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Failure to rescue (FTR)-death following a potentially manageable complication-has become a key quality indicator. Although clinical and systemic contributors to FTR are well described, how surgeons make sense of these events and how this sense-making shapes communication, escalation, and learning remains underexplored. To explore surgeon interpretations of FTR events and perceptions of factors that contribute to FTR and to identify insights to inform improvements in surgical education and culture. Qualitative study using convenience sampling to recruit board-certified surgeons with 5 or more years of experience in Switzerland and Austria via email. Semistructured interviews were conducted between February and May 2023. Data analysis was performed between February 2024 and April 2025. Direct involvement in FTR events. Interviews were analyzed using a constructivist grounded theory approach to identify themes characterizing surgeons' perceptions of FTR. Fourteen surgeons were interviewed, including 12 men (85.7%) aged 33 to 67 years (mean [SD] age, 49 [9] years). Specialties included abdominal surgery (9 surgeons [64.3%]), orthopedics or traumatology (4 surgeons [29%]), and vascular surgery (1 surgeon [7.1%]). Five themes were developed: (1) being trapped in a flawed system: surgeons perceived FTR as inevitable within systemic and institutional constraints; (2) hierarchical barriers: the continued predominance of barriers hinder adequate reaction and shared decision-making; (3) being imperfect heroes: surgeons saw themselves as passionate, resilient, and driven, yet vulnerable to narcissism, peer hostility, and performative behaviors; (4) coping with failure: participants reflected that FTR experiences, though painful, contributed to improving their clinical expertise; and (5) strategies and tools for rescue: these were characterized by sharing personal strategies and proposing system-level improvements. In this qualitative study of 14 surgeons, participants described how confidence, grit, and self-reliance were essential in surgery but could also hinder timely recognition and response to complications. Fostering humility, reducing hierarchical barriers, and increasing peer support may transform FTR from a heroic surgeon's hubris into an opportunity for collective learning and cultural growth.
Total hip arthroplasty (THA) in Crowe type IV developmental dysplasia of the hip (DDH) is technically demanding due to high dislocation, abnormal femoral morphology, and soft-tissue contractures. Subtrochanteric shortening osteotomy (SSO) is often required to restore the anatomic hip center and prevent excessive lengthening, yet the ideal osteotomy design and fixation remain controversial. The step-cut SSO offers greater rotational stability and bone contact but is technically complex and biomechanically under-evaluated. This report describes a clinical case supplemented by computational biomechanical analysis evaluating a hybrid fixation technique using a titanium plate reinforced with ultra-high-molecular-weight polyethylene (UHMWPE) tape. In this clinical case, a 35-year-old female with bilateral Crowe IV DDH underwent staged THA with step-cut SSO at the National Scientific Center of Traumatology and Orthopedics, Astana, Kazakhstan. Approximately 4.5 cm of femoral shortening was performed per side. The osteotomy was stabilized with a locally designed titanium plate and UHMWPE tape cerclage. Both procedures were uneventful, achieving equal limb lengths, early mobilization, and complete bone union by four months. Finite element analysis (FEA) was performed to evaluate mechanical behavior under single-leg-stance loading (1000 N vertical, 200 N horizontal). The hybrid construct demonstrated favorable stress distribution: peak von Mises stress values of 137 MPa in cortical bone and 94 MPa in the plate - both below yield limits. Maximum displacement was 0.16 mm, and safety factors exceeded 2.9, confirming high rigidity. Clinically, both hips showed stable fixation, pain-free gait, and excellent functional outcomes with a Harris Hip Score of 90 for the right hip and 88 for the left hip at one-year follow-up. In this case, the combination of step-cut SSO with hybrid titanium-plate and UHMWPE-tape fixation demonstrated favorable biomechanical characteristics and successful clinical outcome. Finite element analysis supported the mechanical stability of the construct. These findings should be considered preliminary and represent a proof-of-concept observation. Further experimental and multicenter clinical studies are required to confirm the generalizability of this approach.
