Volumen 2 (2019): Edición 2 (December 2019)

The article represents an analysis of a confirmed case of digestive neoplasia noted during the last trimester of pregnancy, in which we tried to assess osseous metastases, in correlation with their clinical development and histopathological features. The International Agency for Research on Cancer reported that during the year of 2018, in Romania, a total of 11.076 new cases of colorectal cancer were documented, ranking this type of neoplasia as the 2nd among the most common types of cancer in our country.

Aim. The purpose of the study was to follow up the clinical and functional results of the patients with major acetabular bone defects in revision hip surgery.

Materials and methods. The study was retrospective, over a period of six years (from January 2014 to January 2019), and included all the patients with hip replacement, with major acetabular bone defects, who needed Tantalum blocks substitution.

11 patients were included in the study (8 men and 3 women). The average age was 71 years (between 64 and 78 years old). The average follow up period was 23 months (between 11 and 36 months). Paprosky radiological classification was used for the preoperatory evaluation of the bone defects. In 9 cases, the bone defect was of type 2B Paprosky and in 2 cases, of type 3A. Harris score was determined preoperatory and postoperatory for the appreciation of functional results.

Results. 6 patients were underwent replacement for coxarthrosis secondary to dysplasia, 2 patients for coxarthrosis secondary to aseptic necrosis and 3 patients for primary coxarthrosis.

The average time elapsed from the moment of primary arthroplasty to the need of revision surgery was on average of 13 years (between 7 and 16 years). The postoperatory radiological evaluation showed an improvement of the hip rotation center from an average postoperative vertical position of 3.1 cm (between 1.2 and 4.6 cm) at an average postoperatory position of 1.1 cm (between 0.5 and 2.3). The average result of Harris score postoperatively was 36 (between 39 and 96). During the follow up period, no early loosening, infection or prosthesis dislocation was registered. Conclusions. The Tantalum Augments used in major acetabular bone defects in revision surgery represent a good option, correcting the hip rotation center, thus considerably improving the functional score.

In comparison with other medical specialties, Orthopedics and Traumatology are continuously impressively developing, intrinsically connected to technological evolution. More than in other fields, in Orthopedics and Traumatology, the technological progress becomes obvious also by the frequent use of implants or osteosynthesis materials. By performing a simple search in the specialty literature, an exponential growth of arthroplasty surgeries in correlation with the life span of the population and implying a need that presupposes the increase of the quality of life, also by maintaining or improving mobility at a satisfying level, can be observed. At the same time, due to the increase in the number of traffic and sports accidents, the use of artificial joints and implants for osteosynthesis will constantly rise. The prostheses and the osteosynthesis materials used for the treatment of degenerative, traumatic or even esthetic pathologies are made of materials with a good biocompatibility.

Candida albicans is an optional anaerobic microorganism so the experiments performed with different volumes of environment were most likely influenced by the amount of oxygen, nutrient.

In the described research, we demonstrated that, using microcalorimetry, it is possible to identify this fungus in half the time required for classical microbiological identification. In addition, as our team has shown, there is the possibility of real-time antifungigram by using microcalorimetry.

Introduction. Patellofemoral instability is a troublesome condition that results in significant morbidity, frequently associated with persistent anterior knee pain, long-term osteoarthritis and reduced quality of life.

Purpose. The purpose of this study was to describe functional outcomes following surgical treatment of patients who underwent Elmslie-Trillat procedure and reconstruction of medial patellofemoral ligament (MPFL) correlated with Elmslie-Trillat in the treatment of recurrent patellar dislocation and subluxation.

Methods. We prospectively followed 23 patients (24 knees) with patellofemoral instability who underwent realignment surgery procedures between 2015 and 2017, 14 knees by the Elmslie-Trillat procedure (Group 1) and 10 knees by Elmslie-Trillat combined with MPFL reconstruction (Group 2). The patients were evaluated pre and postoperatively by clinical examination, knee radiographs, CT scans and functional outcome Kujala score.

Results. At a follow up period of 2 years, the apprehension sign remained positive in 6 knees in Group 1, and only one in Group 2. On the skyline radiographs and axial CT scans, stability was significantly better in group 2 than in group 1. The mean Kujala score was 65.2+/ -9.39 points in group 1, and 87.1+/ -6.43 points in group 2, at 2 years evaluation, significantly higher than before surgery. No patient developed osteoarthritis while being followed up.

Conclusion. Based on these findings, we were able to conclude that the reconstruction of the MPFL combined with the osteotomy of distal tuberosity is a useful treatment of recurrent patellar dislocation and subluxation. However, further studies are needed to assess the impact of the realignment procedures in the prevention of joint degeneration.

