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Cureus Feb 2020Slipped capital femoral epiphysis (SCFE) is a frequent cause of nontraumatic painful hip of the adolescence. It is the result of the separation of the proximal femoral... (Review)
Review
Slipped capital femoral epiphysis (SCFE) is a frequent cause of nontraumatic painful hip of the adolescence. It is the result of the separation of the proximal femoral growth cartilage at the level of the hypertrophic cell zone. The femoral neck metaphysis rotates externally and migrates proximally relative to the femoral head epiphysis, which is stably seated in the acetabulum; early diagnosis and in situ stabilization grants the best long term results. Numerous factors affect treatment outcomes. Not all implants have the same effect on the slipped physis. Application of the traditionally used implants, such as non-threaded pins and cannulated screws, is questioned. Modern implants are available, which stabilize the slip without accelerating physis fusion. This allows femoral head and neck growth and remodeling to limit the post-slip sequellae on hip anatomy and function. Femoroacetabular impingement (FAI) complicates almost all slips. It causes progressive labral and articular cartilage damage and leads to early hip osteoarthritis and total hip replacement, approximately ten years earlier compared to the general population. Avascular necrosis of the femoral head is a dramatic complication, seen almost exclusively in unstable slips. It develops within months after the slip and leads to immediate articular joint degeneration and the need for total hip replacement. Another serious complication of SCFE is chondrolysis, which is a rapid progressive articular cartilage degeneration leading to a narrow joint space and restriction of hip motion. Implant-related complications, such as migration and loosening, may lead to the progression of the slip. Though bilateral disease is quite frequent, there is no consensus about the need for preventive surgery on the healthy contralateral hip. Diagnosis of SCFE is frequently missed or delayed, leading to slips of higher severity. Silent slippage of the capital femoral epiphysis is highly suspected as an underlying cause of cam-type FAI and early-onset hip osteoarthritis. There is controversy, whether asymptomatic implants should be removed. Novel surgical techniques, such as the modified Dunn procedure and hip arthroscopy, seem to be effective modalities for the prevention of FAI in SCFE.
PubMed: 32190446
DOI: 10.7759/cureus.6883 -
Journal of Clinical Medicine Jul 2021Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern.... (Review)
Review
Ulcerative colitis (UC) is an inflammatory condition that generally affects the rectum and extends proximally into the colon in a continuous, distal-to-proximal pattern. Surgical resection (total proctocolectomy) is the only cure for UC and is often necessary in managing complicated or refractory disease. However, recent advances in biologically targeted therapies have resulted in improved disease control, and surgery is required in only a fraction of cases. This ever-increasing array of options for medical management has added complexity to surgical decision-making. In some circumstances, the added time required to ensure failure of medical therapy can delay colectomy in patients who will ultimately need it. Indeed, many patients with severe disease undergo trials of multiple medical therapies prior to considering surgery. In severe cases of UC, continued medical management has been associated with a delay to surgical intervention and higher rates of morbidity and mortality. Biomarkers represent a burgeoning field of research, particularly in inflammatory bowel disease and cancer. This review seeks to highlight the different possible settings for surgery in UC and the role various biomarkers might play in each.
PubMed: 34362144
DOI: 10.3390/jcm10153362 -
Orthopaedic Journal of Sports Medicine Nov 2022Common classification schemes, measurements, and surgical planning for trochlear dysplasia are predicated on 2-dimensional imaging views.
BACKGROUND
Common classification schemes, measurements, and surgical planning for trochlear dysplasia are predicated on 2-dimensional imaging views.
PURPOSE
To investigate patellofemoral joint osseous anatomy using 3-dimensional (3D) printed models to describe osseous anatomic trochlear variations in patients with recurrent patellar dislocation.
STUDY DESIGN
Cross-sectional study; Level of evidence, 3.
METHODS
Computed tomography scans were obtained from 20 patients with recurrent patellar dislocation and 10 healthy control knees, and 3D prints generated from these computed tomography scans were studied with respect to mediolateral positioning of the proximal trochlear groove and groove obliquity as well as changes in the appearance, height, and orientation of the medial and lateral trochlear ridges. Each trochlea was centered with respect to a vertical line perpendicular to the distal femoral condyles and through the central intercondylar notch roof, with the 3D models resting on their posterior femoral condyles. A novel 3D measurement method was devised to assess groove obliquity, termed the entry point-transition point (EP-TP) angle. The EP was defined as the midpoint of the flattened region of the proximal trochlea where the lateral and medial ridges of the proximal trochlea meet, and the TP was the point along the trochlear groove at which the groove shape changes from an oblique orientation proximally to one more vertical distally. Measurements were obtained by 3 reviewers, and reliability analyses were performed.
