Dupuytren's disease is a fibroproliferative disorder that involves collagen deposition and affects hand mobility, grip strength and limits the daily activities. Selective palmar fasciectomy is the most widely used surgical treatment. Short and medium term results of patients operated on an outpatient basis at our intitution are presente.
A retrospective review of all Dupuytren's disease operated between 2015 and 2018 on outpatient basis was performed. Criteria for outpatient surgery include: existence of a hospital unit <50 km from home and an ASA I or II score. 24-hour satisfaction questionnaires and patients clinical files were reviewed.
76% (108 hands) of hands with Dupuytren's disease were operated on an outpatient basis. 80.5% of the patients were male with a mean age of 63.6 years. General anesthesia was performed in 22 cases, peripheral block in 83, sedation in 2, and a combination of block and general anesthesia in one. It was possible to obtain information at 24h in 100 cases, of which 2 patients reported moderate pain in the postoperative period, 1 patient required an overnight stay, 3 patients reported an important limitation in daily activities (all with peripheral block ) and none resorted to health care for immediate postoperative complications. In follow-up consultations, complications were seen in 11 patients (1 nerve injury, 6 scar complications, 1 algodystrophy and 3 skin necrosis). A patient's follow-up was lost.
Outpatient surgery is a viable option in patients with Dupuytren's contracture, even with severe disease, allowing the reduction of hospitalization costs without increase of postoperative complications.

Objective: To evaluate patients who underwent Anterior Cruciate Ligament Reconstruction (ACLR) during the COVID-19 pandemic, and to compare their demographics, postoperative rehabilitation process and outcomes to patients in the corresponding period in 2019.
Methods: A retrospective study of patients who underwent primary isolated ACLR between February 2019 and July 2020. Two different periods were evaluated; The “COVID group” represents the period between February 1st to July 1st of 2020 and the “non-COVID group” represents the equivalent period in 2019. Rehabilitation features as well as the effect of the COVID-19 pandemic on rehabilitation habits were assessed. Patient outcome scores were assessed using the Lysholm, Tegner and the International Knee Documentation Committee (IKDC) questionnaires. Subjective satisfaction, post-operative complications and subsequent surgery were recorded.
Results: 46 patients (36 males) in the non-COVID group and 28 patients (24 males) in the COVID group were included. Both groups did not differ significantly in demographics, functional outcome scores and subjective satisfaction.There was no significant difference between the groups in rehabilitation patterns. In the COVID group, 12 patients (43%) reported difficulty to coordinate post-operative physiotherapy resulting in delay of initiating treatment. Only one patient (4%) reported online physiotherapy participation.
Conclusions: The current study has demonstrated that patients who underwent primary isolated ACLR during the COVID-19 pandemic had no difference in their post-operative rehabilitation patterns, including duration, length and environment of the training, compared to patients in the preceding non-COVID year. The patient's outcome scores, subjective satisfaction and subsequent surgery rate did not differ between the groups.

Introduction: The golden ratio = 1.61803..., usually defined by the Greek letter φ (phi), has attracted broad attention for a long time. It has been found in many phenomena in the universe, including biomechanics, body symmetry and locomotion. Within this context, the purpose of our study was to evaluate normal morphometric measurements of the wrist in paediatric population and to identify the role of phi (φ) in the distal radioulnar joint. Methods: We retrospectively reviewed the hospital records of all distal radius fractures needing surgical intervention in skeletal immature population in our unit between January 2010 and January 2017. We define and describe a reproducible method to measure the ratio of the distal radius and ulnar physis. Results: A total of 268 procedures were included. The mean age was 9.41 (3-16). There was male predominance, with boys representing 63.4% and girls 36.6% of our study population. Our calculation showed that the proportion between the overall segment of radial and ulnar growth plate and radial growth plate was relatively equal with number φ. The mean average of this ratio of all our patients was 1.619684 (1.5848 to 1.6643). Conclusion: In conclusion, we found that the golden ratio resides in our body to play its harmony in wrist joint since birth. We believe that with the support of further studies, the golden ratio or proportion might inherently yield diagnostic and prognostic implications in the treatment of distal radius/ulnar fractures and/or abnormalities.

