Search Results (126)

Ungual disorders can impact quality of life, with onychomycosis and nail psoriasis being the most prevalent disorders among the general population. In humans, the main functions of the nail apparatus comprise protection against trauma, improvement of tactile sensations, and allowing precision gripping. In order to perform such functions, the nail plate has a hard structure formed by dead keratinized corneocytes tightly bound to each other, giving the nail plate a “barrier-like” character. Due to this property of the nail plate, drug delivery to the region is hindered, making the treatment of ungual disorders difficult, either by systemic or topical drug administration. Many strategies have been developed in the last few decades in an attempt to increase the bioavailability of drugs in the nail. Interest in the employment of nanostructured drug delivery systems aiming to increase the bioavailability of drugs in the nail plate upon topical administration has increased. Moreover, the association of the nanotechnological approaches with other methods may be a beneficial strategy when aiming to increase drug permeation through the nail barrier. In this sense, the present review has the intention of presenting the panorama of the current technological development of nanostructured systems designed for the local treatment of ungual disorders. Through this extensive literature review, it was possible to recognize, among the studies, a lack of standardization regarding the methodology of nail permeation assessment, which imposes an obstacle to comparison. Full article

Background/Objectives: Trochanteric femoral fractures pose significant surgical challenges, particularly in elderly patients. Intramedullary nailing (IMN) and plate fixation (PF) are the primary operative strategies, yet their comparative efficacy and safety remain debated. This meta-analysis synthesizes randomized controlled trials (RCTs) to evaluate clinical, functional, perioperative, and biomechanical outcomes of IMN versus PF specifically in trochanteric fractures. Methods: A systematic search of six databases was conducted up to 20 May 2024, to identify RCTs comparing IMN and PF in adult patients with trochanteric femoral fractures. Data extraction followed PRISMA guidelines, and outcomes were pooled using random-effects models. Subgroup analyses examined the influence of fracture stability, implant type, and patient age. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results: Fourteen RCTs (n = 4603 patients) were included. No significant differences were found in reoperation rates, union time, implant cut-out, or mortality. IMN was associated with significantly reduced operative time (MD = −5.18 min), fluoroscopy time (MD = −32.92 s), and perioperative blood loss (MD = −111.68 mL). It also had a lower risk of deep infection. Functional outcomes and anatomical results were comparable. Subgroup analyses revealed fracture stability and nail type significantly modified operative time, and compression screws were associated with higher reoperation rates than IMN. Conclusions: For trochanteric femoral fractures, IMN and PF yield comparable results for most clinical outcomes, with IMN offering some advantages in surgical efficiency and perioperative morbidity, though functional outcomes were comparable. Implant selection and fracture stability influence outcomes, supporting individualized surgical decision making. Full article

Background: Atypical subtrochanteric femoral fractures (ASFs), frequently linked to long-term bisphosphonate use, present significant fixation challenges due to impaired bone healing. While intramedullary (IM) nailing is the standard treatment, delayed union or nonunion remains common. This study aimed to evaluate whether supplementing IM nailing with lateral plate augmentation improves radiographic healing in patients with ASFs. Methods: This retrospective comparative study included 12 elderly female patients with ASFs treated between October 2013 and October 2023. Five patients underwent IM nailing alone (IM group), while seven received IM nailing with additional lateral plate fixation (Plate + IM group). Fracture healing was assessed using the modified Radiographic Union Score for Tibial fractures (mRUST) at 3, 6, and 12 months postoperatively. Intergroup comparisons were performed using the Mann–Whitney U test. Results: The median mRUST scores in the IM group were 4 (IQR 3.5–4), 6 (IQR 4.5–6.5), and 8 (IQR 7–9) at 3, 6, and 12 months, respectively. In the Plate + IM group, the scores were 5 (IQR 4–6), 8 (IQR 8–8), and 10 (IQR 10–11), respectively. The Plate + IM group demonstrated significantly higher mRUST scores at all assessed time points (3 months: p = 0.018; 6 months: p = 0.003; 12 months: p = 0.006). No implant failures or postoperative infections occurred in either group during the 12-month follow-up period. One patient (20%) in the IM group developed fracture nonunion, while no nonunion cases were observed in the Plate + IM group. Conclusions: Lateral plate augmentation as an adjunct to IM nailing may promote faster and more consistent radiographic healing in atypical subtrochanteric femoral fractures. This dual-fixation strategy may offer a biomechanically more robust option for patients at risk of delayed union, potentially contributing to a lower risk of nonunion, though further prospective studies are required to confirm this finding. Full article

