Search Results (99)

New Delhi metallo-β-lactamase (NDM)-producing Enterobacterales represent a major therapeutic challenge due to their resistance to nearly all β-lactams and frequent co-resistance to other antibiotic classes, leaving clinicians with few effective options. These challenges are amplified in orthopedic infections with hardware involvement, where biofilm formation and the need for prolonged antimicrobial therapy limit success. We describe a 55-year-old female with a history of right type 3 open pilon fracture complicated by hardware failure and revision, who presented with septic tibial nonunion and chronic drainage. During this admission, she underwent irrigation and debridement with hardware removal and intramedullary nail placement. Cultures grew Enterobacter cloacae complex resistant to meropenem, ceftazidime–avibactam, meropenem–vaborbactam, and cefiderocol, as well as Candida parapsilosis. Molecular testing confirmed NDM production, while reference testing showed susceptibility to aztreonam–avibactam (ATM-AVI). The patient was treated with ATM-AVI plus micafungin, achieving clinical stability within three days. Due to outpatient administration barriers with ATM-AVI, the patient was transitioned to eravacycline and micafungin. At eight-week follow-up, the patient remained clinically improved without relapse or adverse effects. This case highlights ATM-AVI as a critical therapy for NDM-producing orthopedic infections involving hardware and supports eravacycline as a feasible step-down option in outpatient management. Full article

In less than 30 years, Deep Brain Stimulation (DBS) has evolved from an antiparkinsonian rescue intervention into a flexible neuromodulatory therapy with the potential for personalized, adaptive, and enhancement-focused interventions. In this review we collected evidence from seven areas: (i) modern eligibility criteria, and ways to practically improve on these, outside of ‘Core Assessment Program of Surgical Interventional Therapies in Parkinson’s Disease’ (CAPSIT-PD); (ii) cost-effectiveness, where long-horizon models now show positive incremental net monetary benefit for Parkinson’s disease, and rechargeable-devices lead the way in treatment-resistant depression and obsessive–compulsive disorder; (iii) anatomical targets, from canonical subthalamic nucleus (STN) / globus pallidus internus (GPi) sites, to new dual-node and cortical targets; (iv) mechanistic theories from informational lesions, antidromic cortical drive, and state-dependent network modulation made possible by optogenetics and computational modeling; (v) psychiatric and metabolic indications, and early successes in subcallosal and nucleus-accumbens stimulation for depression, obsessive–compulsive disorder (OCD), anorexia nervosa, and schizophrenia; (vi) procedure- and hardware-related safety, summarized through five reviews, showing that the risks were around 4% for infection, 4–5% for revision surgery, 3% for lead malposition or fracture, and 2% for intracranial hemorrhage; and (vii) future directions in connectomics, closed-loop sensing, and explainable machine learning pipelines, which may change patient selection, programming, and long-term stewardship. Overall, the DBS is entering a “third wave” focused on a better understanding of neural circuits, the integration of AI-based adaptive technologies, and an emphasis on cost-effectiveness, in order to extend the benefits of DBS beyond the treatment of movement disorders, while remaining sustainable for healthcare systems. Full article

Fracture-related infections (FRIs) represent a significant complication in orthopedic trauma care, often leading to delayed bone healing, prolonged hospital stays, and increased patient morbidity. Pathogenesis involves microbial contamination during injury or surgery, compounded by patient-related risk factors such as diabetes, smoking, or immunosuppression. Diagnosis of FRI relies on a combination of clinical, radiological, and microbiological criteria. Common signs include persistent pain, swelling, erythema, purulent discharge, and non-union of the fracture. FRIs are classified based on the timing of infection onset into acute, delayed, and chronic forms, each requiring tailored management strategies. Treatment generally involves aggressive surgical debridement, possible hardware removal or retention, and targeted antibiotic therapy. In cases of severe tissue loss, reconstructive procedures may be necessary to restore bone and soft tissue integrity. Treatment strategies include early administration of prophylactic antibiotics, meticulous surgical technique, and timely soft tissue coverage in open fractures. A multidisciplinary approach involving orthopedic surgeons, infectious disease specialists, and microbiologists is essential for successful management. Early recognition and appropriate intervention are crucial to improving outcomes and minimizing long-term disability in patients with fracture-related infections. Full article

