Search Results (370)

Extremity vascular malformations in children and adolescents are congenital vascular developmental abnormalities that often present to pediatric orthopedic surgeons with pain, swelling, restricted motion, contracture, gait disturbance, limb asymmetry, and growth-related deformity rather than with an obvious vascular phenotype. The orthopedic importance of these lesions lies less in surface appearance than in their potential to affect muscle balance, joint integrity, osseous development, and peri-procedural safety. This review translates contemporary vascular anomaly classification and multidisciplinary management pathways into a practical orthopedic framework for diagnosis, referral, and longitudinal limb management. The most useful first step is to distinguish low-flow from high-flow lesions and then define lesion depth, periarticular or osseous involvement, coagulopathy risk, and syndromic overgrowth phenotype. Ultrasound is usually the first-line imaging modality for flow characterization, whereas magnetic resonance imaging is the cornerstone for defining extent and planning treatment. Plain radiographs remain highly relevant for identifying phleboliths, osseous remodeling, arthropathy, contracture-related deformity, and limb-length discrepancy. Venous malformations generally warrant pathway-based coagulation assessment, especially D-dimer and fibrinogen, because localized intravascular coagulopathy has direct implications for intervention and surgery. Arteriovenous malformations are best managed within specialist multidisciplinary teams. Fibro-adipose vascular anomaly and syndromic overgrowth phenotypes warrant particular attention because they frequently drive pain, contracture, and progressive limb imbalance. Outcome assessment in this field should extend beyond lesion size and incorporate pain, function, quality of life, and growth-related consequences. For pediatric orthopedic surgeons, management should move from late deformity correction toward early classification, early referral, longitudinal surveillance of joint and growth-related complications, and careful integration of local, surgical, and systemic therapies. Full article

Background: Breast augmentation is traditionally performed under general anesthesia, but tumescent local anesthesia (TLA) offers advantages in terms of rapid recovery and reduced risks. This study presents the largest European series on the use of TLA for breast augmentation, analyzing the cumulative results of 16 years of experience. Methods: A multicenter retrospective analysis was conducted on 1644 consecutive patients (982 subglandular and 662 subpectoral) between 2008 and 2024. All procedures were performed under TLA with conscious sedation without the use of general anesthesia. The tumescent solution consisted of 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. Infiltration protocols differed between groups: the subglandular approach utilized a single-plane technique (mean 589 mL per breast), whereas the subpectoral approach required a two-stage process (pre-fascial and retromuscular) with a higher mean volume (770 mL per breast). Intraoperative parameters, complication rates, and patient-reported outcomes (BREAST-Q) were analyzed. Statistical comparisons between the two surgical planes were performed using Independent Samples T-tests. Results: The procedure was successfully completed under TLA in 100% of cases, with no conversions to GA. The subpectoral approach was associated with significantly higher mean operating times (141 ± 11.2 min vs. 90.3 ± 11 min; p < 0.001) and TLA solution volumes (770 ± 16.1 mL vs. 589 ± 53.6 mL; p < 0.001). The overall major complication rate was 4.74%, with a significantly higher incidence of hematoma in the subpectoral group compared to the subglandular group (3.51% vs. 1.83%; p = 0.015). Regarding severe capsular contracture (Baker III–IV), although a slightly higher incidence was observed in the subpectoral cohort compared to the subglandular group (2.11% vs. 1.22%), this difference was not statistically significant (p = 0.155). Patient satisfaction via Breast-Q was high, with dissatisfaction exclusively linked to implant dislocation. Conclusions: This 16-year cumulative analysis validates TLA as a safe, effective, and reproducible alternative to general anesthesia for both subglandular and subpectoral breast augmentation. While the subpectoral plane entails longer surgical times and a slightly higher risk of minor complications, the TLA protocol ensures excellent pharmacological safety and rapid functional recovery, supporting its use in modern outpatient surgical settings. Full article