Background: There are no clear guidelines to support management decisions for patients with three-part fractures of the proximal humerus. The aim of the study is to identify the treatment used and to assess the functional and radiological outcomes at follow-up. Methods: A total of 126 patients were retrospectively included in the study and were divided into two groups based on the type of surgery: plate and nail group. We collected data on the patient’s sex, age, fracture type, surgery duration, fracture healing, initial and final neck–shaft angles, shoulder joint score, and complications. Results: A total of 69 patients received locking-plate internal fixation, while 77 patients underwent fixation with intramedullary nail. The two groups were comparable, with no significant differences observed in age, sex, or the number of patients. The average operation time for the locking-plate group (88.7 ± 10.5 min) was significantly longer compared to the intramedullary nail group (70.2 ± 8.3 min). The Constant–Murley score was 91.2 ± 6.7 (range 79–98) in the plate group and 90.5 ± 7.7 (range 80–98) in the nail group, with no statistically significant difference. Complications were observed in 16 patients (23.2%) of the locking-plate group and in 7 patients (9.1%) of the intramedullary nail group, with significant difference. Conclusions: Our assessment revealed no significant differences in fracture healing times, loss of reduction, or Constant–Murley scores between two groups. However, our results suggest that intramedullary nails have an advantage over locking plates in terms of reduced operation time and complications. Full article

Introduction: Monteggia fractures, first described by Giovanni Battista Monteggia, involve a fracture of the proximal ulna with anterior dislocation of the radial head. Bado’s 1967 classification divides these injuries into four types. Rare mixed patterns exist, overlapping with other forearm injuries such as Galeazzi and Essex–Lopresti lesions. These complex fractures/dislocations pose significant diagnostic and therapeutic challenges and are not adequately represented in current classification systems. Methods and Case Presentation: We report the case of a 56-year-old woman with a complex forearm injury sustained from a fall, presenting with radial head fracture/dislocation, mid-shaft radial fracture, distal ulna fracture, and ulnar collateral ligament rupture. Intraoperative imaging confirmed DRUJ stability and partial interosseous membrane disruption. Surgical management included radial head prosthesis implantation, radial shaft fixation with an anatomical locking plate, intramedullary nailing of the distal ulna, and ligament reconstruction. At two-year follow-up, the patient demonstrated full recovery of elbow flexion–extension and satisfactory forearm function. A narrative literature review was also conducted, focusing on hybrid injury variants. Results: Intraoperative examination under anesthesia revealed good elbow stability with 130° flexion, 15° extension lag, and forearm pronation/supination of 70°/60°. An initial Mayo Elbow Performance Score (MEPS) of 65 was recorded, limited by range of motion and stability. Pain during passive mobilization was mild, with a Visual Analogue Scale (VAS) score of 3/10. Postoperative recovery included 15 days of immobilization followed by structured rehabilitation. At two years, the patient regained full elbow flexion–extension but had residual deficits in pronation–supination, attributed to pre-existing conditions. Conclusions: This case illustrates a previously unreported hybrid Monteggia variant, combining features of Monteggia, Galeazzi, and Essex–Lopresti injuries. It highlights the limitations of current classification systems and supports the need for an expanded diagnostic framework. Successful management required a multidisciplinary surgical approach tailored to the injury’s complexity. Further studies are warranted to refine classification and treatment strategies for these rare combined injuries. Full article

