Search Results (19)

Background/Objectives: Dyskinetic cerebral palsy (DCP) often implies severe motor impairment and risk of health problems. Our aim was to follow up a group of young adults with DCP that we previously examined as children, to describe health, function, and living conditions. Methods: Interviews regarding health issues, treatments, and living conditions, and quality of life (RAND-36) and fatigue questionnaires were completed. Gross and fine motor function, communication, and speech ability were classified, and weight, height, spasticity, and dystonia were assessed and compared to previous data. Joint range of motion (ROM) was compared to older adults with DCP. Results: Dystonia was present in all fifteen participants, and spasticity in all but two. A decrease was found mainly in those who received intrathecal baclofen (ITB). ROM limitations were most pronounced in shoulder flexion, abduction and inward rotation (while outward rotation was hypermobile), hip abduction, hamstrings, and knee extension. The majority had frequent contact with primary and specialist healthcare. Seven participants were underweight, eight had a gastrostomy, and seven had ITB. Upper gastrointestinal and respiratory problems were frequent. Orthopedic surgery for scoliosis was reported in five, and lower extremity in nine, while fractures were reported in six participants. RAND-36 revealed physical functioning, general health, and vitality as the greatest problem areas. Fatigue was significant in 64%. Eight participants lived with their parents. Participants at more functional levels completed tertiary education and lived independently. Conclusions: Most participants had severe impairment and many health issues, despite decreased dystonia and spasticity due to ITB. Sleep problems and pain were uncommon. Full article

Background: Cardiovascular diseases (CVD) are recognized as a leading cause of morbidity and mortality in the population worldwide. A healthy cardiovascular system enables adaptation to trauma and physical stress. This study targets the reciprocal relation between CVD and postoperative complications after trauma surgery. Methods: In 2014, a randomized and standardized acquisition of study patients was initiated at a Level I trauma center in Germany. The burden of CVDs and the location, type, and severity of injuries were categorized. Clavien–Dindo classification was used to record postoperative complications. Results: The study analyzed a cohort of 1262 patients, representing a diverse range of orthopedic treatment disciplines within the hospital. It highlighted that patients with lower leg fractures experienced significantly higher complication rates, particularly linked to heart valve diseases and chronic venous insufficiency. Age and sex were not found to have a significant impact. Multivariate analysis identified additional key influencing factors for the development of complications, including the number of CVDs, nutritional status, smoking habits, and mobility levels. Conclusions: CVDs play a pivotal role in elevating complication rates post-trauma-surgery. Trauma-related extremity conditions are notably more severe when accompanied by CVD. A personalized approach that accounts for cardiovascular risk factors could significantly improve treatment outcomes in the future. Full article

Background and Objectives: In the triaging of polytrauma, patients with less severe injuries and lower somatic stress often undergo isolated definitive orthopedic surgery without damage-control procedures. Adverse events, particularly sepsis, should be minimized. We aimed to identify sex-specific predictors for sepsis in polytrauma patients undergoing stand-alone definitive surgery. Materials and Methods: Our institutional trauma database, containing data from 3653 patients between 1996 and 2022, was filtered for polytrauma patients who underwent definitive surgery, were aged ≥16 years, and had an Injury Severity Score (ISS) ≥16. Injury and physiological parameters were documented upon admission, as well as on the first and second days thereafter. Surgical data were also recorded. All factors were evaluated for their association with sepsis development. Results: Among the 276 patients (71.1% male; mean age 45.0 years, 95% confidence interval 42.7–47.2 years; median ISS of 27, interquartile range, 20–34), the rate of sepsis was 13.8% (n = 38), with a higher incidence in males (16.7%; n = 33) than in females (6.8%; n = 5) (p = 0.026). Head and thorax injuries were more common and severe in septic males, with thorax injuries being predictive. Male patients who developed sepsis also had a higher ISS, an increased heart rate (HR), and lower pH at admission, with ISS and HR being predictive of sepsis. On the first day post-admission, septic males showed higher Base Excess and lower Prothrombin Time. Lactate levels were elevated on both the first and second days post-admission. Surgical predictors for males included less primary extremity surgeries and later secondary spine surgeries. Conclusions: Sepsis is more common in males undergoing stand-alone definitive surgery. Several factors, particularly acidosis and coagulopathy, are associated with this phenomenon. Fewer primary extremity surgeries and delayed secondary spine surgeries were also linked to a higher sepsis risk in males. These findings may help identify patients eligible for stand-alone definitive surgery and underscore the need for more data on female polytrauma patients. Full article