Background and Objectives: Tuberous breast is a complex congenital deformity that requires correction of the underlying stenotic anatomy. Clinical evidence on the use of conical polyurethane implants in this setting is limited. To evaluate clinical outcomes and patient-reported satisfaction following correction of tuberous breast deformity using a standardized, implant-assisted reconstructive protocol with exclusive use of conical polyurethane implants. Materials and Methods: An ambispective study included 50 patients with tuberous breast deformity treated between 2020 and 2025 by two surgeons using a standardized implant-assisted reconstructive protocol. All patients underwent systematic glandular ring release and inframammary fold repositioning, followed by placement of conical polyurethane implants. Outcomes included complications, reoperations, and BREAST-Q Augmentation V2.0 scores. The mean follow-up was 17 months (range, 9–24 months). Results: The mean patient age was 29.8 years. According to the Grolleau classification, 62% of patients were type I, 30% type II, and 8% type III. The mean implant volume was 258.2 cc. Overall complication rate was 10%, including one case (2%) of capsular contracture secondary to infection, with a reoperation rate of 8%. Postoperative BREAST-Q scores showed high levels of patient satisfaction, with mean “satisfaction with breasts” scores of 90.1 ± 11.9 and 92.0 ± 9.7 at the first and second postoperative assessments, respectively. Conclusions: Within a standardized reconstructive protocol, conical polyurethane implants were associated with high postoperative patient satisfaction and acceptable complication rates during early-to-mid-term follow-up in the correction of tuberous breast deformity. These findings suggest that the use of conical polyurethane implants within a standardized reconstructive approach is feasible in selected cases. Further comparative studies with longer follow-up are warranted. Full article

Background/Objectives: Bruck syndrome type 2 (BS2) is an ultra-rare autosomal recessive disorder within the osteogenesis imperfecta (OI) spectrum caused by biallelic pathogenic variants in PLOD2, which encodes lysyl hydroxylase 2 (LH2), an enzyme essential for bone-specific collagen cross-linking. Marked clinical heterogeneity complicates diagnosis, particularly in patients with atypical or incomplete presentations. We aimed to further delineate the clinical and molecular spectrum of PLOD2-associated disease. Methods: In this descriptive case series, we performed clinical, radiological, and molecular evaluations of four patients from three unrelated families, including two previously reported siblings. Molecular testing comprised targeted next-generation sequencing or whole-exome sequencing, followed by Sanger sequencing for variant confirmation and familial segregation analysis where feasible. Results: Four PLOD2 variants (NM_182943.3) were identified: homozygous c.1885A > G (p.Thr629Ala) in two siblings; c.8dup (p.(Cys4MetfsTer35)) and c.2222G > A (p.(Gly741Glu)) in one patient; and homozygous c.2027A > C (p.(Tyr676Ser)) in one infant. Three variants were previously unreported. Two missense variants remained classified as variants of uncertain significance, and the phase of the two heterozygous variants detected in one patient could not be established because a paternal sample was unavailable. Clinical severity was variable: age at first fracture ranged from 3 months to 4 years, and cumulative fracture burden ranged from 3 to multiple recurrent fractures. One 10-year-old patient had a severe OI-like phenotype without congenital contractures. Older patients showed additional axial and pelvic involvement, including craniovertebral junction abnormalities and acetabular protrusion. Conclusions: This case series broadens the range of clinical presentations observed in PLOD2-associated disease and indicates that severe bone fragility may occur in the absence of congenital contractures. These findings support inclusion of PLOD2 in the differential diagnosis of patients with unexplained bone fragility and progressive skeletal deformities. Additional well-characterized cases and functional studies are needed to refine genotype–phenotype correlations and clarify the clinical significance of newly identified variants. Full article