Background/Objectives: Distal forearm fractures are the most common fractures in children. Three surgical techniques are most commonly used at the level of the radial diametaphysis on the distal forearm in children: K-wire, ascending ESIN (elastic stable intramedullary nail) or plate osteosynthesis. The aim of this study was to compare these procedures in children with distal diametaphyseal radius fractures regarding operative and functional outcome. Methods: A retrospective study was conducted in two level 1 trauma centers. Children and adolescents aged 2 to 15 years were included. The study period was from January 2010 to December 2022. The hospital information system was used to record patient age, gender, height, weight, fracture location, degree of angular deformity postoperatively, surgical procedure and postoperative complications, which were described in the medical records of the hospital information system. Complications graded by modified Clavien–Dindo–Sink served as the primary outcome. Reduction accuracy, operative and fluoroscopy times, immobilization length and postoperative motion were the secondary endpoints. Results: A total of 213 children were included in the study. K-wire osteosynthesis was performed in 25%, nailing in 19% and volar plate osteosynthesis in 55%. All ESIN were inserted in ascending technique. Complications occurred in 22% of patients and did not differ overall between techniques (p = 0.20). Severe complications were significantly more frequent after ESIN (20%) than after K-wires (7%) or plates (4%) (p = 0.04). Plate fixation achieved the most accurate alignment (≤5° angular deformity in 93% vs. 57% K-wires and 61% ESIN; p < 0.0001) and the fewest late motion restrictions (p = 0.02). K-wire surgery was fastest technique and required the least fluoroscopy, but necessitated the longest postoperative cast. Conclusions: Volar plating combines reliable anatomical reduction with a low rate of major complications and early mobilization, supporting its use in older children whose remodeling potential is limited. K-wires are a swift, minimally invasive option for younger patients, albeit with less precise reduction and prolonged immobilization. Conventional ESIN showed the highest burden of severe complications. Full article

Hallux valgus (HV) is a common forefoot deformity for which numerous surgical techniques have been proposed, with the Lapidus procedure representing a powerful and durable solution, especially in cases of moderate to severe deformities and first ray hypermobility. Initially described in the early 20th century, the Lapidus procedure involves first tarsometatarsal joint (TMTJ) arthrodesis and has undergone multiple modifications over time to reduce complications such as nonunion, malunion, shortening, and recurrence. The technique offers triplanar correction, addressing axial, sagittal, and coronal deformity components. Despite its proven corrective potential, the procedure remains technically demanding, and no universal consensus exists on the ideal fixation method or postoperative protocol. Recent developments in fixation strategies—including crossed screws, locking plates, intramedullary nails, nitinol staples, external fixation, and arthroscopic approaches—have aimed to improve stability, union rates, and the possibility of earlier weight-bearing. This narrative review provides a comprehensive overview of the Lapidus procedure, focusing on surgical indications, technical variants, fixation methods, clinical outcomes, and complications, with the goal of offering practical guidance for optimizing surgical decision-making in various clinical settings. Full article

Background: Displaced proximal humerus fractures (PHFs) in adults represent a common orthopedic challenge, especially in elderly patients with compromised bone quality. Intramedullary nails (IM) and locking plates (LP) are the most widely used fixation techniques, though the literature remains inconclusive regarding their comparative efficacy. Methods: This retrospective cohort study included 187 patients (mean age: 65.4 years) treated surgically for Neer ≥ 2-part proximal humerus fractures at a single tertiary referral center between 2018 and 2023. Patients underwent either IM nailing or LP fixation. Baseline characteristics included age, sex, smoking status, ASA score, trauma mechanism, and bone quality (assessed by the Deltoid Tuberosity Index). Functional outcomes (DASH and Constant–Murley scores), range of motion (ROM), radiographic healing, and complications were evaluated at 1, 3, 6, and 12 months postoperatively. Results were stratified by fracture type (two-, three-, and four-part fractures) and treatment group. Results: At 12 months, no statistically significant differences were found between groups in terms of DASH (p = 0.484) or Constant–Murley scores (p = 0.057). ROM recovery was comparable across all time points. Stratified analysis showed similar outcomes across fracture types. Age, smoking, and bone quality did not significantly influence clinical results. The overall complication rate was 11.8%, with no significant difference between groups. Avascular necrosis and hardware-related issues occurred predominantly in four-part fractures. Conclusions: Both intramedullary nailing and locking plate fixation provided comparable short-term outcomes for displaced PHFs. Functional recovery appeared more dependent on fracture complexity than on the choice of implant. Surgical technique should therefore be selected based on fracture morphology, patient characteristics, and surgeon experience. Full article