To investigate whether posterior tibial slope (PTS) is associated with failure after posterior cruciate ligament reconstruction (PCLR) in a cohort of patients undergoing isolated PCLR and PCL-based multiligament knee injuries (MLKI) reconstruction. The hypothesis was that (1) a reduced PTS is a factor affecting PCLR failures in isolated PCLR, but (2) it is not in the context of PCL-based MLKI. A multicentric retrospective study was conducted across four high-volume knee surgery centres. Patients were contacted to assess the occurrence of additional surgical procedures, knee stability and satisfaction using the simple knee value (SKV). PTS of medial compartment was measured on lateral radiographs. Survival analysis was performed using the Kaplan-Meier method with failure as the endpoint (revision PCL reconstruction, persistent posterior instability documented by a positive posterior drawer test), and Cox regression was used to evaluate the association between PTS and failure. Patients were stratified according to tertiles of PTS distribution (low ≤7°, intermediate 7°-10°, high >10°). Additionally, PTS was compared between failure and non-failure groups using the Mann-Whitney U test (p < 0.05). A total of 173 patients met the inclusion criteria; 24 (13.9%) were considered failures. The overall survival rate was 86.1%, 96% at 2 years, and 70% at 15 years. PTS was slightly higher in patients who failed compared to those who did not (9.1 ± 2.3° vs. 8.0 ± 3.2°; p < 0.05). However, no significant differences in survivorship were observed across PTS tertiles. Kaplan-Meier and Cox regression analyses did not demonstrate a significant association between PTS and failure. PTS was not associated with failure after PCLR. These findings indicate that sagittal tibial alignment alone may have a limited role in determining reconstruction survivorship and do not support routine correction of PTS in primary PCLR. Level IV, retrospective cohort study.
To conduct the first large-scale, population-level CT evaluation of palmar cortical ridges. This study aimed to characterize their prevalence, anatomic distribution, and morphologic features, and analyze associations with demographic factors. This retrospective, single-center study included 459 consecutive patients (279 men, 180 women; mean age, 40.1 ± 17.3 years) who underwent hand CT between 2022 and 2024 for various clinical indications. Twelve-digit phalanx sites (2nd-5th digits; proximal, middle, distal phalanges) were evaluated for the presence, laterality, and severity of palmar ridges. Associations with age, sex, and side were assessed using chi-square tests, and multivariable logistic regression models were used to assess the independent association of age and sex with ridge presence. Interobserver agreement was evaluated using intraclass correlation coefficients (ICCs). Palmar ridges were consistently identified in the proximal and, to a lesser extent, middle phalanges, most commonly at the 4th (84.3%) and 3rd (74.7%) proximal phalanges. No ridges were observed in any distal phalanx. Ridge prevalence and prominence increased progressively with age (p < 0.001) and were significantly higher in women (p < 0.001). Bilateral involvement predominated (up to 94.8% at the 4th digit-proximal phalanx), and when unilateral, ulnar orientation was more frequent than radial. Interobserver reliability was excellent (ICCs = 0.83-0.94). Our findings indicate that palmar cortical ridges follow a predictable, age-related, and digit-specific distribution, representing physiological enthesis-related cortical adaptations rather than signs of pathology. Recognizing these cortical adaptations - particularly at the proximal phalanges of the 3rd and 4th digits - is essential to avoid diagnostic confusion with periosteal reaction or early arthropathy, thereby improving the accuracy of hand CT interpretation.
Repairing large segmental bone defects remains a major challenge in orthopedics, with conventional autografting and allografting limited by donor shortages and high complication rates. Tissue-engineered bone substitutes have emerged as a potential solution. This study aimed to assess the vascular regeneration of dual-vascularized tissue-engineered bone substitutes in the reconstruction of large segmental bone defects in rabbits. Demineralized bone matrix (DBM) was used as a scaffold, with endothelial progenitor cells (EPCs) seeded onto it. A vascular channel was created within the DBM-EPCs composite scaffold, and the radial artery was implanted into this channel. New Zealand white rabbits were used to create a 15-mm critical-sized rabbit radial bone defect model, with animals divided into four groups: DBM, DBM+EPCs, DBM+Vascular Bundle,and DBM+EPCs+Vascular Bundle (n = 9 per group).X-ray examinations,gross morphological observations,and CD31 immunofluorescence staining were conducted at 4, 8,and 12 weeks post-surgery. Micro-CT was used to reconstruct the three-dimensional structures of the defects after 12 weeks. The DBM+EPCs+Vascular Bundle group demonstrated the most significant bone regeneration and vascularization across all time points.X-ray,gross morphology, Micro-CT analysis,HE staining,and CD31 immunofluorescence staining all revealed superior bone regeneration and vascular density in this group compared to the others. In conclusion, the dual vascularization strategy significantly enhanced bone regeneration and angiogenesis in the reconstruction of large bone defects. This approach has potential clinical applications for repairing critical-sized bone defects, particularly in anatomical regions with multiple arterial supplies such as the upper limbs and lower legs.