Capsular contracture is a common complication following breast implant surgery and is primarily associated with peri-implant fibrotic responses. This study evaluated the effects of an acellular dermal matrix (ADM) powder-coated breast implant on capsular contracture-related outcomes using a rabbit model. Non-textured, smooth-surface breast implants coated with ADM powder were implanted into the subpectoral pocket, and peri-implant tissues were harvested 12 weeks after implantation. Capsule thickness was assessed using hematoxylin and eosin (H&E) staining, while fibrotic changes were evaluated by measuring collagen density in Masson’s trichrome (MT)-stained sections. Immunohistochemical analysis was performed to examine the expression of α-smooth muscle actin (α-SMA) and transforming growth factor-β (TGF-β). Compared with non-textured smooth (NTS) surface breast implants, ADM powder-coated implants demonstrated reduced capsule thickness and collagen density, together with decreased expression of α-SMA and TGF-β. These results suggest that ADM powder coating may attenuate peri-implant fibrotic responses and serve as a feasible approach for reducing capsular contracture. Full article

Background and Clinical Significance: Dupuytren’s disease (DD) typically affects the palmar fascia and proximal digital structures, with distal interphalangeal joint (DIPJ) involvement considered rare. True extension of DD into the volar pulp has not been previously documented. Distal lesions may be misdiagnosed as neoplastic or inflammatory masses, and optimal management of isolated distal cords remains uncertain. We present the first histologically confirmed case of DD extending beyond the DIPJ into the volar pulp, accompanied by a systematic review of reported DIPJ-dominant DD. Case Presentation: A 30-year-old right-hand-dominant male presented with a two-year history of progressive flexion deformity of the little finger. Examination demonstrated a 90° proximal interphalangeal joint and 55° DIPJ contracture. Ultrasound and MRI showed a well-circumscribed soft-tissue lesion along the radial middle phalanx but did not suggest DD. Open exploration via an ulnar digital approach revealed a discrete DD cord extending distally beyond the DIPJ into the volar pulp, closely associated with the ulnar neurovascular bundle. Limited fasciectomy achieved full correction without neurovascular compromise. Histopathology confirmed classic DD. At the twelve-month follow-up, the patient maintained full extension and function with no recurrence. Conclusions: This study reports the first confirmed case of DD extending into the volar pulp and highlights that atypical distal DD can occur even in young patients. Imaging may fail to identify DD in uncommon sites, reinforcing the importance of clinical suspicion. Limited fasciectomy remains safe and effective in the distal phalanx. Recognition of this phenotype or histopathological examination may improve diagnostic accuracy and guide tailored operative planning. Full article

Capsular contracture (CC) remains the most common long-term complication of implant-based breast reconstruction (IBBR), significantly impacting cosmetic outcomes, patient satisfaction, and reoperation rates. Despite substantial advances in surgical technique, implant technology, and perioperative management, the incidence of clinically significant contracture persists at approximately 3–5% at five years in non-irradiated patients and escalates dramatically—to 20–50%—in those receiving postmastectomy radiation therapy (PMRT). The etiology is multifactorial, involving subclinical biofilm formation, a dysregulated host immune and foreign-body response, and radiation-induced fibrosis. This narrative review synthesizes contemporary evidence on the pathophysiology, clinical assessment, and modifiable risk factors for CC in IBBR, with particular emphasis on implant surface characteristics (smooth, textured, and polyurethane[PU]-coated), placement plane (prepectoral versus subpectoral), the role of acellular dermal matrices (ADMs), reconstruction timing (direct-to-implant versus two-stage), and the complex interplay with radiotherapy—including radiation timing, fractionation, and emerging delivery techniques. We also address ongoing controversies, including the lack of standardized objective diagnostic criteria, the comparative effectiveness of ADM versus PU-coated implants, and the optimal sequencing of radiation relative to reconstruction. By integrating the latest evidence from very recent major meta-analyses and national registries, this review provides an updated synthesis. We further propose an evidence-based clinical decision framework for CC risk mitigation. This review aims to inform individualized surgical decision-making and identify priority areas for future investigation. Full article

