis, extensive loosening and history of multiple surgeries consist the most common etiologies. Reconstruction of extensive bone loss of the proximal femur during a revision hip arthroplasty is a major challenge for even the most experienced orthopaedic surgeon. The amount of femoral bone loss and the bone quality of the remaining metaphyseal and diaphyseal bone dictate the selection of appropriate reconstructive option. These include the use of impaction allografting, distal press-fit fixation, allograft-prosthesis composites and tumor megaprostheses. This review article is a concise review of the current literature and provides an algorithmic approach for reconstruction of different types of proximal femoral bone defects.
doi:10.5312/wjo.v5.i5.614
PMCID: PMC4133469  PMID: 25405090
Arthroplasty; Proximal; Femur; Reconstruction; Bone loss
4.  Bent Intramedullary Femoral Nail: Surgical Technique of Removal and Reconstruction 
Case Reports in Orthopedics  2011;2011:614509.
A secondary high-velocity trauma to a previously stabilized femoral fracture with intramedullary nailing is rare. In this paper, we present the management of a 40-year-old man presented with a bent intramedullary nail due to secondary trauma. A lateral longitudinal femoral osteotomy was used for the resection of the distorted nail. The femur was reconstructed with a new nail, and the fixation of the osteotomy was achieved with plate and cerclage wires. Five months postrevision surgery, callus formation was evident and the patient regained a normal range of motion and gait, walking with a single cane.
doi:10.1155/2011/614509
PMCID: PMC3504200  PMID: 23198220
5.  Reconstruction of the Acetabulum in Developmental Dysplasia of the Hip in total hip replacement 
Developmental dysplasia of the hip (DDH) or congenital hip dysplasia (CDH) is the most prevalent developmental childhood hip disorder. It includes a wide spectrum of hip abnormalities ranging from dysplasia to subluxation and complete dislocation of the hip joint. The natural history of neglected DDH in adults is highly variable. The mean age of onset of symptoms is 34.5 years for dysplastic DDH, 32.5 years for low dislocation, 31.2 years for high dislocation with a false acetabulum, and 46.4 years for high dislocation without a false acetabulum. Thorough understanding of the bony and soft tissue deformities induced by dysplasia is crucial for the success of total hip arthroplasty. It is important to evaluate the existing acetabular deformity three-dimensionally, and customize the correction in accordance with the quantity and location of ace tabular deficiencies. Acetabular reconstruction in patients with DDH is challenging. Interpretation of published data is difficult and should be done with caution because most series include patients with different types of hip disease. In general, the complication rate associated with THA is higher in patients with hip dysplasia than it is in patients with osteoarthritis. Overall, clinical and functional outcomes following THA in patients hip dysplasia (DDH) differ from those treated for primary hip osteoarthritis, possibly due to the lower age and level of activity. Although function scores decline with age, the scores for pain and range of motion presented with a statistically significant improvement in the long-term.
PMCID: PMC4225014  PMID: 25386570
Acetabulum; Arthroplasty; Congenital; Developmental; Hip
6.  Insidious Onset of Tetraparesis due to Cervical Epidural Abscess from Enterococcus faecalis 
Case Reports in Medicine  2013;2013:513920.
We report a case of cervical epidural abscess from Enterococcus faecalis, which caused an insidious onset of tetraparesis. This 53-year-old female with a history of diabetes mellitus and chronic renal failure under hemodialysis presented with pain and progressive weakness of upper and lower extremities without fever. Although a recent MRI she did at the beginning of symptoms showed no significant pathologies, except for a cervical disc herniation and adjacent spinal degeneration, and stenosis that confused the diagnostic procedure, newer imaging with CT and MRI, which was performed due to progression of tetraparesis, revealed the formation of a cervical epidural abscess. Surgical drainage was done after a complete infection workup. The patient showed immediate neurological improvement after surgery. She received antibiotics intravenously for 3 weeks and orally for another 6 weeks. The patient was free from complications 24 months after surgery. A high index of suspicion is most important in making a rapid and correct diagnosis of spinal epidural abscess. The classic clinical triad (fever, local pain, and neurologic deficits) is not sensitive enough for early detection. Continuous clinical, laboratory, and imaging monitoring are of paramount importance. Early diagnosis and surgical intervention could optimize the final functional outcome.
