Background: In V.A. Nasonova Research Institute of Rheumatology developed an original fixator (OF) for open wedge high tibial osteotomy (OWHTO) and a surgical technique for its implantation, designed to reduce complications (postoperative lateral tibial plateau fracture, delayed union or non-union, loss of correction), and improve the results of the operation. Objective: to evaluate the immediate results of OWHTO in patients operated on using an OF and a surgical technique of its implantation. Methods: 30 patients with primary and secondary knee OA I-III stages who were operated in 2018-2020 using an OF consisting of a porous modular titanium spacer (fills the entire medial space of the gap and no need for bone grafting), a connecting screw and locking compression plate with angular stability and a surgical technique of its implantation. Results: one year after OWHTO there were no unsatisfactory results. An excellent result was obtained in 59.3%, good in 33.4% and satisfactory in 7.3% of patients. Complications included 1 case of intraoperative lateral tibial plateau fracture and 4 cases of pain in the area of the implanted plate in patients who had gap size >10mm. The lateral tibial plateau fracture consolidated within 3 months after surgery without fixator fracture and loss of correction. Conclusions: the use of an OF and a surgical technique of its implantation made it possible to achieve the nearest excellent and good results in 92.7% of cases. The use of an OF allows to avoid postoperative lateral tibial plateau fractures, non-union and loss of correction.

AIM: To study is to analyze the functional & radiological outcomes following hinged knee total knee replacement as primary prosthesis.INTRODUCTION: Newer generation rotating mobile hinged prosthesis can be used as primary TKA prosthesis in case of severely deformed knee or extreme ligament laxity or imbalance, resection of tumor around distal femur, end-stage Osteoarthritis, rheumatoid arthritis, traumatic dislocation of the knee, gross flexion & extension gap imbalance, ankylosis, intense varus and valgus of the knee. MATERIALS & METHODS: Prospective study of 12 cases, operated from 2014-2016 for various diagnosis were studied. Preoperative and postoperative scoring includes WOMAC score, Knee society score and Oxford score were modulated to know the functional outcome. All surgeries were done by a solitary knee arthroplasty expert.RESULT: At a minimum of 4 year follow-up, functional outcomes in terms of the 3 scores proved to be superlative. The mean scores were WOMAC (12), OXFORD (32), and COMBINED KSS (148). Patients of this group also had a convincing knee ROM and gross deformity has been corrected. CONCLUSION: The most important finding in this report is about the use of hinged knee system as primary implant of choice, most eminently the 4-year implant survivorship is good, failure and complication-free. Hinged knee continues to be the value of choice as a primary implant in global instability or severe deformity and can be considered as a vital alternate.

Femoroacetabular Impingement (FAI) is a well described cause of pain and movement restriction in the young, non arthritic patients. Extra articular impingement is still underrecognized but must be considered as a differential or associated diagnosis, requiring a high index of suspicion. Subspine Hip Impingement, in particular, is increasingly recognized and approached by hip arthroscopy, with recent publications showing satisfactory functional results.
A 17 year old male patient, football player, presented with persistent anterior hip/groin pain during sports practice and limitation i hip flexion, rotation and sudden accelerations He had history of an avulsion fracture of the anterior inferior iliac spine at age 12 treated conservatively. On physical examination, the FADIR and Stinchfield tests elicited anterior groin pain and the AIIS was tender to palpation. X ray revealed a low lying and prominent AIIS (type III), consistent with Subspine Impingement, and a slightly elevated alpha angle 62º, indicating Cam type FAI. MRI showed an anterolaterally located acetabular labrum delamination. The pre operative HAGOS score was P80 S54 A80 SP34 PA13 and Q25. The patient underwent arthroscopic subspine decompression by AIIS plasty and femoral osteoplasty. The labrum was repaired using suture anchors. Post-operative radiographs confirmed correction of the crossover sign, decompression of the subspine region and improvement of femoral head morphology. At 11 months post operative, the HAGOS score was P95, S93, A95, SP88, PA88 and Q85.
This report illustrates an uncommonly diagnosed case of FAI and Subspine impingement. The results of arthroscopic treatment was excellent as described in the literature.