Background: Advanced sensor insoles and motion capture technology can significantly enhance the monitoring of rehabilitation progress for patients with distal tibial fractures. This study leverages the potential of these innovative tools to provide a more comprehensive assessment of a patient’s gait and weight-bearing capacity following surgical intervention, thereby offering the possibility of improved patient outcomes. Methods: A patient who underwent distal medial tibial plating surgery in August 2023 and subsequently required revision surgery due to implant failure, involving plate removal and the insertion of an intramedullary nail in December 2023, was meticulously monitored over a 12-week period. Initial assessments in November 2023 revealed pain upon full weight-bearing without crutches. Following the revision, precise weekly measurements were taken, starting two days after surgery, which instilled confidence in accurately tracking the patient’s progress from initial crutch-assisted walking to full recovery. The monitoring tools included insoles, hand pads for force absorption of the crutches, and a motion capture system. The patient was accompanied throughout all steps of his daily life. Objectives: The study aimed to evaluate the hypothesis that the approximation and formation of a healthy gait curve are decisive tools for monitoring healing. Specifically, it investigated whether cadence, imbalance factors, and ground reaction forces could be significant indicators of healing status and potential disorders. Results: The gait parameters, cadence, factor of imbalance ground reaction forces, and the temporal progression of kinematic parameters significantly correlate with the patient’s recovery trajectory. These metrics enable the early identification of deviations from expected healing patterns, facilitating timely interventions and underscoring the transformative potential of these technologies in patient care. Conclusions: Integrating sensor insoles and motion capture technology offers a promising approach for monitoring the recovery process in patients with distal tibial fractures. This method provides valuable insights into the patient’s healing status, potentially predicting and addressing healing disorders more effectively. Future studies are recommended to validate these findings in a larger cohort and explore the potential integration of these technologies into clinical practice. Full article

Background and Clinical Significance: Non-prosthetic peri-implant fractures (NPPIFs) are rare injuries occurring around internal fixation devices, and are distinct from periprosthetic fractures. While most studies focus on the femur, humeral NPPIFs remain poorly documented. This case illustrates a complex humeral NPPIF and highlights key surgical considerations. Case Presentation: A 62-year-old woman presented with a spiral humeral shaft fracture (AO 12B2) after a fall. Following closed reduction and antegrade intramedullary nailing, an intraoperative peri-implant fracture occurred at the distal interlocking screw. CT imaging revealed a complex fracture extending from the lateral condyle to the proximal humerus. Treatment included implant removal and open reduction with dual plate fixation—lateral distal and helically contoured proximal plates—plus cerclage bands and antibiotic-loaded beads. Recovery was uneventful, with a full range of motion achieved at six months. At one year, the DASH score and MEPS were 86 and 75, respectively. Conclusions: Humeral NPPIFs are challenging and require individualized, biomechanically sound strategies. This case reinforces the importance of intraoperative assessment and careful implant selection in humeral fracture management. Full article

Onychomycosis, a fungal nail infection, affects about 4% of the global population. Current topical antifungals like ciclopirox and amorolfine have limited effectiveness, highlighting the need for better treatments. WSNS-PO is a novel water-soluble therapy designed to treat and prevent onychomycosis by enhancing nail health. This study evaluated WSNS-PO’s ability to penetrate the nail plate and to treat and prevent infection by Trichophyton rubrum using bovine hoof membranes and human nail clippings. The anti-fungal efficacy of WSNS-PO was additionally evaluated against other dermatophytes, non-dermatophyte fungi, and yeast. The results showed that WSNS-PO effectively permeated nails and reduced and prevented the colonization of human nail fragments by T. rubrum ex vivo, demonstrating an efficacy comparable to ciclopirox and amorolfine. WSNS-PO also prevented the transfer of T. rubrum infection between nails and inhibited the fungal colonization of human skin by dermatophyte and non-dermatophyte fungi and yeast. Together, these results indicate that WSNS-PO possesses fungistatic, barrier-forming, and anti-adhesive properties, suggesting that it holds promise as an onychomycosis treatment against dermatophytes, yeast, and molds. Full article

Background/Objectives: Endonyx onychomycosis is a chronic infection of the nail plate that presents as milky white discoloration, without hyperkeratosis or onycholysis, and was originally described as being caused by T. soudanense and T. violaceum. Methods: In the present review, the definitions used in the different articles and the clinical characteristics of patients diagnosed with this onychomycosis variant were analyzed through a systematic review of the reported cases in the literature using the terms “endonyx” AND “onychomycosis” in PUBMED, SciELO, SCOPUS, Web of Science, and Google Academics databases. Results: We found 28 articles with a total of 175 patients diagnosed with endonyx onychomycosis, mainly reported in Asia and Africa. Nine papers presented detailed descriptions. From these, a total of 15 immunocompetent patients were registered, and the etiological agents reported were Trichophyton soudanense, T. rubrum, T. violaceum, T. tonsurans, and Fusarium spp. After analyzing the definitions employed in the remaining articles, only 47.3% cited or described a concept consistent with the original description. The other 47.3% of the studies lacked a traceable criterion for the diagnosis of these cases. Moreover, most studies analyzed their data at a global level, describing little information to provide specific insights into the endonyx variant. Conclusions: Emphasis on clinical description and histopathological analysis is essential to confirm the role of less commonly reported fungi, and more accurate diagnostic and treatment protocols for this condition are mandatory. Full article

