Tibial plateau fractures in a limited-resource setting: A prospective study of surgical techniques and outcome over three years

Introduction: Tibial plateau fractures form a wide spectrum of injuries accounting for 1.2% of all fractures and a prevalence of 10 cases per 100,000 inhabitants. Methodology: A prospective consecutive multicentre study from May 2018 to May 2021 was carried out in Yaounde. All consenting cases of tibial plateau fracture underwent surgical treatment while patients with pathologic fractures, previous knee osteoarthritis, medically unfit for surgery, and discharging against medical advice were excluded. Data was analysed with SPSS 26.0 and the level of significance set at p<0.05. Results:Eighty-four (84) cases of tibial plateau fractures were sampled and 68 consented to surgery. The mean age was 42 ±13.6 years and sex ratio 2.4. Estimated prevalence was 2.2 cases per 100,000 inhabitants. Schatzker type II fractures were most represented (33.3%). The left leg was affected in 57.1%. Motorbike accidents were the main cause of injury (66.7%). Of the 68 operated, 63.3% by plating osteosynthesis, 32.4% by external fixation, and 4.4% by screws fixation. Tricortical iliac bone graft was realised in 4 cases. The minimum follow-up was 6 months, with a median of 18 months (5 to 37 months). Plating osteosynthesis (p<0.001), operative time between 60 to 120 minutes (p<0.02) and a good radiologic fracture healing (p<0.04) were associated with a satisfactory outcome. Poor prognosis was seen with open fractures (p<0.001), bridging external fixation (p<0.001), and Schatzker VI fractures (p<0.02). Complications included post-traumatic osteoarthritis (64.7%), post-traumatic osteomyelitis (29.4%), knee ankylosis (5.9%), and limb malalignment (30.9%). Conclusion:The prevalence of tibial plateau fractures remains lower than reported in literature but it is projected to rise. Plating remains a viable treatment option. A larger scale study will establish the burden of this entity in our context.

Indications and Outcomes of the Kocher-Langenbeck Surgical Approach in the Management of Acetabular Fractures in a Resource Limited Setting

The Kocher-Langenbeck (K-L) approach is the ‘workhorse’ of surgery for acetabular fractures needing posterior fixation. It is indicated for most of these fractures for proper surgical technique and optimal outcome. We therefore evaluated the outcome of surgically treated acetabular fractures through the K-L approach in our setting with limited resources. 57 patients were operated by the K-L approach during the 3-year study period. The most common indications of this approach were: posterior wall (38.6%) and transverse + posterior wall fractures (36.8%). Based on Matta’s criteria of fracture reduction, 81 % were judged anatomic, 16% imperfect and 3 % poor. A surgery waiting time of 8 to 14 days after injury, significantly favoured anatomic fracture reduction. The MAP score was excellent in 72 % and unacceptable in 10.6 %. Factors associated with poor outcomes were poor fracture reduction and the development of early post-operative complications. Iatrogenic sciatic nerve palsy (ISNP) was the most significant post-operative complication (19.3%). The levering of Hohmann retractors in the sciatic notches was the major risk factor for developing ISNP, compared to the use of sciatic nerve retractors. Other early and late complications included surgical site infections (12.3%) and heterotopic ossification (8.8 %), respectively. The overall outcome following surgery by the K-L approach is satisfactory. However, there is need to ameliorate the technique, especially at the level of instrumentation, to limit post-operative complications.

