Search Results (75)

Background: Reverse-oblique femoral fractures are regarded as highly unstable and are still associated with high complication and failure rates. A new classification system is said to facilitate risk assessment and decision-making. Methods: Over ten years, 7804 patients with per/subtrochanteric fractures were screened in this retrospective analysis. A total of 552 patients with a reverse-oblique fracture pattern were included. The fractures were classified according to the new classification system. The choice of implants, complication rates, revision surgery, and time of surgery were recorded. Radiological outcome parameters and dislocation were measured. Results: For the classification, a good intra-rater reliability (r = 0.77) and inter-rater reliability (k = 0.64) were calculated. The complication rate was overall 19% (n = 105). More than 60% of complications needed revision surgery. The most common complications were cut-out and implant failure (3%); only Parker’s ratio, as a radiological parameter, had prognostic value. Malreduction had a negative impact on mal- or non-unions (p < 0.01), and a trend towards higher overall complications (p = 0.52). Prolonged time of surgery increased the overall complication rate (r = 0.2, p < 0.001). The same was found after open reduction (p = 0.005, OR 2.00). The use of cerclage wires had no positive or negative effects. The use of short or long implants did not influence the outcome. Conclusions: Reverse-oblique femoral fractures are associated with a high complication rate. Short implants can be safely used in cases without severe dislocation if a sufficient working length is considered. Anatomical reduction benefits the outcome as long as it can be performed closed. The classification system presents good inter- and intra-rater reliability. Full article

Objective: The objective of this study was to evaluate the association between cervical management strategies, specifically pessary placement, cervical cerclage, or expectant management, and gestational age at delivery in twin pregnancies and to assess the prognostic value of cervical characteristics for early preterm birth (<33 weeks). Methods: We conducted a retrospective cohort study including 120 twin pregnancies managed at a tertiary referral center between 2019 and 2024. Pregnancies with positive vaginal or cervical microbiological cultures or abnormal cervical cytology were excluded. The management strategy was selected based on cervical characteristics and clinical judgment. Gestational age at delivery was compared across intervention groups using descriptive statistics, kernel density plots, boxplots, and Kaplan–Meier survival analysis. Multivariable Cox proportional hazards regression was performed to estimate adjusted hazard ratios (HRs) for early delivery, including intervention type and cervical parameters (length, diameter, and funneling). Results: Overall, 26 of 120 pregnancies (21.6%) resulted in delivery before 33 weeks. Pessary placement was associated with longer gestational duration compared with cerclage or expectant management. Kaplan–Meier analysis demonstrated a clear separation of survival curves by intervention group, with the pessary group maintaining pregnancy to later gestational ages (log-rank p < 0.001). In multivariable Cox regression analysis, pessary use was associated with a significantly lower hazard of early delivery compared with cerclage (HR = 0.088, 95% CI: 0.035–0.220; p < 0.001). Expectant management showed a trend toward an increased risk of early delivery (HR = 2.44; p = 0.067). Cervical length and diameter were not independently associated with early delivery after adjustment for intervention type. Funneling was associated with a lower hazard of early delivery, a finding that warrants cautious interpretation. Conclusions: In this retrospective cohort of twin pregnancies without microbiological evidence of infection, pessary placement was associated with prolonged gestation and a lower hazard of early preterm delivery compared with cerclage or expectant management. These findings support a personalized, risk-adapted approach to cervical intervention selection in twin pregnancies. Prospective, randomized studies incorporating etiologic stratification are needed to confirm these associations and guide clinical practice. Full article

