Bibliometric analysis of research on the effects of human immunodeficiency virus in orthopaedic and trauma surgery

BACKGROUND There is little research investigating how human immunodeficiency virus(HIV)affects outcomes in orthopaedic surgery.With advances in treatment,HIV has become a chronic health problem and the chance of orthopaedic surgeons encountering it in clinical practice is increasing.AIM To ascertain the quantity and quality of peer-reviewed publications in orthopaedic journals about HIV.METHODS A search of the Web of Science database was carried out,identifying any articles relating to HIV published in orthopaedic journals.These were assessed for geographic origin and level of evidence.RESULTS Of 48.7%of orthopaedic journals listed on the Web of Science database had published articles relating to HIV.There were 168 articles about HIV in orthopaedic journals with only 40.5%(n=68)published in the time frame we analysed(January 2007 to September 2017).Very few articles came from lowincome countries and any articles published from that setting were collaborations.All of the articles were low level of evidence.CONCLUSION There is a need for more high level orthopaedic and trauma research investigating the effects of HIV,particularly research from low-income countries,where higher level research will help to guide improvements in their treatment of its musculoskeletal manifestations and complications.

Evaluation of Some Treatment Options Inlate and Neglected Hip Fractures Using the Modified Harris Hip Score

Background: The choice of the appropriate operative intervention in patients with late and neglected hip fracture continuous to be a huge dilemma for orthopedic surgeons. Purpose: To evaluate the satisfaction or otherwise of some treatment options using the modified Harris-hip score (HHS) in resource poor setting. Materials and Methods: A retrospective cross-sectional study conducted at ATBUTH, Bauchi. Data of 60 patients over the age of 18 years with hip fractures (femoral neck, intertrochanteric and sub trochanteric fractures) who had operative intervention between 1st September 2019 and 31st August 2020 with cannulated screws, Proximal femur lock compression plate (PFLCP), cementlessor cemented bipolar hemiarthroplasty (BHA). Results: The mean age of studied patients was 65.7 ± 16.1 years, with age ranging from 19 - 101 years. M:F ratio was 1.2:1 across all age groups and 1:1.4 amongst those >60 years. 51 patients (85%) presented > 1 week after injury with 24 patients (40%) sustaining hip fractures from low energy trivial indoor fall and 28 patients (46.7%) mostly younger sustaining fractures from high energy motor vehicular accident (MVA). The prevalence rate for femoral neck, intertrochanteric and subtrochanteric fractures were 32 (53.3%), 17 (28.3%) and 11 (18.3%) respectively. From the data retrieved, 21patients (35.0%), 17 patients (28.3%), 20 patients (33.3%) and 2 patients (3.3%) had PFLCP, cemented BHA, cementless BHA and cannulated screw fixation respectively. Most (66.7%) of those who had PFLCP achieved satisfactory radiologic union and there was also 94.1% and 85% satisfactory outcome rate amongst the patients with cemented BHA and cementless BHA respectively. Irrespective of the operative intervention method at 1 year follow-up, there was a statistically significant improvement in post-operative HHS (P value 0.02), with 83.4% having good to excellent results. Conclusion: There is highrate of late and neglected hip fracture in our environment. Satisfactory outcome with statistically significant improvement in Post-operative HHS was achieved in patients treated for hip fractures.