Introduction:Nerve conduction studies have a high false negative rate for diagnosing carpal tunnel syndrome ranging from 16% to 34%. Ultrasound have been tested as alternative method for diagnosis of CTS. The cross-sectional area of the median nerve at the level of pisiform has been the most evaluated method for diagnosis of carpal tunnel syndrome (CTS). Considering the variation among different ethnicity, the weight and age, wrist to forearm ratio has been proposed using median nerve at the forearm as an internal control. The aim of this paper is to analyse the literature regarding the diagnostic accuracy of the ratio of the cross- sectional area of the median nerve on ultrasound at the level of forearm relative to the cross-sectional area at the wrist (WFR) vs cross sectional area of median nerve at the level of pisiform (CSA) Method: For this meta-analysis four data bases were searched that included Pubmed, Embase, Scopus and Cochrane library. Initially, 271 articles were selected from which 12 were included in this study. Results: This meta-analysis shows pooled sensitivity of 90% and 88%, specificity of 82% and 80%, positive likelihood ratio of 5.3 and 4.5, negative likelihood ratio of 0.12 and 0.15 diagnostic odds ratio of 45 and 30 as well as area under the curve of 0.93 and 0.9 for both CSA and WFR respectively. Conclusion: This meta-analysis shows that cross-sectional area of median nerve has better diagnostic potential for carpal tunnel syndrome than wrist to forearm ratio.

Purpose: When associated with significant soft tissue injury, extremity arterial injury (EAI) is challenging to be repaired. This study aimed to investigate factors that affect outcomes of EAI repair as it relates to the degree of injury of the surrounding soft tissue envelope.
Methods: A clinical retrospective study was conducted on the cases of EAI between January 2003 and December 2019. All cases were allocated into three groups according to the soft tissue coverage of the injured vessel: (A) adequate vital soft tissue coverage, (B) insufficient vital soft tissue coverage, (C) indeterminate extent in soft tissue injury. The vascular repair methods and outcomes in each group were studied particularly.
Results: A total of 106 patients (108 cases) were included. In group A (n=61), suture (41/61, 67.2%) and vessel graft (20/61, 32.8%) achieved 95.1% and 85.0% successful limb reperfusion respectively. In group B (n=31), vessel reconstruction with and flap coverage (7/31, 22.6%) was successful 100%. In group C (n=16), no vascular repair method achieved a successful primary outcome. All cases that failed to restore limb perfusion in three groups underwent additional surgeries. There were significant differences among the three groups in the primary outcome (P<0.001) and limb salvage (P<0.001).
Conclusion: For EAI, the extent of associated soft tissue injury is a variable that is highly associated with different vascular repair methods and outcomes. Therefore, we propose a classifying these injuries into one of three types according to the extent of the soft tissue injury as this will help predict outcomes.

Background:Charcot arthropathy is a progressive, non-infectious, destructive inflammatory process. Charcot arthropathy of the knee (CK) is rare and diagnosis is often delayed, resulting in detrimental outcomes. To our knowledge, there have been no prior systematic/scoping reviews for CK. This scoping review aims to investigate the literature on CK, present the pathognomonic features of CK to aid early diagnosis, and suggest the best management options for CK.

Methods:A systematic search of PubMed, EMBASE, Web of Science for literature relevant to CK was performed. Primary studies such as case reports, case series, retrospective studies were included. Review articles and animal studies were excluded.

Results:Of the 513 results, 58 were included in qualitative synthesis. Average time from symptom onset to diagnosis was 50.5 months. 18 patients had diabetes mellitus, 21 had syphilis. 21 studies reported pain as a presenting complaint, but the degree of pain didn’t correspond with the level of destruction. Oedema and joint effusion were noticed in 34 studies. 29 studies reported lower limb hypoesthesia and 17 studies reported decreased or absent tendon reflex. 28 studies reported initial conservative treatment, often knee brace with minimal weight bearing, 9 required subsequent surgery. 12 studies utilised arthrodesis, with fracture at the intramedullary nail entry site being the most common complication. 24 studies opted for TKA.