To determine whether different peri-hip muscle groups show differential associations with fear of falling and past-year fall history in older adults with hip fractures, and whether muscle density is more informative than cross-sectional area. This single-center, post hoc cross-sectional analysis was conducted within a prospective cohort of 590 patients aged ≥65 years with hip fractures. Fear of falling was evaluated using the Modified Falls Efficacy Scale, and past-year fall history was obtained by questionnaire. Muscle density and cross-sectional area were measured from computed tomography (CT) scans for the gluteus maximus muscle (G.MaxM), the gluteus medius and minimus muscles (G.MedMinM), and the upper thigh muscles (thighM). Multivariable logistic regression and subgroup analyses were performed. Of the 590 patients, 214 (36.3%) reported fear of falling and 331 (56.1%) had had prior falls. All muscle measures were lower in the fear-of-falling group. After multivariable adjustment, only G.MedMinM density remained independently associated with lower odds of fear of falling (OR 0.77, 95% CI 0.60-0.98, P = 0.031). In contrast, G.MaxM density, thighM density, and all muscle area parameters were not independently associated with fear of falling after full adjustment. For past-year falls, G.MedMinM density showed a similar inverse association in partially adjusted models, but this association was attenuated after additional adjustment for hip bone mineral density (OR 0.82, 95% CI 0.65-1.03, P = 0.082). Associations were stronger in patients aged≥80 years, with visual impairment, or low physical activity. Among the peri-hip muscle groups examined, G.MedMinM showed the strongest associations with fear of falling and past-year falls. Muscle density was more informative than muscle size, and G.MedMinM density remained independently associated with fear of falling. Opportunistic preoperative hip CT may help support perioperative risk stratification after hip fracture.
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against factor VIII and may present with life-threatening hemorrhage. Postoperative presentation is uncommon and may lead to delayed diagnosis, as bleeding is often initially attributed to surgical causes. We report a 64-year-old man with post-traumatic knee arthritis and retained hardware who underwent navigation-assisted total knee replacement. The procedure was uneventful with an estimated blood loss of 300 mL. On postoperative day two, he developed acute knee swelling with persistent bleeding through a negative-pressure wound dressing. Urgent re-exploration and hematoma evacuation were performed; however, diffuse bleeding persisted despite adequate surgical hemostasis, requiring activation of a massive transfusion protocol. Laboratory investigations demonstrated isolated prolongation of activated partial thromboplastin time (aPTT) at 65.3 seconds. Further coagulation studies revealed markedly reduced factor VIII activity with circulating factor VIII inhibitors, confirming AHA. Hemostasis was achieved following treatment with FEIBA and NovoSeven under hematology guidance. The patient subsequently recovered well and was discharged with outpatient follow-up. This case highlights acquired hemophilia A as a rare but important differential diagnosis in persistent postoperative bleeding following total knee replacement. Early recognition, prompt coagulation workup, and multidisciplinary management are essential to improve outcomes.