Return to sport following tibial plateau fractures: A systematic review

AIM To systemically review all studies reporting return to sport following tibial plateau fracture, in order to provide information on return rates and times to sport, and to assess variations in sporting outcome for different treatment methods.METHODS A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, MEDLINE, PEDro, Scopus, SPORTDiscus and Web of Science was performed in January 2017 using the keywords "tibial", "plateau", "fractures", "knee", "athletes", "sports", "non-operative", "conservative", "operative", "return to sport". All studies which recorded return rates and times to sport following tibial plateau fractures were included. RESULTS Twenty-seven studies were included: 1 was a randomised controlled trial, 7 were prospective cohort studies, 16 were retrospective cohort studies, 3 were case series. One study reported on the outcome of conservative management(n = 3); 27 reported on the outcome of surgical management(n = 917). Nine studies reported on Open Reduction Internal Fixation(ORIF)(n = 193), 11 on Arthroscopic-Assisted Reduction Internal Fixation(ARIF)(n = 253) and 7 on Frame-Assisted Fixation(FRAME)(n = 262). All studies recorded "return to sport"rates. Only one study recorded a "return to sport" time. The return rate to sport for the total cohort was 70%. For the conservatively-managed fractures, the return rate was 100%. For the surgically-managed fractures, the return rate was 70%. For fractures managed with ORIF, the return rate was 60%. For fractures managed with ARIF, the return rate was 83%. For fractures managed with FRAME was 52%. The return rate for ARIF was found to be significantly greater than that for ORIF(OR 3.22, 95%CI: 2.09-4.97, P < 0.001) and for FRAME(OR 4.33, 95%CI: 2.89-6.50, P < 0.001). No difference was found between the return rates for ORIF and FRAME(OR 1.35, 95%CI: 0.92-1.96, P = 0.122). The recorded return time was 6.9 mo(median), from a study reporting on ORIF.CONCLUSION Return rates to sport for tibial plateau fractures remain limited compared to other fractures. ARIF provides the best return rates. There is limited data regarding return times to sport. Further research is required to determine return times to sport, and to improve return rates to sport, through treatment and rehabilitation optimisation.

Lower limb stress fractures in sport:Optimising their management and outcome

Stress fractures in sport are becoming increasing more common,comprising up to 10%of all of sporting injuries.Around 90%of such injuries are located in the lower limb.This articles aims to define the optimal management of lower limb stress fractures in the athlete,with a view to maximise return rates and minimise return times to sport.Treatment planning of this condition is specific to the location of the injury.However,there remains a clear division of stress fractures by"high"and"low"risk."Low risk"stress fractures are those with a low probability of fracture propagation,delayed union,or non-union,and so can be managed reliably with rest and exercise limitation.These include stress fractures of the PosteroMedial Tibial Diaphysis,Metatarsal Shafts,Distal Fibula,Medial Femoral Neck,Femoral Shaft and Calcaneus."High risk"stress fractures,in contrast,have increased rates of fracture propagation,displacement,delayed and non-union,and so require immediate cessation of activity,with orthopaedic referral,to assess the need for surgical intervention.These include stress fractures of the Anterior Tibial Diaphysis,Fifth Metatarsal Base,Medial Malleolus,Lateral Femoral Neck,Tarsal Navicular and Great Toe Sesamoids.In order to establish the optimal methods for managing these injuries,we present and review the current evidence which guides the treatment of stress fractures in athletes.From this,we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport.Following this,key recommendations are provided for the management of the common stress fracture types seen in the athlete.Five case reports are also presented to illustrate the application of sportfocussed lower limb stress fracture treatment in the clinical setting.

Hip hemi-arthroplasty for neck of femur fracture:What is the current evidence?

This editorial reviews and summarises the current evidence(meta-analyses and Cochrane reviews) relating to the use of hip hemi-arthroplasty for neck of femur fractures. Regarding the optimal surgical approach,two recent meta-analyses have found that posterior approaches are associated with: higher rates of dislocation compared to lateral and anterior approaches; and higher rates of re-operation compared to lateral approaches. Posterior approaches should therefore be avoided when performing hip hemi-arthroplasty procedures. Assessing the optimal prosthesis head component,three recent meta-analyses and one Cochrane review have found that while unipolar hemiarthroplasty can be associated with increased rates of acetabular erosion at short-term follow-up(up to 1 year),there is no significant difference between the unipolar hemi-arthroplasty and bipolar hemi-arthroplasty for surgical outcome,complication profile,functional outcome and acetabular erosion rates at longer-term follow-up(2 to 4 years). With bipolar hemi-arthroplasty being the more expensive prosthesis,unipolar hemi-arthroplasty is the recommended option. With regards to the optimal femoral stem insertion technique,three recent metaanalyses and one Cochrane Review have found that,while cemented hip hemi-arthroplasties are associated with a longer operative time compared to uncemented Hip Hemi-arthroplasties,cemented prostheses have lower rates of implant-related complications(particularly peri-prosthetic femoral fracture) and improved postoperative outcome regarding residual thigh pain and mobility. With no significant difference found between the two techniques for medical complications and mortality,cemented hip hemi-arthroplasty would appear to be the superior technique. On the topic of wound closure,one recent meta-analysis has found that,while staples can result in a quicker closure time,there is no significant difference in post-operative infections rates or wound healing outcomes when comparing staples to sutures. Therefore,either suture or staple wound closure techniques appear equally appropriate for hip hemiarthroplasty procedures.