Conclusion:The literature on CK remains sparse, with most publications being case reports. Given that CK dramatically reduces quality of life, increases morbidity of patients, there is need for more literature on evidence-based options for early diagnoses and management.

Background:Knee pain is one of the commonest symptoms in patients who attend the Orthopaedic outpatient clinics.Chondral defects are one of the causes for a painful knee.Incidence of chondral defect is reported to be between 5-10% over the age of 40.Chondral defects can lead to osteoarthritis.Early detection of these lesions and cartilage repair surgery can delay the onset of osteoarthritis.The purpose of this study is to highlight the incidence of cartilage defects in patients who present to the clinic with knee pain and introduce a new concept for measuring severity of defect. Methods:A retrospective analysis was carried out on patients who had Magnetic Resonance Imaging(MRI) scans for painful knees between June 2017 and May 2019.227 consecutive knees were studied for the incidence of chondral defects,number of lesions,grade and size of lesion,geographical location and also associated pathology in the knee.Results:All the 227 patients had chondral lesions.Most patients had 2 to 3 lesions(66.1%) with patellar lesions(76.6%) being the commonest followed by medial femoral condyle(59.9%).Associated pathologies included effusion(86.34%), synovitis(30.39%) and bone oedema(17.18%).Discussion:Cartilage defect in the knee is the leading cause of pain.All knees in our study have chondral defects with patellofemoral joint involvement being the commonest. Probability of patella maltracking cannot be ruled out in these knees.A new concept 'Volume Index(VI)' is introduced to measure size and grade of lesions.Conclusion:Incidence of cartilage defect in the knee is very high.VI is a promising strategy for measuring cartilage defects.Appropriate history,radiographs and cartilage sequencing scans have to be performed for early diagnosis and adequate treatment.

Proximal humeral fractures are the third most frequent bone injuries of the limbs. Mostly elderly people are involved because of cognitive disfunction, disbalance, comorbidities and weaker bone stock. Frequency is higher in females. While nondisplaced fractures can be managed successfully non operatively, the adequate therapy of displaced, especially comminuted fractures can be challenging. In the lecture we present a systematic review of the current literature and share our experiences in the treatment of proximal humeral fractures in a Hungarian level I trauma center. Between 01.01.2016 and 31.12.2020, 115 patients (81 female /70%/ and 34 /30%/ male) above 65 years of age (mean 76.4) were treated operatively for proximal humeral fractures. Most cases were treated by osteosynthesis. Primary shoulder replacement was done in 14 patients. Many aspects must be considered during decision making. General state and expectation of patient, compliance, bone quality, fracture patterns, experience of the surgeon and technical background are all important. In active patients with relatively good bone quality, movement stable osteosynthesis, e. g. plating or nailing is preferred. Early rehabilitation is important. When surgical repair is technically impossible or the patient is older, shoulder replacement recommended. If surgical restoration of the proximal humerus is possible osteosynthesis is recommended. In case of impacted fractures bone grafting is taken into consideration. If replacement is needed a reverse prosthesis has a better functional outcome than an anatomical type. In the elderly pain free rehabilitation is needed for an acceptable outcome.