RESULTS
With the dysplastic knees arranged according to flattening of the trochleas, increased obliquity of the trochlear grooves was observed, as reflected by increased EP-TP angles as well as more lateral patellar EPs into the proximal trochleas of these recurrent patellar dislocation knees when compared with the control knees. The degree of trochlear dysplasia (according to the Dejour classification and trochlear flatness in the frontal and axial planes) was associated with diminished prominence of the lateral trochlear convexity, increasingly lateralized proximal trochlear EPs, increased trochlear groove obliquity, lateral trochlear curvature, and progressive medial ridge deformity.
CONCLUSION
The 3D reproductions enabled unique conceptualization of trochlear deformity associated with recurrent patellar dislocation.
PubMed: 36458105
DOI: 10.1177/23259671221138257 -
Ultrasound in Obstetrics & Gynecology :... Oct 2021Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing...
OBJECTIVE
Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair.
METHODS
This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI.
RESULTS
Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS.
CONCLUSIONS
EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Adult; Anal Canal; Cicatrix; Delivery, Obstetric; Fecal Incontinence; Female; Humans; Pregnancy; Retrospective Studies; Single-Blind Method; Tomography, X-Ray Computed; Ultrasonography; Vulva
PubMed: 34170050
DOI: 10.1002/uog.23719 -
JBJS Essential Surgical Techniques 2022Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities. Many patients want to...
UNLABELLED
Achilles tendon ruptures commonly occur in physically active individuals and drastically alter the ability to perform recreational activities. Many patients want to continue participating in recreational activities, which can be facilitated by operatively treating the injury in a timely fashion, maximizing their functional recovery. The Percutaneous Achilles Repair System (PARS) Jig (Arthrex) can be utilized in patients with acute mid-substance Achilles tendon ruptures.
DESCRIPTION
Begin by positioning the patient prone with a thigh tourniquet on the operative side. Mark a 3-cm transverse incision 1 cm distal to the proximal Achilles stump and make the incision, taking care to protect the sural nerve laterally. Next, create a transverse paratenon incision and bluntly dissect it from the Achilles circumferentially. After gaining access to the proximal Achilles stump, clamp it with an Allis clamp and insert the PARS Jig between the Achilles tendon and paratenon, sliding it proximally to the myotendinous junction. To secure the jig to the proximal Achilles tendon, insert a guide pin into the jig position-1 hole. To pass sutures through the Achilles tendon, insert pins with their respective sutures into positions 2 through 5 and insert the FiberTape suture (Arthrex) in position 1. Remove the jig from the transverse incision, pulling the suture ends out of the incision. Once they are out, reorient the sutures on the medial and lateral sides to match their positions when initially placed. On both sides, wrap the blue suture around the 2 striped green-and-white sutures twice, and pull the blue suture through the looped green-and-white suture on the ipsilateral side. After doing that, fold the blue suture on itself to create a shuttling suture with the green-and-white suture. Next, pull on the medial non-looped green-and-white suture until it has been pulled out medially, and repeat that with the lateral non-looped green-and-white suture until it has been pulled out laterally, to create a locking stitch. Group the medial sutures together and the lateral sutures together, and utilize a free needle to further incorporate both bundles of sutures into the Achilles tendon. Next, create bilateral mini-incisions 1.5 cm proximal to the calcaneal tuberosity. Insert a rigid cannulated suture-passing device into each mini-incision, pass it through the distal Achilles tendon, load the ipsilateral suture bundle into the Nitinol wire, and pull the suture-passing device out the distal mini-incision to approximate the Achilles. To prepare the calcaneus, drill calcaneal tunnels toward the midline bilaterally, taking care to avoid convergence of the tunnels. Place a suture-passing needle in the tunnels to assist with placing the anchors. Next, tension the sutures, cycling them 5 to 10 times to remove any slack in the system. With the ankle in 15° of plantar flexion, anchor the sutures with cortical bioabsorbable interference screws, following the angle that the suture-passing needles are in. After confirming function of the Achilles tendon, close the peritenon, deep tissues, and superficial tissues, and place the ankle in a splint in 15° of plantar flexion.
ALTERNATIVES
Acute Achilles ruptures can be treated operatively or nonoperatively. Operative techniques include open, percutaneous, or minimally invasive Achilles tendon repair. Open Achilles tendon repair involves making a 10-cm posteromedial incision to perform a primary repair, while percutaneous Achilles tendon repair involves the use of medial and lateral mini-incisions to pass needles and sutures into the Achilles tendon to repair it. Minimally invasive Achilles tendon repair involves the use of a small 3 to 4-cm incision to introduce instrumentation such as modified ring forceps or an Achillon device (Integra), along with a percutaneous technique, to repair the Achilles tendon. Nonoperative treatment can be utilized in patients with <5 mm of gapping between the ruptured tendon edges on dynamic ultrasound in 30° of plantar flexion, in patients with limited activity, or in patients whose comorbidities make them high-risk surgical candidates. Nonoperative treatment includes a below-the-knee rigid cast in 30° of plantar flexion or the use of a functional splint in 30° of plantar flexion with gradual progression to a neutral position, along with early rehabilitation according to the postoperative protocol described in the present article.