Knee osteoarthritis (KOA) causes pain, functional impairments, and sleep disturbances. This study aimed to assess differences in pain pattern, insomnia, function, and muscle strength across Kellgren-Lawrence grades in patients with KOA. In this cross-sectional study, 82 patients (65.8 ± 7.8 years) were categorized into Kellgren-Lawrence Grade 2 (n = 20), Grade 3 (n = 20), and Grade 4 (n = 42). Pain (VAS, ICOAP), insomnia (ISI), knee function (KOS-ADLS), functional performance (Timed-Up and Go [TUG], Five Times Sit-to-Stand [FTSST]), and isometric muscle strength were evaluated. Comparisons were performed using ANCOVA, adjusting for age and BMI. Groups differed significantly in age and BMI (p < 0.001 and p = 0.024), with higher values in Grade 4. Significant between-group differences were observed in VAS (p = 0.006), ICOAP-constant pain (p = 0.037), ICOAP-total pain (p = 0.035), TUG (p = 0.021), KOS-ADLS (p = 0.015), and quadriceps strength of the affected knee (p < 0.001) and hip adductor strength (p = 0.046). No significant differences were found for ICOAP-intermittent pain, ISI, or non-affected knee quadriceps strength (p > 0.05). Pairwise comparisons showed that Grade 4 patients had significantly worse outcomes than Grade 2 in VAS (p = 0.013), ICOAP-constant pain (p = 0.041), and total pain (p = 0.047), and TUG (p = 0.025), as well as reduced quadriceps strength of both affected (p < 0.001) and non-affected (p = 0.019) knees. Differences between Grades 2 and 3 were limited to VAS (p = 0.026), while Grades 3 and 4 differed only in KOS-ADLS (p = 0.022). Higher Kellgren-Lawrence grades were associated with greater pain, poorer function, and reduced quadriceps strength, particularly in Grade 4, emphasizing the clinical relevance of radiographic grading in characterizing symptom burden in KOA.
Distal femoral deformities are common in metabolic bone disease and often require surgical correction. Retrograde Fixator-Assisted Nailing(r-FAN) stabilizes the femoral axis, yet the influence of nail-to-bicondylar ratio (NBR) and coronal-plane knee alignment patterns(CPAK) on deformity and osteoarthritis(OA) progression remains unclear. We retrospectively evaluated 30 limbs from 17 patients with distal femoral deformities treated with r-FAN, with a mean follow-up of 10.5 ± 4.6 years. Pre- and postoperative radiographs were analyzed for mechanical lateral distal femoral angle (mLDFA), arithmetic hip-knee-ankle angle (aHKA), joint line obliquity (aJLO), and CPAK classification. NBR and osteotomy-to-nail ratio (ONR) were measured. Predictors of mLDFA progression were assessed using Elastic Net and Ordinary Least Squares (OLS) regression, while Bayesian ordinal regression was applied to determine predictors of OA progression (KL grades). Postoperative alignment improved in both varus (mLDFA 111.88° → 96.32°) and valgus knees (71.14° → 94.00°), with aHKA approaching physiological ranges (valgus 19.50° → -3.50°, varus -24.32° → -7.14°). aJLO progression was more pronounced in valgus knees (3.23° vs -1.54°, p = 0.018). CPAK types shifted postoperatively, reflecting variable coronal alignment, but were not significant predictors of deformity or OA progression. Elastic Net and OLS regression identified NBR as the only significant predictor of mLDFA progression (β = -2.550 per 0.02-unit increase; 95%CI -3.962 to -1.136; p = 0.001; R2 = 0.535). Bayesian ordinal regression confirmed its protective effect on KL progression (OR = 0.967 per 0.02-unit increase; 95%CrI 0.932-0.998). Other demographic and surgical variables, including sex, etiology, preoperative alignment, and osteotomy count, were not significant. In patients with metabolic bone disease undergoing r-FAN, higher NBR was associated with less radiographic deformity progression and lower odds of OA progression. In contrast, single time-point CPAK assessments were not associated with progression outcomes in this cohort. Level IV.
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Infantile myofibromatosis (IM) is a rare benign myofibroblastic neoplasm of infancy that usually involves the skin, bone, muscle, and soft tissue and rarely visceral organs. The aim of this study is to describe solitary IM involving bone or soft tissue in the extremities across different ages and sexes and to explore whether larger tumor size and beta-catenin (β-catenin) positivity were more frequently observed in recurrent cases. This multi-center study included 15 patients diagnosed and treated with IM between January 2004 and December 2019. All patients were diagnosed with incisional biopsy before definitive surgery to rule out the risk of sarcoma. Data including age, sex, duration of complaints, time to diagnosis, size, tumor histology, surgery type, complications, recurrence, functional outcomes and follow-up were recorded. β-catenin immunoreactivity was assessed in all patients, and the findings were analyzed descriptively because of the small sample size. The mean age of the patients was 8.3 ± 6.4 years with male predominance. Recurrence was observed in five patients. Tumors larger than 5 cm and β-catenin positivity were more frequently observed in recurrent cases. Neurovascular involvement, documented on preoperative imaging and/or intraoperative findings, was seen in both recurrent and non-recurrent cases. Given the very small cohort, these observations are presented descriptively. Soft tissue IM is difficult to diagnose and can be misdiagnosed as malignancy. Therefore, biopsy before definitive surgery remains crucial. In this series, recurrence was observed in a subset of solitary extremity IM cases, and recurrent cases more often showed larger tumor size and β-catenin positivity. However; Further large-scale, prospective studies are needed to draw more reliable conclusions on this subject. Level III, retrospective study. Not applicable.