Introduction: Management of trochanteric fractures in revision hip surgery has a high incidence of non-union and complications. Fixation devices are often bulky, prone to breakage, and necessitate reoperation. This study describes a novel soft tissue and bony abductor repair that reduces the forces on bony fragments without the need for prominent metalwork. Methods: This novel surgical technique involves fixation of the abductor mechanism with polyester and polyethylene sutures that are woven through the abductors and secured to the femoral shaft with a proprietary suture cerclage tape with cerclage wire supplementation in select cases. All patients undergoing fixation were retrospectively reviewed with a minimum follow-up period of 12 months. Outcomes relating to dislocation, reoperation, fracture union and the incidence of symptomatic Trendelenburg gait were recorded. Results: A total of 17 patients underwent this novel intervention. There were no dislocations or reoperations for prominent metalwork at the last follow-up. One patient had evidence of greater trochanter (GT) non-union, and three had GT displacement of over 3 mm. Eight (47.1%) patients were independently mobile and seven (41.2%) were mobile with only one walking aid. No patients required plate or bolt fixation. Conclusions: GT fractures and abductor deficiency are difficult to manage, with most reported methods utilising bulky metalwork to treat a soft tissue injury. We describe a novel combined soft tissue and bony fixation without the need for excessive metalwork. Our pilot study demonstrates satisfactory outcomes of this intervention that are technically reproducible and more appropriately addresses the deforming forces involved with a low complication profile. Full article

Objective: The objective was to evaluate the optimal timing of cervical cerclage insertion for perinatal outcomes, such as birthweight, gestational week, and pregnancy prolongation in women with diagnosed cervical insufficiency (CI). Methods: This retrospective study was conducted at the 1st Department of Obstetrics and Gynaecology of the Medical University of Warsaw, over a 10-year period. Maternal and perinatal outcomes were compared between 75 women divided into three groups based on the gestational week (GW) at cerclage insertion: (1) before 18 GW (n = 31), (2) 18–22 GW (n = 31), (3) after 22 GW (n = 13). Only single pregnancies were included in the final analysis in order to maintain the homogeneity of the population. The primary outcomes included the week of delivery and pregnancy prolongation following cervical cerclage insertion. Numerous secondary outcomes were also evaluated, including neonatal mortality, need for NICU hospitalization, Apgar score, birthweight, maternal white blood cell (WBC) count and C-reactive protein (CRP) levels. Results: Birth week was significantly associated with GW at insertion—35.8 ± 3.8 vs. 34.8 ± 5.2 vs. 32 ± 5.7, respectively, p = 0.016. Moreover, statistical difference was also found regarding birthweight of the analysed groups—2723.8 ± 951.6 g vs. 2518.5 ± 1167.9 g vs. 1886.7 ± 1011.2 g, respectively, p < 0.001, and pregnancy prolongation following cerclage insertion 20.4 ± 4.2 vs. 14.7 ± 5.5 vs. 7.3 ± 5.7 weeks, respectively, p < 0.001. Conclusions: Earlier cerclage placement (<18 weeks) is associated with significantly improved perinatal outcomes. However, this association largely reflects the benefit of prophylactic intervention over emergency ‘rescue’ procedures (common in the >22-week group). The sharp decline in outcomes after 22 weeks highlights the risks of advanced cervical dilation, suggesting that clinical management should prioritize risk assessment within the prophylactic window. Full article

Background/Objectives: Preterm birth remains a major cause of neonatal morbidity and mortality, particularly in multiple pregnancies and in cases of cervical shortening. While cervical cerclage is established in singleton pregnancies, its efficacy in multiple gestations remains uncertain. This study compares pregnancy and neonatal outcomes following second-trimester cerclage in singleton and multiple pregnancies with a short cervix. Methods: In this retrospective cohort study, 96 women underwent second-trimester cerclage at a tertiary perinatal center between 2020 and 2024. All had a cervical length ≤ 25 mm or prolapsed membranes without infection or premature rupture. Primary outcomes included term delivery rate, gestational age, mode of delivery, and neonatal outcomes; secondary outcomes comprised surgical complications and rehospitalization, defined as the need for renewed inpatient care due to threatened preterm labor or procedure-related complications. Results: In total, 79 singleton and 17 multiple pregnancies were analyzed. Term delivery occurred more often in singletons (54%) than multiples (18%, p = 0.006). Mean gestational age at birth was 258 ± 25 days in singletons versus 228 ± 28 days in multiples (p < 0.001). Birth weight was significantly lower in multiples (1985 g vs. 2943 g; p < 0.001), and neonatal infections were more frequent (53% vs. 26%; p = 0.008). Caesarean delivery was more common in multiples (82% vs. 33%; p < 0.001). Apart from increased postoperative contractions in multiples (24% vs. 5%; p = 0.031), complication rates and rehospitalization (27% vs. 29%; p = 0.8) were similar. Conclusions: Second-trimester cerclage is less effective in preventing preterm birth in multiple pregnancies compared to singleton pregnancies; however, it appears to be associated with a stabilizing clinical course and may facilitate outpatient management in selected high-risk cases. These findings support individualized counseling and shared decision-making, particularly in multifetal gestations. Full article