Local recurrence of a parosteal osteosarcoma 21 years after incomplete resection

Parosteal osteosarcoma (POS) is the most common form of surface osteosarcoma. Its symptoms are insidious and its duration prior to diagnosis is considerably longer than that of other types of osteosarcoma. We report a case of POS with a growing mass but no evidence of metastasis. This tumor, which was diagnosed as calcified hematoma with benign characteristics, was incompletely resected in our hospital 21 years before the diagnosis of recurrence. The patient underwent a wide en bloc resection in our hospital and was free of symptoms, with no signs of tumor recurrence or metastasis during a 53-month follow-up.

Return to sport following scaphoid fractures:A systematic review and meta-analysis

BACKGROUND Scaphoid fracture is the most commonly fractured carpal bone in the athletic patient, accounting for over 85% of all sport-related carpal bone fractures, and is particularly common in sports involving high impact injuries to the wrist. The management of such injuries comprises both conservative and surgical techniques, as guided by fracture location and type. Athletes demonstrate a unique challenge with regards to the management of scaphoid fractures due to their requirement to return to sport, as soon as able.AIM To review systemically all studies recording return to sport following scaphoid fractures, to collate information on return rates to sport(RRS) and mean return times(RTS) to sport and to determine differences in sporting outcome for the various treatment methods.METHODS A systematic search of MEDLINE, EMBASE, CINAHAL, Cochrane, Google Scholar, Physiotherapy Evidence Database, SPORTDiscus, Web of Science and Scopus was performed in August 2018 using the keywords "scaphoid","fracture", "acute", "carpal", "athletes", "sports", "non-operative","conservative", "operative" and "return to sport". All studies that recorded RRS and RTS following scaphoid fractures were included. RTS was recorded as the length of time from commencement of either primary conservative management or primary surgical procedure to return to sport.RESULTS Eleven studies were included: Two randomised controlled trials, six retrospective cohort studies and three case series. Seven studies reported on conservative management(n = 77), and eight studies reported on surgical management(n =83). For conservative management, RRS was 90%(69/77), and the mean RTS was9.6 wk. Three studies allowed to return to sport in cast [RRS 89%(25/28); RTS 1.9 wk], and four studies required completion of cast treatment prior to returning to sport [RRS 90%(44/49); RTS 13.9 wk]. Four studies recorded fracture union data:Union rate 85%(47/55); mean time to union 14.0 wk. For surgical management,RRS was 98%(81/83), and RTS was 7.3 wk. Three studies reported on Percutaneous Screw Fixation [RRS 97%(32/33); RTS 6.5 wk], and five studies reported on Open Reduction Internal Fixation [RRS 98%(49/50); RTS 7.9 wk]. Six studies recorded fracture union data: Union rate 97%(69/71); mean time to union9.8 wk. On meta-analysis, RRS(RR = 1.09; 95% confidence interval(CI): 1.00-1.18;P < 0.045), RTS(MD 2.3 wk; 95%CI: 0.79-3.87; P < 0.002), union rates(RR = 1.14;95%CI: 1.01-1.28; P < 0.030) and mean times to union(MD 4.2 wk; 95%CI: 3.94-4.36; P < 0.001) were all significantly better for the surgical cohort compared to the conservative cohort.CONCLUSION Surgical management of scaphoid fractures can provide significantly improved RRS and RTS to sport compared to conservative management. Both treatments,however, remain acceptable options, and athletes should be fully informed of the benefits and risks of both prior to deciding treatment plans. Immediate return to sport in a cast should be avoided due to the significant risk of non-union.

