Search Results (146)

Background and Clinical Significance: Mallet finger is a common injury of the extensor mechanism at the distal interphalangeal (DIP) joint; however, open double mallet lesions are rare and may present a complex reconstruction challenge. Case Presentation: A 15-year-old male high school student who sustained an open injury to the left ring and little fingers after a high-energy buggy accident. The ring finger showed an open double mallet lesion in which the extensor tendon remained attached to a tiny avulsion fragment, and a separate dorsal base fragment was also present. The adjacent little finger had a concomitant open fracture with substantial soft tissue injury. Emergency surgery was performed on the day of the injury. For the ring finger, reduction of the tendon-attached avulsion fragment and separate dorsal base fragment was achieved using extension-block pinning, transarticular DIP pinning, and pull-out fixation over a volar button. For the little finger, cross-pinning was performed because the distal fragment was too small for stable non-transarticular fixation. Serial radiographs showed maintained alignment and progressive healing. At the final follow-up, 21 months after the injury, residual deformity and limitation of DIP motion remained; however, no infection, major skin complications, or nail deformity were observed. The little finger DIP joint became ankylosed, whereas some residual mobility remained in the ring finger DIP joint. Despite persistent functional limitations, the patient was able to continue school attendance and percussion-related activities. Conclusions: This case highlights that in an open double mallet lesion, disruption of both the tendon-attached fragment and its bony bed should be considered, and stabilization of the base may be useful in selected injury patterns before definitive tendon-side repair. Full article

Objectives: We aimed to explore foot condition and toe strength in older adults undergoing heart valve surgery. Materials and Methods: This exploratory pilot study included nine older adults undergoing heart valve surgery. Subjective data on foot-related symptoms, self-care status, nail care, footwear, exercise habits, and fall history were collected. Preoperative foot and nail conditions were assessed using observation and photography. Toe strength was measured preoperatively in all participants and postoperatively in a subset of participants when feasible. Descriptive analyses were primarily conducted, with exploratory group comparisons. Results: Participants frequently reported foot-related symptoms and difficulties with foot self-care prior to hospitalization. Lower toe strength appeared to be related to greater difficulties in foot self-care, whereas higher toe strength was more commonly observed in those reporting regular exercise habits. Postoperative toe strength was reassessed in six participants. In a participant with prolonged intensive care unit (ICU) stay, delayed recovery of toe strength was observed. Conclusions: These preliminary findings suggest that foot condition and toe strength may be relevant to physical function and fall prevention-related factors in older a dults undergoing cardiac surgery. Reduced toe strength may be related to self-care difficulties, and prolonged ICU stay may influence the recovery of toe strength. However, due to the small sample size, these findings should be interpreted as exploratory and hypothesis-generating. Full article

Background: Digital pulp reconstruction with toe-based flaps reliably restores sensibility and contour, yet the healing behavior of viable subcutaneous fat remains underexplored. Because adipose tissue exhibits patient-specific regenerative and volumetric responses, its preservation represents a key element of personalized fingertip reconstruction. This study evaluates the outcomes of toe pulp flaps with targeted fat preservation to assess how individual tissue biology influences contour and functional recovery. Methods: We retrospectively reviewed consecutive digital reconstructions performed with free toe flaps and several variations (pulp toe flap, chimeric pulp toe flap, trimmed great toe flap and chimeric pulp+ trimmed great toe). Particular attention was given to healthy subcutaneous fat that was deliberately maintained or exposed to help shape the final contour. All patients were followed clinically and photographically until complete healing occurred. Results: A total of 126 patients underwent a finger reconstruction with free toe flaps and several variations. The preserved fat layer was intentionally left exposed to promote healthy granulation and spontaneous epithelialization, contributing favorably to the final contour of the distal pulp as the nail advanced. All wounds healed without the need for skin grafts. All patients achieved good to excellent functional and esthetic outcomes with minimal donor-site morbidity. Conclusions: This large retrospective series confirms the reliability of a healthy flap to help shape the digital reconstruction, highlighting the regenerative potential of viable digital fat. Incorporating this concept into the flap design may reduce the need for grafting, minimize donor-site morbidity, and enhance reconstructive outcomes in hand surgery. Full article