Emery–Dreifuss muscular dystrophy (EDMD) is a rare inherited neuromuscular disorder within the spectrum of nuclear envelope diseases, classically characterized by early musculo-tendinous contractures, slowly progressive myopathy, and cardiac involvement dominated by conduction disease and arrhythmias, with variable evolution toward cardiomyopathy and heart failure. This narrative review provides a comprehensive and clinically actionable synthesis of cardiovascular manifestations across EDMD genotypes and phenotypes, outlining pragmatic diagnostic and therapeutic pathways for real-world care. A targeted literature search was performed in PubMed, Embase, and Web of Science, focusing on studies addressing cardiovascular involvement in EDMD. Relevant original studies, case series, registries, guideline documents, and high-quality reviews were selected and synthesized narratively, with particular emphasis on diagnostic strategies, risk stratification, and management approaches. Cardiac involvement in EDMD encompasses a broad and heterogeneous spectrum, including atrial disease and conduction disturbances, ventricular arrhythmias, dilated cardiomyopathy, thromboembolic complications, and sudden cardiac death. Phenotypic expression varies according to the underlying genetic substrate, with distinct atrial- and ventricular-dominant trajectories. Early recognition and structured cardiovascular surveillance are essential to guide timely intervention, including anticoagulation, device therapy, and heart failure management. Despite growing awareness, significant gaps remain in risk prediction and standardized management strategies. EDMD represents a paradigmatic model of cardiomyopathy characterized by prominent electrical instability and systemic involvement. A structured, genotype- and phenotype-informed approach centered on early surveillance, proactive arrhythmia and thromboembolic risk management and timely device therapy may improve clinical decision-making in real-world settings. Future perspectives include the integration of precision medicine and the development of gene- and pathway-targeted therapies, with the potential to shift from symptomatic management toward disease-modifying strategies. Full article

Background: Percutaneous needle fasciotomy has been practiced for many years as a therapeutic alternative to open fasciectomy in Dupuytren’s disease. In addition to collagenase injection, it has established itself as a minimally invasive procedure in everyday clinical practice. This study analyzes the treatment results of 1146 patients. Methods: Patients at a center for needle fasciotomy were surveyed retrospectively by means of a questionnaire. In addition to previous illnesses and the localization and number of affected fingers, the frequency of recurrences, the need for renewed treatment, and satisfaction with the surgical result were also surveyed. Results: Between 1994 and 2012, 1146 patients with 1803 finger rays were treated and their data analyzed on the basis of records. In addition, a questionnaire survey on patient satisfaction was conducted and 174 questionnaires were analyzed. Overall, 83% of the patients were male and 16% female. In 50% of cases the right side was treated, in 45% of cases the left side (5% unknown), while 46% of the finger rays treated were on the little finger and ring finger. In all but one case, an improvement in the contracture was achieved. Complications included skin tears (264 cases), increased swelling (five cases), hypesthesia (one case), flexor tendon rupture (four cases) and a mid-limb base fracture (one case). The mean operation time was 26.9 min, the duration of pain was 2.7 days, and patient satisfaction on a scale of 1–10 was 7.2. Overall, 77% of patients stated that there had been a further deterioration or recurrence within one year of treatment, and 35% of these patients stated that further treatment was necessary. Conclusions: Needle fasciotomy is a safe and effective method with a low complication rate, but targeted and stringent follow-up treatment is necessary, as is information about possible recurrences or further deterioration of the result. Full article

Background/Objectives: This study aimed to evaluate the femoral rotation angle (FRA) before and after THA using a single approach and to identify its influencing factors through three-dimensional measurements. Methods: This retrospective study analyzed patients undergoing 108 primary unilateral THA via the anterolateral-supine approach (ALSA) from May to October 2023. Patients with hip contractures, femoral deformities, or other specific conditions were excluded for precise FRA measurements. Preoperative and postoperative CT scans were used for measurements of the FRA, anteversion, leg lengthening, and global offset. FRA was defined as the angle between the posterior condylar line and the line connecting the bilateral anterosuperior iliac spines, with external rotation as positive. Multiple linear regression, adjusted for age, sex, body mass index, and stem design, assessed the influence of anteversion change, leg lengthening, global offset change, and soft tissue release on the difference in FRA. Results: The mean FRA changed significantly from −2.8° preoperatively to −11.8° postoperatively (p < 0.001), demonstrating an average internal rotation of 9.0° after THA. Anteversion increased by a mean of 9.0° (p < 0.001), leg length increased by 9.0 mm (p < 0.001), and global offset decreased by 1.7 mm (p < 0.001). Multivariate analysis revealed that anteversion change (β = −0.41, p < 0.001) and global offset change (β = 0.40, p = 0.022) were significantly associated with FRA differences. Leg lengthening and ischiofemoral ligament or conjoint tendon resection were not significant (p = 0.089, p = 0.917, and p = 0.750, respectively). Conclusions: ALSA THA significantly rotates the femur internally, associated with an increase in anteversion and a decrease in global offset. Full article