SINGLE STAGE KNEE ARTHROPLASTY REVISION SURGERY, OUR EXPERIENCE WITH ELEVEN CASES AND REVIEW OF THE LITERATURE

Knee replacement is a widely performed and very successful procedure for the management of knee arthritis. Nevertheless, it is postulated that a total of 2-5% of primary and revision total knee arthroplasties (TKAs) is infected every year [1,2]. Despite the low incidence, the absolute numbers of prosthetic joint infections (PJIs) are growing, owing to an increased number of replacement surgeries, and are associated with significant morbidity and socioeconomic burden [3,4]. Although several definitions of PJI exist, Musculoskeletal Infection’s Society (MSIS) definition is based on strict criteria and is one of the most used [5]. Patients with certain risk factors have an increased risk to develop PJI [6,7]. Risk factors include presence of systemic or local active infection in an arthritic knee; previous operative procedures in the same knee, diabetes mellitus, malnutrition, smoking, alcohol consumption, co-morbidities, and immunosuppression; end-stage renal disease on hemodialysis, liver disease, intravenous drug abuse, and low safety operative room environment. PJIs are classified according to the depth of infection, to superficial and deep infections. Superficial infections are limited to the incision and superficial tissues, while deep infections, that involve deep layers, may occur up to one year postoperatively, and influence surgical management strategy. Timing of infection is also an important factor in guiding treatment. PJIs are classified to acute postoperative, within a month of the index procedure, acute haematogenous, presenting with acute symptoms in a previously well – functioning joint, and late chronic, where infection develops later than one month postoperatively [8]. Management of PJI’s is mainly surgical, reserving conservative treatment for patients unable to undergo surgery [9]. Surgical options include debridement and retention of the prosthetic implants (DAIR), two – stage exchange revision, single – stage exchange revision, permanent resection arthroplasty, and finally amputation as the last measure [10]. DAIR is a viable option in early stages of acute infections, but established chronic infections necessitate more radical methods. Two – stage revision that was originally described by Install [11], secondly modified through the development of static spacers [12], and then articulating spacers [13], is considered the gold standard of TKA infection management [14]. A large volume of literature reports successful eradication of PJIs in more than 90% of patients using this approach [15,16,17]. Nevertheless, this procedure is costly, time-consuming, develops stiffness, arthrofibrosis, impairs mobility and increases inpatient stay. Single-stage revision arthroplasty for infection was first described in the 1980s [18, 19], has gained popularity for use in selected patients [20]. Infection control using this approach is achieved in 67% to 95% of patients [21, 22, 23, 24]. Furthermore, it is associated with less patient morbidity, improving functional outcome and reducing cost [25, 20]. This paper seeks to systematically review the results of using single – stage revision arthroplasty for chronic infection of TKAs. Furthermore, we report our experience with eleven cases of chronic knee arthroplasty infection, which were treated with the aforementioned technique.

An isolated pilomatricoma of the leg: a rare location – A Case Study

Pilomatricoma is a rare, benign skin tumour arising from the hair matrix. The usual locations are the head and neck. Localization in the lower limbs is exceptional. The diagnosis of certainty is histological. Treatment is complete surgical removal to avoid recurrence. We report in this article the case of a rare localization of a pilomatricoma on the right leg, in a 25-year-old patient operated with complete surgical removal. The postoperative course was simple and without recurrence after 2 months of follow-up.

Motion and its Effects on the Cement Mantle – A Biomechanical Analysis of Femoral Stem Displacement during Implant Cementation

Background: It is a common notion that motion of a femoral component during cementation should be avoided as it may weaken the cement mantle. We created an in vitro model of cemented femoral components and subjected them to varying rotational motion during the cement curing process, to measure the effect on the pullout strength of the stem. Methods: 21 sawbones femurs were separated into four groups. The first group served as control and was cemented in a standard fashion. The remainder of the stems were divided into groups and subjected to angular rotational displacement within the cement mantle during curing . Anteroposterior and lateral radiographs were obtained of each model to evaluate for cement defects. Pullout strength testing was performed. Results: Despite rotational displacement, no cement defects were noted on imaging. The control stems showed an average pullout strength of 3735.79N. The experimental groups showed a trend for lower failure loads but it was not statistically significant (P=0.063). Of the 21 stems tested, three encountered cement mantle failure and associated stem pullout and the remainder failed by peripros-thetic fracture. Conclusion: Despite conventional thinking that rotational displacement during the cementing process leading to disruption of the cement mantle integrity, this was not borne out in our study. This should give surgeons confidence that in the set-ting of unintended rotational displacement of a femoral stem, returning the stem to its original position does not significantly compromise the integrity of the cement mantle or the pullout strength of the femoral implant. Small displacement of the femoral stem with prompt correction during cement curing does not cause evident cement mantle defects or a loss of femoral stem pullout strength.

CURRENT STATUS OF DIAGNOSIS AND TREATMENT OF FEMORAL NECK FRACTURES IN THE ELDERLY

Femoral neck fractures are common fractures in the elderly, especially in elderly women. There are many mature treatment methods for femoral neck fractures. However, which option is better is still controversial. In order to allow clinicians to better develop treatment plans for elderly patients with femoral neck fractures, this article summarizes the diagnosis and treatment status of elderly femoral neck fractures from the aspects of epidemiology, etiology and diagnosis, treatment methods and progress of elderly femoral neck fractures.

