Introduction: The irreducible intertrochanteric fracture (ITF) is a thorny issue. Preoperative prediction based on the fracture characteristics shown in X-ray or computerized tomography is challenging. This study aimed to summarize the fracture morphological characteristics of irreducible ITFs and establish the prediction model and interpretation model to achieve the preoperative prediction of irreducible ITFs.
Methods: The fracture mapping technique was used to depict the fracture line distribution characteristics of ITFs. The key characteristics of ITFs were identified by quantitative statistics with the new proposed partition of the proximal femur. Multiple machine learning classification models were integrated to analyze and identify the optimal model, and Shapley Additive exPlanations (SHAP) interpretation was developed for model explanation and personalized risk assessment.
Results: Involvement of the lateral cortex, the location of the main fracture line, the presence of a large posteromedial bone fragment, the direction of the main fracture line, the comminuted degree of the fracture and involvement of the lesser trochanter were identified as the key variable of ITFs by comparing the difference of fracture line distribution. Among all classification models, the logistic classification model was the optimal model with the area under the curve 0.72 (95% confidence interval: 0.61-0.89). The location of the major fracture line and involvement of the lateral cortex were the most important features to influenced the fracture reduction.
Conclusions: Machine learning models effectively predict irreducible ITFs using fracture line distribution and fracture morphological characteristics. The SHAP model can further enhance the interpretability of the prediction model.

This study is aimed to explore the correlation between cervical spine and lumbopelvic sagittal parameters in elderly women, emphasizing the compensatory role of cervical lordosis within the global spine alignment influenced by bone quality and muscle strength. We focused on a cohort of 189 women aged 65 and above, capable of walking independently and demonstrating low bone mass as indicated by DEXA T scores. Comprehensive evaluations included whole-spine standing lateral radiographs to measure various sagittal parameters.

Statistical analysis using correlation coefficient tests and multiple regression highlighted significant findings: menopause period and BMI positively correlated with the C7 slope, suggesting that these factors influence cervical spine curvature. Conversely, grip strength showed a negative correlation with the C7 slope, indicating that stronger grip might be associated with more favorable cervical alignment. Additionally, thoracic kyphosis, lumbar lordosis, and pelvic incidence also displayed significant correlations with other spinal parameters, revealing complex interdependencies within spinal alignment.

The results underscore the intricate relationships between cervical lordosis and pelvic parameters, highlighting the cervical spine's role in maintaining overall spinal balance in the elderly. It may provide valuable insights into the compensatory dynamics of spinal alignment in response to age-related changes in bone and muscle, offering a potential foundation for tailored interventions aimed at mitigating spinopelvic malalignment and enhancing life function in older adults. The results of this study may contribute to the broader understanding of spinal health in the geriatric population, emphasizing the need for targeted spinal care strategies.

Purpose:To investigate the clinical efficacy of modified kidner procedure combined with subtalar arthroereisis in the treatment of adolescent type II painful accessory navicular with flexible flatfoot.
Methods:From January 2018 to January 2022,25 adolescent patients with painful type II accessory navicular and flexible flatfoot admitted to our hospital were enrolled in the study.All patients underwent modified kidner procedure combined with subtalar joint arthrodesis.The Meary Angle,APTMT,the second metatarsal Angle of talus,Pitch Angle, talus tilt Angle,TCA,LTCA,and calcaneal Angle were measured on weight bearing anteroposterior and lateral x-ray films before operation and at last follow-up.AOFAS score and VAS were used to evaluate the improvement of foot function and pain.
Results:All patients were followed up for average 17.4±2.6 months.There was no screw withdrawal or secondary operation to remove the screw in all patients.At the last follow-up, the postoperative visual analogue scale (VAS) score of the affected foot was significantly lower than that before operation, and AOFAS score was significantly higher than that before operation.At the last follow-up,the weight bearing anteroposterior and lateral foot x ray films showed that:The Meary Angle,APTMT,the second metatarsal Angle of the talus,Pitch Angle,talar tilt Angle,TCA,LTCA,and calcaneal Angle significantly improved when compared with those before operation.
Conclusions:The modified kidner procedure combinedwith subtalar arthroereisis has a good clinical effect in the treatment of adolescent type II painful accessory navicular with flexible flatfoot,which can effectively improve the pain symptoms,improve the foot function and imaging manifestations, and correct the flatfoot deformity.

