rss_2.0Romanian Journal of Orthopaedic Surgery and Traumatology FeedSciendo RSS Feed for Romanian Journal of Orthopaedic Surgery and Traumatology Journal of Orthopaedic Surgery and Traumatology 's Cover management of blunt splenic injuries beyond safety conditions A short narrative review<abstract> <title style='display:none'>Abstract</title> <p>Although the introduction of specific guidelines regarding the acute management of trauma patients have resolved many inconsistencies in the acute treatment pathways, grey areas are still preventing consensus and unitary standards of care. The treatment of splenic injuries has seen a notable shift from splenectomy only in the early 20th century to mainly non-operative contemporary approaches. However, there is no current agreement on the optimum timing of switching from conservative to operative decisions, raising the legitimate question of whether some patients are put at risk by waiting too much or other patients are deprived of a necessary organ by not waiting enough.</p> <p>This paper focuses on the non-operative paradigms of blunt splenic injuries and their immediate and long-term clinical implications presented as a short narrative review. It presents the historical perspective on the treatment of splenic injuries, the role of surgery and selective angioembolisation and their repercussions on the immunological functions of the spleen.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00A rare case of knee joint mucormycosis with pathological fracture after COVID-19 infection<abstract> <title style='display:none'>Abstract</title> <p>Mucormycosis is a fungal infection that generally occurs in patients with some degree of immunosuppression, such as patients with malignancies, diabetes, HIV infection, or patients who require the administration of immunosuppressive drugs.</p> <p>The final diagnosis is established by collecting some tissue from the infectious process and isolating the fungus using lab cultures.</p> <p>The treatment of mucormycosis is complex and consists of trying to reduce risk factors, rigorous surgical debridement, and specific antifungal treatment.</p> <p>We present the case of a 54-year-old male patient with a background of SARS-COV2 infection (moderate form), that started 3 months prior to presentation to our hospital, initially treated at home.</p> <p>The patient presented to the Orthopaedics Department of the University Emergency Hospital of Bucharest with pain and total functional impotence in his left knee as a result of a trauma that occurred about 2 months before the presentation to the hospital, at that moment with progressive worsening of the symptoms. Clinical and imaging examination established the diagnosis of pathological supra-intercondylar fracture of the left femur.</p> <p>The purpose of this case report is to present the risk of infection with an opportunistic agent as a result of immunosuppression induced by COVID-19 or its treatment with immunosuppressive agents necessary to combat the inflammatory process. The patient presented with a moderate form of COVID-19 treated at home with nonsteroidal anti-inflammatory drugs and antibiotics to prevent a bacterial superinfection.</p> <p>Mucormycosis remained a challenging situation for the physician, regardless of his medical specialty, both in terms of diagnosis and treatment. In this case, COVID-19 is one of the risk factors that contributed to the appearance of mucormycosis.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00Malignant granular cell tumor of the arm – case report<abstract> <title style='display:none'>Abstract</title> <p>Granular cell tumor (GCT) is a rare form of soft tissue cancer that is usually benign. Its malignant evolution is encountered in less than 2% of cases, having a more rapid and unfavorable evolution. Clinical presentation betraying malignant features could be increased tumor size, rapid growth, deep localization, and female gender.</p> <p>This paper presents the case of a 52-year-old patient with a hard, rapidly evolving tumor in the left arm. The diagnosis of granular cell tumor was made based on histopathological examination using the Fanburg and Smith criteria to differentiate the formation as malignant, but with certainty this was subsequently confirmed by the existence of a metastasis. Surgical excision was performed and the evolution was favorable.</p> <p>Evolution and treatment differ depending on the benign or malignant form, but surgical treatment with wide local excision is recommended. This may be followed by chemotherapy or radiotherapy, and follow-up of patients for the rest of their lives is mandatory.