Background: The purpose of the present study was to systematically review the current treatment strategies for the treatment of Neer type IIB distal clavicle fractures in terms of functional outcome and complication rates and to examine the most appropriate surgical method by comparing all the available surgical techniques and implants. Methods: We performed a systematic review of the existing literature (2000–2021) in accordance with the PRISMA statement. We searched PubMed, Scopus, Web of Science, Research Gate and Google Scholar using the general terms ‘distal AND clavicle AND fracture’ to capture as many reports as possible. The MINORS tool was used to assess the risk of bias of the nonrandomized studies. We categorized the reported surgical techniques into four main types: open or arthroscopic coracoclavicular (CC) stabilization, locking plate fixation with or without CC augmentation, hook plate fixation and acromioclavicular joint (ACJ) transfixation. We reported findings for two main outcomes: clinical results and complication rates categorized into major and minor. Results: Our database search yielded a total of 630 records; 34 studies were appropriate for qualitative analysis. There were 790 patients, with a mean age of 40.1 years, a female percentage of 37% and a mean follow-up period of 29.3 months. In total, 132 patients received a hook plate, 252 received a locking plate, 368 received CC stabilization and 41 received transacromial transfixation. All studies were retrospective and had fair MINORS scores. Locking plate, CC stabilization and ACJ transfixation showed similar clinical results but were much better than hook plate fixation; CC augmentation did not significantly improve the outcome of locking plate fixation. The rate of major complications was similar among groups; hook plate and AC joint transfixation had the worst rates of minor complications. Open CC techniques were slightly better than arthroscopic techniques. Conclusions: The present systematic review for the optimal fixation method for Neer type IIB fractures of the distal clavicle showed similar major complication rates among techniques; the hook plate technique demonstrated inferior clinical results to other techniques. Open CC stabilization and locking plate fixation without CC augmentation seem to be the best available treatment options.

Pain management after open inguinal hernia repair has become an issue that physicians deal with on a daily basis. The purpose of this study was to investigate the analgesic effect of three different regimens of analgesics administered to patients undergoing open inguinal hernia repair. A total of 259 patients undergoing open inguinal hernia repair were enrolled. Patients were randomly allocated to one of three groups on admission, which would determine the prescribed post-operative analgesic regimen. Patients allocated to group A receiving a combination of 1gr/8hours intravenous (IV) acetaminophen and 50mg/6hours intramuscular (IM) pethidine, patients in group B receiving a combination of 1gr/8hours IV acetaminophen and 40mg/12hours IV parecoxib, while patients of group C received 1gr/8hours IV acetaminophen monotherapy. All patients remained overnight at the hospital and discharged the day after. Analgesic therapy was administered at regular intervals. Pain was evaluated utilizing the numeric rating scale (NRS) at 5 time points: the first assessment was done at 45 minutes, the second at 2 hours, the third at 6 hours, the fourth at 12 hours and the fifth at 24 hours post-administration. The postoperative pain intensities measured by NRS within groups and between groups at each time were analyzed using one-way repeat measured ANOVA and Post Hoc Test-Bonferroni Correlation. The analgesic regimens of groups A and B (combination regimens consisting of IV acetaminophen and intramuscular pethidine and IV acetaminophen and IV parecoxib, respectively) were found to be of equivalent efficacy (P-value=1.000). In contrast, patients in group C (acetaminophen monotherapy) had higher NRS scores, compared to both patients in groups A (P-value<0.0001) and B (P-value<0.0001). The combinations of IV acetaminophen with either intramuscular pethidine or IV parecoxib are superior to IV acetaminophen monotherapy in achieving pain control in patients undergoing open inguinal hernia repair.