Background:

Advanced surgical techniques for local control of pediatric sarcomas pose significant challenges in resource-limited settings, characterized by limited experience and suboptimal infrastructure. The objective of this study is to analyze the outcomes of surgical treatment at a pediatric oncology unit operated by an NGO in Syria.

Methodology:

This is a retrospective analysis of pediatric patients (age < 18 years) diagnosed with bone or soft-tissue sarcomas treated at BASMA Pediatric Oncology Unit in Damascus between June 2018 and August 2023. The outcomes analyzed were the type of surgical local control, short-term complications, rate of local relapse, and overall treatment outcome

Results:

The study analyzed the outcomes of 85 pediatric patients (median age: 11 years) diagnosed with osteosarcoma (n=45), Ewing Sarcoma (n=34), and non-rhabdomyosarcoma soft tissue sarcoma (NRSTC) (n=6). The surgical interventions included amputation (n=14), tumor resection without prosthesis (n=17), and tumor resection with prosthesis (n=51). Following a median follow-up of 33 months, 55 patients (64%) were still alive, with 49 patients (57%) showing no evidence of disease. Short-term complications included pulmonary embolism-related death in one patient who underwent tumor resection with a prosthesis, wound dehiscence post-tumor resection with a prosthesis (n=2), and prosthesis fracture (n=2). Local relapse was noted in 15 patients. Most local recurrences (n=11) occurred after tumor resection with prosthesis.

Conclusions:

The surgical outcomes for achieving local control of pediatric sarcomas in resource-limited settings can be deemed satisfactory given the presence of a skilled surgeon and the availability of adequate resources and infrastructure.

The optimal method of reduction for late-detected developmental dysplasia of the hip (DDH) remains controversial. Gradual reduction (GR) using traction is a safer and more reliable option for DDH than closed reduction or open reduction. GR using overhead traction (OHT) has been indicated for DDH in the walking age up to 4 years of age. We report on three children with late-detected DDH whose hips were treated between 4 and 6 years of age with GR using OHT. The procedure is composed of three steps including horizontal skin traction in a slightly abducted position, vertical traction (overhead traction) with the knees extended, and above-knee traction. The first step aims to stretch muscles and soft tissues surrounding the hip joint and to achieve an acceptable descent of the femoral head. In the second step, we employ a dedicated apparatus to maintain the hip at 90 to 100 degrees of flexion. We increase hip abduction once a day by 10-degree increments up to 70 degrees. In the third step, the knees are allowed to flex actively so that the muscle tone in the hip adductors and hamstrings can be reduced. The dislocated hips are usually reduced spontaneously at an early phase of this step. Although stable reduction without subsequent redislocation was technically accomplished for all patients, clinically significant AVN has developed in patients aged 5 years or older, indicating the need for some modifications to the conventional technique or reconsideration of the upper age limit for this method.

Introduction: Ankle fractures can be broadly categorized into three main groups: Stable, Unstable and Complex fractures. Stable ankle fractures do not displace under physiological weight bearing. They are associated with pain, resulting in it being difficult or even impossible to weight bear. Treatment is non-operatively, although it often takes 6 weeks or more for the bone to heal. Methods: A retrospective audit of patients with stable ankle fractures referred to the fracture clinic in August 2021. A total of 40 patients reviewed. The typical pathway of patient being followed-up with stable ankle fractures: 1st visit in fracture clinic surgeon should assess stability, VTE risk assessment and initial management. 6th week visit surgeons should assess healing status and give rehabilitation and recovery advice. To consider further ongoing care if required.
Results: During the 1st Visit 15% had weight bearing x-rays done and 33% had VTE risk assessment documented. 92% were managed with a boot allowing for full-weight bearing. 30% were seen again in 1-2 weeks. Stabiliy test done with x-ray done for 92% of patients. Only 25% were discharged back to GP following the first week visit. During the 6th week visit 75% were assessed. 33% of patients seen face to face had x-rays done. 22% were given further follow-up. 25% of the patients during telephone consultation revealed ongoing pain or swelling and therefore offered further assessment. Conclusion: We believe that a standardized pathway and a patient information leaflet would improve patient experience, optimises resources and better comply with BOAST guidelines.

