Acetabular Migration of Lag Screw of Intramedullary Nail Used as Treatment for Intertrochanteric Fracture. Case Study

Most trochanteric fractures of the femur are classified as low-energy fractures as they are seen in people with decreased mechanical properties of bone tissue. The treatment is assumed to provide biomechanical fixation with the possibility of dynamization between bony fragments to stimulate the biological processes of bone union. The aim of the study was to analyze a complication presenting as migration of the cervical screw of an intra­medullary nail towards the hip joint acetabulum and present the therapeutic management of this complication. The case report concerned a 74-year-old patient with an AO/OTA type 31 A2.2 fracture of the trochanteric massif of the right femur treated with the Gamma3 intramedullary nail. An assessment of changes over time of the radiological appearances on A-P images after the surgery showed migration of the cervical screw towards the acetabulum and displacement of the major trochanter fracture. Extensive destruction of the acetabular fossa made biologic restorative treatment impossible. A total hip joint prosthesis with a modular stem and MDM articulation was implan­ted and the trochanter was fixed with a "hook" plate with a "cable system". The postoperative course was uneventful. Failure to perform axial radiographs in the preoperative and postoperative period made it impossible to objectively determine the type of fracture and the quality of screw insertion into the femoral neck, and assessment limited to A-P images turned out to be deceptive. The wandering of the screw towards the acetabulum led to extensive destruction of the acetabular fossa. The decision to stop biological treatment, which, if properly performed, stimulates bone union, and perform the mechanical procedure of endoprosthesoplasty was fully prognostically justified. The early and late postoperative course was not complicated.

The Use of a Megaprosthesis in the Management of Stem Loosening after Revision Hip Arthroplasty in a Patient with Extensive Femoral Bone Destruction. Case Study

This paper presents the case of a female patient who underwent eleven revision surgeries after primary hip arthroplasty due to infection and loosening of the stem and acetabulum. We decided that in order to save the limb, it was necessary to use a total femur prosthesis. Three years’ follow-up showed that the patient was satis­fied with the outcome of the surgery.

Two-stage Reimplantation in Infected Total Knee Arthroplasty by Using Resterilized Femoral and Tibial Components with a New Polyethylene Insert: Report of 4 Cases with at Least 15 Years’ Follow-up

Background. This study evaluates 15 years’ results of the implantation of autoclaved femoral and tibial prosthesis components together with a new same brand polyethylene insert which were used as a temporary articulating spacer in patients with periprosthetic infection of total knee arthroplasty (TKA) in a two-stage reimplantation procedure in 6 patients. Material and methods. The femoral and tibial prostheses of 6 patients with deep chronic periprosthetic infection of TKA who underwent elective two-stage exchange arthroplasty were autoclaved and reinserted with a new polyethylene insert of the same brand and bone cement mixed with tecoplanin in 2004. Results. Four patients were followed for 15 years. They were all female and between 47-70 years old. The infectious agent was meticillin-resistant Staphylococcus aureus (MRSA) in 3 and coagulase negative Staphy­lococcus in one patient. Patients were invited for second stage reimplantation, but they refused to undergo the second stage. Three of them had their second stage reimplantation after 15, 13 and 10 years while one patient was reinfected after 5 years, in 2009, and arthrodesis was performed. They were all happy with the result and infection free at last follow-up. Conclusions. 1. Regarding the results of our patients, reinsertion of autoclaved femoral and tibial prostheses together with a new same brand polyethylene insert with teicoplanin loaded bone cement can be used cautiously in the management of periprosthetic deep infection of TKA. 2. That is because patients might not want the second stage reimplantation. 3. We believe that the refusal of patients to undergo the surgery shows that the single-stage treatment is effective.