MicroRNAs (miRNAs) and the NAD+-dependent deacetylase SIRT1 are critical regulators of hepatic metabolism, inflammation, and stress responses. Growing evidence suggests that miRNA-SIRT1 interactions are frequently disrupted during the pathogenesis of liver diseases, including Metabolism-Associated Steatotic Liver Disease (MASLD), Alcohol-Associated Liver Disease, Drug-Induced Liver Injury (DILI), fibrosis, and hepatocellular carcinoma (HCC).In the context of metabolic liver diseases, specific miRNAs, such as miR-122, miR-93, miR-132, miR-34a, and miR-141, regulate lipid and energy metabolism by modulating SIRT1 and its downstream targets, notably AMPK and PGC-1α. Furthermore, miRNAs can suppress SIRT1 activity during liver injury, exacerbating oxidative stress, mitochondrial dysfunction, and inflammation. In HCC, the role of SIRT1 is context-dependent; influenced by the stage of differentiation and genetic factors such as p53, SIRT1 may exert either tumor-suppressive or tumor-promoting effects. While preclinical studies demonstrate the therapeutic potential of targeting the miRNA-SIRT1 pathway, current evidence remains largely experimental. Pharmacological modulation, via SIRT1 activators, small-molecule compounds, or RNA-based therapeutics, has shown promise in experimental models. However, significant hurdles impede clinical translation, including poor bioavailability, off-target effects, and, most critically, the complex, context-specific biological role of SIRT1 within the liver. Ultimately, while the miRNA-SIRT1 axis appears to be a central regulatory pathway in liver disease, its translational potential and safety in humans require further mechanistic and clinical investigation.
Knee osteoarthritis is heterogeneous in radiographic severity, pain, and multimorbidity, and racial disparities in pain and knee replacement are documented. We derived knee osteoarthritis phenotypes from electronic health record and radiograph data and assessed their associations with race and incident total knee arthroplasty. We conducted a retrospective cohort study in the Emory Knee Radiograph dataset of adults aged ≥40 years with knee osteoarthritis (n = 33,553). Among participants with pain scores within ±90 days of the index radiograph (n = 20,030), we applied k-means clustering to features including age, radiographic severity, pain measures, and comorbidity indicators to define phenotypes. Among participants without pre-index strict total knee arthroplasty, we used Cox proportional hazards models to evaluate time to incident post-index strict total knee arthroplasty, with follow-up censored at last observed contact and capped at the procedure-code ascertainment horizon. Clustering identified three phenotypes: structural/metabolic disease characterized by radiographic severity and multimorbidity; younger trauma-associated mild disease; and pain-dominant disease with pain disproportionate to radiographic severity. Black individuals were overrepresented in the pain-dominant phenotype and underrepresented in the structural/metabolic phenotype, whereas White individuals showed the opposite pattern. In time-to-event models, higher radiographic severity and male sex were associated with faster time to total knee arthroplasty, whereas the younger trauma-associated and pain-dominant phenotypes were associated with lower hazard of total knee arthroplasty than the structural/metabolic phenotype. These findings were preserved in known-race-only and categorical Kellgren-Lawrence grade sensitivity analyses. Routinely available electronic health record and radiographic data can identify clinically meaningful knee osteoarthritis phenotypes that differ by race and are independently associated with subsequent total knee arthroplasty. These findings support further validation of phenotype-aware approaches to studying disparities and guiding osteoarthritis care.