Intertrochanteric fractures become more and more relevant in an aging population. Despite significant progress in the treatment of these fractures, some technical details, concerning the surgical procedure, are still a matter of strong debate. In this review of the literature, we have included the best evidence available from the last decade in an effort to shed light on some of the most controversial subjects related to intertrochanteric fractures: Treatment in the case of polytrauma or monotrauma? Reconstruction or arthroplasty? Open or closed reduction? Reconstruction with or without additional cables and plates? Cephalomedullary nail or dynamic hip screw (DHS)? Long cephalomedullary nail or short cephalomedullary nail? The results of this scoping review are controversial. By introducing a new therapeutic algorithm, we do not intend to present a new finished guideline but rather arouse a controversial debate about a relevant aspect in geriatric traumatology. These conflicting results are an indication that larger and more well-conducted, high-quality trials are needed in order to gain more secure answers. Full article

Background/Objectives: Limited surgical invasiveness is desirable in elderly patients with femur fracture. Serum cytokines have been considered as a possible marker but with inconclusive evidence. The present study aimed to assess the systemic inflammatory response to surgical trauma through the serum levels of several cytokines (IL1β, IL6, IL8, and IL-10), inflammatory markers (c reactive protein—CRP), and muscular damage markers (creatinkinase—CK) at different time intervals in a consecutive series of patients affected by pertrochanteric fractures (PFs) and treated by two different surgical devices (intramedullary nailing (IM) vs. dynamic hip screw plate—DHS). Methods: A total of 60 consecutive patients (45 female and 15 male, mean age 85.6 years) with PFs (AO31A1.2-2.2) were randomly assigned to two groups according to the surgical procedure used (IM vs. DHS). Specimens of venous blood were collected 1 h preoperatively and at 24, 48, and 72 h postoperatively. Commercial ELISA kits were used. Results: In the adjusted linear mixed model, the serum levels of IL-1β, IL-8, IL-10, CRP, and CK revealed no statistically significant correlation with the type of surgical intervention performed. A significant (p < 0.001) correlation was found for IL-6 values in patients undergoing IM, showing higher serum values than patients receiving DHSs in all postoperative blood sample collections. Conclusions: The results of this study reveal that the use of DHSs may have less biological impact than IM in frail elderly due to a more limited secretion of IL-6 cytokines deriving from the preservation of the femoral medullary canal, representing a possible guide for the choice of the surgical device. Full article

Background: Systemic therapy is frequently utilized because of its easy accessibility, low cost, and high efficacy. However, it can be linked with systemic adverse effects and drug–drug interactions, especially in immunocompromised and poly-medicated patients. Topical antifungals, associated with a low risk of systemic adverse effects and drug–drug interactions, have emerged as the most suitable treatment option for patients with diabetic foot disease. However, the duration of topical treatment can extend up to 12 months. Consequently, there is a need to bolster these topical treatments with complementary therapies. Methods: The current study acquired approval from an ethics committee (code 24/241-E) and Clinical Trials (code NCT06485050). No patients were excluded, irrespective of comorbidities or the severity of onychomycosis. Patients included in the study were administered Ciclopirox 8% (consisting of ethyl acetate, 96% ethanol, ketostearyl alcohol, hydroxypropyl chitosan, and purified water) once daily for 6 months. This was supplemented with photodynamic therapy (three sessions in the first 2 months) using toluidine blue gel and a 635 nm diode laser lasting 10 min, as well as monthly debridement of the nail plate. Results: All patients (10/10) included in the study exhibited negative microbiological culture results 6 months after the study began. Of these, 90% (9/10) were clinically cured, and thus, fully cured. No adverse effects or complications secondary to the treatments were observed in any of the cases. The average Onychomycosis Severity Index (OSI) value was initially 18.50 ± 8.947, reduced to 10.30 ± 6.129 at 3 months, and finally fell to 4.10 ± 4.08 at the end of the treatment. Conclusions: The current study demonstrated the clinical improvement, mycological cure, effectiveness, and safety of combination therapy of ciclopirox 8% and photodynamic therapy over 6 months. Full article