Background/Objectives: In 2021, the Food and Drug Administration approved liposomal bupivacaine injectable suspension for single-dose infiltration in patients ≥ 6 years of age. Liposomal bupivacaine and bupivacaine hydrochloride admixtures may also be administered off-label for pediatric regional anesthesia including peripheral nerve blocks (PNBs). This single-injection, long-acting technique is not well described in pediatrics but may have benefits over traditional continuous catheter-based systems. The purpose of this investigation was to examine an adolescent cohort who received liposomal bupivacaine/bupivacaine hydrochloride PNBs for orthopedic surgery. Methods: Patient, surgical, anesthetic, block characteristics, and post-anesthesia care unit (PACU) outcomes were retrospectively reviewed from February 2020 to June 2024. From February to December 2022, a short follow-up survey was conducted to assess post-discharge patient-reported outcomes. Results: There were 524 liposomal bupivacaine/bupivacaine hydrochloride PNBs (106 upper-extremity and 418 lower-extremity) performed in 374 patients with a mean (standard deviation, range) age of 16 (1.2, 11–17) years. Two unilateral PNBs were performed in 150 (40%) patients to ensure an adequate sensory neural blockade. The interscalene (n = 81, 15%) and adductor canal (n = 140, 27%) blocks were the most common upper- and lower-extremity PNBs, respectively. Intraoperatively, the majority of the cohort (n = 258, 69%) underwent monitored anesthesia care (MAC). No patient required conversion from MAC to general anesthesia due to pain. In PACU, 288 (77%) patients reported no pain. Mild and moderate pain were reported by 56 (15%) and 30 (8%) patients, respectively. No patients developed local anesthetic toxicity. The survey results (n = 66) indicate that the majority of patients (96%) were satisfied with block analgesia postoperatively. Conclusion: Liposomal bupivacaine/bupivacaine hydrochloride PNBs were used successfully in adolescents undergoing a variety of orthopedic surgeries. Full article

Introduction: Peripheral arterial disease (PAD) impedes the ability to recover from lower extremity arthroplasties (LEA) while simultaneously increasing risks of peri- and postoperative complications, morbidity, and mortality. Despite the known risks that PAD presents, there are currently no standards outlining how practitioners should screen patients prior to undergoing LEA. The purpose of this manuscript is to facilitate the improved diagnosis of PAD, leading to appropriate vascular surgery consultation prior to undergoing orthopedic surgeries. Recommendations for Preoperative Assessment: Screening begins with a succinct history and physical exam, looking for signs and symptoms of diminished vascular integrity. A heightened suspicion for PAD should prompt the immediate enactment of an ankle brachial index, or alternatively, a pressure volume recording or the skin perfusion pressure technique. Full article

The optimal management of bone tumors requires a multidisciplinary strategy to guarantee high-quality care. At specialized centers, the medical team responsible for managing patients with bone cancer comprises oncologists, surgeons, radiologists, pathologists, and rehabilitation specialists. The goal of treatment is to achieve long-term survival with minimal disability and pain. Postoperative rehabilitation is a fundamental therapeutic approach to enhance functionality and sustain the utmost quality of life following a limb-sparing surgery. Currently, megaprostheses are used for reconstructing bone defects after tumor resection, but in the literature, only a few studies have investigated rehabilitation outcomes in terms of functionality and impact on daily activities. This narrative review explores the functional and quality of life outcomes after the implantation of MUTARS^® prostheses in patients with lower extremity bone tumors. A comprehensive search was conducted on PubMed and Scopus using the following MESH terms: “MUTARS”, “Megaprosthesis”, “bone”, “tumors”, “metastasis”, “lower limb”, “rehabilitation”, “outcome”, and “quality of life”, and 10 studies were included. The most frequent oncological pathology was found to be primitive bone tumors treated with modular prostheses. The outcome measures used were the Henderson et al. classification, Harris Hip Scale, Musculoskeletal Tumor Society score, Visual Analog Scale, Range Of Motion, Karnofsky Performance Scale, and quality of life questionnaire. MUTARS^® is a well-established treatment option after bone tumor resection, although it involves extensive and complex post-resection reconstruction that exposes joints and tissues to substantial mechanical stress. Proper rehabilitation after MUTARS^® surgery is a fundamental therapeutic step, although there is still insufficient evidence in the literature focusing on functional and rehabilitative outcomes. Therefore, more studies and guidelines are needed to define standardized rehabilitation protocols for clinical practice after orthopedic oncologic surgery. Full article