For decades, cervical insufficiency (CI) has been framed predominantly as a mechanical failure of the cervix resulting in painless mid-trimester dilatation. This disease-centered paradigm, reinforced by clinical teaching and administrative coding, does not fully capture the dynamic and biologically integrated nature of cervical remodeling. Accumulating evidence suggests that cervical change is governed by coordinated mechanical, inflammatory, and immunologic interactions rather than by a purely anatomic defect. To outline a process-oriented conceptual framework that situates CI within the broader preterm-birth continuum, this perspective aims to integrate biomechanical, inflammatory, and immunologic dimensions of cervical remodeling and to emphasize that infection- and inflammation-related changes represent dynamic, potentially modifiable elements that may inform more individualized, biology-guided clinical decision-making. This Perspective traces the evolution from a traditional “disease entity” interpretation of CI toward a more integrated view of cervical remodeling as a dynamic, biology-responsive process. Emerging data suggest that when intra-amniotic infection or inflammation is appropriately managed, cervical competence may be partially restored, and mechanical support can be applied more safely in selected patients. Clinical observations indicate that infection-controlled cerclage is associated with meaningful prolongation of gestation. Earlier reports describing double-level mechanical reinforcement techniques conceptually align with contemporary interpretations of infection-controlled emergent cerclage by linking surgical timing with the underlying biology of cervical change. Rather than proposing a prescriptive management pathway, this framework highlights how mechanical, inflammatory, and immunologic factors may interact across heterogeneous CI etiologies and how individualized intervention may be guided by biologic context. Understanding CI as a dynamic rather than a fixed condition provides a framework that integrates its mechanical, inflammatory, and immunologic dimensions within the preterm birth continuum. Such a perspective encourages individualized, biology-informed interpretation of cervical change and supports more context-specific use of established interventions such as cerclage. By emphasizing developmental processes rather than a static defect, this approach seeks to bridge classical clinical practice with contemporary insights into cervical remodeling. Full article

Background and Objectives: Unstable distal clavicle fractures (Neer type II) have a relatively high risk of nonunion and often require operative fixation. Hook plates are widely used, particularly when the distal fragment is small or comminuted, because they provide strong vertical stability. However, hook plates are associated with subacromial irritation, acromial wear, and the need for routine implant removal. Distal locking plates with supplementary cerclage augmentation can achieve fixation without subacromial impingement and may reduce implant-related complications. This study aimed to compare clinical and radiologic outcomes of hook plates versus locking plates with or without cerclage augmentation for Neer type II distal clavicle fractures. Materials and Methods: In this single-center retrospective cohort, adult patients with Neer type II distal clavicle fractures who underwent open reduction and internal fixation between March 2021 and August 2022, with ≥6 months of follow-up, were reviewed. Patients were allocated into two groups according to implant: hook plate (Group 1, n = 16) and distal locking plate with or without cerclage augmentation (Group 2, n = 26). Primary outcomes were complication rate, radiographic union, and shoulder range of motion (ROM). Secondary outcomes included pain (PVAS) and functional scores (SANE, ASES, Constant, UCLA). Results: Forty-two patients were analyzed (locking n = 26, hook n = 16). Groups were comparable in age (51.3 ± 16.0 vs. 54.4 ± 17.1 years), follow-up (7.0 ± 4.0 vs. 8.4 ± 4.3 months), sex distribution, smoking status, and mechanism of injury. Radiographic union was achieved in 24/26 (92.3%) patients in the locking group and 14/16 (87.5%) in the hook group; two cases of nonunion or reduction failure occurred in each group (p = 0.612). Final patient-reported outcomes and ROM were similar between groups (e.g., ASES 68.2 ± 15.5 vs. 64.4 ± 18.3, Constant 57.3 ± 9.5 vs. 44.9 ± 20.5; all p > 0.05). Forward flexion tended to be higher in the locking group (138.9 ± 28.0° vs. 113.3 ± 36.7°, p = 0.182), although without statistical significance. No deep infection, peri-implant fracture, or hardware failure requiring unplanned revision was observed. Subacromial wear was identified in four patients (25%) in the hook plate group, whereas no such change was observed in the locking group. Conclusions: Both hook plates and distal locking plates (±cerclage) provided high union rates and satisfactory functional outcomes for Neer type II distal clavicle fractures. However, hook plates were associated with subacromial wear, whereas locking plate constructs avoided subacromial complications. When distal fragment purchase is feasible—or can be supplemented with cerclage augmentation—locking plate fixation represents a reliable first-line option, with hook plates reserved for cases with minimal distal bone stock or complex comminution. Full article