RATIONALE
This technique allows patients to begin early postoperative rehabilitation, limits wound and soft-tissue complications such as superficial and deep infections, and protects neurovascular structures such as the sural nerve that may be injured if utilizing other techniques. These benefits are achieved through the use of a minimally invasive knotless approach that places nearly all of the suture material into the Achilles tendon, reducing friction within the paratenon and potentially facilitating improved gliding. Additionally, securing the sutures into the calcaneus minimizes postoperative Achilles tendon elongation and facilitates early postoperative rehabilitation.
EXPECTED OUTCOMES
Patients undergoing this procedure can expect to return to their baseline physical activities by 5 months, with the best functional results observed at ≥12 months postoperatively. One retrospective cohort study compared the results of 101 patients who underwent Achilles repair with use of the PARS Jig and 169 patients who underwent open Achilles repair, and found that 98% of PARS patients returned to baseline activities in 5 months compared with 82% of patients undergoing open Achilles repair (p = 0.0001). Another retrospective chart review assessed the results of 19 patients who underwent Achilles repair with the PARS Jig and found that patients began to return to sport as early as 3 months postoperatively and that functional scores in patients increased as time progressed, with significant increases observed at 12 months and longer postoperatively.
IMPORTANT TIPS
Locate the Achilles tendon rupture site prior to marking the transverse incision.Bluntly dissecting the paratenon during closure stimulates healing and reduces scarring, thereby maintaining the integrity of the tissue.When advancing the PARS Jig, ensure that the proximal Achilles tendon remains inside the device.Maintaining meticulous suture management and organization prevents tangles and improves suture shuttling.Ensure that the Achilles tendon is tensioned with the ankle in 15° of plantar flexion prior to distal anchor fixation.
ACRONYMS AND ABBREVIATIONS
MRI = magnetic resonance imagingUS = ultrasoundBID = twice dailyPRN = as neededDVT = deep vein thrombosis.
PubMed: 36816527
DOI: 10.2106/JBJS.ST.21.00050 -
World Journal of Orthopedics Mar 2020The uncemented Arcos Modular Femoral Revision System (ARCOS) is a new comprehensive, press-fit revision design. The modular design offers a wide range of possible...
BACKGROUND
The uncemented Arcos Modular Femoral Revision System (ARCOS) is a new comprehensive, press-fit revision design. The modular design offers a wide range of possible combinations to accommodate different variations of anatomy and bone stock. The ARCOS is made by a proximal body and a distal stem. As probably the only ones worldwide we predominantly use a combination of body and stem which supports proximal fixation and load, since this mimics the concept of the primary total hip arthroplasty with proximal weight-bearing, leading to bone stock preservation and no stress shielding or thigh pain.
AIM
To evaluate the early results after femoral revision in a consecutive series of patients undergoing surgery over 3 years.
METHODS
We included 116 patients in the study. They were operated in the period August 2011 to December 2014 and we got a clinical mean observation time of 4 (0.5-6) years. Clinical and radiographical follow-up included present function of the hip assessed by Harris Hip Score, Oxford Hip Score, and EQ5D (measure of health outcome). Of the 116 patients, 17 died in the interim and were consequently included only in the implant survivorship analysis; 46 patients attended the follow-up control.
RESULTS
In total 6 (5%) hips were re-revised due to infection ( = 3), fracture ( = 2) or subsidence ( = 1). No patient was re-revised due to aseptic loosening. The 1-, 2- and 5-year probability of implant survival (95%CI) were 97% (93%-100%), 97% (93%-100%) and 96% (92%-99%), respectively. In this cohort 95 patients received a combination of a proximal broach and a distal curved and slotted stem (BS), aiming for proximal fixation and load bearing; 21 patients received a different combination. When comparing these two groups the BS-group had a 5-year implant survival probability (95%CI) of 97% (93%-100%) compared with the group of other combinations with a 5-year implant survival probability (95%CI) of 90% (78%-100%) ( = 0.3). Our regression analysis showed that periprosthetic fracture as an indication for the ARCOS operation was the only significant negative outcome predictor. The mean Harris Hip Score result (100 points being best) was 83 (range 5-98). The mean Oxford Hip Score result (48 points being best) was 40 (range 19-48).
CONCLUSION
The early results of the ARCOS are promising compared with similar studies. We encourage the use of the BS combination whenever the bone stock proximally is adequate.
PubMed: 32280606
DOI: 10.5312/wjo.v11.i3.167