Volumen 1 (2018): Edición 2 (December 2018)

Distal tibial fractures usually result from high-energy trauma, affecting young, active people, producing long-term disability and numerous complications. Their treatment is difficult, especially in type C fractures, which affect both the articular surface and the metaphysis, are quite frequent comminuted fractures, and are accompanied by soft tissue injuries. In these situations, External Fixation (EF) is used as a temporary bridging method, either for treating concomitant soft tissue injuries (in open fractures) or for achieving and maintaining reduction in order to prevent blisters or compartment syndrome, possibly resulting from severe displacement, bleeding or oedema. It must be however underlined that EF is rarely a definitive method for these fractures, especially when the ankle is splinted, and it must be followed by definitive Internal Fixation (IF) - the so-called “sequential method”, otherwise restoration of a normal ankle anatomy and function is improbable, resulting in ankle stiffness or even osteoarthritis. This paper presents a case in which this principle was only partially applied, thus requiring corrective surgery followed by a long-term recovery period.

In the context of an ever-increasing elderly population, we attempted to trace the portrait of the typical orthopedic patient of the future. We presented the case of a 92-year-old woman who presented with a midshaft femoral fracture and a rich medical and surgical history. We reported the management, treatment, and evolution while touching upon the economic side of orthopedic surgery.

Knee osteoarthritis (gonarthrosis) is the most prevalent knee pathology encountered nowadays in the third age population, leading to severe disability and reduced life quality. Secondary gonarthrosis may be caused by a traumatic event, which subjects the knee joint to a transitory highly increased mechanical stress, initiating a rapidly progressive degrading process of the articular cartilage and subjacent bone tissue. TKA is intended to replace all the intra-articular components with artificial parts, in order to relieve pain, compensate for ligament instability, correct deformities, and restore proper joint functionality. Semi-constrained, non-hinged implants are usually used for revision TKA, in knees that already had a primary TKA but sustained complications. Nevertheless, here we reported the case of a 66-year-old female patient diagnosed with posttraumatic gonarthrosis who underwent TKA with a revision total stabilizer implant as primary treatment due to severe joint instability and high grade valgus deviation. The outcome of the surgical procedure was positive, with significant pain relief and increased knee stability. The valgus angle was reduced from 37° to 4° and the KSS score increased from 3 to 87 points. Therefore, revision semi-constrained prosthesis may be used as a primary implant with promising result in severe cases.

Purpose. Damage Control Orthopedics (DCO) is a surgical concept used in the recovery of seriously injured patients. Given that the leading cause of death among trauma patients remains uncontrolled hemorrhage, DCO emphasizes on preventing the "lethal triad” of acidosis, coagulopathy and hypothermia, rather than correcting the anatomy immediately. Thereby, we are presenting the crucial importance of using this technique in severe trauma cases. Methods. A 23-year-old female was admitted in the Emergency Room as a multi-trauma patient. Following the Advanced Trauma Life Support protocol, fully exposure examination showed bilateral forearm and femur deformities, with bilateral open femur fracture, left ankle deformity and pelvic ecchymosis. X-rays confirmed fractures of the ribs, bilateral pulmonary contusion, fracture of the left ankle fracture, bilateral superior and inferior pubic ramus, and bilateral femur fractures with both bone midshaft fracture on the right leg. DCO was proceeded immediately, during which external fixators were placed on the fractures, while splinting both forearms. After 11 days in the Intensive Care Unit (ICU), the patient underwent the definitive surgeries. Results. Managing the patient with the DCO protocol first and not rushing with the definitive surgical procedures resulted in a proper stabilization. After two years follow up, the patient fully recovered and returned to a normal life style. Conclusion. Performing a definitive operation on severely injured patients results in deleterious effects that could lower life expectancy. Short-term physiological recovery should be prioritized over definitive management and DCO should be proceeded in order for the best outcomes to be achieved.

Although most soft tissue tumors are benign, with a high healing rate after surgical excision, there is a variety of malignant tumors with differences in progression and prognosis. The study aimed to assess the survival rate in patients diagnosed with this pathology, based on the patient’s characteristics (age, gender, race), as well as the tumor’s histological type, differentiation degree, location and size. The retrospective study included a group of 103 patients diagnosed during 2010 and 2017 in our department. Considering the high healing rate of benign tumors, only the group of neoplastic patients (45 cases) was involved in the survival rate estimation, assessing tumor characteristics and individual comorbidities. Within this lot, we emphasized a predominance of neoplasm in patients aged over 50 years (32 cases), men (29 cases), and localization of the neoplasm in the thigh (23 cases). The predominant histopathological type, liposarcoma, was diagnosed in 67% of the cases, with dimensions over 6 cm and with local extension. There have been significant variations in mortality between the different histological subtypes (liposarcoma vs. synovial sarcoma). Local recurrences were showed in 18 cases of liposarcoma in the first 2 years after the surgical excision, with an increased aggressiveness of this neoplasm in men over 50 years. 12 cases developed distant metastasis, and until the end of the study, 7 deaths were reported in 3 cases involving associated comorbidities. The five-year survival is inversely proportional to the extent of the tumor and the local invasion, as well as to the age of the patient. An overall survival rate is difficult to appreciate in the context of a heterogeneous group of tumors so it must be evaluated for every histological subtype taking into account the patient’s particularities.