Background and Objectives: The aim of this study was to compare the clinical and radiological outcomes of the nail-plate combination (NPC) and double-plate (DP) fixation techniques in revision surgery performed after fixation failure of periprosthetic distal femur fractures. Materials and Methods: Patients who underwent revision surgery for periprosthetic distal femur fractures following fixation failure between 2018 and 2023 at a tertiary referral center were retrospectively reviewed. Based on the surgical technique, patients were divided into two groups: NPC group (n = 27) and DP group (n = 45). Demographic characteristics, operative time, intraoperative blood loss, and fluoroscopy time were recorded. Radiological evaluation included union time, while clinical outcomes were assessed with the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) health survey. Complications (infection, thromboembolism, implant failure, nonunion, malalignment), reoperation, and 1-year mortality rates were also analyzed. Results: The NPC group had significantly shorter operative time (107 vs. 134 min, p < 0.001) and lower intraoperative blood loss (412 vs. 634 mL, p < 0.001). Hospital stay was shorter in the NPC group (6.9 ± 1.5 vs. 10.2 ± 3.3 days, p < 0.001). Mean union time was approximately three weeks shorter in the NPC group (15.4 vs. 18.8 weeks, p < 0.001). Functional outcomes (KSS, WOMAC, SF-36) did not differ significantly between groups. Complication rates were comparable; implant failure was the most frequent complication (NPC: 3.7% vs. DP: 13.3%). One-year mortality did not differ significantly (NPC: 7.4% vs. DP: 11.1%). Conclusions: Compared with DP fixation, the NPC technique offers clear perioperative advantages in revision surgery performed after fixation failure of periprosthetic distal femur fractures, including shorter operative time, reduced blood loss, and faster union. Functional outcomes and complication rates were similar between techniques. These findings suggest that the NPC may represent a safer and more feasible alternative. Full article

Background: Elastic stable intramedullary nailing (ESIN) is widely used in pediatric trauma surgery for benefits such as early limb loading, short hospital stays, and easy implant removal. Perioperative antibiotic prophylaxis (PAP) is used to reduce surgical site infections (SSIs). However, the necessity of PAP in minimally invasive pediatric procedures like ESIN remains unclear. Methods: This retrospective analysis reviewed all pediatric fractures treated with ESIN osteosynthesis at a pediatric trauma center over a time span of 10 years. Focus was set on the use of PAP during implantation and complications in the period between osteosynthesis and implant removal, which was used as follow-up. Results: Between January 2013 and December 2023, a total of 979 ESIN osteosyntheses were performed. In total, 4.1% were lost to follow-up resulting in 939 eligible cases. Complications occurred in 14.7% of all cases. However, complications such as wound healing disorders, wound infections, and osteomyelitis were rare, at 1.7%. Between the different subgroups regarding the application of PAP, type of reduction, openness of the fractures, or localization, no significant differences were found. Conclusions: Besides the most minor complications, ESIN osteosynthesis in children and adolescents is safe treatment. No increased risk for complications was observed when closed reduction was performed without the administration of PAP. Full article

Background/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol—including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex—was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67–79 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3–10 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16–22 weeks; range 16–24 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials. Full article