Systematic detection of risky nutrition behaviors after sports surgery may better promote healing for return-to-sport. The purpose of this study was to assess nutritional behavior differences between patients following anterior cruciate ligament reconstruction (ACLR) and following other lower-extremity orthopedic surgeries. One pediatric sports medicine center was reviewed for a custom Sports Nutrition Assessment for Consultation, which investigates nutrition-related risk factors for youth athletes at their first post-operative visit. Patients reported “Yes” or “No” to eight questions, after which they were offered a nutrition consultation for any response indicating risk. A total of 243 post-ACLR and 242 non-ACLR patients were reviewed. The post-ACLR patients more often reported a change in appetite (p = 0.021), recent weight changes (p = 0.011), a desire to better understand nutrition (p = 0.004), and recommendations to change their body composition (p = 0.032). More post-ACLR patients were identified for a nutrition consultation (p = 0.002), though an equal percentage accepted the consultation between groups. Age and sex were not determined to be significant confounders after matched sub-analysis. The post-ACLR patients more often reported nutrition risks, specifically weight-related issues, regardless of age or sex. Sports surgeons should regularly inquire about nutrition-related concerns with patients and refer to sports dietitians for recovery nutrition support as needed, particularly after ACLR. Full article

(1) Background: This prospective observational study aimed to investigate the predictors affecting DMT requirements for sedation during regional anesthesia. (2) Method: A total of 108 patients who received regional anesthesia with intravenous DMT administration for orthopedic upper- or lower-extremity surgery were enrolled. Following successful regional anesthesia, DMT was administered at a rate of 4 µg/kg/h until reaching loss of consciousness (LOC). The administered dose of DMT per body weight until LOC (DMT_LOC; µg/kg) was evaluated. The infusion was maintained at a rate of 0.2–0.7 µg/kg/h during the surgery. At the end of surgery, the elapsed time to a BIS value of 90 (T_BIS90; s) was recorded. Linear regression models were used to identify potential predictors of DMT_LOC and T_BIS90. (3) Results: One hundred patients were analyzed. There were negative relationships between DMT_LOC and age (r = −0.297, p = 0.003) and DMT_LOC and body mass index (BMI) (r = −0.425, p < 0.001), respectively. Multiple linear regression models revealed that both increasing age and BMI were significantly related to DMT_LOC (r² = 0.259, p < 0.001), but those variables showed no association with T_BIS90. (4) Conclusions: The results of this study suggest that initial loading of DMT should be carefully titrated to minimize risk in elderly and obese surgical populations. Full article

(1) Background: limited data exist regarding the occurrence of hypotension associated with dexmedetomidine use and its risk factors in the context of intraoperative sedation for patients receiving peripheral nerve blocks. (2) Method: This single-center retrospective study assessed the incidence of hypotension in patients undergoing orthopedic upper extremity surgery with brachial plexus blockade. Patients were classified into three groups: group N (non-sedated), group M (midazolam), and group D (dexmedetomidine), based on their primary intraoperative sedative use. The primary outcome was the incidence of perioperative hypotension, defined as systolic blood pressure (SBP) < 90 mmHg or mean blood pressure (MBP) < 60 mmHg, at a minimum of two recorded time points during the intraoperative period and post-anesthesia care unit stay. Multivariable logistic models for the occurrence of hypotension were constructed for the entire cohort and group D. (3) Results: A total of 2152 cases (group N = 445, group M = 678, group D = 1029) were included in the analysis. The odds ratio for the occurrence of hypotension in group D was 5.68 (95% CI, 2.86 to 11.28) compared with group N. Concurrent use of a beta blocker, longer duration of surgery, and lower preoperative SBP and higher preoperative heart rate were identified as significant risk factors. (4) Conclusions: the increased risk of hypotension and the associated factors should be taken into account before using dexmedetomidine in these cases. Full article

Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7–14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration. Full article