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00Current review of surgical management options for total knee arthroplasty in the rheumatoid knee<abstract> <title style='display:none'>Abstract</title> <p>Rheumatoid arthritis (RA) represents a condition that can erode cartilage and damage joints, leading to inflammation and loss of movement, characterized by inflammatory synovitis. While the widespread use of potent disease-modifying medications has increased opportunities for RA patients, orthopedic surgery and complete joint arthroplasty remain an important option in end-stage joint treatment. The knee is one of the most frequently affected joints in chronic rheumatoid arthritis patients. The severity of RA ranges from a moderate illness to a serious, rapidly progressing, destructive version, gradually leading to incessant pain and joint deformity. Despite recent advances in biological agents and therapeutic modalities in the field of rheumatology, certain patients with RA, who ultimately undergo joint surgery, tend to experience progressive joint damage. Though, TKA can be performed in these patients, increased complications and poorer outcomes may result after total knee arthroplasty, because of the particularities given by RA. They are associated with extended operating time, specifically resulting in increased infection, blood loss and deep vein thrombosis. However, because RA patients present additional risk factors for complications, certain critical preoperative examination and surgical aspects need to be considered in order to maximize TKA outcomes in this subgroup of patients.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00Multimodal analgesia in primary bone tumors<abstract> <title style='display:none'>Abstract</title> <p>Introduction: A worrying increase in the number of bone tumors that appear at younger ages justifies the efforts aimed at optimizing perioperative management practices in orthopedic tumor surgery. Pain control is critical in the prognosis and postoperative outcome of these procedures.</p> <p>Material and methods: Our study included a group of 11 patients diagnosed with bone malignancies. These patients were hospitalized in the Orthopedic Clinic of the University Emergency Hospital Bucharest. Under our supervision, they underwent surgical treatment of the tumor under combined general anesthesia and epidural anesthesia for the pelvic limb, and general anesthesia only for the upper limb. We performed perioperative pain management with multimodal analgesia (continuous epidural analgesia with ropivacaine 0,2% and fentanyl 2 mcg/ml in association with systemic analgesics). Following this procedure, we measured the intensity of the postoperative pain at intervals of 48 hours and one week after surgery and compared with preoperative pain intensity using the visual analogue pain scale (VAS).</p> <p>Results: Multimodal analgesia (epidural analgesia associated with systemic analgesics – paracetamol, COX2 inhibitor, gabapentinoids) was performed well in the postoperative pain of the tumor prosthesis, with a significant decrease in VAS from a mean value of 7.63 preoperatively to an average of 3 in the first 48 hours postoperatively. After the removal of the epidural catheter, which also coincided with patient mobilization, the level of pain registered a slight increase to a mean value of 3.23.</p> <p>Conclusions: Multimodal analgesia is currently considered the gold standard in perioperative pain management. The use of multimodal analgesia during perioperative period in patients with bone tumors has been shown to decrease the length of hospital stay, improve surgical outcome, reduce the number of systemic complications, and improve the long-term prognosis of the patient. Efficacy of analgesia correlates with tumor site and vascularization.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00Posterior interosseous nerve entrapment by intramuscular lipoma arising from the supinator muscle - a case report<abstract> <title style='display:none'>Abstract</title> <p>Background: Lipomas are benign, slow-growing tumors frequently subcutaneous and asymptomatic, intramuscular lipoma constituting a rare subtype. However, a lipoma occurring nearby the proximal radius may cause posterior interosseous nerve (PIN) entrapment.</p> <p>Case presentation: We described an uncommon case of a 45-year-old-man with a history of progressive, painless proximal right (dominant) forearm swelling for 4 months associated with PIN entrapment syndrome, presenting as fingers extension weakness. Intramuscular lipoma was observed in the supinator muscle in the magnetic resonance imaging (MRI). Lipoma surgical excision and release of the PIN through proximal forearm direct anterior approach was performed.</p> <p>Results: The histopathological examination confirmed the diagnosis of benign intramuscular lipoma. The follow-up of the patient showed full recovery within three months postoperatively.</p> <p>Discussion: Intramuscular lipoma is rare; however, it could originate from supinator muscle in the forearm, presenting with vague pain and could lead to compression of nearby neurovascular structures such as the PIN. Clinical evaluation and imaging studies, especially MRI, are crucial for diagnosis. If neural compression is evident, surgical resection is mandatory.</p> <p>Conclusion: Intramuscular lipoma entrapping PIN is rare and requires early clinical diagnosis confirmed by imaging and neurophysiological studies, surgical excision being the method of choice for optimum functional outcomes.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00When an old pigmented lesion becomes serious: the problematic diagnosis of low-grade skin malignancies – Bednar tumor with fibrosarcomatous transformation<abstract> <title style='display:none'>Abstract</title> <p>Bednar tumor is a rare cutaneous neoplasm, regarded as a variant of dermatofibrosarcoma protuberans with melanotic colonization and it usually affects young and middle-aged adults or children. This lesion is considered a low-grade malignant tumor, which can be associated with multiple local recurrences after surgical excision. Although a rare phenomenon, these lesions may undergo fibrosarcomatous transformation, which implies a poorer prognosis of the disease, as the tumor has a more locally aggressive behavior and patients might also develop distant metastases.