In the field of orthopedic surgery, particularly distraction osteogenesis (DO), the mechanical environment plays a decisive role in the quality of bone regeneration and the safety of the soft tissue envelope. The continuous monitoring and accurate prediction of distraction resisting forces (DRF) are critical for preventing soft tissue complications such as nerve ischemia, joint contractures, and mechanical failure of the lengthening device. However, current clinical practice relies heavily on subjective assessment or passive monitoring tools that lack predictive capabilities. To address this gap, this study proposes a comprehensive solution combining a custom mechanical acquisition system with a high-fidelity finite element (FE) prediction method. The system design features a novel “double-ring” sensor interface specifically engineered to decouple axial distraction forces from parasitic bending moments generated by asymmetric muscle tension. Furthermore, a patient-specific FE model utilizing the Ogden hyperelastic constitutive law was derived, explicitly based on the patient’s muscle volume from preoperative CT imaging, to predict the non-linear force evolution. The feasibility and accuracy of the system were validated in a pilot in vivo study using a single ovine model ($N=1$). To isolate the soft tissue resistance from callus formation, distraction was performed immediately postoperatively up to a total length of 4 cm. Experimental results demonstrated the system’s high linearity ($R^2>0.999$) and its ability to capture the characteristic viscoelastic relaxation of living tissues. The FE model successfully predicted the peak distraction forces, showing improved agreement with experimental data at larger distraction magnitudes. By integrating mechanical sensing with predictive modeling, this framework lays the foundation for future closed-loop, patient-specific control in distraction osteogenesis. Full article

Post-stroke upper limb pain is prevalent and challenging to manage once established. Early use of botulinum toxin can reduce spasticity and contracture development and has potential to prevent or reduce pain. A secondary analysis of the EUBoSS study was undertaken to report pain prevalence in people post-stroke with severe upper limb impairment and spasticity in a hyper/acute setting, identify if botulinum toxin Type-A (BoNTA) could prevent pain developing and reduce pain if already present and evaluate differences in analgesic use between BoNTA and placebo groups. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Ninety-three participants (48F:45M) were randomised at a median of 11 days post-stroke (IQR 8–19) and included in the intention-to-treat analysis. Pain prevalence increased from 29.0% (95% CI [20.1–37.9%]) to 63.4% (95% CI [54.0–72.9%]) at six months. BoNTA treatment may prevent the development of pain at six months (OR = 0.42, 95% CI [0.18 to 1.01]) but not at three months (OR = 0.57, 95% CI [0.25 to 1.32]). The odds ratio for being on at least one analgesic at six months in the BoNTA group was 0.35 ([95% 0.14 to 0.87]). This secondary analysis suggests that early treatment of spasticity with BoNTA may potentially help prevent post-stroke upper limb pain and reduce analgesic use but appears less effective once pain is established. Further prospective studies are required to verify the hypotheses generated from this secondary analysis. Full article