Introduction: Severe injuries with wide injury zone, like amputations, have very limited possibilities to preserve anatomical integrity and function of extremity. Healing is complicated, has several phases and it is certainly a challenge.
Aim: This paper shows clinical series of complex injuries on extremities and results achieved by one surgical team.
Method: The initial surgical treatment considers replantation or revascularisation. The next step is defect covering and then tissue grafting by distraction osteogenesis or distraction histiogenesis. We talk about distraction histiogenesis because when we apply distraction on extremity, we do not only produce the bone, but all the tissues.
Results: The results primarily depend on good plan of healing which is based on estimation of possibilities for reconstructive healing. Results confirm complementarity of microsurgery and distraction osteogenesis. After replantation, shortened part can be elongated as much as needed by distraction osteogenesis or histiogenesis.
Conclusion: Surgical healing of most complicated injuries often demands application of several available surgical techniques and it often should be performed in several phases. Surgical techniques like microsurgery and distraction osteogenesis provide exceptional possibilities to achieve anatomical integrity and recovery of function. Furthermore, in situations where only one surgical technique would not provide acceptable recovery, the use of both techniques extends indications for microsurgery and distraction osteogenesis
Keywords: Reconstructive surgery of extremities, microsurgery, distraction osteogenesis, distraction histiogenesis

Background: Cervical disc arthroplasty (CDA) is a potentially feasible alternative surgical technique for patients with cervical disc degeneration disease (CDDD). Periprosthetic bone loss (BL) is a radiological phenomenon which was proposed in recent years. This study aims to the study aims to comprehensively explore the risk factors of BL and attempted to furtherly reveal its underlying mechanism and influence on outcomes. Methods: A retrospective and comparative study was conducted of consecutive patients who had undergone one-level CDA, two-level CDA or two-level hybrid surgery (HS) at our institution to treat CDDD. Demographic, perioperative and radiological data were correspondingly recorded or evaluated. Patients were divided into different groups in reference to existence and degree of BL, following with inter-group comparisons. Results: A total of 324 patients were enrolled in this study, with 384 arthroplasty segments involved in total. BL was detected in 57.72% (187/324) patients and 53.91% (207/384) arthroplasty segments during the whole follow-ups. The final multivariate regression model shows that age≥45 years and two-level HS were independently associated with a lower risk of BL. Besides, a greater change of disc angle (ΔDA) was an independent risk factor of BL. The results further indicated that severe BL may lead to a higher rate of endplate subsidence and collapse. Conclusion: Younger age and greater ΔDA were independent risk factors of BL, while HS potentially exerted preventative effect. Bone remodeling and micromotion may potentially initiate the BL process. Subsequent research should focus on elucidating the mechanisms and preventive measures for severe BL.

Objectives: The aim of this case study is to examine a rare instance of transverse colon cancer that presented as septic arthritis of knee. This case study emphasizes the significance of a thorough diagnostic process in cases of joint presentations. Methods: The study focused on the use of clinical examination, laboratory tests, knee aspiration, imaging studies, and colonoscopy to establish the diagnosis and guide treatment decisions. The study highlighted the importance of collaborative decision-making by multidisciplinary team. Results: Initial assessment revealed acute left knee pain and swelling in a 78-year-old male with a history of left knee replacement. Clinical suspicion of septic arthritis was confirmed by elevated inflammatory markers and knee aspiration growing Streptococcus Gallolyticus. Intraoperative findings during knee arthrotomy revealed ruptured patella tendon. Given the association of Streptococcus Gallolyticus with Colon Cancer, further investigations were done. CT Chest Abdomen Pelvis revealed transverse colon malignancy, subsequently confirmed by colonoscopy. Multidisciplinary consultation guided the decision for hemicolectomy for definitive treatment of the malignancy. The decision was made to proceed with arthrodesis of the left knee after resolving the underlying systemic disease. Conclusion: This case highlights the challenges of diagnosing systemic diseases that manifest with unusual joint symptoms. The timely recognition of the association between Streptococcus Gallolyticus and Transverse Colon Malignancy, facilitated by comprehensive imaging and multidisciplinary collaboration, led to the successful diagnosis and management of transverse colon malignancy in this patient presenting with septic arthritis of the knee.