Bone is a typical location of metastasis that usually reflects a negative outcome in oncologic patients. Once cancer has spread to the bones, it can rarely be cured, but sometimes it can be treated to minimize its rate of proliferation. Most skeletal metastases are produced by tumors originating in the breast and prostate. Osseous metastases are actually much more frequent than primary bone tumors, especially in adults. The diagnosis relies on signs, symptoms, and imaging techniques. This paper is a review of all cases of bone metastasis from our unit and a comprehensive review regarding the clinical approach and treatment of patients with such lesions.

Introduction: In order to diagnose and stage malignant bone tumors, the pathologic examination of harvested pieces with immunohistochemistry test is necessary; they also provide information regarding the prognosis on a medium to long term. Among tissular biomarkers with potential predictive value, a raised Ki-67 protein level is used to determine the risk of local recurrence or metastasis.

Material and method: This study was performed on 50 patients with primary malignant bone tumors admitted in the Traumatology and Orthopedy Department of University Emergency Hospital, Bucharest. Patients repartition according to diagnosis was the following: 21 patients with osteosarcoma, 18 patients with chondrosarcoma, 6 patients with Ewing sarcoma, 3 patients with malignant fibrous histiocytoma, and 2 with fibrosarcoma. The follow-up period was between 12 and 72 months with a mean of 26 months.

Results: Patients were aged between 18 and 77 years old, with a mean age of 41,36. There were 22 women and 28 men. No sex or age difference was notable for the tumor outcome. After calculating the Ki-67 LI, 36 patients were included in the high-risk group (Ki-67 LI > 25%), while 14 had a low risk for metastasis and local relapse (Ki-67 < 25%). The low-risk patients had chondrosarcoma (8 patients), osteosarcoma (5 patients), and fibrosarcoma (1 patient). During the follow-up, 8 patients, all belonging to the high risk group, developed metastasis, while 5 patients developed local recurrences; 4 patients who relapsed belonged to the high risk group and 1 to the low risk group. Metastases developed in 3 patients with osteosarcoma, 2 with Ewing sarcoma, 2 with chondrosarcoma and 1 patient with fibrosarcoma. Most metastases occurred within one year after surgery. The other fibrosarcoma patient developed local recurrence after 6 months, while the other local recurrences occurred in osteosarcoma patients (2 cases) and 1 in a Ewing sarcoma patient and chondrosarcoma patient.

Conclusions: Our study concluded that while Ki-67 LI values are useful in determining the aggressivity of primary malignant bone tumors, it should always be used in conjunction with the clinical, imaging and anatomopathological diagnosis methods in order to accurately predict the patients’ outcome.

Flail chest in a trauma patient presents itself with a number of problems. The mainstay treatment in the past was analgesia with non-operative observation but due to the increased rate of complications, new treatment modalities have been researched. Chest wall plate fixation has emerged as the go-to solution for these patients but consensus lacks regarding when it should be applied, to what category of trauma patients, which technique and which surgical specialty should be the promoter of this technique. All these problems have arisen due to the lack of large prospective studies. A number of these studies are ongoing with results to be published in the near future. Until then, preliminary data have demonstrated the superiority of plate fixation in flail chest in comparison with the non-operative management.

Total joint arthroplasty (TJA) including total hip arthroplasty (THA) and total knee arthroplasty (TKA) are performed for patients with primary osteoarthritis (OA). Also, there are patients who undergo TJA for management of inflammatory arthritis (IA), including patients with rheumatoid arthritis (RA), Spondyloarthritis (SPA) including ankylosing spondylitis (AS) and psoriatic arthritis (PSA) and systemic lupus erythematosus (SLE).

The purpose of this review was to evaluate the current knowledge about the risk of complications after TJA in patients with IA and perioperative management of antirheumatic drugs.

THA and TKA are orthopedic surgeries that help patients with arthritis restore function, mobility and reduce pain. Patients with inflammatory arthritis have systemic disorders that cause a high rate of complications associated with the surgery.

Patients with inflammatory arthritis, including RA, SPA, and SLE who need TJA have a higher risk of developing complications compared to patients with OA.

Information about cardiovascular risk factors and other comorbidities is important to better control and reduce the risk of postoperative complications.

Abbreviations

TJA = total joint arthroplasty, THA = total hip arthroplasty, TKA = total knee arthroplasty, OA = osteoarthritis, SPA = spondyloarthritis, IA = inflammatory arthritis, RA = rheumatoid arthritis, AS = ankylosing spondylitis, PSA = psoriatic arthritis, SLE = systemic lupus erythematosus, DMARDs = Disease-modifying antirheumatic drugs, PJI = prosthetic joint infection, VTE = venous thromboembolism, HCQ = hydroxychloroquine, SSZ = sulfasalazine, TNF = tumor necrosis factor, GS = corticosteroids.

This review of literature classifies and describes the most common periprosthetic fractures after total knee arthroplasty. Classification systems are usually considered useful when they describe the condition and offer guidelines for the management of a certain condition and are specific and comprehensive. The Lewis and Rorabeck classification can be used to describe these fractures.