Background/Objectives: The optimal duration of antibiotic therapy for bacterial prosthetic joint infections (PJI) remains a topic of considerable debate. Current recommendations are often based on limited evidence and expert consensus. Emerging data suggest that shorter antibiotic courses may be as effective as prolonged treatments in select cases. Shortening the duration of therapy offers several advantages, including a reduced risk of bacterial resistance, fewer adverse events, and cost savings. However, this approach must be carefully balanced with the individual patient’s risk of treatment failure. This narrative review aims to synthesize current evidence regarding the duration of antibiotic therapy in PJIs, according to surgical strategies—DAIR (debridement, antibiotics, and implant retention), one-stage exchange, two-stage exchange, and resection without reimplantation—and to identify parameters that may guide individualized and potentially shortened regimens. Methods: We conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases through January 2025, including observational studies, randomized controlled trials, and international guidelines. Reference lists of key articles were also screened. Results: Studies on DAIR suggest that longer regimens (e.g., 8–12 weeks) are necessary, especially in staphylococcal infections, as confirmed by the DATIPO trial, which showed higher failure rates with 6 weeks compared to 12 weeks. Evidence on one-stage exchange is limited but increasingly suggests that 6 weeks may be sufficient in selected patients; however, no dedicated trial has confirmed this. In two-stage exchange, small retrospective series report successful outcomes with short antibiotic therapy combined with local antibiotics, but randomized trials show trends favoring longer regimens. For patients treated with permanent resection arthroplasty, arthrodesis, or amputation, antibiotic durations are highly variable, with few robust data. Across all strategies, most studies are limited by methodological weaknesses, including small sample sizes, retrospective design, lack of microbiological stratification, and heterogeneous outcome definitions. Conclusions: Despite growing interest in shortening antibiotic durations in PJIs, high-quality evidence remains limited. Until additional randomized trials are available—particularly in one- and two-stage exchange settings—12 weeks remains the safest reference duration for most patients, especially those with retained hardware. Future studies should incorporate stratification by infection type, causative organism, and host factors to define tailored and evidence-based antibiotic strategies. Full article

Introduction: Ankylosing spondylitis (AS) is a chronic inflammatory disorder that causes progressive ossification and fusion of the spine, particularly in the cervical region. This results in a rigid spinal column that is highly susceptible to unstable fractures, even after low-energy trauma. Cervical fractures in AS are often complex, extending through multiple spinal segments, and are associated with a high risk of neurological compromise. Esophageal injury associated with such fractures is rare but clinically significant, as the anatomical vicinity of the esophagus makes it vulnerable to direct trauma, delayed perforation, or secondary damage from fracture displacement and hardware failure. Aim: The purpose of this review is to present and highlight the clinical relevance of esophageal injury in cervical spine trauma among patients with AS, emphasizing the diagnostic challenges and surgical treatment in order to improve outcomes. Results: Esophageal injuries in the context of AS-related cervical trauma are frequently overlooked due to subtle clinical manifestations such as dysphagia, subcutaneous emphysema, or covert signs of mediastinitis. Plain radiographs are insufficient to identify such complications; advanced imaging modalities are often required for detection. Management is complex and usually demands a multidisciplinary approach, involving both stabilization of the cervical spine and repair of the esophagus. Despite treatment efforts, these patients remain at increased risk for morbidity and mortality, mainly due to infection and sepsis. Conclusions: Esophageal injury in cervical spine trauma associated with AS is an uncommon but life-threatening condition. Early recognition, comprehensive radiologic evaluation, and careful surgical planning are crucial for optimal management. Heightened clinical suspicion and awareness of this rare complication are essential to improve diagnostic accuracy and patient outcomes. Full article