Hip fractures are an increasingly common injury among older people who usually experience significantly worse mobility, independence in function, health, quality of life, and high rates of institutionalization. Studies have shown that only 40-60% of participants recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while for those who are independent in self-care prior to the fracture, 20-60% still require assistance for various tasks one or two years after the fracture. As the cumulative incidence of a second hip fracture has been estimated to reach 8.4%, prevention of the second hip fracture is a major concern of the health system and the society focused mainly on lifestyle modifications, osteoporotic treatment, and fall-prevention strategies. The aim of the present study was to compare morbidity/mortality, functional results, and type of recovery between the first and second hip fractures in elderly patients. Patients with a contralateral hip fracture were prospectively recruited during a three-year period (2016-2019). Level of independence, gait aids, type of rehabilitation, American Society of Anesthesiologists (ASA) physical status, Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale were evaluated at admission for the second fracture and at the last reexamination. Twenty-seven out of 33 patients, aged 87.93±6.6, underwent surgery for contralateral hip fracture and followed up for 42.52±16.46 months; the mean interval between the two fractures was 39.63 months. The HHS averaged 86.19±12.18 and 59.01±32.83 and the WOMAC 86.37±12.09 and 68.22±26.18 before and after the second fracture, respectively. The mortality rate was 37.03%, 14.8±12.93 months after the second operation, with a significant relationship between the mortality time and the interval between fractures (p=0.028). Twelve and 14 of the patients received geriatric nursing care after the first and second fracture, respectively, without significant improvement in their functional results compared to home care. Mobility of nursing care patients after the second fracture was significantly improved (p=0.019). Mortality is higher in the second year after the second hip fracture and strongly correlated with the time interval between fractures. A higher possibility to return in previous mobility status occurs after geriatric nursing care.

Stress shielding and aseptic loosening are complications of short stem total hip arthroplasty, which may lead to hardware failure. Stems with increased porosity toward the distal end were discovered to be effective in reducing stress shielding, however, there is a lack of research on optimized porous distribution in stem’s coating. This study aimed to optimize the distribution of the coefficient of friction of a metaphyseal femoral stem, aiming for reducing stress shielding in the proximal area. A finite element analysis model of an implanted, titanium alloy short-tapered wedge stem featuring a porous coating made of titanium was designed to simulate a static structural analysis of the femoral stem's behavior under axial loading in Analysis System Mechanical Software. For computational feasibility, 500 combinations of coefficients of friction were randomly sampled. Increased strains in proximal femur were found in 8.4% of the models, which had decreased coefficients of friction in middle medial areas of porous coating and increased in lateral proximal and lateral and medial distal areas. This study reported the importance of the interface between bone and middle medial and distal lateral areas of the porous coating in influencing the biomechanical behavior of the proximal femur, and potentially reducing stress shielding.

Background: Proximal femur reconstruction after bone tumor resection in children is a demanding surgery for orthopaedic oncologists because of the small bone size and possible limb-length discrepancy at the end of skeletal growth owing to physis loss. The most commonly used reconstruction types used for the proximal femur are modular prostheses and allograft-prosthesis composites. To our knowledge, there are no previous studies comparing the outcomes after modular prosthesis and allograft-prosthesis composite reconstruction of the proximal femur in children with primary bone tumors. Questions/purposes: (1) What was the cumulative incidence of reoperation for any reason after allograft-prosthesis composite and modular prosthesis reconstructions of the proximal femur in children with primary bone tumors? (2) What was the cumulative incidence of reconstruction removal or revision arthroplasty in those two treatment groups? (3) What complications occurred in those two treatment groups that were managed without further surgery or with surgery without reconstruction removal? Methods: Between 2000 and 2021, 54 children with primary bone tumors underwent resection and reconstruction of the proximal femur at a single institution. During that time, allograft-prosthesis composite reconstruction was used in very young children, in whom we prioritize bone stock preservation for future surgeries, and children with good response to chemotherapy, while modular prosthesis reconstruction was used in older children and children with metastatic disease at presentation and poor response to chemotherapy. We excluded three children in whom limb salvage was not possible and 11 children who underwent either reconstruction with free vascularized fibular graft and massive bone allograft (n = 3), an expandable prosthesis (n = 3), a massive bone allograft reconstruction (n = 2), a rotationplasty (n = 1), standard (nonmodular) prosthesis (n = 1), or revision of preexisting reconstruction (n = 1). Further, we excluded two children who were not treated surgically, three children with no medical or imaging records, and three children with no follow-up. All the remaining 32 children with reconstruction of the proximal femur (12 children treated with modular prosthesis and 20 children treated with allograft-prosthesis composite reconstruction) were accounted for at a minimum follow-up time of 2 years. Children in the allograft-prosthesis group were younger at the time of diagnosis than those in the modular prosthesis group (median 8 years [range 1 to 16 years] versus 15 years [range 9 to 17 years]; p = 0.001]), and the follow-up in the allograft-prosthesis composite group was longer (median 5 years [range 1 to 23 years] versus 3 years [range 1 to 15 years]; p = 0.37). Reconstruction with hemiarthroplasty was performed in 19 of 20 children in the allograft-prosthesis composite group and in 9 of 12 children in the modular prosthesis group. A bipolar head was used in 16 of 19 children, and a femoral ceramic head without acetabular cup was used in 3 of 19 children in the allograft-prosthesis composite reconstruction group. All 9 children in the modular prosthesis group were reconstructed with a bipolar hemiarthroplasty. Reconstruction with total arthroplasty was performed in one child in the allograft-prosthesis composite group and in three children in the modular prosthesis group. For both groups, we calculated the cumulative incidence of reoperation for any reason and the cumulative incidence of reconstruction removal or revision arthroplasty; we also reported qualitative descriptions of serious complications treated nonoperatively in both groups. Results: The cumulative incidence of any reoperation at 10 years did not differ between the groups with the numbers available (36% [95% confidence interval 15% to 58%] in the allograft-prosthesis composite group versus 28% [95% CI 5% to 58%] in the modular proximal femoral replacement group). The cumulative incidence of reconstruction removal or revision arthroplasty at 10 years likewise did not differ between the groups with the numbers available (10% [95% CI 2% to 28%] versus 12% [95% CI 0% to 45%], respectively). In the allograft-prosthesis composite group (20 children), hip instability (n = 3), nonunion (n = 2), fracture of the greater trochanter (n = 1), screw loosening (n = 1), limb-length discrepancy (n = 1), and coxalgia due to acetabular wear (n = 1) were treated surgically without reconstruction removal. Complications treated without surgery included resorption of the allograft at the trochanteric region (n = 4), fracture of the greater trochanter (n = 4), limb-length discrepancy (n = 6), and coxalgia due to acetabular wear (n = 2). In the modular prosthesis group (12 children), hip instability (n = 1), coxalgia due to acetabular wear (n = 1), and limb-length discrepancy (n = 1) were treated surgically without reconstruction removal. Complications treated without surgery included hip instability (n = 2), stress shielding (n = 6), infection (n = 1), sciatic nerve palsy (n = 1), and limb-length discrepancy (n = 3). Conclusion: Although the two groups of children were not directly comparable due to differences in age and clinical characteristics, both modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur after bone tumor resection appear to be reasonable options with similar revision-free survival and complications. Therefore, the type of reconstruction following proximal resection in children with bone sarcoma should be chosen taking into consideration factors such as patient age, bone size, implant availability, technical expertise, and the surgeon’s preference. Although children treated with expandable prostheses were not included in this study, such prostheses may be useful in bridging the surgical defect while correcting residual limb-length discrepancies even though they face limitations such as small intramedullary...