Total hip revision with custom-made spacer and prosthesis:A case report

BACKGROUND Both periprosthetic joint infections(PJIs)and severe femoral segmental defects are catastrophic complications of total hip arthroplasty(THA),and both present a significant challenge in revisional surgery.There are limited data available to guide clinical decision making when both occur concurrently.CASE SUMMARY A 61-year-old woman presented with a 6-mo history of a sinus tract at the site of her original THA incision.Radiological imaging revealed a total hip joint implant with an ipsilateral segmental femoral defect.Based on histological,radiological,laboratory,and clinical features,a diagnosis of concurrent chronic PJI and segmental femoral defect(Type IIIB,Paprosky classification)was made.After multidisciplinary team discussion,three-dimensional(3D)-printed,custom-made antibiotic spacers were created that could be used to mold antibiotic-loaded cement spacer.These were placed following PJI debridement in the first stage of revision surgery.After the PJI was eliminated,a 3D-printed,custom-made,femoral prosthesis was created to repair the considerable femoral defect.After 20-mo follow-up,the patient had excellent functional outcomes with a near-normal range of hip movement.So far,neither evidence of recurrent infection nor loosening of the prosthesis has been observed.CONCLUSION We describe a case of“two-stage,custom-made”total hip revision to treat PJI with a concurrent segmental femoral defect.Use of a personalized,3D-printed spacer and proximal femoral prosthesis led to satisfactory hip function and no early postoperative complications.Use of a customized implant provides surgeons with an alternative option for patients where no suitable spacer or implant is available.However,the long-term function,longevity,and cost-effectiveness of the use of custom-made prostheses have yet to be fully explored.

Three-dimensional reconstructed magnetic resonance scans:Accuracy in identifying and defining knee meniscal tears

AIM To determine whether three-dimensional(3D) reconstruction from conventional magnetic resonance imaging(MRI) is able to accurately detect a meniscal tear, and define the configuration.METHODS Thirty-three patients' 3T MRI scan data were collected and sagittal uni-planar 3D reconstructions performed from the preoperative MRI. There were 24 meniscal tears in 24 patients, and nine controls. All patients had arthroscopic corroboration of MRI findings. Two independent observers prospectively reported on all 33 reconstructions. Meniscal tear presence or absence was noted, and tear configuration subsequently categorised as either radial, bucket-handle, parrot beak, horizontal or complex.RESULTS Identification of control menisci or meniscal tear presence was excellent(Accuracy: observer 1 = 90.9%; observer 2 = 81.8%). Of the tear configurations, bucket handle tears were accurately identified(Accuracy observer 1 and 2 = 80%). The remaining tear configurations were notaccurately discernable.CONCLUSION Uni-planar 3D reconstruction from 3T MRI knee scan sequences are useful in identifying normal menisci and menisci with bucket-handle tears. Advances in MRI sequencing and reconstruction software are awaited for accurate identification of the remaining meniscal tear configurations.

Fractures in sport: Optimising their management and outcome

Fractures in sport are a specialised cohort of fracture injuries, occurring in a high functioning population, in which the goals are rapid restoration of function and return to play with the minimal symptom profile possible. While the general principles of fracture management, namely accurate fracture reduction, appropriate immobilisation and timely rehabilitation, guide the treatment of these injuries, management of fractures in athletic populations can differ significantly from those in the general population, due to the need to facilitate a rapid return to high demand activities. However, despite fractures comprising up to 10% of all of sporting injuries, dedicated research into the management and outcome of sport-related fractures is limited. In order to assess the optimal methods of treating such injuries, and so allow optimisation of their outcome, the evidence for the management of each specific sport-related fracture type requires assessment and analysis. We present and review the current evidence directing management of fractures in athletes with an aim to promote valid innovative methods and optimise the outcome of such injuries. From this, key recommendations are provided for the management of the common fracture types seen in the athlete. Six case reports are also presented to illustrate the management planning and application of sport-focussed fracture management in the clinical setting.

A Review of Hip Fracture Mortality—Why and How Does Such a Large Proportion of These Elderly Patients Die?

As the number of aged patients presenting with hip fractures continues to rise [1], the substantial mortality associated with this pathology must continue to be an area of scrutiny and improvement. While some dismiss the high mortality as an inevitable consequence of the comorbidities inherent in the original injury and the patient population, data suggest that at 2 years post-hip fracture, survivors’ risks have regressed significantly and in fact, return to the same mortality risk as the non-fracture population [2]. This indicates that the risk of death is largely created specifically by the hip fracture and its treatment per se rather than the comorbidities of the hip fracture population, and offers scope for the potential reduction of these causes of death if we can identify and manage them appropriately. At a time when the incidence of hip fracture worldwide is on a steady rise, this review considers why and how these older patients die, and whether our developing guidelines and continuing research is adequately addressing these causes of death.