The review not only provides the results of the classic techniques, but also new and combined techniques tried by some of the authors. For this review, only original studies, published between 2013 and 2019, were selected. The articles included in the database were selected from PubMed, ScienceDirect and SpringerLink. The searched keywords used to identify the articles were TKA, periprosthetic fractures and total knee arthroplasty.

The aim of this paper was to review the clinical studies related to periprosthetic fractures after total knee arthroplasty from the last six years, in order to understand current perspectives, epidemiology, treatment, and management.

In conclusion, periprosthetic fractures after total knee arthroplasty represent an important problem in medicine, but due to the low number of cases. Despite the increase in incidence, guidelines are mostly based on retrospective studies, personal observations, and expert opinion. The consensus is that treatment should be assigned depending on the patient’s profile and the fracture’s characteristics. Further studies should be performed in order to guide future practitioners in the treatment of periprosthetic fractures.

Introduction: Pelvis fractures that associate bleeding with hemodynamic instability warrant immediate treatment. The therapeutic options in these cases vary from angioembolization to extraperitoneal pelvic packing.

Material and method: The P.I.C.O.S guidelines were used to structure the questions and the research topic as to attain clinical validity. The results of the research were filtered in accordance with the PRISMA checklist.

Results: 38 papers were identified. After screening, 27 papers were used to complete the analysis.

Discussion: Frequently, bleeding has a venous source in the pelvis. In the case of pelvic fractures with hemodynamic instability, extraperitoneal pelvic packing is one of the core treatments but not a stand-alone treatment, as it needs to be coupled with a pro-efficient trauma resuscitation protocol. Its intended use is as a bridge therapy until conclusive investigations regarding the place of bleeding can be obtained. Angiography is recommended if hemodynamic instability exists after pelvic packing and effective hemodynamic resuscitation.

Conclusion: Even with all these recent efforts, the wide-use of this therapy is precluded due to the absence of a standardized evaluation of these patients and large multicentric studies.

Introduction. Sarcopenia is a common complication and a frequently encountered feature in liver cirrhosis. Also, sarcopenia is a strong prognosis factor and a predictor of mortality in patients with advanced liver disease. However, in clinical practice, there are no well-established criteria for the diagnosis of this common complication of cirrhosis, the mechanisms which are involved are poorly understood and the possible therapeutic options are still undergoing randomized clinical trials.

Materials and methods. To summarize the actual understanding of sarcopenia in cirrhosis, a literature search was performed using PubMed, MedLine, and Web of Science, to find articles related to definition, physiopathology, and treatment of sarcopenia of these patients.

Results. A number of 30 papers that were suitable for this review were found. Most of them concluded that sarcopenia is a strong predictor of mortality, has a higher risk of hepatic encephalopathy and an increased health related cost in cirrhotic patients. The factors involved in this condition are far more complex than malnutrition and reduced protein intake, and include metabolic switch to the use of amino acids and fats to produce glucose. According to actual guidelines, beside moderate physical exercise and BCAA intake, therapeutic intervention with testosterone and ammonia-lowering therapies might have the potential to reverse sarcopenia in cirrhosis.

Conclusion. Improved understanding of factors such as underlying nutritional imbalances, amount of oral protein intake, dose, type and duration of supplementation and the compliance of physical exercise, should be the focus of further research with randomized controlled trials.

Hallux valgus is one of the most common forefoot pathologies, with a multifactorial etiology that causes important functional impairment and metatarsalgia. The characteristic deformity originates from a biomechanical imbalance induced by the disruption of first metatarsophalangeal joint alignment and manifests as an abnormal weight transfer on the first ray during walking. Conservative treatment is unable to correct the deformity or stop the evolution of the disease but can distinctly control the symptoms. With time, a myriad of surgical correction techniques have been developed but no definitive surgical treatment algorithm has been generally accepted. Nonetheless, the decision process for choosing the suitable technique must be completed on an individual basis after considering the deformity severity stratification, status of the metatarsophalangeal and tarsometatarsal joints, bone anatomy, and associated comorbidities. In spite of a large variety of surgical options, there are a few main strategies that incorporate these variations: metatarsophalangeal and/or tarsometatarsal joint fusion, metatarsal osteotomies and soft tissue procedures. Nowadays, the surgical management of hallux valgus is dominated by first metatarsal osteotomies performed through open surgery or minimally invasive techniques. Hallux valgus angle has been found to be the single most important parameter for surgical outcome prognostic.

Malignant peripheral nerve sheath tumors are a type of soft tissue sarcoma deriving from Schwann cells that usually appear in type 1 neurofibromatosis patients but also sporadically. Tumors frequently interest the nerves in the limbs. They represent a therapeutical challenge due to difficulty of resection and relative radio-resistance and chemo-resistance. The paper aims to describe targeted therapy used in this setting and news concerning the molecular changes that lead to carcinogenesis initiation and promotion. A short selection of literature data was made using PRISMA criteria on this topic. However, due to the rarity and heterogeneity of these tumors, personalized treatment is necessary.