Background/Objectives: Cervical insufficiency remains a leading cause of second-trimester pregnancy loss and early preterm birth. Although single-level cerclage techniques such as McDonald or Shirodkar are widely accepted, the potential advantages of double or modified double-level cerclage remain controversial. Methods: This systematic review was conducted in accordance with PRISMA guidelines. Comprehensive searches of PubMed, Embase, Web of Science, and the Cochrane Library (to September 2025) were supplemented by Google Scholar and conference proceedings. Eligible studies included randomized controlled trials, comparative cohort studies, and case series directly comparing double versus single transvaginal cerclage. A total of twenty-six sources were included, spanning randomized trials, comparative cohort studies, published protocols, case series, systematic reviews, conference abstracts, and early technical or historical reports. The primary outcome was preterm birth before 34 weeks; secondary outcomes were GA at delivery, latency, neonatal morbidity and mortality, and maternal complications. Results: Across prophylactic (history- or ultrasound-indicated) settings, double sutures produced outcomes comparable to single-level cerclage without consistent superiority. In contrast, in emergency or exam-indicated cases with advanced cervical dilation or bulging membranes, double or double-level cerclage significantly prolonged latency and reduced very preterm birth (<32–34 weeks). Double-level reinforced techniques (including monofilament-based and modified Wurm-type approaches) showed improved mechanical support and lower neonatal intensive-care admission. Case series further demonstrated successful rescue procedures beyond 24 weeks, indicating expanded surgical feasibility in selected patients. Conclusions: While double cerclage yields similar results to single cerclage in prophylactic use, it appears advantageous in high-risk or emergency scenarios. Comparative analyses suggest that combined mechanical and infection-controlled approaches may improve cervical competence and prolong gestation in selected patients. Ongoing multicenter randomized trials are needed to establish its definitive role in modern obstetric practice. Full article

Background/Objectives: Cervical insufficiency affects 1–2% of pregnancies and represents a significant cause of second-trimester loss and spontaneous preterm birth. This review synthesizes current evidence across the clinical spectrum of cervical insufficiency, providing evidence-based management guidance and identifying areas requiring further investigation. Methods: We conducted a comprehensive review of the current literature, evidence-based clinical guidelines, and landmark randomized controlled trials examining diagnostic frameworks, therapeutic interventions, and clinical outcomes across different presentations of cervical insufficiency. Our analysis incorporated data from major obstetric databases, professional society recommendations, and recent comparative effectiveness research. Results: Cervical insufficiency diagnosis encompasses three primary categories: history-based, ultrasound-based, and physical examination-based. Vaginal progesterone achieves a 31% reduction in preterm birth before 33 weeks (RR 0.69, 95% CI 0.55–0.88; NNT= 14). Ultrasound-indicated cerclage achieves a 30% relative risk reduction for delivery <35 weeks. The landmark SuPPoRT trial (n = 386) demonstrated no statistically significant differences among cerclage, pessary, and progesterone (p = 0.4), though formal equivalence trials have not been conducted. Multiple gestations show no benefit from singleton-derived interventions (RR 0.99–1.04). Conclusions: Optimal cervical insufficiency management emphasizes individualized approaches based on comprehensive risk stratification and objective cervical assessment, with vaginal progesterone and cervical cerclage serving as cornerstone therapies supported by robust clinical evidence. Full article