INTRODUCTION- A monteggia fracture-dislocation to occur in the setting of interossei membrane injury resulting in distal radioulnar joint disruption with the absence of radial neck or head fracture is an extremely rare entity and only one such case has been reported in the literature to date. CASE REPORT- A 21-year-old right-hand dominant male patient presented with pain and swelling over the left elbow for 3 days. He was diagnosed to have a closed Bado type-1 Monteggia fracture-dislocation following radiological examination. The patient was operated on immediately with open reduction and internal fixation with compression plating and closed reduction of the radial head dislocation was achieved. The wrist was routinely examined intra-operatively following the completion of the above procedure for monteggia fracture and distal radio-ulnar joint instability was diagnosed and confirmed under a fluoroscope. It was reduced and pinned with a 2 mm k-wire engaging 4 cortices. The forearm was protected with an above elbow plaster for 4 weeks following which the k-wire was removed and elbow range of motion started. At two-year follow-up, radiographs revealed a reduced radio-capitellar joint and a reduced distal radio-ulnar joint with no functional limitations or pain. CONCLUSIONS- The complete longitudinal instability of the forearm as seen in our case represents a variation of the Essex-Lopresti injury. Hence, all the patients who are diagnosed with a monteggia fracture-dislocation should undergo a thorough wrist examination even in the absence of symptoms to rule out injury to the interossei membrane resulting in distal radio-ulnar joint dislocation.

Introduction: Headless Compression screws (HCS) have a variable thread pitch and headless design enabling them to embed below the articular surface and generate compression force for intra-articular fracture healing without restricting movement. However, their expense, limited specifications and availability can restrict their use. Locking screws have greater variety of dimensions and a threaded pitch mirroring the HCS design. This study aims to compare the compressive forces generated by HCS versus locking screws.Methods: 2.8mm Micro Acutrak 2 and 3.5mm Mini Acutrak 2 headless compression screws were compared to 2.7mm, 3.5mm Smith & Nephew and 2.7mm, 3.5mm Synthes locking screws. Synthetic bone models were cut to simulate a transverse fracture. Compression force (N) was measured using sensors between blocks. Mean peak compression force was calculated and one-way ANOVA test was used to determine statistical significance (p=<0.05). Results: The 3.5mm Synthes (75 ± 8N, p= 0.641) and Smith & Nephew (79 ± 18N, p=0.990) locking screws generated similar peak compression force to the Mini Acutrak 2 screw (79.67 ± 7N) with no significant difference. The 2.7mm Synthes (17 ±4N, p=<0.001) and Smith & Nephew (13 ±9N, p=<0.001) locking screws also generated compression, although significantly less than the Micro Acutrak 2 screw (54.33 ±4N).Conclusion: Independent locking screws are capable of generating compression forces like headless compression screws. This supports their inclusion in screw selection for intra-articular fractures as a potential alternative. Further studies are needed to determine the impact of torque and longevity in vivo.

Background:Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments, to slightly enhanced real-world environments. In the past two decades, XR assisted surgery has seen an enormous increase in research and development.

Aim:Our research aims to understand the impact of extended reality on surgery by reviewing literature on historical trends, current usage, and future prospects, of extended reality assistance in the surgical process.

Methods:A systematic search of Medline, Scopus and Embase for literature related to XR-assisted surgery and telesurgery was performed. Primary research investigating patients undergoing surgical procedures, and surgical residents undergoing training, were included. Review articles, non-surgical procedures, medical student studies, and animal trials were excluded.

Results:Of the 2391 articles, 213 articles were finally included for qualitative synthesis. Data derived from these articles was divided into three main categories: impact on surgery, impact on the patient, and impact on the surgeon. These were further divided into subcategories, namely pre-operative planning(36), intra-operative guidance(59), pain sensation(14), anxiety/understanding(12), surgical training(68), surgeon confidence(13) and telesurgery(7). Among these, augmented reality was utilised most often intra-operatively, whereas virtual reality was most prevalent pre-operatively and during training. The most commonly reported outcomes were operative time, tool path length, and surgeons’ subjective views.

Conclusion:XR assisted surgery has emerged as a dominant field of innovation in the past decade. The greatest areas impacted have been; improving synthesis of complex data pre-operatively, reducing need to break line-of-sight intraoperatively, reducing patient need for pharmacological analgesia, and increasing flexibility during surgical training for residents.