Case Presentation: Woman, 51 years old, suffered a gunshot to the right thigh, presenting with a large and deep wound, with an open comminuted fracture of the femoral diaphysis and superficial femoral artery injury with acute ischemia. The patient was submitted to revascularization and osteotaxis of the femoral fracture with an external fixator and skin graft. Two months later, the external fixator was removed and femoral nailing was performed. During follow-up, although there were no symptoms and a normal gait, there was a poor radiologic consolidation with pseudarthrosis, reason why the patient was later submitted to surgical cleaning of the pseudarthrosis with bone graft and growth factors interposition. Although there was a positive clinical evolution, due to poor bone callus formation, a dynamization of the femoral nailing was performed, with a consequent progressive impaction of the femoral fragments and limb shortening. Later, the femoral nail was extrated, osteotomy of the proximal femur performed and an external fixator inserted in order to compress the fracture site and to perform a proximal elongation. There was a clinically good outcome 1 year later, with a reduction of the lower limb length discrepancy. Discussion: The management of gunshot-induced fractures with associated neurovascular injuries is complex requiring a multidisciplinary approach to this type of patients at presentation, as well as during their follow-up. Possible complications are wound infection, compartment syndrome, delayed union or nonunion of the fractures. The use of external fixator as a temporary measure before definitive treatment has many advantages.

[Objective] Despite menopausal women frequently experience pain or numbness in their hands due to osteoarthritis, entrapment neuropathy or tenosynovitis, there were no specific treatment for these menopausal women’s conditions. We report the treatment of this condition with equol supplement. [Methods] Thirty-five women who have pain or numbness in their hands were included. The mean age was 53.4 (3 cases between 36-44yo, 26 cases between 45-60yo, and 6 cases between 61-80yo). 9 cases of tenosynovitis, 6 cases of entrapment neuropathy and 25 cases of osteoarthritis were included. 16/26 cases (61.5%) aged between 45-60 experienced systemic menopausal symptoms (ex. hot flashes). 10mg/day of equal supplement was administered for all patients during the follow up periods. We investigated the improvement of hand symptoms for all patients and associated systemic menopausal symptoms for women aged 45-60. [Results] Improvement of hand symptoms was found in 61.5% and associated menopausal symptoms in 87.5% for 45-60 yo patients. On the other hand, only 33.3% improved the hand symptoms for 36-44 yo and 16.7% for 61-80 yo. These patients showed improvement within 3 months after administration of equal.[Summery] Equal, a metabolite of the isoflavone daidzein, has estrogen-like properties. The effectiveness of equal for hot flashes in postmenopausal women was reported in the literature. We speculate estrogen-like properties of equal contributed to the improvement of hands symptoms according with the fact that equal administration was highly effective for women aged around menopausal status. Equal supplement can be a good treatment option for menopausal women’s various hands symptoms.

Introduction: Nontuberculous mycobacterium causes infection in humans. In addition, it causes purulent flexor tendon tenosynovitis with poor inflammatory findings. Mycobacterium haemophilum (M. haemophilum) belongs to the group of nontuberculous mycobacterium. They have been rarely reported to occur on the hands. Here, we report the surgical treatment of a case of recurrent purulent flexor tendon tenosynovitis due to M. haemophilum in an immunocompromised patient.
Case: A 73-year-old Japanese woman underwent living renal transplantation 20 years ago and was on constant oral immunosuppressants. She noticed swelling, redness, and pain of the left middle finger and visited her previous doctor. She underwent synovectomy upon the diagnosis of purulent flexor tenosynovitis. An acid-fast bacterium was detected. However, the specific species was not identified. She presented to our hospital because the swelling gradually appeared on the left thumb 2 months after the initial operation. Synovectomy of the left thumb was performed. Gene sequence analysis identified M. haemophilum, and she received antibacterial therapy. However, 6 months after the second operation, recurrence of synovitis of the left middle finger was observed. She underwent a third synovectomy, and M. haemophilium was identified again. No recurrence was observed 2 years after the operation.
Discussion: Purulent flexor tendon tenosynovitis caused by M. haemophilum has been rarely reported. A combination of mycobacterial therapy is commonly used; however, it is difficult to identify this bacteria using conventional methods.
Conclusion: M. haemophilum may cause purulent flexor tenosynovitis in immunocompromised patients. It is important to consider genetic testing to identify this bacterium.