Measurement of forces generated during distraction of growing-rods in early onset scoliosis

AIM: To measure the forces applied during distraction of growing-rods in early onset scoliosis(EOS), aimed at developing a motorized elongation device.METHODS: A consecutive series of measurements were carried out to analyze the forces applied by the surgeon during distraction of single growing-rods in 10 patients affected by EOS(mean age 8.3 years; range 6 to 10 years) undergoing the first distraction 6 months following implantation of the rods. For each measurement, output from the transducer of a dedicated pair of distraction calipers was recorded at zero load status and at every 1 mm of distraction, up to a maximum of 12 mm for each of the two connected rods.RESULTS: Twenty measurements were obtained showing a linear increase of the load with increasing distraction, with a mean peak force of 485 N at 12 mm distraction and a single reading over 500 N. We did not observe bone fractures or ligament disruptions during or after rod elongations. There was one case of superficial wound infection in the cohort.CONCLUSION: The safe peak force carrying capacity of a motorized device for distraction of growing-rods is 500 N.

Plate vs reverse shoulder arthroplasty for proximal humeral fractures:The psychological health influence the choice of device?

BACKGROUND Proximal humeral fractures represent the third most common observed osteoporotic fracture;the treatment in three and four-part proximal humeral fractures in patients over 65 years is still controversial.Among the treatments described in literature,open reduction and internal fixation(O.R.I.F)and reverse shoulder arthroplasty(RSA)are gaining an increasing popularity.AIM To investigate the correct treatment for three and four-part proximal humeral fractures according to psychological aspects.METHODS It was conducted a prospective study with a series of 63 patients treated with O.R.I.F.(group A)and with RSA(group B)for three and four-part proximal humeral fractures according to Neer classification system.A conservative treatment group,as control,was finally introduced.One independent observer performed clinical and a psychological evaluation at one(T0),six(T1)and twelve months(T2)postoperatively.The Constant’s score and The Disabilities of the Arm,Shoulder and Hand(DASH score)were used for clinical evaluation,while General Anxiety Disorder-7(GAD-7)and Caregiver Strain Scale(CSS)were used for psychological evaluation.RESULTS At one month follow up in group A the mean values were DASH score 50.8,Constant score 36.1,GAD-7 score 5.4,CSS 5.0.For the group B,the average values at T0 were:DASH score 54.6,Constant score 32.0;GAD-7 score 6.4,CSS 6.2.At six months in group A the average values were DASH score 42.1,Constant score 47.3,GAD-7 score 4.3,CSS 3.9.For the group B,the average values at T1 were:DASH score 39.1,Constant score 43.2,GAD-7 score 5.7,CSS 5.5.At twelve months in the group A,the mean values were DASH score 32.8,Constant score 60.0,GAD-7 score 3.2,CSS 3.1.For the group B shown these mean values:DASH score 33.6,Constant score 52.9,GAD-7 score 4.3,CSS 4.5.We demonstrated a better clinical and psychological outcome at T2 in the group treated with osteosynthesis compared to the group treated with arthroplasty(Constant P=0.049,GAD-7 P=0.012 and CSS P=0.005).A better clinical and psychological outcome emerged in control group at T2 comparing with surgical group(DASH score P=0.014,Constant score P<0.001,GAD-7 P=0.002 and CSS P=0.001).CONCLUSION Both open osteosynthesis and reverse shoulder arthroplasty are valid treatments for proximal humeral fractures.According to the best osteosynthesis results the authors suggested to perform a psychological analysis for each patient in order to choose the appropriate treatment.

Distal locking in femoral intramedullary nailing system: Is one cross screw sufficient?