Objective: The current gold standard for detection of implant-related infections is the intraoperative collection of tissue samples. However, false-negative results frequently occur, particularly in infections caused by biofilm-forming bacteria. As a complementary method, sonication has therefore been established for detecting implant-associated infections, especially in periprosthetic joint infections. In trauma surgery, this technique is still rarely used. The aim of this study is to evaluate the diagnostic significance of sonication after osteosynthesis. Methods: A retrospective single-center analysis was conducted on all patients who underwent plate osteosynthesis removal between 1 January 2019, and 1 May 2021, with both sonication and intraoperative tissue sampling performed. Patients with inlying arthroplasties or nail-less osteosynthesis systems were excluded. Pre- and postoperative infection parameters (leukocytes, CRP) were recorded, and preoperative clinical findings were used to classify suspected infection. Results: A total of 57 patients (30 men, 27 women; mean age 57.6 years, range 12–91) were included. The mean treatment duration was 20.1 days (range 1–152). Sonication was positive in 33 patients, tissue samples in 28, with 31 cases (54%) showing concordant results. In cases with preoperative suspicion of infection, sonication was positive in 21 of 26 cases (80.7%) and tissue samples in 18 of 26 (69.2%), whereas without suspicion, positivity rates were 38% and 31%, respectively. Sonication and tissue results matched in 14 of 26 cases; in the remainder, results were different or incomplete. Preoperative CRP elevation and the presence of an infection membrane influenced sensitivity: sonication generally detected more bacteria (59–81%) than tissue samples (49–73%), though discrepancies remained. Conclusions: Sonication represents a valuable complementary method for detecting implant-related infections. Due to its high sensitivity but limited specificity, it should not be used as a standalone diagnostic method. Full article

Background/Objectives: Unstable intertrochanteric femur fractures (IFFs) in geriatric patients are associated with high rates of morbidity and mortality due to poor bone quality, multiple comorbidities, and limited functional capacity. This study aimed to compare the clinical outcomes of cementless bipolar hemiarthroplasty (BHA) performed via a transtrochanteric approach and proximal femoral nailing (PFN) in elderly patients with unstable IFFs. Methods: This retrospective comparative study included 131 patients aged ≥70 years who underwent surgery for AO/OTA 31-A2 and 31-A3 unstable fractures between January 2021 and July 2025 were retrospectively reviewed. 64 patients received cementless BHA and 67 underwent PFN. Eligible patients were ambulatory prior to fracture (independently or with a cane/walker); patients with pathological fractures/malignancy, alternative procedures (cemented or posterolateral BHA, total hip arthroplasty, tumor prosthesis, or other osteosynthesis methods), incomplete records, or <6 months of follow-up were excluded. Demographics, perioperative variables, mechanical complications, revision requirement, time to mobilization, and 1- and 6-month mortality rates were analyzed. Primary outcomes were mortality and perioperative clinical parameters. Results: The two groups were comparable in age, sex, ASA scores, and fracture patterns. Intraoperative blood loss and transfusion requirements were significantly higher in the BHA group (both p < 0.001). Mobilization was observed earlier in patients treated with BHA (1 [1,2] vs. 3 [2,3] days; p < 0.001). Mechanical complications were more frequently observed after PFN, which was associated with a higher revision requirement (17.9% vs. 4.7%; p = 0.018). Operative time, hospital stay, and 1- and 6-month mortality rates showed no significant differences between the groups. Conclusions: In geriatric patients with unstable IFFs, cementless BHA performed via a transtrochanteric approach may be considered a viable surgical option with appropriate patient selection, taking into account its association with earlier mobilization and the observed mechanical complication profile. PFN offers advantages of reduced blood loss and lower transfusion needs. Surgical decision-making should be individualized based on fracture morphology, bone quality, and the patient’s overall medical condition. Given the heterogeneity of unstable fractures within the AO/OTA classification and the retrospective nature of the present study, larger, multicenter prospective investigations incorporating functional outcomes are warranted to further clarify optimal treatment strategies. Full article

Background: Reconstructing large bone defects in pediatric patients after tumor resection is challenging, as conventional techniques are associated with high complication rates and morbidity. The Intramedullary Bone Transport Nail (IMBTN) may reduce these complications while preserving limb alignment and skeletal growth in pediatric oncologic reconstruction. Methods: A 15-year-old female with an osteofibrous dysplasia-like adamantinoma of the tibial diaphysis underwent complete en-bloc resection, leaving a 9 cm bone defect. An IMBTN (Precice, NuVasive) was implanted for distraction osteogenesis, with distraction starting eight days post-surgery at 0.25 mm twice daily. Follow-up visits monitored bone healing, alignment, and limb length. Results: The 9 cm defect was successfully reconstructed, with complete bone healing at the distraction site. Complete consolidation was confirmed at 18 months. The transport nail was removed at two years, and no further revisions were necessary. At two-year follow-up, the patient reported minimal pain on the Visual Analog Scale 1/10, and no recurrence of the tumor was noted. Conclusions: The use of IMBTN for large bone defect reconstruction following tumor resection in pediatric patients is a safe and effective technique. It enables stable bone transport while preserving alignment, maintaining limb length, and is less invasive than traditional reconstructive approaches. Full article