Accurate and rapid detection of Plasmodium falciparum parasites in blood smears is critical for the timely diagnosis and treatment of malaria, particularly in resource-constrained field settings. This paper presents a proof-of-concept solution demonstrating the feasibility of the Google Coral Edge Tensor Processing Unit (TPU) for real-time screening of thin blood smears for P. falciparum infection. We develop and deploy a lightweight deep learning model optimized for edge inference using transfer learning and training data supplied by the NIH. This model is capable of detecting individual parasitized red blood cells (RBCs) with high sensitivity and specificity. In a final deployment, the system will integrate a portable digital microscope and low-power color display with the Coral TPU to perform on-site image capture and classification without reliance on cloud connectivity. We detail the model training process using a curated dataset of annotated smear images, potential future hardware integration for field deployment, and performance benchmarks. Initial tests show that the Coral TPU-based solution achieves an accuracy of 92% in detecting P. falciparum parasites in thin-smear microscopy images, with processing times under 50 ms per identified RBC. This work illustrates the potential of edge AI devices to transform malaria diagnostics in low-resource settings through efficient, affordable, and scalable screening tools. Full article

Objectives: This study aimed to compare the clinical, functional, and radiological outcomes of three different fixation techniques—dorsal locking plate, crossed cortical screw, and a combination of both—used in first metatarsophalangeal (MTP) joint arthrodesis for advanced-stage hallux rigidus. The goal was to provide evidence-based guidance for surgical technique selection. Methods: This retrospective cohort study included 52 patients with advanced hallux rigidus (stage III–IV, Coughlin–Shurnas classification) who underwent surgical treatment between 2023 and 2025 at the Department of Orthopedics and Traumatology of Ankara Etlik City Hospital, with a minimum follow-up of one year. Patients were categorized into three groups according to the fixation technique used. Visual Analog Scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, and Foot Function Index (FFI) were assessed using validated Turkish-language versions of the questionnaires. Radiological parameters included hallux valgus angle, first toe dorsiflexion angle, distal interphalangeal (DIP) arthritis, and radiographic union—defined as trabecular bridging across at least three cortices on weight-bearing anteroposterior and lateral radiographs. ANCOVA was performed with age as a covariate. Results: A total of 52 patients were included: Group 1 (dorsal plate fixation, n = 19), Group 2 (crossed cortical screw fixation, n = 16), and Group 3 (combined fixation, n = 17). Group 1 patients were significantly older (mean age: 64 ± 6 vs. 55 ± 6 and 59 ± 5 years; p < 0.001). After age adjustment, VAS pain scores were significantly higher in Group 1 compared to Group 3 (mean VAS: 2.8 ± 0.6 vs. 1.9 ± 0.5; p = 0.010). AOFAS scores did not differ significantly (p = 0.166), although Group 2 showed the highest median value (90 [70–93]). FFI scores differed significantly (p < 0.001), with Group 1 reporting worse outcomes (19 [17–31]) than Group 2 (15 [13–22], p = 0.03) and Group 3 (15 [11–16], p = 0.01). Dorsiflexion angle was significantly lower in Group 2 than Group 1 (median 19° vs. 27°; p = 0.04), though all remained within the physiological range. Radiographic union was achieved in 50/52 patients (96.2%), without significant intergroup differences (p = 0.612). Complications included two cases of wound dehiscence in Group 1; no infections, symptomatic non-union, malalignment, or hardware irritation were observed. Conclusions: Crossed cortical screw fixation yielded the most favorable functional outcomes, whereas the combined technique achieved the lowest postoperative pain scores. Dorsal plate fixation alone consistently underperformed. While outcomes were adjusted for age, residual confounding cannot be excluded. These results highlight the importance of tailoring fixation strategy to patient profile, with crossed screw and combined methods representing reliable choices for optimizing postoperative outcomes in advanced hallux rigidus. Full article