Background and Objectives: Melorheostosis, also referred to in the literature as Leri’s disease, is an unusual mesenchymal dysplasia with the clinical appearance of benign sclerosing bone dysplasia; it frequently occurs in late adolescence. Any bone in the skeletal system can be affected by this disease, though the long bones of the lower extremities are the most common, at any age. Melorheostosis has a chronic evolution, and symptoms are usually absent in the early stages. The etiopathogenesis is still unknown, however, numerous theories have been proposed that could explain the appearance of this lesion formation. An association with other benign or malignant bone lesions is also possible, and associations with osteosarcoma, malignant fibrous histiocytoma, or Buschke–Ollendorff syndrome have also been reported. There have also been reported cases of the malignant transformation of a pre-existing melorheostosis lesion into malignant fibrous histiocytoma or osteosarcoma. The diagnosis of melorheostosis can be made only based on radiological images, but, due to its polymorphism, additional imaging investigations are often necessary and sometimes only a biopsy can establish a definite diagnosis. Because there are currently no guidelines for treatment based on scientific evidence, due to the low number of cases diagnosed worldwide, our objective was to highlight the early recognition and specific surgical treatments for better prognosis and outcomes. Materials and Methods: We conducted a review of the literature consisting of original papers, case reports, and case series and presented the clinical and paraclinical characteristics of melorheostosis. We aimed to synthesize the treatment methods available in the literature as well as determine possible future directions related to the treatment of melorheostosis. Furthermore, we presented the results of a case of femoral melorheostosis admitted to the orthopedics department of the University Emergency Hospital of Bucharest in a 46-year-old female patient with severe pain in the left thigh and limitation of joint mobility. Following the clinical examination, the patient complained of pain in the middle third of the left thigh in the antero-medial compartment; the pain appeared spontaneously and was aggravated during physical activity. The pain started about two years prior, but the patient experienced complete pain relief after the administration of non-steroidal anti-inflammatory drugs. In the last six months, the patient presented an increase in pain intensity without significant improvement following the administration of non-steroidal anti-inflammatory drugs. The patient’s symptoms were mainly determined by the increase in the volume of the tumor and the mass effect on the adjacent tissues, especially on the vessels and the femoral nerve. The CT examination and bone scintigraphy showed a unique lesion in the middle third of the left femur and no oncological changes in the thoracic, abdominal, and pelvic regions; however, at the level of the femoral shaft, there was a localized cortical and pericortical bone lesion formation that surrounded approximately 180 degrees of the femoral shaft (anterior, medial, and lateral). It had a predominantly sclerotic structure but was associated with lytic areas with thickening of the bone cortex and areas of periosteal reaction. The next therapeutic gesture was to perform an incisional biopsy using a lateral approach at the level of the thigh. The histopathological result supported the diagnosis of melorheostosis. Additionally, immunohistochemical tests completed the data obtained after the microscopic examination through the classic histopathological technique The patient was discharged and included in a full medical recovery program for eight weeks in a specialized medical center, during which she also received analgesic treatment in maximum doses, but without improvement regarding her symptoms. Taking into account the chronic evolution of the pain, the complete lack of response to conservative treatment after eight weeks, and the lack of treatment guidelines in the case of melorheostosis, a surgical approach needed to be considered. The surgical option in this case, considering the circumferential location of the lesion at the level of the femoral diaphysis, was a radical resection. The surgical approach consisted of segmental resection to healthy bone tissue and reconstruction of the remaining defect with a modular tumoral prosthesis. At the 45-day postoperative control, the patient no longer complained of pain in the operated-on limb and was mobile with full support without gait difficulties. The follow-up period was one year, and the patient presented complete pain relief and a very good functional outcome. Results: In the case of asymptomatic patients, conservative treatment seems to be a good option with optimal results. However, for benign tumors, it remains unclear whether radical surgery is a viable option. Conclusions: Melorheostosis remains an incompletely understood disease, given the limited number of cases worldwide, and thus, there is a lack of clinical guidelines regarding specialized treatment. Full article

The number of legal disputes in the field of medical liability has increased exponentially in the last decades. The aim of this study is to investigate the outcomes of criminal cases against healthcare professionals in Italian criminal courts. The hypothesis is that the majority of cases are dismissed and/or most professionals in these cases are acquitted. This retrospective analysis considers criminal proceedings related to medical professional liability registered with the general register of crime reports of the Public Prosecutor’s Office of Rome in the time interval between 1 January 2000 and 31 December 2015. A total of 4793 criminal proceedings were ultimately identified. Proceedings related to the field of orthopedic trauma were then examined and identified. A complete analysis of 132 of the identified files (76.7%) was carried out. The field with the highest risk of disputes was determined to be the field of trauma. The most frequent complaint was found to arise from unsatisfactory surgical outcomes following elective surgery. The most affected anatomical district is the lower limb in both elective and trauma cases, followed by the upper limb in traumatology and spine cases. The surgeon is the most frequently quoted role of the professional involved. The number of physicians actually convicted (3.93%) and for whom liability was thus recognized, i.e., the existence of a causal link between their conduct and the event that took place was established, appears to be extremely small when compared with the far more significant values related to dismissals (53%) and acquittals (14.2%). Adequate legal reform aiming to reduce this disproportion is necessary to ensure physicians experience a more relaxed daily profession and to restore the original connotations of the doctor–patient relationship with the abolition of defensive medicine. Full article