Background and Objectives: Preterm birth (PTB) remains a leading cause of neonatal morbidity and mortality worldwide, particularly among women with cervical insufficiency. This study aimed to identify whether transvaginal sonographic parameters assessed following McDonald cerclage could act as predictors for the risk of spontaneous PTB < 34 weeks. Materials and Methods: A cohort of singleton pregnancies without structural abnormalities that underwent McDonald cerclage and had at least one transvaginal ultrasound (TVUS) examination between 16–25 weeks’ gestation was retrospectively analyzed. Two blinded reviewers evaluated the images. Measurements included total cervical length, cervical lengths above and below the stitch, anterior and posterior cervical widths at the suture level, as well as anterior and posterior stitch depths. Additionally, the angle between the cervical canal and the anterior uterine wall was assessed at both the internal and external os. Presence of funneling and intra-amniotic sludge was also noted. Maternal demographic and obstetric data were collected, and ultrasound findings were compared between women who delivered before and after 34 weeks. Results: A total of 45 women were enrolled, with cerclage indications categorized as history-based (76%), ultrasound-based (9%) or exam-based (15%). Overall, PTB < 34 weeks occurred in 38% (n = 17). Maternal characteristics did not vary between groups. However, both total cervical length and cervical length above the stitch were significantly shorter in women with PTB < 34 weeks vs. PTB ≥ 34 (27.60 ± 8.81 mm vs. 35.89 ± 7.09 mm, p = 0.012; and 13.15 ± 9.17 mm vs. 21.87 ± 8.95 mm, p = 0.004, respectively). Funneling beyond the cerclage was observed exclusively in women who delivered < 34 weeks (29.4%, p = 0.005). Funneling at the internal os (58.8% vs. 3.6%, p < 0.001) and intra-amniotic sludge (29.4% vs. 3.6%, p = 0.023) were likewise more frequent in this group. Conclusions: In addition to cervical length measurement, post-cerclage transvaginal ultrasound—through the evaluation of suture position, cervical funneling, and intra-amniotic sludge—may assist in identifying women at higher risk of PTB < 34 weeks. Full article

Background and Objectives: Hook plate fixation has been widely used for unstable distal clavicle fractures, but concerns remain regarding implant-related complications and the need for secondary removal. Locking plate fixation with supplementary cerclage wiring has been proposed as an alternative that may provide stability while reducing complications. This study compared the clinical and radiologic outcomes of locking plate fixation with cerclage wiring versus hook plate fixation. Materials and Methods: A retrospective review was performed on patients who underwent open reduction and internal fixation for unstable distal clavicle fractures (Cho’s classification type II) between 2015 and 2024. Patients with at least 6 months of follow-up were included. Two techniques were evaluated: locking plate with cerclage wiring (Group 1) and hook plate fixation (Group 2). Clinical outcomes, including complications, range of motion, and patient satisfaction, were compared at the final follow-up. Results: A total of 52 patients met the inclusion criteria: 27 in Group 1 and 25 in Group 2. The overall mean follow-up period was 13.17 ± 8.46 months. The distribution of fracture types was not significantly different between groups (p = 0.287). Complications were more frequent in Group 2 (40%), including postoperative stiffness requiring capsular release (70%), nonunion requiring revision (20%), and peri-implant fracture (10%). The overall union rate was 100% in Group 1 and 80% in Group 2. In contrast, Group 1 had only one complication (3.7%), a peri-implant fracture (p = 0.002). Shoulder range of motion at the final follow-up showed no significant difference between groups. Conclusions: Hook plate fixation was associated with a significantly higher complication rate compared with locking plate fixation with cerclage wiring. Locking plate fixation with supplementary cerclage wiring appears to be a better surgical option for unstable distal clavicle fractures. Full article