Background: Sepsis is a leading cause of morbidity and mortality among patients receiving maintenance hemodialysis (HD), reflecting a unique combination of immunologic dysfunction, comorbidities, and healthcare-related exposures. Despite advances in dialysis technology and infection control, outcomes for septic HD patients remain disproportionately poor. Objective: This review aims to synthesize current evidence on the epidemiology, risk factors, diagnostic challenges, and treatment considerations of sepsis in HD patients, highlighting persistent vulnerabilities and areas for clinical improvement. Methods: A structured narrative review was conducted, focusing on high-quality cohort studies, surveillance data, and pharmacologic analyses published over the past two decades. The literature search was performed using PubMed, Web of Science, and Google Scholar. A total of 37 studies were included in the final synthesis. Key themes were organized around epidemiologic trends, infection sources, risk modifiers, treatment outcomes, and antimicrobial considerations in the dialysis population. Results: The review found that sepsis in HD patients is multifactorial and systemic. Diabetes, advanced age, and central venous catheters remain strong risk factors, while a substantial proportion of infections arise from non-access-related sources. Mortality rates remain high, often due to delays in recognition, inappropriate empiric therapy, and challenges in antimicrobial dosing. Pharmacokinetic alterations in renal replacement therapy complicate treatment, requiring individualized approaches. Despite variations in infection rates across centers, systemic vulnerabilities—rather than dialysis modality alone—drive outcomes. Conclusions: Sepsis in hemodialysis patients is not solely a hardware-related complication but reflects deeper systemic and immunologic challenges. Improving outcomes will require earlier recognition, tailored antimicrobial strategies, standardized infection control protocols, and broader attention to patient-specific risk factors. Future research should focus on ESRD-adapted sepsis diagnostics and interventional models to reduce infection-related mortality in this high-risk group. Full article

Background and Objectives: Hemophilic arthropathy, the end result of recurrent hemarthroses in patients with hemophilia, often necessitates total knee arthroplasty (TKA) using constrained implants to address severe deformities and joint destruction. Revision TKA is often required due to aseptic loosening, implant malposition, infection, or periprosthetic fractures. The extended tibial tuberosity osteotomy (ETTO) has emerged as a critical technique for the safe removal of well-fixed tibial stems in such complex cases, demonstrating high union rates and minimal complications. The aim of this study is to evaluate the safety, effectiveness, and clinical outcomes of the ETTO technique during complex revision TKA in patients with hemophilia. Materials and Methods: A retrospective analysis was conducted on seven male hemophilic patients who underwent revision TKA with ETTO between 2015 and 2023. The procedure involved the creation of an extended proximal tibial bone flap, laterally retracted to facilitate tibial stem exposure and removal. Postoperative outcomes included radiological confirmation of osteotomy union, assessment of complications, and evaluation of functional outcomes, including range of motion and extensor mechanism integrity. Results: Osteotomy union was achieved in all patients (mean age 57.5 ± 1.50 years and mean body mass index 26.07 ± 0.67 kg/m²) within four months, confirmed by radiographic evidence of bridging callus. No significant complications, such as nonunion, fragment displacement, or symptomatic hardware, were observed. There was one patient who experienced delayed wound healing, managed successfully with surgical debridement. Postoperative mean knee flexion was 92°, with no extensor lag reported. ETTO enabled safe tibial stem removal and successful revision arthroplasties in all cases. Conclusions: ETTO is a technically demanding but indispensable approach for addressing the challenges of revision TKA in patients with hemophilia. It allows for secure tibial stem removal while maintaining excellent union outcomes and a low rate of complications. Due to its complexity, ETTO should be performed by experienced surgeons in specialized centers. Full article