Radiation-free Insertion of Interlocked Intramedullary Tibial Nail in Closed Extra-articular Displaced Tibial Shaft Fractures in an Emergency Setup

Background. Interlocking nailing is considered a gold standard surgical treatment of mid-shaft closed diaphyseal tibial fractures. With increasing exposure of orthopaedic surgeons to radiation, we propose a solution to this health hazard through a study wherein we perform the surgery without any radiation or C-arm exposure. Material and methods. This prospective study was done at GMC Jammu from January 2017 to February 2020 and included 218 patients, with 18 patients having bilateral tibia fractures in the age group 15 to 58 years (mean of 37.6 years), including 63.7% males (n=139) and 36.3% females (n=79). The 236 extra-articular closed tibial mid-diaphyseal fractures were operated on and intramedullary tibial nailing was performed without a single C-arm exposure. Postoperative x-rays were done and reduction assessed by standard acceptable criteria. Results. Among 236 cases in which nailing was done, 227 (96%) patients were successfully distally locked, including 128 (56.3%) locked through the jig and 99 (43.6%) by “hit and trial method.” All cases met acceptability criteria set for management of tibia by nailing. Conclusions. 1.This study strengthens the proof that closed extra-articular diaphyseal fractures of the tibia can be managed by nailing without using the C-arm with excellent results. 2.The C-arm is always available for cases where distal locking could not be achieved. 3. The technique has a great role in centres with limited facilities of intra-operative radiography in emergency operation theatres.

Clinical Presentation and Outcomes of Surgery for Upper Extremity Lipomas

Background. Lipomas are benign neoplasms arising from fat tissue, with an incidence in the upper extremity of 1%-3,8%. There is scarce literature on the outcomes of the treatment of lipomas in this region. The objective of this study was to assess clinical manifestations and outcomes of surgery for upper extremity lipomas. Material and methods. The sample comprised 40 patients, including 26 women (65%) and 14 men (35%), at a mean age of 37 years, with lipomas located in the upper limbs. Treatment outcomes were assessed at a mean of 4.2 years after surgery in 27 patients from this group. Results. Most of the tumours (29 cases, 73%) were located in the forearm and arm, with 11 patients (27%) presenting with lipomas of the metacarpus and wrist. In 35 patients (87%), lesions were located superficially, within subcutaneous tissue, whereas in 5 (13%) they were located more deeply, in the metacarpus and in the forearm muscles. The follow-up assessment was conducted as telephone interviews in 27 patients. No recurrence was noted. Seven patients (26%) complained of mild tenderness of the postoperative scar. Conclusions. 1. Lipomas are moderately frequent benign lesions occurring in the upper limb. 2. Surgical treat­ment is effective and the recurrence rate is very low.

Comparative Assessment of Functional Outcomes of Surgical Treatment in Patients with Distal Radial Fractures

Background. Unstable and comminuted distal radial fractures require surgical treatment by percutaneous insertion of Kir­schner wires, open reduction and fixation with a non-locking or locking plate or with an external device. The aim of this paper was to try to answer the following question: are there differences in functional treatment outcomes in patients after surgery with the use of Kirschner wires vs LCP plate fixation? Material and methods. The study group included 100 patients after surgical treatment by closed reduction and simple fixation with Kirschner wires (50 patients) and by open reduction and LCP locking plate fixation (50 patients). The study assessed the following parameters: global grip strength, pain severity in a VAS scale, range of motion, functional status of the wrist based on the Fernandez classification, quality of life according to the QuickDASH score, and the frequency of complications. These parameters were assessed at 6 and 12 months after surgery. Results. An assessment of the treatment outcomes at 6 and 12 months after surgery showed statistically significant differences between the treatment methods in the following parameters: pain severity, global grip strength and range of motion in the sagittal plane. A comparison of the functional status of the wrist at 6 and 12 months between the groups showed considerably worse results in the Kirschner wire fixation group. The frequency of postoperative complications at 12 months was 6% in the Kirschner wire fixation group and 2% in the LCP plate fixation group. Conclusions. 1. Treatment outcomes were better in patients with distal radial fractures managed with LCP plate fixation. 2. The use of LCP plate fixation predisposes pa­tients to better ranges of mobility in the sagittal plane in the radiocarpal joint. 3.The values of global grip strength were higher in the group treated with LCP plate fixation. 4. Patients treated with LCP plates have better limb function and quality of life and lower pain intensity after treatment completion. 5. The number of complications was higher in pa­tients treated with Kirschner wire fixation.

