Volumen 3 (2020): Edición 1 (June 2020)

Epidermoid bone inclusion cysts are pathological structures bordered by a layer of stratified squamous epithelium containing keratin debris. They are also called epidermal bone cysts. Intraosseous epidermoid cysts are rare entities; these lesions may occur as a result of trauma (puncture wound or pressure erosion).

They appear to be well defined, translucent lytic lesions with sclerotic margins on imaging studies. The most frequent sites affected are: the distal phalanx and the calvaria - intradiploic, but a few cases of larger bone involvement have been reported. The imagistic differential diagnosis of this lesion includes intraosseous extension of a glomus tumor, enchondroma, osteoid osteoma, acral metastases, some primary vascular bone tumors, giant cell reparative granuloma, subungual nodular melanoma or other lytic non-neoplastic lesions such as osteomyelitis. We present the case of a 70-year-old man experiencing anxiety and pain due to distal phalanx expansion of the IV digit, following hand trauma. An X-ray was performed, showing a radiotransparent lesion located in the distal phalanx. An intramedullary inclusion cyst must be taken into account as a clinical differential diagnosis. Due to the extensive destruction of the distal phalanx, amputation was necessary. Gross examination of the surgical specimen revealed a cystic lesion that contained whitish, creamy material with extensive necrotic areas. Microscopic examination revealed a ruptured intraosseous epidermoid inclusion cyst, which was successfully excised.

Introduction: Myxofibrosarcoma is a rare subtype of soft tissue sarcoma with a locally infiltrative behavior and ability to determine distant metastases.

Materials and methods: We presented two myxofibrosarcoma cases who benefited from segmental or radical resection.

Management and outcome: In the case of the 80-year-old woman, with grade 3 myxofibrosarcoma, we practiced radical surgery with scapulohumeral disarticulation followed by adjuvant radiotherapy.

The therapeutic option for the 77-year-old man with grade 2 myxofibrosarcoma was segmental resection followed by adjuvant radiotherapy. After three months, the patient was in a good clinical condition with no sign of local recurrence, but with the presence of pulmonary metastases for the patient who benefited of segmental resection.

Discussion: The radical resection had better short-term results, with no local or distant metastases at three months after surgery, although the tumor had a higher grade (G3), compared to segmental resection practiced for a lower grade tumor (G2), in which case the patient developed pulmonary metastasis at three months follow up.

Conclusion: Myxofibrosarcoma represents a challenging situation regarding the management due to its unpredictive clinical course. Our cases raised the following question: should we consider treating it more aggressively in order to obtain good local control and reduce the risk of metastasis?

Introduction: The aim of the study was to report the clinical and functional outcomes in patients undergoing limb salvage with various reconstruction techniques in primary malignant bone tumor.

Materials and methods: This study was performed between 2011 and 2018 on 52 patients with primary malignant bone tumors admitted to the Department of Orthopaedics and Traumatology of University Emergency Hospital, Bucharest. All the patients underwent surgical treatment (resection-reconstruction technique) followed by oncologic therapy. The mean follow-up was 3 years and 8 months and the minimum follow-up was 12 months.

Results: The best results were obtained in patients in whom resection of the tumor followed by reconstruction was possible, without affecting the adjacent joint through arthrodesis or arthroplasty. These patients had an average MSTS score of 75.2%. The patients who underwent reconstruction procedures by endoprosthesis also had good results with an average MSTS score of 72.3%, while patients with arthrodesis obtained rather modest results – the average MSTS score being 67.3%. When taking into consideration the location of tumors, the best MSTS scores were obtained in patients with tumors of the distal radius – 80%, followed by femoral and humeral diaphysis – 75.6%, distal femur – 75.2%, proximal femur – 73.3%, proximal humerus – 72.3%, tibial diaphysis – 72.2%, distal tibia – 70% and proximal tibia 68.7%.

Conclusions: The orthopedist must judiciously chose the surgical technique, taking into consideration the anatomical particularities and the needs of the patient. Given the functional results and the emotional acceptability, reconstruction with tumor prosthesis represents the first option.