Objectives: Operative fixation of displaced midshaft clavicle fractures has become increasingly the more acceptable choice of care in recent years, based on evidence supporting its effectiveness. However, this practice presents challenges due to the complex S-shaped morphology of the clavicle and its subcutaneous location. Despite the introduction of anatomically pre-contoured plates, achieving optimal implant-to-bone fit remains difficult, prompting the development of newer plate generations. The aim of this study was to compare the hardware removal rates of second-generation 2.7 mm thinner plates (SGPs) with those of first-generation 3.5 mm plates (FGPs). Methods: A retrospective comparative cohort study was conducted at a level one trauma center. A total of 187 patients received FGPs, and 67 received SGPs, both positioned on the superior bone surface. All surgeries were performed by fellowship-trained surgeons, and patients were followed for at least one year. Data were extracted from medical records and the PACS system. Results: The patients’ demographics (age: 32.86 vs. 33.14 years; gender: 16.85% vs. 14.92% female) and fracture type (AO/OTA) were similar between the two groups. The rate of implant removal (20.1% vs. 20.9%) did not differ significantly between groups. Complications included nonunion (1.6% vs. 1.7%, statistically not significant) and infection (three cases in the FGP group, none in the SGP group). Conclusions: Despite the high success rate of clavicle fixation procedures, the superior clavicular plate removal rate remains significant, regardless of the implant design. Full article

Background/Objectives: The purpose of this review was to determine the impact of osteoporosis on outcomes after surgery for cervical deformity. Cervical deformity involves abnormal curvature or misalignment of the cervical spine, often resulting in a significant loss of quality of life and requiring surgical correction. While osteoporosis has been associated with hardware failure including screw loosening and cage migration in spine surgery, its role in cervical deformity remains unclear. Existing studies report mixed findings with regard to postoperative sequelae in patients with osteoporosis undergoing surgical correction of cervical deformity. Methods: A systematic review using PRISMA guidelines and MeSH terms involving spine surgery for cervical deformity and osteoporosis was performed. The Medline (PubMed) database was searched from 1990 to August 2022 using the following terms: “osteoporosis” AND “cervical” AND (“outcomes” OR “revision” OR “reoperation” OR “complication”). This review focused on radiographic outcomes, as well as post-operative complications. Results: Eight studies were included in the final analysis. Three papers assessed risk factors for the development of post-operative distal junctional kyphosis (DJK), but only one found osteoporosis as a predictor for DJK. Although three studies found that osteoporosis was not significantly associated with the incidence of surgical complications, one highlights osteoporosis as a predictor of complications at 90 days postoperatively (p < 0.001) and another associates osteoporosis with overall poor outcomes (p = 0.021). Furthermore, one study assessing the relationship between osteoporosis and reoperation found no association. Conclusions: Overall, our systematic review suggests that in patients undergoing surgery for cervical deformity, osteoporosis is not predictive of the need for reoperation or the development of postoperative complications, such as DJK, dysphagia, superficial infection, and others. These findings highlight the need for further study regarding the role of osteoporosis in surgical correction of cervical deformity. Full article

Epidemics caused by respiratory infections have become a global and systemic threat since humankind has become highly connected via modern transportation systems. Any new pathogen with human-to-human transmission capabilities has the potential to cause public health disasters and severe disruptions of social and economic activities. During the COVID-19 pandemic, we learned that proper mask-wearing in closed, restricted areas was one of the measures that worked to mitigate the spread of respiratory infections while allowing for continuing economic activity. Previous research approached this issue by designing hardware–software systems that determine whether individuals in the surveilled restricted area are using a mask; however, most such solutions are centralized, thus requiring massive computational resources, which makes them hard to scale up. To address such issues, this paper proposes a novel decentralized, federated learning (FL) solution to mask-wearing detection that instantiates our lightweight version of the MobileNetV2 model. The FL solution also ensures individual privacy, given that images remain at the local, device level. Importantly, we obtained a mask-wearing training accuracy of 98% (i.e., similar to centralized machine learning solutions) after only eight rounds of communication with 25 clients. We rigorously proved the reliability and robustness of our approach after repeated K-fold cross-validation. Full article