Background: For high-grade dislocation of the acromioclavicular (AC) joint, surgical treatment is widely recommended. This study aimed to evaluate the clinical and radiological outcomes after arthroscopic-assisted stabilization of acute high-grade AC joint dislocations using a low-profile suture button (LPSB) combined with percutaneous AC cerclage fixation. A secondary objective was to quantify clavicular tunnel widening (cTW) and explore its correlation with clinical and radiological outcomes. Methods: This retrospective study included 45 patients with acute Rockwood type V injuries treated with the LPSB technique and additional AC cerclage. Clinical outcomes were the Constant Score (CS), Subjective Shoulder Value (SSV), Taft Score (TF), AC Joint Instability Score (ACJI), and VAS for pain upon palpation. Radiological assessment included coracoclavicular (CC) distance and percentage deviations compared to the contralateral side, reclassified according to Rockwood, dynamic posterior translation (DPT), cTW measurements, and assessment of ossifications and AC joint osteoarthritis. Results: After 35.3 months, significant improvements were observed in CC distance and percentage deviation. A total of 27.3% were reclassified as Rockwood type III and 2.3% as type V. Initial overreduction persisted in 18.2%. DPT was observed in 34.1% of cases. The mean CS was 89.64, the SSV was 91.1, and the VAS was 0.8. cTW occurred only below the superior button and increased significantly over time, showing a negative correlation with the SSV but no correlation with any radiological outcome parameter. No implant-related revision surgery was reported. Conclusions: Arthroscopic-assisted stabilization of acute high-grade AC joint dislocations using the LPSB technique with AC cerclage fixation provides excellent clinical outcomes and high patient satisfaction, with minimal implant-related complications and no need for revision surgery due to implant issues. Although cTW occurs, its clinical impact appears limited within this procedure. Full article

Singleton pregnancies complicated by a short cervical length (≤25 mm) are at significantly increased risk for spontaneous preterm birth. Several treatment strategies aimed at reducing this risk and improving perinatal outcomes have been evaluated, including vaginal progesterone, cervical cerclage, and cervical pessary. This review summarizes the latest evidence regarding the efficacy of these interventions. Vaginal progesterone and/or cervical cerclage have been identified as proven evidence-based practices for preterm birth prevention and improve neonatal outcomes. Vaginal progesterone reduces the risk of preterm birth < 35 weeks by 27% (relative risk 0.73, 95% confidence interval 0.58–0.90). Cervical cerclage has been shown to reduce the risk of preterm birth < 35 weeks by 30% (relative risk 0.70, 95% confidence interval 0.55–0.89) in patients with a short cervical length and prior preterm birth. In contrast, recent data suggest that cervical pessary should no longer be considered a management option for these patients. A continued focus on individualized, evidence-based approaches remains essential to optimizing outcomes in this high-risk population. Full article

Cranial cruciate ligament (CrCL) rupture is a common orthopedic disorder in dogs, leading to stifle joint instability and progressive osteoarthritis. This study aimed to develop and biomechanically evaluate a novel intra-articular reconstruction system designed to mimic the natural ligament and restore joint stability following CrCL excision. The system consisted of a 3D-printed thermoplastic polyurethane (TPU) graft, cerclage wire, and H-button fixation. Fourteen pelvic limbs from mature mixed-breed cadaveric dogs were used. The inclination angle, dimensions, volume, tensile strength, and elongation of the native CrCL were measured. Seven CrCL-deficient stifles were reconstructed using the proposed system and tested biomechanically. The native CrCL showed a significantly higher tensile strength than the TPU graft; however, the TPU demonstrated a greater flexibility. The reconstruction system successfully stabilized the joint and provided repeatable fixation. Significant correlations were found between CrCL volume and both age and body weight. These findings support the mechanical suitability of the proposed system for ex vivo stifle stabilization and highlight the potential of 3D-printed TPU in ligament reconstruction. Further in vivo studies are recommended to assess long-term performance, including implant integration, tissue remodeling, and clinical outcomes. Full article

Background/Objectives: Obstetrical monitoring following radical trachelectomy (RT) for cervical cancer is marked by the lack of a standardized protocol, which may lead to delays in the intervention for cervical shortening. In light of the typical cervical remodeling process that occurs at the onset of labor, we hypothesized that the onset of premature cervical shortening in patients who have undergone radiotherapy commences at the internal ostium. Methods: We introduced the concepts of internal distance (distance between internal cervical ostium and cerclage thread) and the latent shortening of internal distance, which is characterized as a painless reduction in the internal distance, serving as an early marker of preterm contractions, thus enabling timely tocolytic intervention. Results: Three patients spontaneously conceived after RT. They were obstetrically followed-up after RT, using a combined approach of transvaginal ultrasound cervical markers and cardiotocography. Active tocolysis was used if internal distance shortening was observed. All patients delivered term healthy babies. Conclusions: The consistent ultrasound evaluation of both internal and external distances permits the proactive diagnosis of premature contractions and enables swift therapeutic measures. Full article