Introduction: Lateral patellar dislocation (LPD) is a common injury of the knee, most frequent in young patients. It has a multifactorial etiology with several underlying risk factors. In most cases, patellar dislocation occurs on the lateral side, with the rupture of the medial patellofemoral ligament (MPFL), appearing in more than 80% of the cases. The tibial tuberosity-trochlear groove (TT-TG) distance of 20 mm or more in patients with lateral patellar dislocation is a gold standard for the surgical indication of tibial tubercle osteotomy (TTO).

Hypothesis: Our investigation aimed to establish whether there is a correlation between the TT-TG distance and other bony landmarks, like trochlear groove medialization, tibial tuberosity lateralization, and knee rotation angle, in the surgical algorithm for the patient with patellar dislocation.

Methods: We conducted a prospective study, analyzing and comparing data from two groups, 33 patients with a diagnosis of patellar dislocation, and a control group of 30 patients, with meniscal injury, but healthy contralateral limb. Using computed tomography, we measured the TT-TG distance, femoral anteversion, tibial torsion, knee rotation angle, tuberosity lateralization, and trochlear groove medialization of all the patients in our study. The measurements were conducted by two independent orthopedic surgeons in a randomized manner. Using an unpaired t test, we compared and analyzed each parameters value from the study and the control group.

Results: Comparing the two groups, we observed a significant difference for TT-TG distance, knee rotation angle and tibial tuberosity lateralization with higher values in the study group compared to the control group (CI 95% 6.44-9.72, CI 95% 8.64-10.39, CI 95% 3.77-5.46, respectively), with a p value < 0.0001 in all cases. Also, the TT-TG distance positively correlated with knee rotation angle (r=.97, p=0.01) and tibial tuberosity lateralization (r=.86, p=0.0001) in the study group.

Conclusions: The TT-TG distance measurement usually defines the lateralization of the tibial tuberosity; yet, in some cases, it can be caused by the trochlear groove medialization, or high rotation between the femur and tibia. Our study revealed that knee rotation and tuberosity lateralization were factors implicated in patellar dislocation and they should be taken into account when making the decision of tibial tubercle osteotomy.

Amputation of the limb is a major psychological health issue that was not fully studied. Patients and their families struggle with symptoms of depression, posttraumatic stress disorder, anxiety, phantom limb phenomena, etc. There is also a tremendous impact on the person’s quality of life.

Aim: This study aimed to assess the psychological symptoms of depression, anxiety, and the quality of life among persons suffering from amputation of the limb.

Methods: 31 respondents agreed to participate in the study. They were recruited from the Department of Orthopaedics and Traumatology, University Emergency Hospital, Bucharest, Romania. The medical conditions and the socio-demographic data (i.e., gender, marital status, income, etc.) along with the assessment of the psychological conditions and quality of life were contributions to the statistical analysis of the study.

Results: This study showed that levels of depression are moderate to severe for a significant percent of the population (i.e., a “moderate to severe” or “severe” level of depression was presented by 29% of the patients according to the PHQ-9 test, and 16.1% of the patients according to Beck’s Depression Inventory). Moreover, the levels of anxiety were relatively higher than those of the general population (i.e., severe anxiety was confirmed by the GAD-7 test in the case of 38.7% of the patients) and for most of them the quality of life was impaired.

Discussion: Amputation occurs mainly in adults/elderly aged over 50 years, married, living in urban areas, with different levels of depression and anxiety. At least half of them had a self-perceived health condition that was deteriorated, their physical and role functioning being primarily affected.

Conclusion: There is a need for psychological support of the patients suffering from limb amputation as most of the studies showed high prevalence of depression and anxiety. Socio-demographic factors also represent important elements in defining the quality of life of those patients.

Introduction. Over the last few years, lower limb amputations have represented a prevalent worldwide burden in the evolution of diabetic patients, but at what extent this burden affects the Roma population compared to Caucasians in Romania still needs further comprehension.

Aim. The purpose of this study was to assess the prevalence of lower extremities amputations in a Roma population, compared to a Caucasian population, in the presence of diabetes mellitus (DM), as well as to identify the risk factors associated.

Materials and methods. We included 536 patients, of whom 257 Roma subjects and 279 Romanian Caucasians, with the following socio-demographic status: the Roma group included 123 women (48.1%) and 134 men (51.9%), aged between 18 and 86 years, while the Caucasian group registered 107 women (47.9%) and 172 men (61.6%), aged between 18 and 89 years.