Background/Objectives: Children with cerebral palsy (CP) often develop altered muscle architecture and calf muscle contractures. Orthotic immobilization aims to provide prolonged stretch to lengthen the muscle belly and muscle–tendon unit (MTU), but immobilization may also cause atrophy. This study investigated whether immobilization combined with periods of daily muscle activation has a different effect on calf muscle properties than continuous immobilization alone. Methods: Fourteen children with CP and equinus deformity (mean age: 9.9 ± 3.0 years; GMFCS Level I: 10, II: 4) were enrolled in a 12-week randomized controlled trial. Participants were allocated to one of two groups: continuous immobilization (23 h per day) with a dynamic ankle–foot orthosis (AFO), or a combined regimen consisting of immobilization (14 h) and a daily activity phase (10 h). Gastrocnemius medialis (GM) MTU properties, including muscle belly and Achilles tendon (AT) length, fascicle length, and muscle volume, among others, were assessed four times using three-dimensional (3D) freehand ultrasound. Results: Significant within-group increases in MTU and AT lengths were observed over time at both a 90° ankle position (p < 0.01) and a more dorsiflexed ankle position (4 Nm applied torque, p < 0.01). However, no significant group × time interactions were observed for any parameter. Conclusions: Contrary to our hypothesis, combining activity and immobilization did not confer additional benefits. Nevertheless, shorter orthosis-wearing time had the same effect on the MTU and could lead to improved compliance with orthosis treatment in CP. Larger trials are needed to support our findings. Full article

Background: Chronic Recalcitrant Plantar Fasciopathy (CRPF) is resistant to conservative treatments and has historically been managed with Open Plantar Fasciotomy (OPF). This systematic review aims to evaluate the role of the Gastrocnemius Release Procedures (GRPs) in treating CRPF, focusing on its indications, surgical techniques and clinical outcomes. Methods: A systematic literature search was conducted following PRISMA guidelines using MEDLINE, Cochrane and Scopus. Studies pertinent to the topic were screened, and those that reported clinical outcomes of GRPs in patients with CRPF were retrieved. The quality assessment was carried out using the Newcastle–Ottawa Scale. Results: Eighteen studies met the inclusion criteria, analyzing a total of 901 patients with a mean follow-up of 27.8 months. Indications for performing GRPs subsisted if conservative treatment failed to relieve pain and if Isolated Gastrocnemius Contracture (IGC) was present. All GRPs significantly reduced pain, with Visual Analogue Scale (VAS) scores decreasing from a mean of 7.3 pre-operatively to 2.56 post-operatively (64.93% reduction). American Orthopaedic Foot & Ankle Society (AOFAS) scores improved from 50.1 to 84.7 on average. Ankle dorsiflexion increased by an average of 7.75°. Patient satisfaction was high, with an average rate of 85% (range 61.6% to 100%). Minor complications were reported but resolved in most cases. Conclusions: Indications for performing GRPs still need to be clarified, and the best surgical technique remains to be defined. Nevertheless, the GRP seems to offer sustained pain relief and functional improvement in patients with CRPF. Full article

Shoulder spasticity is a common consequence of upper motor neuron lesions and may be associated with soft tissue contractures, limiting functional recovery. While both cryoneurolysis and tendon lengthening procedures are used individually in refractory cases, their combined effect has not been clearly established. It is consequently necessary to assess the efficacy of combining cryoneurolysis and percutaneous pectoral tenotomy in reducing shoulder spasticity and improving passive range of motion in patients with refractory shoulder spasticity and contracture. This retrospective, single-centre cohort study included 15 adults (≥19 years) with chronic shoulder spasticity and clinically confirmed musculotendinous contracture, previously treated with botulinum toxin injections without sufficient functional response, and free of pharmacological effects (last injection >4 months prior). All patients underwent cryoneurolysis targeting motor branches to the pectoral muscles. Outcomes included Modified Ashworth Scale (MAS) and shoulder Passive Range Of Motion (PROM). The combined approach provided significant improvements in spasticity severity for shoulder flexion (p < 0.01) and abduction (p < 0.01), and significant improvements in maximum PROM for shoulder flexion (p < 0.0001) and abduction (p < 0.0001). Combining cryoneurolysis and pectoral tenotomy appears feasible, safe, and clinically beneficial in selected patients with both spasticity and tendon contracture. Cryoneurolysis addresses the neural component, while tenotomy may restore mechanical excursion. This sequential diagnostic and therapeutic approach may enhance personalized management of mixed spastic–contracture shoulder limitations and could be applicable to other joints. Full article