Aesthetic submental liposuction (ASL) is a widely performed procedure for lower facial and anterior neck contouring. Despite its clinical acceptance, there is no clear consensus regarding the frequency and characteristics of ASL-related adverse events. This systematic review aimed to estimate prognosis panoramas: 1) the frequency of adverse events associated with ASL and 2) their principal clinicodemographic characteristics. Eligibility criteria were based on the Population, Exposure, Comparison, Outcomes, and Study Design (PECOS framework: adult patients (≥18 years) undergoing ASL; outcomes comprising intraoperative or postoperative adverse events; and observational study designs limited to case reports and case series. Studies unrelated to mechanical ASL, employing other methodological designs, lacking full-text availability, or presenting duplicate samples were excluded. Electronic searches were performed in 6 databases and gray literature sources in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools. Descriptive statistical analyses were performed. Thirteen studies (0.14% of the 8,915 initially identified records), encompassing 2,085 ASL cases, were included. A total of 270 ASL-related adverse events were identified, corresponding to an event rate of 12.9% per procedure. Demographic data, when available, indicated a predominance of female individuals (80.0%), with a mean age of 40.5 ± 13.5 years. ASL was predominantly performed by nonoral and maxillofacial surgeons (n = 203/77.5%), in hospital-based surgical centers (n = 230/98.7%), most commonly under tumescent/local anesthesia (n = 133/54.7%). Isolated ASL was the most frequently performed procedure (n = 144/54.1%). Minor adverse events accounted for 74.8% of reported complications, mainly represented by seromas (n = 57/21.1%), skin surface irregularities or asymmetries (n = 52/19.1%), and platysmal banding (n = 50/18.5%). The mean time to onset of adverse events was 1.7 ± 3.2 months, and the median follow-up duration was 10 months (interquartile range, 4 to 12). Adverse events following ASL appear to be not uncommon, most are minor in severity and can be effectively managed in outpatient settings. This review ratifies significant evidence limitations and the importance of further well-designed clinical studies to better estimate complication rates and identify predictive factors.
The strain required to optimize controlled micromotion in indirect (callus-mediated) fracture healing remains uncertain. Although the classic 2% to 10% strain range proposed by Perren is widely cited, several animal and clinical studies have reported healing at higher strain levels. This study evaluated the strain-healing relationship in a controlled micromotion model. We hypothesized that the strain threshold that supports healing exceeds 10%. A standardized 2-mm transverse osteotomy was created in Sprague-Dawley rats and stabilized with an external fixator capable of delivering precise micromotion. Five strain levels (0%, 10%, 20%, 30%, 40%) were applied once daily at 0.5 Hz for 30 minutes beginning 2 weeks after surgery and continued for 2 weeks. Healing was assessed by radiographs, micro-computed tomography, mechanical testing, histology, and immunohistochemistry. A strain level of 20% was associated with the most favorable overall healing profile across radiographic, structural, and mechanical assessments, with no cases of nonunion. Lower strains demonstrated limited callus formation, while higher strains produced abundant early cartilage but delayed conversion to bone and reduced mineralization. Moderate strain was accompanied by balanced expression of IL-6, IL-1β, and RANKL/OPG, whereas excessive strain showed patterns consistent with impaired remodeling. Under stable fixation and before the fracture gap transitions to stiffer cartilaginous tissue, the functional upper limit of beneficial strain appears to exceed the traditional 10% threshold. Approximately 20% of compressive strain, applied between day 14 and 21 postosteotomy, provided the most balanced combination of early repair and subsequent remodeling in this model. These findings suggest that controlled micromotion with 20% interfragmentary strain may be most relevant to fractures managed under relative stability and healing through callus formation. However, faster callus-mediated healing is not inherently clinically advantageous, and its value depends on fracture type, anatomical site, and fixation strategy.