doi:10.1155/2013/513920
PMCID: PMC3616352  PMID: 23573096
7.  Use of external fixation for perilunate dislocations and fracture dislocations 
The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18–59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2–12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18–68 months). Range of motion and grip strength were measured. Cooney’s scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney’s clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.
doi:10.1007/s11751-014-0201-3
PMCID: PMC4278973  PMID: 25301167
Carpal; Dislocation; Minimal; External fixation; Ligamentotaxis
8.  Highly Cross-Linked Polyethylene May Not Have an Advantage in Total Knee Arthroplasty 
HSS Journal  2013;9(3):264-269.
Background
Long-term results after total knee replacement (TKR) with conventional and compression-molded polyethylene (PE) have been excellent. The introduction of highly cross-linked polyethylene (XLPE), which has demonstrated superior wear properties in total hip replacement (THR), has led to its recent use in TKR. However, the knee has a unique biomechanical environment characterized by large contact stresses and shear forces and differs from the highly conforming articulation (and primarily abrasive and adhesive wear) found in THR. For this reason, XLPE, with its decreased fatigue resistance and toughness compared to PE, may not be the best material to withstand these unique forces.
Questions
This review and evaluation of the literature aims to answer the following questions. What are the advantages and disadvantages of XLPE in TKR? Does its success in THR ensure a favorable outcome in TKR? Does the increased cost of XLPE justify its use in TKR?
Methods
A systematic literature review of MEDLINE, Science Direct, and Google Scholar databases was performed searching for advantages and disadvantages of XLPE in TKR. We found 18 biomechanical in vitro investigations and 3 clinical studies comparing conventional and XLPEs. We included levels I through IV published articles in peer-reviewed journals in English language.
Results
Several in vitro studies found XLPE to have significantly better wear properties compared to conventional PE. However, the two clinical investigations that directly compared conventional PE and XLPE found no difference in clinical or radiographic outcomes. Additionally, clinical studies with long-term follow-up on TKR with conventional PE did not find wear-induced osteolysis to be a major cause of failure. Four studies did find cost to be significantly higher for XLPE compared to conventional PE.
Conclusions
Based on our review, we concluded that (1) the material properties of XLPE reduce adhesive and abrasive wear, but not the risk of crack propagation, deformation, pitting, and delamination found in TKR; (2) wear-induced osteolysis in TKR has not been found to be a major cause of failure at long-term follow-up; (3) mid-term follow-up studies show no difference in any recorded outcome measure between conventional PE and XLPE; and (4) XLPE is two to four times the cost of conventional PE without an improvement in clinical or radiographic outcomes. For these reasons, we currently cannot recommend the use of XLPE in TKR. Conventional compression-molded polyethylene with its outstanding long-term results should remain the material of choice in TKR.
Electronic supplementary material
The online version of this article (doi:10.1007/s11420-013-9352-x) contains supplementary material, which is available to authorized users.
doi:10.1007/s11420-013-9352-x
PMCID: PMC3772158  PMID: 24426878
cross-linked; polyethylene; total knee replacement; annealed; remelted; radiation; crack; compression molded
9.  Analysis of kidney dysfunction in orthopaedic patients 
BMC Nephrology  2012;13:101.
Backround
This retrospective study was undertaken to determine the incidence of kidney dysfunction (KD) and to identify potential risk factors contributing to development of KD in orthopaedic population following an elective or emergency surgery.
Methods
A total of 1025 patients were admitted in our institution over a period of one year with various indications. Eight hundred and ninety-three patients (87.1%) had a surgical procedure. There were 42 (52.5%) male and 38 (47.5%) female with a mean age of 72 years (range: 47 to 87 years). We evaluated the following potential risk factors: age, comorbidities, shock, hypotension, heart failure, medications (antibiotics, NSAIDs, opiates), rhabdomyolysis, imaging contrast agents and pre-existing KD.