Background: Proximal tibial fractures can lead to post-traumatic osteoarthritis (PTOA), and subsequent total knee arthroplasty (TKA) in such patients is associated with elevated complication rates. A two-stage approach, involving the elective removal of osteosynthetic hardware prior to TKA, is recommended. The utility of microbiological sampling from macroscopically unremarkable tissue during TKA implantation remains controversial. Objective: To retrospectively evaluate the rate of periprosthetic joint infection (PJI) following TKA after PTOA and to assess the potential benefit of intraoperative microbiological sampling. The secondary objective was to evaluate the presence of prior colonization in osteosynthetic hardware among the affected cases. Patients and Methods: A retrospective screening of the hospital database was conducted between 2008 and 2022, including only AO/OTA type 41-B and 41-C fractures. Patients were assigned to a sampling group (with microbiological sampling during TKA) or a control group (without sampling). All patients received structured follow-up to assess postoperative complications. Results: A total of 40 patients met the screening criteria. In the sampling group (n = 29), 17.24% required surgical revision, and the rate of PJI was 3.45%. In the control group (n = 11), 18.14% underwent revision surgery, with a PJI rate of 9.09%. The average follow-up period was 4.35 years (range 2–11.6 years). Discussion: TKA in patients with PTOA is associated with a heightened risk of complications. A noteworthy possible correlation between systematic microbiological sampling and reduced PJI incidence was observed. While the small sample size limits definitive conclusions regarding causality, the findings support the potential value of consistent intraoperative sampling. Full article

Open reduction and internal fixation (ORIF) is widely regarded as the primary treatment for acetabular fractures, but limitations arise in complex cases, leading to non-anatomical reductions and increased risk of post-traumatic osteoarthritis. Given the high incidence of secondary arthritis (12–57%) following ORIF, total hip arthroplasty (THA) is often necessitated, particularly in scenarios unsuitable for ORIF, such as extensive comminution or combined femoral head and neck fractures. The surgical landscape has shifted from a traditional “fix or replace” to a more integrated “fix and replace” approach, especially beneficial in managing elderly patients with osteoporotic bones. THA is applied across various timelines, including acute (0–3 weeks), delayed (3 weeks to 3 months), and late (beyond 3 months), each presenting distinct challenges and requiring specific strategies to optimize outcomes. The importance of precise bone defect classifications and the role of dual mobility cups in reducing dislocation risks are highlighted, alongside the use of modern surgical and fixation techniques to improve stability and patient outcomes. Enhanced recovery protocols and meticulous postoperative management are critical to addressing complications, such as infections and hardware interference, tailoring treatment approaches to each patient’s needs, and advancing care for complex acetabular fractures. Full article

Background/Objectives: High-energy trauma to the lower limb often results in extensive soft tissue loss with exposure of critical structures, posing a serious threat to limb viability. Early and effective coverage is crucial to prevent infection, promote bone healing, and preserve function. This report presents the use of a latissimus dorsi free flap for circumferential soft tissue reconstruction following a severe crush injury. Methods: We describe the case of a young female patient who sustained a high-energy crush trauma with a comminuted, displaced fracture of the middle and distal third of the tibia and complete circumferential soft tissue loss. Due to the extent and location of the defect, a latissimus dorsi free flap was selected for reconstruction. The surgical technique, microsurgical anastomosis, postoperative care, and rehabilitation protocol are detailed. Results: The latissimus dorsi flap provided reliable coverage of the entire defect, protected the underlying bone and hardware, and promoted wound healing. No major complications were observed. Functional recovery was satisfactory, with progressive weight-bearing and joint mobility achieved during follow-up. Conclusions: In complex lower limb injuries with extensive soft tissue damage, free flap transfer remains a key strategy for limb salvage. The latissimus dorsi flap, due to its size, reliability, and versatility, represents a valuable option for circumferential coverage and restoration of limb function following high-energy trauma. Full article