Lateral Compression Sacral Fractures Have Less Favourable Outcome Compared to Crescent Fractures in Patients Less Than 50 Years Old

Background. Lateral compression (LC) accounts for a wide spectrum of pelvic ring injuries (PRIs). The primary aim of this study was to assess the health-related quality of life outcomes of surgically fixed LC crescent versus sacral fractures in patients less than 50 years old after high energy trauma. Material and methods. We retrospectively reviewed the database for PRIs treated surgically from Decem­ber 2011 to January 2019 at our tertiary level trauma centre. The EuroQoL-5D (EQ5D5L) questionnaire was elec­tronically sent to all patients. Multiple linear regression was conducted to determine the predictors of quality-adjusted life-years (QALYs). Results. The study included 37 patients. The mean age was 26 SD 9.46 years. The mean duration of follow-up was 3.78 (r:1-9) years. Twenty-one (56.8%) and 16 (43.2%) patients sustained sacral fractures and crescent fractures, respectively. Multi-regression analysis showed that any patient with LC injury without a sacral fracture is expected to have a utility value of QALY= 0.876. A reduction of 0.072 units in QALYs is expected in the presence of sacral fracture. About 71% of patients with sacral fractures were able to return to work and this probability increased by 40% among patients with crescent fractures (RR=1.4, p=.015). Conclusions. 1. Younger patients with crescent fractures tend to have better quality of life (higher EQ5D and QALYs) compared to those with LC sacral fractures. 2. Moreover, patients with LC sacral fractures have less chan­ce to return to their pre-injury level of work compared to those with crescent fractures.

Foot Macrodactyly Associated with Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome is a rare congenital malformation which may be associated with macrodactyly. The main problem is the need for custom-made shoes. We describe the case of a female newborn affected by Klippel-Trenaunay syndrome, with a larger and longer right foot; the difference increased progressively and, at 5 years of age, the right foot was 50% larger and 38% longer than the left one. Due to the progression of the deformity, reduction surgery was advised to reduce the foot’s width. Resection of the second ray and 2nd cuneiform was performed. The result was excellent and there were no complications during a 10-year follow-up period with a decrease of width and length difference to 10% and 4%, respectively, in comparison to the contralateral foot. There were no gait anomalies. Abnormal foot width and length represented the main problems and guided the surgical strategy. Second ray resection was effective, without complications and with a good long-term functional outcome. Possibility of wearing fashionable conventional shoes without insoles was achieved to the patient’s satisfaction

Legal and Normative Requirements Related to Medical Devices for Individual Supply in Clinical Practice

This article has the form of a communication presenting recent legal changes in relation to medical devices. Until 26 May 2021, three medical directives were in force, namely Directive 98/79 / EC, Council Directive 93/42/ EEC and Council Directive 90/385 / EEC. They have been replaced by two regulations: Regulation (EU) 2017/745 on medical devices and Regulation (EU) 2017/746 on in vitro diagnostic medical devices. The article presents the reasons for introducing the changes and the new obligations that these changes bring for manufacturers of medical devices, in particular, products manufactured individually on a special order as necessary for the implementation of personalized therapies in clinical practice. There are also forecasts for the industry and end users of medical devices manufactured to order and used individually at medical centers.

Treatment of acetabular fractures in paediatric patients

Background. Acetabular fractures are rare in children, constituting approximately 1–4.6% of all paediatric fractures. Material and methods. Nine patients (4 girls and 5 boys) with a mean age of 14.5 years (range, 12–16.5 years) were treated due to acetabular fractures between 2000 and 2020. Most of the fractures were caused by road accidents. Before the patients were qualified for treatment, they underwent a CT scan (all patients) and an MRI scan (8 patients) of the hip. Surgical treatment was used in 6 patients while the other 2 were managed conservatively. Results. Mean follow-up period was 6.2 years (range, 2–10 years). Bone union was achieved in all patients after 76 days on average (range, 65–90 days). The mean Merle d’Aubigne score at 12 months after treatment was 17.1 points (range, 13–18 points). Conclusions. The treatment of acetabular fractures in paediatric patients during or after puberty may be the same as in adults. An MRI scan of the hip joint is recommended for assessing the fracture, particularly the triradiate cartilage.