Background/Objectives: Ingrown toenails are a common podiatric condition that can significantly impair the quality of life of affected patients. The aim of the study was to assess the impact of plastic surgery of the nail folds, preceded by conservative nail plate reconstruction, on the quality of life of patients with ingrown toenails. Methods: The DLQI was assessed before (n = 108) and after treatment (n = 107). The procedure combined plastic surgery of the nail folds with conservative nail plate reconstruction. Results: A significant improvement was observed in DLQI scores (p < 0.0001) between baseline (DLQI1) and at least 6 months post-procedure (DLQI2). Quality of life improved in all assessed domains, with an average score reduction of 10.09 points. Thirteen patients did not achieve the minimal clinically important difference (MCID). Significant differences in DLQI2 outcomes were also observed by age (p = 0.009) and gender (p = 0.025). Conclusions: Plastic surgery of the nail folds combined with conservative nail plate reconstruction proved effective in improving quality of life in patients with ingrown toenails. Full article

We report a rare case of squamous cell carcinoma (SCC) arising from an intraosseous epidermal cyst (EC) in the distal phalanx of the left thumb. A 76-year-old male presented with progressive thumb pain experienced over the previous six months. Radiography revealed a radiolucent lesion without marginal sclerosis, and magnetic resonance imaging showed peripheral contrast enhancement with no solid components. Surgery revealed a bone-originating mass without adhesion to the surrounding skin or nail bed, which histopathological findings determined contained both cystic epithelium with laminated keratin and invasive keratinizing tumor cells, confirming SCC arising from an intraosseous EC. No primary lesion or lymph node enlargement was identified by postoperative computed tomography. Although wide resection and chemotherapy were proposed, the patient declined further intervention beyond the curettage performed during surgery, opting for close observation only. No recurrence or metastasis has been observed in the five years since the surgery. Intraosseous ECs are extremely rare, with malignant transformation even more uncommon. Accurate diagnosis requires histopathological confirmation, as imaging alone is insufficient. This case highlights the importance of considering intraosseous EC in the differential diagnosis of bone lesions and underscores the need for further case accumulation to clarify optimal management strategies. Full article

Background/Objectives: Acral melanoma (AM) is a rare and aggressive melanoma subtype that arises on sun-shielded, non-hair-bearing skin of the palms, soles, and nail beds. Although more common among individuals of non-European descent, AM remains underrecognized and understudied in the Middle East and North Africa (MENA). This study presents the first dedicated AM registry from Lebanon, aiming to characterize clinical, histopathological, and molecular features and evaluate diagnostic, referral, treatment approaches, and clinical outcomes over a 12-year period. Methods: This retrospective cohort study was conducted at the American University of Beirut Medical Center (AUBMC), a major tertiary referral center in the MENA region. All melanoma cases diagnosed between January 2012 and January 2024 were identified through electronic health records. From this cohort, all adult patients (≥18 years) with biopsy-confirmed AM or tumors located on the palms, soles, or under the nails were selected. Results: Our cohort consisted of 26 adult AM patients, identified from a total of 331 melanoma cases during the study period (8%). Median age at diagnosis was 58.5 years; 54% were female; and 96% of Middle Eastern origin. Most tumors were plantar (81%), and over half (53%) were diagnosed at early stages (Stage I–II). Surgery was performed in 92% of patients, yet 55% had positive margins. Sentinel lymph node biopsy was performed in 46%, and 35% received immunotherapy. Only 35% underwent molecular testing, identifying BRAF mutations in 11% of those tested; no patients received circulating tumor DNA analysis. At a median follow-up of 24.5 months, recurrence occurred in 27%, and metastasis developed in 23%. At the last follow-up, 92% were alive. Conclusions: Despite early-stage detection, high rates of positive margins and limited molecular testing reveal care gaps. This first national registry highlights the need to improve surgical management and expand access to precision oncology in the region. Full article