Introduction: Tibial plateau fractures are often complex intra-articular fractures that require anatomic reduction. The selection of the best suitable surgical approach is crucial and based on fracture pattern, condition of the soft tissues, accompanying injuries and surgeon experience. Methods: A forty-five year-old male fell riding a bicycle with direct trauma of lower limb. Deformity and crepitation were evident around the knee. Radiographically there was a posteromedial column slipt and depression of tibial plateau. A Lobenhoffer posterior approach was chosen for open reduction and fixation of posteromedial column fracture with a buttress plate. Two cannulated screws were inserted from lateral to medial to help with reduction and give support to the construct. Results: Postoperatively, no neurovascular injury was noted and physical therapy was stared with assisted and active motion of the knee. He was discharged at 25 days postoperative, non-weight bearing with two crutches, range of motion 0-90 degrees. At 2 months postoperative he started partial weight bearing and progressed to complete weight bearing over the next couple of months. At 4 months postoperative he had mild pain, walked with no difficulty and barely noticeable limp (Knee Society Score 87). Discussion: Tibial plateau fractures are becoming increasingly more frequent mainly due to high energy traumas in young adults. The choice over the most appropriate approach for each case is crucial. This case is a good example of one of the utilities for the Lobenhoffer approach which allows direct visualization of posteromedial plateau, thus enabling anatomic reduction and adequate fracture fixation.

Introduction: Successful implementation of outpatient arthroplasty services is likely to a play a central role in reducing cost and nosocomial spread as elective services resume following the pandemic crisis. The aim of this study was to identify the potential pre-operative predictors for implementation of successful outpatient lower limb arthroplasty surgery. Methods: We analysed data from our institutional database on a cohort of 696 lower limb arthroplasty patients. Data on length of stay (LOS), age, gender, Oxford joint scores, BMI, socioeconomic deprivation index (SDI), ASA grade, comorbidities, functional comorbidity index(FCI), preoperative blood parameters, implant type, day of week; timing of surgery and 30-day readmission rates were recorded for all patients. Univariate and subsequent multivariate regression modelling was undertaken to identify preoperative predictors of discharge within the day of arthroplasty surgery. Results: Forty-five (7.43%) patients were discharged within 24 hours of surgery. Discharge within 24 hours did not increase the incidence of unplanned 30 day readmissions (p>0.05). Weekend or afternoon surgery did not contribute to increasing LOS beyond 24hours (p>0.05). There was no difference in comorbidities, FCI, SDI and preoperative blood parameters between patients discharged within and beyond 24hours. Multivariate analysis identified age < 65 years (OR 2.41; 95% CI 1.02-5.74) and partial knee replacement (OR 8.91; 95% CI 3.05-26.04) as the strongest predictors of discharge within 24hours. Conclusion: Outpatient arthroplasty may successfully be implemented in patients below 65 years of age undergoing partial knee replacement surgery regardless of ANY other patient, comorbidity and hospital episode related factors.

Introduction: Residual laxity of the knee after reconstruction of the anterior cruciate ligament (ACL) with the hamstrings tendon is well known but often ignored and its clinical impact remains under estimated. The aim of our study was to clinically evaluate residual laxity as well as functional results and return to sport after ligamentoplasty of the ACL with hamstrings tendon graft on an athletic patient. Methods: Our descriptive and retrospective study included 54 athletic patients who have had primary ACL reconstruction with hamstrings tendon graft with a minimum follow-up of one year. Results: The mean follow-up was 19.4 months. Mean time interval between the trauma and the surgery was 10.2 months. All our patients have had anatomic single-bundle reconstruction of the ACL with hamstrings tendon. At the last follow-up, 3.7% of patients had reported residual pain, 7.4% still had residual anterior laxity without functional impact. Mean Lyholm-Tegner score was 92.3 and concerning the ARPEGE cotation we have noticed that 90.8% of the results was excellent and good. 72.1% of patients have returned to their athletic activity with mean time interval of 8.5 months. Only a shorter time interval between trauma and surgery was statistically associated to a better functional result. Conclusion: Anatomic ACL reconstruction with hamstrings tendon graft allows a reliable control of anteroposterior as well as rotatory stability of the knee with satisfying functional results in athletic patients. A reduction of the time interval between trauma and surgery is recommended for a better result.