We aimed to investigate how many elbows are patient-reportedly disabled, radiographically destructed and ultrasonographically inflamed in patients with rheumatoid arthritis (RA) in the current medical status. We collected data on patient self-assessment, as well as radiographic and ultrasonographic (US) assessments of the elbow, with the aim of investigating the associations between US-detected synovitis (gray scale; GS, and power doppler; PD), joint destruction (Larsen grade), and patient-reported outcomes (PREE), especially in the elbow. A total of 548 RA patients were recruited and analyzed. The mean age was 63.7 years. The means of ROM of the elbow and grip strength of the right side were 130 and 17.6 kg, respectively. The median of the PREE was 6.0 in the right side and 5.7 in the left side. The percentages of Larsen grade 2 or more was 31.4%. The percentage of GS grade 2 or more, and PD grade 2 or more were 9.4% and 0.4% in the humeroradial joint, and 8.0% and 2.2% in the humeroulnar joint, respectively. GS and PD grades were strongly associated with elbow pain (t values; 7.79 in GS grade and 4.12 in PD grade). Larsen and GS grades were strongly associated with PREE (t values; 7.53 and 7.17, respectively). Grip strength and ROM of the elbow were negatively associated with PREE (t values; -11.5 and -7.36, respectively). Radiographic joint destruction, US-detected synovitis, grip strength and ROM of the elbow are strongly associated with patient reported outcome of the elbow.

Introduction: Scaphoid fractures occur in young patients. Surgical treatment is an effective technique to reduce the complications related to complications. We are reporting surgical treatment using percutaneous scaphoid screwing fractures under WALANT technique. Methods: The Wide Awake Local Anesthesia No Tourniquet (WALANT) technique was performed using 10cc Lidocaine (10mg/mL) Adrenaline (0.005 mg/mL) diluted with 9cc saline solution and 1cc Sodium bicarbonate 10mL, all in 20 cc syringe. A 27 gauge needle was used for cutaneous injection. Median, ulnar and radial blocks of the wrist were performed, 5 mL each. Xylocaine 2% was used for intra articular injection diluted with 9cc saline solution. Results : We report two cases of percutaneous scaphoid screwing under Walant. Both patients presented with a wrist trauma occurring after a road traffic accident. Xray showed a non displaced scaphoid waist fracture. Patients were operated on using a volar incision. We used a retrograde screwing.The insertion point of the K-wire was located using Fluoroscopie. Cannulated headless (Herbert) screw of 2.5 mm were inserted. The mean operative time was 40 minutes. The active mobility of the thumb was obtained peroperatively. We prescribed a 6-week immobilization using a removal wrist splint for both patients. Conclusion : Percutaneous scaphoid screwing under Walant technique offers a better functional result : short immobilization and preserves local vascularity. It is a safe and cost-effective technique. The procedure must be explained to the patient and it is used for non/minimally displaced fractures of scaphoid waist of less than 2 mm.

Introduction: Osteochondritis dissecans (OCD) of the knee it’s a condition of unknow pathoetiology where biological and mechanic events affect both subchondral and articular cartilage. The medial femoral condyle (MFC) is the most frequently involved. It affects mainly males between 12-19yo and athletes. Surgical treatment is recommended either when there is instability or when conservative treatment fails. Surgical technique depends on the age of patient, size and stage of the lesion. Methods: Retrospective study that included all patients that underwent surgery for OCD (2012-2023) - population of 25 patients, 30 knees. Clanton-Lee classification was used in order to correlate lesions with the surgical treatment choice. Results: Median age 19yo, 88% males. 5 patients (25%) with bilateral disease and 77% affected MFC. 6,6% grade 2 (both treated with internal fixation); 60% grade 3 (83% treated with internal fixation, 6% with microfractures and 12% with autograft); 33% grade 4 (70% treated with removal and microfractures and 20% with mosaicoplasty). From 18 patients with internal fixation, 13 made MRI at 6 months with 77% showing complete integration. Discussion: In patients with stage 2 and 3, where there is no displacement of the fragment, internal fixation was the treatment of choice with good results which is agreement with current literature. In the other hand in stage 4, as the fragment is displaced, the preferred treatment was removal and microfractures with graft implantation as alternative. Conclusion: Internal fixation seems to have very good results in the treatment of OCD stage 2 and 3.