Background and Objectives: Intertrochanteric femur fractures are very common, especially in the elderly population, and cause serious morbidity and mortality. Today, the most commonly used implants in the treatment of these fractures are proximal femoral nails (PFNs). This study aimed to analyze the clinical and radiological results of patients who underwent surgical treatment with a proximal femoral nail (PFN) for intertrochanteric femur fractures and later required revision surgery for various reasons. Materials and Methods: Patients who underwent surgical treatment PFN due to intertrochanteric femur fractures between 2022 and 2025 were included in the study, and the patients were divided into revision and non-revision groups. Demographic information, postoperative radiological measurements, complications, and reasons for revision surgery were noted, and risk factors leading to revision were determined using bivariate and multivariate analyses. Results: A total of 207 patients, 97 revision (46.9%) and 110 non-revision (53.1%), were included in this study. Cut-out was identified as the most common revision cause (n = 52, 53.6%), followed by loss of reduction (n = 15, 15.5%), implant failure (n = 14, 14.4%), nonunion (n = 6, 6.2%), infection (n = 4, 4.1%), cut-through (n = 3, 3.1%), and avascular necrosis of the femoral head (n = 3, 3.1%). When bivariate analysis was performed to identify risk factors for revision, it was observed that female gender (p = 0.004), presence of posteromedial comminution (p < 0.001), operation under spinal anesthesia (p = 0.023), surgery in supine position (p < 0.001), using closed reduction techniques (p < 0.001), presence of infection (p = 0.004), and higher Charlson comorbidity index values (p < 0.001) increased the risk of revision. Additionally, positive and neutral medial cortex support (p < 0.001) decreased the risk of revision. Multivariate analysis was also applied to the parameters found to be significant in bivariate analysis. As a result of this analysis, surgery in the supine position (p < 0.001), using closed reduction techniques (p < 0.001), and higher Charlson comorbidity index values (p < 0.001) remained significant. Conclusions: Careful evaluation of the fracture morphology, ensuring optimal reduction, and considering the accompanying comorbidities of the patients in the surgical planning of unstable trochanteric fractures stand out as key elements in increasing surgical success. Full article

Ankle fractures are extremely common and often require surgical management, historically with open reduction and internal fixation (ORIF), although fibular intramedullary nailing (IMN) has demonstrated promising results in recent years. The purpose of this study is to report on risk factors, quality of reduction, and complications in a series of patients undergoing fibular IMN for management of ankle fractures using a novel device via a retrospective case series. Patients undergoing locked fibular IMN with the Flex-Thread nail (Conventus Flower Orthopedics, Horsham, PA, USA) by a single surgeon from January 2023 to March 2025 were included, with at least 6 months of follow-up. Demographics, comorbidities, injury characteristics, reduction quality, and post-operative complications were recorded. Descriptive analyses were reported for categorical variables. A total of 15 patients were included, with a mean age of 58.9 ± 22.0 (range 18–91) and mean BMI of 31.5 ± 5.7 kg/m². All patients experienced a fall as their mechanism of injury, with 12 Weber B and 3 Weber C fractures. The mean time to surgery from the date of injury was 9.5 ± 5.5 days. Of 15 patients, 66.7% had good reduction quality, 26.7% had fair, and 1 patient experienced poor reduction quality requiring subsequent hardware removal. There was one patient who experienced delayed wound healing. Patients undergoing fibular fixation using the novel Flex-Thread nail experience a fair to good quality of reduction, with limited complications. Both young and elderly patients have relatively positive early post-operative outcomes. Additional research with longer-term follow-up will be required to confirm its efficacy. Full article