Treatment of intra-articular fractures of the distal humerus is challenging due to their complexity, comminution, and associated complications. The evolution of surgical approaches and the design of elbow-specific implants over the last decades have failed to improve clinical and radiological outcomes. Studies are sparse regarding the long-term influence of surgical treatment of these types of fractures in the upper limb function. The purpose of the current study was to retrospectively review the long-term functional outcome and complications of all intraarticular (AO type B, C) distal humerus fractures treated surgically in a university hospital during the last 25 years. The study included patients who were surgically treated for an intra-articular distal humerus fracture between March 1991 and May 2016. Our initial search, using ICD-10 codes, identified 63 patients in the specific time period. Twelve patients had died, nine declined to participate, eight had emigrated, nine could not be located and one patient was excluded as he suffered from quadriplegia unrelated to the initial injury. The remaining 25 patients (mean age at surgery 44.2±19.67) were included in a follow-up study protocol. Functional outcome was evaluated according to Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Pain was assessed using the Numerical Pain Rating Scale (NPRS) and subjects were asked to rate their satisfaction. Perioperative and late complications were recorded as well. The average follow-up was 158.16 ± 73.73 months. The average score was 89.4 ± 12.36 for MEPS, 42.68 ± 4.03 for OES, and 8.1 ± 15.38 for the QuickDASH. The patient satisfaction was rated 3.8 ± 1.08 on average. The mean flexion of the affected elbow was 137.6 ± 12.68 degrees while extension deficit was present in 14/25 patients, with a mean of 8.6 ± 8.96 degrees. We did not observe any mal- or non-unions. The re-operation rate was 32% primarily due to stiffness and irritation from the hardware. We noticed one spontaneously resolved ulnar nerve palsy, one combined radial, and ulnar nerve palsy after extensive arthrolysis that also resolved two cases of heterotopic ossification, one case of implant failure, and two cases of infection - one superficial, which was managed with antibiotics, and the other was deep managed with surgical drainage. In our series, we found a satisfying range of motion, good functional outcome, and adequate ability to perform daily activities at a very long follow-up. Posttraumatic arthritis, whenever present, does not seriously affect functional performance. Level of evidence: IV