Introduction: The indications for intramedullary nail fixation of fractures of the femoral shaft have been greatly expanded by techniques of interlocking nailing. However, distal locking screw fixation remains the most technically demanding and problematic portion of the procedure and maybe responsible for as much as one-half of the exposure of the surgeon’s hands to radiation during the procedure. Objective: This biomechanical study was undertaken to compare the stability of using one distal locking cross screw versus two cross screws in femoral fractures fixed with intramedullary nailing (IMN) system. Materials: A composite model made from a stainless steel IMN (12 mm × 1 mm) was connected to a load cell (Instron machine). Axial forces upto 2 kN (3 times body weight) was applied or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was secured with stainless steel cylinders of different dimensions 50 mm × 5 mm, 75 mm × 5 mm and 100 mm × 3 mm to represent the proximal femoral diaphysis, diaphyseo-metaphyseal junction and distal femoral metaphyseal respectively. The distal locking end of the intramedullary nail was attached to the cylinder with a dedicated single or two rods (5 mm diameter), made from stainless steel, to represent the distal locking cross screw. Results: In the 50 mm cylinder, the mean stiffness (±standard deviation) of the system using either single or two screws were similar i.e. 3298 ± 144 N/mm. But in the 75 mm and 100 mm cylinders, the mean stiffness of the fracture model with two distal locking cross screws fixation was 2.059 ± 96 N/mm and 0.816 ± 122 N/mm and with single distal locking cross screw fixation were 0.643 ± 142 N/mm and 0.289 ± 88 N/mm respectively. Conclusion: Single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws when used to fix distal femoral metaphyseal fractures.

Epidemiology of open fractures in sport: One centre's 15-year retrospective study

AIM To describe the epidemiology of sport-related open fractures from one centre's adult patient population over a 15-year period. METHODS A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations.RESULTS Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years(range 15-67). There were 70(83%) males and 14 females(17%).The 6 most common sports were soccer(n = 19, 22%), rugby(n = 9, 11%), cycling(n = 8, 9%), hockey(n = 8, 9%); horse riding(n = 6, 7%) and skiing(n = 6, 7%). The five most common anatomical locations were finger phalanges(n = 30, 35%); tibial diaphysis(n = 19, 23%); forearm(n = 12, 14%); ankle(n = 7, 8%) and metacarpals(n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45(53%) fractures were grade 1; 28(33%) fractures were grade 2; 8(9%) fractures were grade 3a; and 4(5%) fractures were grade 3b. Out of the total number of fractures, 7(8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft(n = 4), fasciocutaneous flaps(n = 2); and adipofascial flap(n = 1). CONCLUSION We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.

Subacute osteomyelitis due to Staphylococcus caprae in a teenager:A case report and review of the literature

BACKGROUND Staphylococcus caprae(S.caprae)is a human commensal bacterium which can be detected in the nose,nails,and skin.It can be responsible for heterogeneous infections such as bacteremia,endocarditis,pneumonia,acute otitis externa,peritonitis,and urinary tract infections.Bone and joint infections due to S.caprae have also been reported,but most of them resulted from the infection of orthopedic devices,especially joint prostheses and internal osteosynthesis devices.Rare cases of primary osteoarticular infections caused by S.caprae have been described,including osteitis,arthritis,or spondylodiscitis.CASE SUMMARY We report an unusual case of subacute osteomyelitis in a toe phalanx caused by S.caprae in a 14.5-year-old girl.CONCLUSION Subacute S.caprae osteomyelitis is a little-known and probably underestimated community-acquired infectious disease.This microorganism’s pathogenicity should be seen as more than a classic nosocomial orthopedic device infection.

Proximal Femoral Allograft in Two-Stage Revision for Failed Septic Hip Arthroplasty

Infection after hip prostheses is a potentially devastating complication, and a serious medical and surgical challenge, especially when associated with Paprosky type III femoral bone loosening. Treatment is difficult and options are limited. We report on a 2-stage revision of 15 patients undergoing femur reconstruction with massive allografts. Materials and methods: This was a prospective study which included 15 patients (10 men and 5 women) with infected hip prosthesis, associated with Paprosky type III femoral proximal massive bone loss. The median age of patients was 64 years with a preoperative functional status score of 6. The average number of procedures to the same hip after the first arthroplasty was 6. All patients benefited from a 2-step surgery with massive allografts and locking prosthesis. The average follow-up time was 36 months. Results: Infection was monomicrobial in 14 cases;and was polymicrobial in 4 cases. Methicillin-resistant Staphylococcus epidermidis was the main bacteria (n = 10). The average C-reactive protein level before the second procedure was 2.3 ± 3.4. It was normalized in 8 cases. We recorded 13 cases of primary consolidation without another surgery, 3 cases of relapse, 2 traumatic dislocations and 2 fractures of the allograft. Conclusion: Hip prosthesis infection is a potentially catastrophic complication with significant negative ramifications for both the patient and the healthcare system. Massive allografts use in Paprosky III femoral defect remains very attractive for bone stock restoration and hip function improvement.