Introduction: There is a paucity of literature reporting risk factors and thirty-day postoperative outcomes of patients with osteonecrosis of the knee (ON) undergoing total knee arthroplasty (TKA). The purpose of this study is to evaluate rates of risk factors and their impact on postoperative outcomes for ON patients undergoing TKA. Methods: A retrospective analysis on the American College of Surgeons National Surgical Improvement Program database between 2008 and 2016 was performed. A total of 225,475 patients undergoing TKA were isolated and matched into ON and non-ON TKA cohorts (n=151 each) using 1:1 propensity score matching based on gender, age, and BMI. Patient demographics, preoperative risk factors, perioperative, and overall postoperative outcomes (complications, reoperation, readmission, or in-hospital mortality) were compared between the two cohorts. Regression models were used to evaluate whether risk factors were independent predictors of adverse events. Results: ON patients had increased rates of chronic obstructive pulmonary disease (COPD) and bleeding disorders. Operative time, length of hospital stay, and overall postoperative outcomes were comparable between the two cohorts (all, p>0.05). Regression models showed none of the preoperative risk factors to be predictive of overall postoperative outcomes (all, p>0.05). Conclusion: Operative time, length of hospital stay, and overall postoperative outcomes are comparable between the ON and non-ON cohorts. There is also an increased frequency of COPD and bleeding disorders in ON patients in the preoperative setting. Further research is needed to better understand the relationship between risk factors and postoperative outcomes of ON patients undergoing TKA.

Backround: The Opera acetabular component was introduced in 1997. It was made of Ultra-high molecular weight polyethylene (UHMWP), featuring a long posterior wall, wire marker and malleable flange, with instrumentation designed to improve positioning and cement pressurisation. The aim was to avoid the presence of a radiolucent line in Zone 1 at 12 months, previously reported to be associated with progression and poorer outcomes. Methods: Data was collected prospectively on 303 consecutive Opera implants (275 patients), performed between March 2000 and December 2005. A posterior approach was used and the acetabulum was prepared with keyholes and pulse-lavage. Palacos-R cement containing Gentamicin was used with a pressuriser. A cemented C-Stem femoral component was used in all cases. Results: There were 185 females (65%) and average age was 69. Aseptic loosening occurred in 31 cases with 16 already revised and 15 currently loose, all associated with increased wear. Only 155 implants had no radiolucent lines at 12-months, which fell to 50% at 5 years and 44% at 10. There was a radiolucent line in Zone 1 at 12 months in 135 hips. Conclusion: 52% of Opera cups lacked a radiolucent line at 12 months, which was poorer than published results with other implants. A radiolucent line in Zone 1 at 12 months frequently progressed and was associated with significantly higher rates of loosening and revision. Although the Opera component was associated with high wear rates, implants without a radiolucent line at 12 months performed well, highlighting the importance of precise surgical technique.

Introduction: The management of a patient with a first time shoulder dislocation remains controversial. The classic treatment remains reduction and immobilization. Management options include surgical treatments however there is a lack of evidence about which method is most effective. The aim of our study was to assess the rate of recurrence and patient-related risk factors for re-dislocation after a first time anteromedial shoulder dislocation. Methods: We conducted a retrospective, multicenter study. Data of patients who consulted for a first time pure anteromedial shoulder dislocation between 2016 and 2018 in the emergency rooms of two trauma center were collected. Results: This study included 221 patients. The recurrence rate of a first time dislocation was 28.1% at 2 year of an average fellow-up and the average time to a first recurrence was 6 months. A symptomatic shoulder with or without recurrence of dislocation was found in 40% of cases. Dislocation of the dominant limb, being a competitive athlete, especially in contact sport and having a laxity of the contralateral limb were predictive factors of recurrence of shoulder dislocation. A multivariate study of these parameters showed that people under 20 years of age are at high risk of recurrence and that this risk increases when it is associated to predictive factors mentioned above. Conclusions: The classic management of a first time anteromedial shoulder dislocation generates a high recurrence rate and significant functional discomfort. A change in attitude is necessary to prevent the transition to chronicity in subjects at high risk of recurrence.

Introduction: Clasically, the role of the extensor retinaculum of the wrist has not received the same attention as the flexor retinaculum, being portions of the extensor retinaculum excised or transposed in surgeries such as flexor pulley reconstruction, extensor carpi ulnaris sling stabilization, zone VII tendon repairs, etc. Methods: 35 years old female, physiotherapist, antecedent of partial section of third finger extensor tendon (zone VII) four years ago, repaired in emergency service. The patient presents progressive lack of wrist and 2, 3, 4 fingers extension compared to contralateral and evident bowstringing. Extensor retinaculum incompetence is diagnosed, proposing surgical treatment to the patient. Surgical revision is performed, observing retinaculum fybrosis and weakening, retinaculotomy is performed observing extensor sinovytis causing space compromise under the retinaculum. Sinovectomy, adherence removal and retinaculum retensing is performed, checking correct extensor tendon´s slide and lack of bowstringing. Results: No wound complications were reported, rehabilitation program was completed and patient had complete functional recovery in 8 weeks after surgery Discussion: Several studies like Palmer, M.J. Brody and Grundberg conclude the importance of extensor retinaculum integrity, with special mention to retinaculum over the fourth dorsal compartment, to avoid extensor lag and bowstringing. In the case of our patient, a probably unnoticed partial section of the extensor retinaculum could lead to functional deficit in middle/ long-term. Conclusion: Exhaustive hand and wrist wound exploration is crucial to identify not only tendon injuries but also other structures such as neurovascular and ligamentary