The primary aim was to report available literature on antibiotic prophylaxis against open fracture-related infections, in populations with antimicrobial resistance patterns similar to Denmark's as reported by the European Antimicrobial Resistance Surveillance Network. Countries included: Denmark, Finland, Germany, Great Britain, Iceland, the Netherlands, Norway, and Sweden. A secondary aim was to compare Danish regional guidelines with these findings. PubMed, Medline, and Embase were searched for studies published between January 1998 and March 2024. Danish guidelines were retrieved on May 7th, 2024, through a systematic search. Out of 6492 studies, 120 were screened in full, and 19 were included for analysis. 9 studies recommended cephalosporins (primarily 1st and 2nd generations) for Gustilo-Anderson Grades I and II, while 10 studies supported further gram-negative coverage for Gustilo-Anderson grade IIIa-c fractures. One study found no significant benefit of antibiotic prophylaxis for reducing fracture-related infections. Danish guidelines varied: The Capital Region of Denmark recommends gram-negative coverage for all Gustilo-Anderson grades, whereas the Region of Southern Denmark and 10/19 studies only recommend it for Gustilo-Anderson grade IIIa-c fractures. This review identifies a lack of data on pathogens causing FRI in regions with similar antimicrobial resistance patterns according to the EARS-Net, complicating optimal antibiotic strategies. The variability of open fractures underscores the need for research to utilize the Gustilo-Anderson classification when planning the treatment regime, focusing on specific grades to improve targeted AP for preventing FRI. Furthermore, taking the cultures after sufficient surgical debridement. Future high-quality studies in populations with homogeneous antimicrobial resistance patterns are needed to optimize national AP protocols.
Chronic scapholunate Geissler grade 3C ligament injuries remain difficult to treat, with a limited consensus on long-term outcomes of joint-preserving procedures. The modified Viegas dorsal capsuloplasty has been proposed as a less invasive surgical option, but long-term data are scarce. This was a retrospective study of patients with arthroscopically confirmed Geissler grade 3C scapholunate ligament injuries treated with modified Viegas capsuloplasty between 2007 and 2016. Clinical and functional outcomes were assessed at long-term follow-up, including range of wrist motion, pain, functional scores and return to high-demand activities. Complications, degenerative progression and revision procedures were recorded. At long-term follow-up, patients showed preserved range of wrist motion, low residual pain levels and satisfactory functional outcomes. Most patients involved in high-demand activities were able to return to their previous level of activity with minimal limitations. Complications were infrequent and consisted mainly of isolated cases of degenerative progression or the need for revision surgery. The modified Viegas dorsal capsuloplasty provides reliable long-term clinical and functional outcomes for chronic Geissler grade 3C scapholunate ligament injuries, with a low complication rate and preservation of wrist motion. It represents a safe and effective joint-preserving surgical option in appropriately selected patients. IV.
An 89-year-old man presented with right elbow pain after a low-energy fall. At age 2 years, he sustained an untreated distal humeral fracture dislocation, which resulted in progressive remodeling and formation of a functional pseudoarticulation. Despite permanent deformity, he maintained stable functional motion for decades and performed heavy manual labor. Imaging revealed a displaced distal humeral fracture through the chronically remodeled elbow. Open reduction and internal fixation with a variable-angle locking plate was performed, while the pseudoarticulation was intentionally left untreated. The patient regained his preinjury functional baseline. Fracture treatment should consider the clinical relevance of pre-existing but functional musculoskeletal abnormalities.
Closed spinal dysraphism (CSD) comprises a heterogeneous group of congenital anomalies that may remain asymptomatic or present with neurological and urological dysfunction. This study aimed to evaluate long-term urological outcomes in children with isolated CSD and to compare outcomes between patients managed conservatively and those who underwent spinal cord untethering (SCU). We conducted a retrospective cohort study of children with CSD treated at Helsinki University Hospital between 1990 and 2015. Forty-three patients were followed for a median of 11.0 years. Urological symptoms were common, and at some point during follow-up, 21 patients (49%) required urological treatment. At the end of follow-up, 27 patients (63%) required no ongoing urological treatment. Before SCU or during conservative treatment, 82% (32/39) of patients older than three years achieved volitional voiding, and 72% (28/39) were continent; 18% required clean intermittent catheterization (CIC), and 19% (7/39) received bladder-directed therapy. Twenty patients underwent neurosurgical spinal cord untethering, most often due to progressive symptoms. Seventeen patients (85%) had volitional voiding preoperatively, whereas only 10 patients (50%) voided volitionally at the last follow-up after SCU (p=0.02). At the last follow-up, there was no significant difference in the need for urological treatment between conservatively treated patients and those who underwent SCU. All patients had normal kidney function at the last follow-up. A substantial proportion of children with CSD require urological treatment during long-term follow-up. Despite postoperative changes in bladder function, long-term urological treatment needs were similar between conservatively managed patients and those who underwent SCU.