Muscle herniation of the lower extremity, such as tibialis anterior muscle herniation (TAMH), is not a rare cause of leg pain in athletes. However, a few studies have reported surgical treatment for TAMH, and the optimal surgical procedure remains controversial. Fasciotomy was reported to be effective for patients with TAMH. However, this procedure would be associated with a risk of intraoperative injury to the superficial peroneal nerve (SPN), although no previous literature has reported this complication. This case report aimed to report a case of bilateral TAMHs in which a traumatic neuroma of the SPN developed after fasciotomy. A 16-year-old baseball player presented with painful swelling lesions of the bilateral lower extremities (1 lesion on the right, 3 lesions on the left) after sports activities. An ultrasonographic evaluation showed swelling lesions of the anterolateral parts of the bilateral lower extremities in the standing position after dashing, while these lesions were not detected in the supine position. A fasciotomy of the crural fascia was performed after conservative treatment failed. Several days after surgery, the patient presented with weakened touch sensation over the dorsal area of the left foot. At the three-month follow-up examination, a swelling lesion with hard elasticity was identified. The palpation of this lesion caused a radiating sensation in the area supplied by the SPN. He was able to return to playing baseball six months after surgery. The patient was asymptomatic without palpation of the traumatic neuroma of the SPN at the latest follow-up examination. In conclusion, the present case report suggests that orthopedic surgeons need to consider the risk of iatrogenic injury to the SPN during fasciotomy for the treatment of TAMHs. However, there may be a risk of injuring the SPN because of the many variants of the course of the SPN within the compartment of the lower extremities. Full article

Orthopedic surgery and soft-tissue sarcoma (STS) both independently increase the risk of developing symptomatic venous thromboembolic events (SVTE), but there are no established risk factors or guidelines for how to prophylactically treat patients with STS undergoing surgery. The objectives of this study were to (1) identify the prevalence of SVTE in patients undergoing STS surgery, (2) identify risk factors for SVTE, and (3) determine the risk of wound complications associated with VTE prophylaxis. This retrospective study was conducted in a tertiary level, academic hospital. A total of 642 patients were treated for soft-tissue sarcoma in the lower extremity with follow up for at least 90 days for the development of SVTE such as deep venous thrombosis and pulmonary embolism. Multivariate logistic regression was used to identify predictors for these events by controlling for patient characteristics, surgical characteristics, and treatment variables, with significance held at p < 0.05. Twenty eight patients (4.36%) were diagnosed with SVTE. Multivariate analysis found six significant predictors ordered based on standardized coefficients: pre-operative (PTT) partial thromboplastin time (p < 0.001), post-operative PTT (p = 0.010), post-op chemotherapy (p = 0.013), metastasis at diagnosis (p = 0.025), additional surgery for metastasis or local recurrence (p = 0.004), and tumor size larger than 10 cm (p < 0.001). The risk of wound complications (p = 0.04) and infection (p = 0.017) increased significantly in patients who received chemical prophylaxis. Our study identifies risk factors for patients at increased risk of developing VTE. Further prospective research is necessary to identify which protocols would be beneficial in preventing SVTE in high-risk patients with a low profile of wound complications. Full article

Epidural analgesia is effective and an accepted treatment for postoperative pain. Urinary retention is a known complication, but its description is mostly in the adult literature. Management of urinary catheter (UC) placement and removal is an important consideration in children receiving epidural analgesia. This is a single-center, retrospective observational study which examined UC management in children undergoing lower extremity orthopedic surgery under general anesthesia with or without epidural analgesia from January 2019–June 2021. Of 239 children included, epidural analgesia was used in 57 (23.8%). They were significantly younger and had more co-morbidities. In total, 75 UCs were placed in the OR, 9 in the ward, and 7 re-inserted. UC placement in the epidural group was more common (93% vs. 17%, p < 0.001) and remained longer (3 days vs. 1 day, p = 0.01). Among children without intra-operative UC, ward placement was more common in the epidural cohort (60% vs. 1.6%, p = 0.007). OR UC placement and ward re-insertion were more common in children with neuromuscular disease (61% vs. 22%, p < 0.001), (17% vs. 3%, p = 0.001), respectively. Based on these findings, we hypothesize that it is justifiable to routinely place a UC intra-operatively in children who undergo hip or lower extremity surgery and are treated with epidural analgesia, and caution is advised before early UC removal in orthopedic children with NMD. Full article