Introduction: Ankle sprain is one of the most common injuries in basketball players. This study aimed to clarify the effect of medical support on preventing ankle sprain in juvenile basketball players. Methods: In this study, 788 basketball players (mean age 10.9 years, 396 boys and 392 girls) were included for analysis. All players received medical support consisting of physical examination, medical lecture about sports injuries, and stretching once a year. A self-administered questionnaire was used to investigate the history of ankle sprain and the presence of ankle pain. Tenderness of the ankle was investigated as a physical finding. The anterior talofibular ligament rupture and avulsion fracture of lateral malleolus were investigated by ultrasonographic examination. Statistical analysis was performed by Chi-square and the Cochran-Armitage tests. A p-value less than 0.05 was considered significant. Results: The prevalence of tenderness of the ankle was 18.5% in 2014 and 13.9% in 2018, which decreased year by year (p<0.05). The prevalence of abnormal findings on ultrasonography of the ankle was 10.8% in 2014 and 5.7% in 2018, showing a significant decrease over the five years (p<0.05). However, the percentage of players with a history of ankle sprain was 36.5% in 2014 and 35.3% in 2018, and there was no statistically significant decrease during five years. Conclusion: Our medical support did not reduce ankle sprain in juvenile basketball players. However, disability after injury might have been reduced after introducing medical support.

Fractures of the patella contributes to 1% of all skeletal injuries.Nonunion and delayed union of patella fractures are rare There exists limited evidence in the literature to guide the clinician in the management of these complications. Case report 25-year-old male came with complaints of pain in the right knee since 1year And difficulty in walking since eight months patient also gives history of clicking sound while doing knee movements since 8 months . Patient was apparently alright one year back when he had fall from bike and sustained trauma to the right knee on investigation, patella fracture was diagnosed and was treated at a local hospital with tension band wiring. Incision centred over the patella and along the previous scar mark was taken. Soft tissue flaps raised on both the sides fracture fragments were identified and separated, the SS wire was identified and taken out.Fracture edges freshened fibrotic tissue removed and first the superolateral fragment was fixed with medial fragment using Partially threaded 4mm cc screw of length 38MM. Then the remaining fragment was held together using encirclage wire and then TBW was done using SS wire.weight-bearing as tolerated by the patient was initiated in postop . patient was advised not to bend the six months follow-up of the patient showing Bony union on x-ray and is able to walk without support. Patient gained full knee flexion and extension conclusion:
TBW and encirclage using SS wire is a best option for treatment of the non united patella fracture.

Background: Open tibial plafond fractures are challenging to manage with high rates of complications associated. After failed fixation of these fractures, post-traumatic arthritis and deformity of the ankle can be treated with calcaneotalotibial arthrodesis as a salvage procedure.
Case Presentation: This case report discusses the operative management of an open tibial plafond fracture nonunion in a 48-years-old male with type II. A fall of a ladder (1-meter height) resulted in an open tibial plafond fracture (AO 43C3.3; GA II), managed initially with closed reduction and external fixation. External fixators were removed due to signs of infection and the fracture was immobilized with a splint. Seven months after, a nonunion and secondary loss of reduction were presented in the X-Ray film. An ankle arthrodesis with a retrograde locking nail was performed with autogenous bone grafting.
Clinical Outcomes: Radiologically and clinically fusion was achieved in 4 months and the patient was able to walk. A leg length discrepancy was avoided using this technique. No complications were described.
Discussion: Patient satisfaction is one major goal to reach in patients with severe pathology in the ankle and foot. Procedures with a high complication rate with infection as in screw, plate and external fixation arthrodesis or nonunion after failed fusion not only endanger the final result but also trouble an already suffering patient. Using a retrograde locking nail, the accepted goals of calcaneotalotibial arthrodesis, which are union, maintenance of hindfoot alignment, limitation of complications and overall patient satisfaction, have been achieved.