Ablation of a Patellar Button by Arthroscopy

Fracture of the patella after total knee arthroplasty is an infrequent complication. In the presence of poor remaining bone stock, avascular necrosis, removal of the implant with partial or complete patellectomy is recommended. Arthroscopic removal of a loose body or cement extrusion has been recently attempted successfully in very few cases, where loose and mobile cement fragments were involved and were often removed piecemeal. The authors experienced an unusual case of a patient a 69-year-old woman who, after having fallen down, presented a comminuted patellar fracture. We recommended an external orthosis and a temporary limitation of activity. Four months later, the patient complained. An X-ray revealed a necrosis of the proximal fragment and a lowering of the patellar button with the distal bone fragment. The removal of the patellar button was performed by arthroscopy. Conservative treatment can be successful for this patients and the removal of the patellar button loosening via arthroscopy appears to be an attractive technique to be used in similar cases.

Shoulder Reconstruction with Massive Scapular-Proximal Humerus Osteoarticular Allograft after Total Scapulectomy for Proximal Humerus Osteosarcoma Recurrence

Bone tumors are infrequent within the scapula. Total scapulectomy with massive allograft reconstruction represents an attractive alternative to amputation when the whole scapula is invaded with tumor and the neurovascular bundle can be preserved during tumor resection. We report a case of resection of the scapula and proximal humerus for recurrent osteosarcoma with massive allograft reconstruction of the scapula and proximal humerus. A 22-year-old male patient was seen in February 1992 for a pathological fracture of the proximal left humerus. In July 1992, a resection of the proximal end of the humerus followed by a reconstruction with osteochondral allograft and nail osteosynthesis was performed. The postoperative course was uneventful. In September 2009, 17 years later, the patient presented with a huge tumor developed at the level of the scapula. There was no vascular or neurological symptom. Plain radiography showed an expansive osteolytic mass. CT scan demonstrated scapular and proximal humerus invasion. An extended assessment revealed the presence of two pulmonary nodules. The biopsy confirmed the recurrence of osteosarcoma. The indication of a resection of both the left scapula and the 1992 allograft which was completely invaded at its proximal portion and the complete reconstruction of the scapula and the proximal humerus with allograft was made. One year postoperatively, we note a favourable outcome in terms of musculoskeletal functions. Despite two resection surgeries of pulmonary nodules and chemotherapy treatments, the patient developed new lung metastases and an unfavourable outcome. Although shoulder function was almost completely eliminated following surgery, preservation of elbow, wrist and finger motion resulted in an acceptable level of postoperative limb function. This reconstruction appears to be an attractive technique to be used in similar cases. The necessity of a reliable tissue bank with quality allografts in sufficient number is paramount.

A wavelet-based super-resolution method for multi-slice MRI

In multi-slice magnetic resonance imaging (MRI), the resolution in the slice direction is usually reduced to allow faster acquisition times and to reduce the amount of noise in each 2D slice. To address this issue, a number of super resolution (SR) methods have been proposed to improve the resolution of 3D MRI volumes. Most of the methods involve the use of prior models of the MRI data as regularization terms in an ill-conditioned inverse problem. The use of user-defined parameters produces better results for these approaches but an inappropriate choice may reduce the overall performance of the algorithm. In this paper, we present a wavelet domain SR method which uses a Gaussian scale mixture (GSM) model in a sparseness constraint to regularize the ill-posed SR inverse problem. The proposed approach also makes use of an extension of the Dual Tree Complex Wavelet Transform to provide the ability to analyze the wavelet coefficients with sub-level precision. Our results show that the 3D MRI volumes reconstructed using this approach have quality superior to volumes produced by the best previously proposed approaches.