Objective
To establish the mode of anterior cervical surgery in outpatient setting, and evaluate its preliminary effectiveness.
Methods
A clinical data of patients who underwent anterior cervical surgery between January 2022 and September 2022 and met the selection criteria was retrospectively analyzed. The surgeries were performed in outpatient setting (n=35, outpatient setting group) or in inpatient setting (n=35, inpatient setting group). The operation time, intraoperative blood loss, total hospital stay, postoperative hospital stay, and hospital expenses of the two groups were recorded; JOA score, VAS-neck score, and VAS-arm score were recorded before and immediately after operation, and the differences of the above indexes between pre- and post-operation were calculated.
Results
The total hospital stay, postoperative hospital stay, and hospital expenses were significantly lower in the outpatient setting group than in the inpatient setting group (P<0.05). The satisfaction of patients was significantly higher in the outpatient setting group than in the inpatient setting group (P<0.05). The JOA score, VAS-neck score, and VAS-arm score of the two groups significantly improved at immediate after operation when compared with those before operation (P<0.05). No surgical complications, such as delayed hematoma, delayed infection, delayed neurological
damage, and esophageal fistula, occurred in the two groups. Conclusion
Outpatient surgery mode can significantly shorten the postoperative hospital stay, reduce hospital expenses, and improve the patients’ medical experience. The key points of the outpatient mode of anterior cervical surgery are minimizing damage, complete hemostasis, no drainage placement, and fine perioperative management.

Distale interprosthetic Femur fractures Double plate osteosynthesis for distal femur fractures in geriatric patients is an excellent tool to allow immediate full weight bearing in presence of large comminution areas.

We report on a 82-year-old female patient who sustained a left distal periprosthetic femur fracture (AO 33A3.3) in January 2023. The initial surgical treatment using a lateral 15-hole LISS plate (Synthes) was difficult due to the lack of osseous references caused by intraoperative complications.

Postoperatively, a femoral internal rotation of 35° and a leg length discrepancy was noted. The patient was mobilized non-weight bearing for 6 weeks. Conventional radiological showed a delayed bone healing.

3.5 months postoperatively, a miss-step resulted in a refracture with a large area of comminution including implant failure. We therefore carried out a complete Implant removal and performed a double plate osteosynthesis in May 2023.
Intraoperatively, the axis, length and rotation were anatomically corrected.

We decided to mobilize the patient early postoperatively, initially with half body weight and Continuous Passive Motion (CPM) device treatment despite the large area of comminution.

Just two months postoperatively, the patient was able to perform full weight using a walker. There was pain free knee flexion off up to 110° with full extension ability. Radiologically we saw rapid and progressive callus formation bridging the fracture. The osteosynthesis material is stable. The patient is now extremely satisfied.

We were able to show that early mobilization with stable double plate osteosynthesis achieved excellent clinical and radiological results despite the large comminuted area.

Backgroung:The pilot audit aimed to assess local compliance with the British Orthopaedic Association Standards for Trauma (BOAST) guidelines regarding plaster cast removal and radiograph utilization in conservatively managed distal radius fracture (DRF) patients.The BOAST guidelines recommend that the cast can be safely removed after four weeks of application, and a radiograph of the wrist at the time of cast removal is not necessary unless there are clinical concerns.Materials, Methods & results:The retrospective first cycle, conducted from February to April 2023, highlighted deviations from the guidelines, with only 20.22% of patients undergoing cast removal at the recommended four-week mark. The majority (59.5%) had their casts removed at six weeks, exceeding the guideline-recommended timeframe. Additionally, a substantial proportion (77%) underwent post-removal radiographs without documented clinical indications, leading to no changes in management plans.Following an educational intervention, the second audit cycle, conducted from July to September 2023, demonstrated some improvement, with 52.67% of patients receiving timely cast removal. However, inappropriate radiograph utilization persisted, with 48.2% of patients undergoing radiographs without documented indications. Conclusion:The study underscores the need for enhanced adherence to BOAST guidelines in the management of conservatively managed DRF patients.Improving compliance with recommended cast removal timing and reducing unnecessary radiographs can enhance patient care quality and optimize resource utilization.Continued education and implementation of best practices are essential to enhance the quality of care provided to DRF patients and promote optimal outcomes.