Ankle fractures are frequent and have a significant impact upon the function of the lower limb, as this joint has a crucial role in standing and especially in walking. Several classification systems have been developed concerning these fractures, connecting the traumatic mechanism to their treatment. Due to their character of articular fractures, functional restoration of local anatomy is necessary; therefore, surgery is mandatory in displaced fractures, affecting the congruency, the stability or the mobility of the ankle joint. The purpose of this paper is to describe the factors influencing the results of surgical treatment in these fractures, as it results from the experience of a level 1 Trauma Centre.

Two types of femoral neck fractures are nowadays identified: those resulting from low energy trauma, usually by direct by falling on the hip, in patients with affected bone stock (the so-called “fragility fractures”) and those produced by high energy trauma, even in younger people, with normal bone stock. These recommendations are addressed to the first category. for which impaired mineral bone density (MBD), osteopenia, and osteoporosis represent major enabling factors. These recommendations refer to classification-based local and general treatment of femoral neck fractures (excluding the basilar neck ones). The presumptive and definitive diagnoses include the precise description of the fracture pattern, by complete imagistic evaluation. The treatment depends on the type of the patient (demanding or non-demanding), on the type of the fracture (stable or unstable), as well as on the facility of early treatment, in certain cases. The main therapeutic goal in femoral neck fractures is early social and professional reinsertion of the patient, by gaining a status as close as possible to the one before the trauma; stable stabilization allowing early mobilization has a key role in fulfilling this objective Therefore, complete evaluation and monitoring of the patient by a multidisciplinary team is mandatory in order to perform a proper evaluation of the anaesthetic and surgical risk ( as these patients usually have pre-existing health problems, sometimes severe) , a safe and adapted (form the point of view of invasivity) surgery and an appropriate post-operative local and general treatment. Therefore, these recommendations have numerous connections with those involving the intervention of physicians from other specialities with whom orthopaedic surgeons must cooperate in these cases

Giant cell tumors of the bone are tumors whose malignant character has long been debated. Lung metastases have been reported in some cases. They usually represent osteolytic, locally aggressive bone tumors for which surgery is the standard of care. Denosumab is the most effective systemic treatment in these cases, but both the timing and the duration are a matter of debate. The aim of this short review was to describe the most important trials that treated patients with this drug and to discuss both advantages and long-term toxicity. It can be concluded from the presented data that the choice of adding denosumab in the treatment sequence of giant cell tumor of the bone has to be taken in a personalized manner for each patient.

Introduction and purpose:Charcot neuroarthropathy defines a cluster of progressive lesions affecting the joints and bones, as well as the soft tissues of the foot in the context of diabetes, a pivotal role being attributed to peripheral neuropathy. Loss of sensation and proprioception, subsequent repeated trauma, muscle and autonomic nervous system impairment contribute to the alteration of the foot’s architecture and distribution of pressure, ultimately triggering ulceration and gangrene. The urge to avoid amputation has fueled the development of conservative and reconstructive techniques capable of delaying, if not preventing such negative outcomes. The purpose of this review was to present the most frequently used reconstruction procedures and the challenges arising in adapting them to particular foot morphologies and lesion stages. Methods:Literature search was conducted using PubMed, resulting in around 90 articles, multicenter studies and reviews, 26 of which were considered most relevant in providing the guidelines for orthopedic reconstruction and postoperative care in Charcot foot patients with diabetic neuropathy prevailing over arteriopathy. Results:The tarsometatarsal and metatarsophalangeal joints are most frequently affected. Closed reduction, arthrodesis, and tendon lengthening are key features of an efficient correction, alternatively accompanied by resections and tenotomies. Ulceration and callus debridement may also be necessary, while prolonged casting and immobilization remain obligatory. Conclusions:Most authors agree that stabilizing the deformities, optimizing the pressure on the soft tissues, and promoting the healing of potential lesions are the main purposes of the interventions. Prompt recognition and correction of Charcot foot deformities improve life quality and minimize the prospects of amputation.

As the population becomes more active and life expectancy increases, gonarthrosis has proportions of epidemics. Total knee arthroplasty (TKA) is an intervention that decreases pain and gives the patients the possibility of quickly returning to the desired level of activity. It is an intervention with a patient satisfaction rate of about 90-95% with a survival of the implant over 15 years of 90%. When dealing with TKA the following elements should be taken into account: clinical examination (walking analysis), leg deformities and knee alignment (foot deformation management), posterior tibial tendon dysfunction, cavovarus foot, posttraumatic deformity, neuropathic arthropathies, ankle arthrosis, foot deformities and knee arthroplasty. Ankle or foot deformity may be causes of progression of gonarthrosis or a TKA failure. Post-operative alignment of TKA is an extremely important element in the long-term survival of the prosthesis. By improving biomechanical alignment of the complete pelvic limb, TKA survival and patient satisfaction will increase.