Results
The overall incidence of KD was 8.9%. Sixty-eight patients developed acute renal injury (AKI) and 12 patients developed acute on chronic kidney disease (CKD). In sixty-six (82.5%) patients renal function was reversed to initial preoperative status. Perioperative dehydration (p = 0.002), history of diabetes mellitus (p = 0.003), pre-existing KD (p = 0.004), perioperative shock (p = 0.021) and administration of non-steroid anti-inflammatory drugs (NSAIDs) (p = 0.028) or nephrotoxic antibiotics (p = 0.037) were statistically significantly correlated with the development of postoperative KD and failure to gain the preoperative renal function.
Conclusion
We conclude that every patient with risk factor for postoperative KD should be under closed evaluation and monitoring.
doi:10.1186/1471-2369-13-101
PMCID: PMC3483193  PMID: 22943390
Kidney dysfunction (KD); Orthopaedic population; Surgical procedure
10.  Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants 
Scoliosis  2011;6:20.
Background
Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies.
Case Description
A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection.
Literature Review
Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition.
Purposes and Clinical Relevance
Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery.
doi:10.1186/1748-7161-6-20
PMCID: PMC3182133  PMID: 21914179
11.  Arthroplasty versus internal fixation for femoral neck fractures in the elderly 
We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60–80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time.
doi:10.1007/s11751-010-0099-3
PMCID: PMC3058186  PMID: 21589676
Femoral neck fracture; Arthroplasty; Internal fixation; Harris hip score
12.  Arthroplasty versus internal fixation for femoral neck fractures in the elderly 
We studied 140 patients with femoral neck fractures treated from January 1999 to December 2006. There were 68 men and 72 women with a mean age of 72 years (range 60–80 years). Seventy patients were treated with closed reduction and internal fixation (group A), and 70 patients with hip arthroplasty (group B). The duration of surgery, length of hospitalization, complications, postoperative Harris hip score, and need for reoperation were recorded. Group B had significantly higher blood loss, increased surgical time and length of hospitalization compared to group A patients. The Harris hip score was significantly higher in group B at the 3, 6, and 12-month follow-up evaluations; however, the differences were no longer significant at the 24-month evaluation. The overall complications rate was 18.6% (13 patients) in group A compared to 25.7% (18 patients) in group B; this was not statistically significant (P = 0.309). A statistically significant difference was found regarding reoperation rate in group A (11.4%, eight patients) compared to group B (1.4%, one patient) (P = 0.016). Arthroplasty compared to internal fixation for displaced femoral neck fractures is associated with a significantly higher functional score and lower risk of reoperation at the cost of greater infection rates, blood loss, and operative time.
doi:10.1007/s11751-010-0099-3
PMCID: PMC3058186  PMID: 21589676
Femoral neck fracture; Arthroplasty; Internal fixation; Harris hip score
13.  Wear debris pseudotumor following total knee arthroplasty: a case report 
Introduction
In patients who have undergone a total joint replacement, any mass occurring in or adjacent to the joint needs thorough investigation and a wear debris-induced cyst should be suspected.
Case presentation
An 81-year-old man presented with a painful and enlarging mass at the popliteal fossa and calf of his right knee. He had had a total right knee replacement seven years previously. Plain radiographs showed narrowing of the medial compartment. Magnetic resonance imaging showed a cystic lesion at the postero-medial aspect of the knee joint mimicking popliteal cyst or soft tissue sarcoma. Fine needle aspiration was non-diagnostic. A core-needle biopsy showed metallosis. Intraoperative findings revealed massive metallosis related to extensive polyethylene wear, delamination and deformation. Revision knee and patella arthroplasty was carried out after a thorough debridement of the knee joint.
Conclusion
Long-term follow-up is critical for patients with total joint replacement for early detection of occult polyethylene wear and prosthesis loosening. In these cases, revision arthroplasty may provide a satisfactory knee function.
doi:10.1186/1752-1947-3-9304
PMCID: PMC2803827  PMID: 20062793

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