Treatment sequence of combined pelvic injury, consisted of upper pubic ramus fracture, sacroiliac joint dislocation with open book injury, using Stoppa approach

Among pelvic serious injuries is the so-called “open book” injury of the pelvis, with Sacroiliac Joint Disruption (SIJD) in combination with upper pubic ramus or anterior column fracture, contralateral or ipsilateral, or both. This combination of pelvic injury could be classified according Young and Burgess classification as LCIII or CM type (Combined Mechanism) and as 61-B3.1 61-B3.2 following AO/OTA classification. Specifically, the upper pubic ramus fracture can be classified according to Nakatani classification as type I medial of the foramen, type II within the foramen and type III lateral to the foramen. The difficulty to deal with these fractures is how to close and reduct the pubic symphysis in mechanically stable way since there is fracture in one or both the upper pubic ramus. The existence of these fractured elements, in this type of pelvis injury allow a lot of degrees of freedom which must be managed from the surgeon in the proper sequence. The incision and the approach are also mandatory for successfully treating these lesions. Anterior Intrapelvic Approach (AIP) or Stoppa approach in conjunction with the first window of ilioinguinal approach is the most appropriate surgical exposure for reduction and fixation.

EFFECTIVENESS OF CONDROPROTECTORS IN TREATING OSTEOARTHRITIS: A BIBLIOGRAPHIC REVIEW

Introduction: Osteoarthritis (OA) is the most common rheumatologic disease in the world and the elderly are the most affected, although there is no defined age for its onset. Obesity is a risk factor, with healthy eating habits and physical exercise practices being recommended for treatment and prevention. The pharmacological treatment for OA is oral chondroprotective agents and viscosupplements, although anti-inflammatory drugs are widely prescribed, they do not cause clinical improvement, they only treat the symptoms of the disease. Objective: This study gathered articles from clinical trials in Brazil with the purpose of investigating whether the pharmacological treatments used are effective. Methods: The electronic platforms used for data collection were: Scielo, CAPES Journal Portal and Google Academic. Articles published in the last six years with clinical trials in Brazil were considered. Articles involving surgeries, those that used physiotherapy as an adjunct therapy and those that used animal or non-human research in their research were excluded. The search was through the descriptors: hyaluronic acid, glucosamine and chondroitin. Results: The search resulted in six articles, in which three were used chondroprotectors and the other three viscosupplements. Chondroprotectors were effective in 66.66% of clinical trials and viscosupplements in 100%. Conclusion: Pharmacological treatments for OA showed high efficacy, however the sample of the present work was small, thus, further studies are needed to confirm the results obtained.

Open Latarjet procedure for the management of anterior instability of the glenohumeral joint

We report in the light of a literature review the results of 10 patients followed for anterior instability of the gleno-humeral joint treated by open Latarjet procedure between January 2017 and December 2020 with a view to a prospective study with longer following up and a greater number of patients.

Foot and Ankle Characteristics in Gout: A Systematic Review

Objectives: Gout has a predilection for the foot and ankle, but the impact of gout has limited presence in the literature. The aim of this systematic review was to synthesise existing literature which has investigated the characteristics of foot and ankle involvement in gout; identifying consensus and highlighting areas for further study. Methods: Studies were included if they were published in English and involved participants over 18 years of age with gout, and presented original findings relating to outcome measures associated with the foot and ankle. Methodological quality was assessed using a modified version of the Quality Index Tool. Results. Of 707 studies identified, 16 met the inclusion criteria and were included in this review. The mean (range) quality score was 68.1% (38.9%-88.9%). Compared to controls, participants with gout reported higher levels of activity limitation, foot-related pain and disability and walked more slowly. Plain radiography, dual-energy Computer Tomography and diagnostic ultrasound consistently demonstrated pathological features of gout in the first metatarsophalangeal joint and Achilles tendon. However, studies offered limited quality, particularly around recruitment strategies, validity and potential impact of confounding factors, making definitive statements difficult. Conclusions: This systematic review highlights the negative impact of gout on the structure and function of the foot and ankle causing significant impairment and disability. To effectively guide management, improvements in methodological quality are recommended.