Results. Analyzing the whole group, the prevalence of amputations was 5% (n=27). A greater proportion of amputations was found in Romanian Caucasians (n=21, 7.5%), where there were 17 men (9.9%) and 4 women (3.7%) affected, compared to the Roma population (n=6, 2.3%), where all amputations occurred in men. Noticeably, this complication is more predominantly afflicting men.

Conclusions. Non-traumatic lower extremity amputation remains a challenge today in the care of diabetic patients. In our study, higher rates of amputations were observed in Romanian Caucasians, in comparison with the Roma population. Apart from this, this condition was accompanied by many cardiovascular risk factors.

Due to its anatomical position, traumatic lesions of the pancreas are rare and difficult to diagnose. Diagnosis time is paramount as an increase in duration translates into an increase in morbidity and mortality. Duct lesions are hard to identify on CT, ERCP being the investigation of choice but it is difficult to obtain as it requires highly specialized staff and equipment. Intraoperative macroscopic and palpatory evaluation of the pancreas in a trauma patient should be elective no matter what other lesions are present. The treatment is mainly dictated by this evaluation and is defined as it follows: stage I and II usually require a conservative approach; stage III, IV, and V usually imply resection of the pancreas although recent advances in conservative management have been made through ERCP and pancreatic duct stenting. In these stages, intraoperative evaluation should ensure the ampulla is intact if the head of the pancreas is not resected. Serum amylase and lipase levels do not offer a concrete direction towards a pancreatic lesion. Currently, there is no standard surgical treatment for these stages thus making intraoperative evaluation mandatory. One must remember that post-traumatic pancreatitis exists, which becomes apparent days after the accident.

Interventions in the field of orthopedics and traumatology involve more and more the frequent use of osteosynthesis materials and prostheses. Therefore, an increasing number of patients live with these implants, having an increased risk in comparison to the general population to develop complications. Although technological developments have brought this change for the better, it must not be forgotten that these foreign materials come with certain risks, the most feared being the associated infections.

For this article, we conducted an epidemiological study on infections identified in patients treated in the Orthopedics and Traumatology Department of University Emergency Hospital in Bucharest, from 01.01.2016 to 01.06.2019. We were able to extract data about patients without neglecting their confidentiality.

The information sought, primarily involved the pathogen causing the infection and its antibiogram, but at the same time we tried to build a more accurate history of each patient in order to determine the cause of infection and the risks posed by various associated pathologies. During these 4 years we were able to identify 139 patients who suffered an infection in the musculoskeletal system. In most cases we identified unimicrobial infections, but there were 7 cases in which two pathogens were identified.

Mesenteric lesions in abdominal trauma are encountered in 3% of the cases. Diagnosis of these lesions is difficult, which translates into important delays until surgery that affects patient survival. The short-term consequences of mesenteric lesions translate in bowel ischemia or important blood loss. If a lesion is confirmed after imagistic investigations, one must have complete knowledge of the anatomy and the particular distribution of the main arterial and venous trunks to predict the region of the small bowel that will have to be observed or resected if surgery is required. The aim of our study was to demonstrate this particular distribution of blood vessels through cadaver dissection and to note the resources available to diagnose such lesions.

Objectives: Gout is the most common inflammatory arthritis of the 21 century, but is still frequently misdiagnosed. This review aims to provide guidance for gout management in clinical practice, which includes the diagnosis, treatment of acute episodes, but also long-term therapy to reduce serum urate, as well as lifestyle changes and prevention of recurrent episodes.

Design: Systematic review without meta-analysis.

Methods: We have systematically searched Google Scholar, PubMed, and all relevant worldwide guidelines to identify and select clinical guidelines for gout. We have included eligible gout articles according to predefined inclusion and exclusion criteria after selecting titles, abstracts and full texts. The characteristics of the recommendations reported in the guidelines included were extracted and analyzed.

Results: We selected 27 eligible papers and tried to facilitate the identification of recommendations for the treatment of gout in the acute phase, but also in the chronic phase. The recommendations were detailed and explained during this extensive review.

Conclusions: Despite the availability of effective serum urate reduction therapies, overall gout management is poor. Achieving therapeutic goals is often low both at the initiation of therapy and in long-term treatment. Optimal strategies for managing gout are necessary in both acute and chronic gout flames in patients who are prone to the development of this pathology.