</p> <p>We present the case of a 53-year-old female patient, with no significant medical history, who presented with a subcutaneous nodule on her upper back, for which a wide surgical excision was performed. The gross examination of the specimen showed a solitary protuberant grey-white nodule with a bluish shade and flecked with pigment. The microscopic examination revealed a malignant proliferation with a predominantly fascicular growth pattern, composed of spindle cells with highly pleomorphic nuclei and high mitotic rate, as well as the presence of dendritic cells with abundant melanin. Upon immunohistochemical analysis, the proliferation showed negative staining for CD 34 and AE 1/3, whereas the scattered dendritic cells stained positive with S100 protein. Ki 67 was positive in 15% of the tumor cells and the absence of p53 expression was noted. Thus, the diagnosis of Bednar tumor with fibrosarcomatous transformation was established.</p> <p>The aim of this paper was to gain further knowledge about the histopathological and immunohistochemical features, as well as about the treatment of Bednar tumor, especially considering its rarity.</p> </abstract>ARTICLE2021-08-13T00:00:00.000+00:00Orthopaedic marketing strategies in Romania to the Editor need for an educational campaign in Romania to encourage people with chronic hip or knee pain to make informed decisions when having surgery during COVID-19 pandemic scooter vs. motorcycle injuries – little toys with an underestimated impact<abstract> <title style='display:none'>Abstract</title> <p>Introduction: The study weighs the impact of accidents involving electric scooters and motorcycles, its main purpose being that of showing the injuries produced by the use of electric scooters.</p> <p>Materials and method: The retrospective study was conducted in the Emergency Unit of the University Emergency Hospital Bucharest, Romania, between 01.06.2020 and 30.09.2020, by analyzing the data from the presentation sheets and the hospital database. It followed and compared a total of 55 cases, out of which 29 patients were involved in motorcycle accidents, and 26 patients were involved in electric scooter accidents, by number, age, sex, imaging investigations, severity of injuries, hospitalization days, and the treatment of discharged patients.</p> <p>General data about the number of analyzed presentations was extracted and compared to similar data from the same period of the year 2019.</p> <p>Results: The study showed an increase in presentations due to electric scooter accidents. Also, most of the injuries in both types of accidents are musculoskeletal (96.5% in motorcycle accidents and 84.61% in electric scooter accidents), and the percentage of discharged patients who needed immobilization by various orthopedic devices was higher in electric scooter accidents (34.8%) than in motorcycle accidents (26%).</p> <p>Discussions: The study was conducted in the middle of the COVID-19 pandemic, in an atypical situation, due to regulations imposed by the authorities.</p> <p>Conclusion: There was an increase in the use of electric scooters in the summer of 2020, which resulted in an increased number of mainly orthopedic injuries, and implicitly of immobilization for discharged patients, underestimated by the population, as protective equipment is not mandatory for people aged over 16 years.</p> </abstract>ARTICLE2020-12-31T00:00:00.000+00:00Decline in hospitalization for all medical conditions during the COVID-19 pandemic<abstract> <title style='display:none'>Abstract</title> <p>Introduction: Hospital admissions fell dramatically in Romania during the COVID-19 pandemic partially due to urgent legislation for controlling the infection rates that influenced the selection criteria for hospitalization and also due to fear of infection with SARS-CoV-2 which resulted in avoiding medical services.</p> <p>Aim: This study aimed to assess the impact of COVID-19 pandemic on the population availability to access medical services by comparing the admission rates for all departments of the University Emergency Hospital, Bucharest, from March to August 2019 and March to August 2020.</p> <p>Methods: A cohort of 38.730 patients was analyzed according to hospitalization rate from March to August 2019 and March to August 2020.</p> <p>Results: From March to August 2020 patients were hospitalized as a result of a medical emergency rather than an appointment, as outpatient and hospitalization rates changed dramatically. Thus, 67.4% accessed hospitalization from March to August 2019 and 32.6% accessed hospitalization from March to August 2020. The proportion of the patients admitted from the Ambulatory Care Unit decreased significantly from 44.2% in 2019 to 32.7% in 2020. Also, the structure of the patients’ profile has been affected.</p> <p>Discussion: The COVID-19 pandemic period in 2020 (March-September) affected the hospitalization rate and the structure of the patients’ profile that came to the University Emergency Hospital in Bucharest, Romania.</p> <p>Conclusion: The patients who would have accessed the medical health services that might have resulted in hospitalization could have resulted in out-of-hospital deaths and this should also be the focus of the public health authorities.</p> </abstract>ARTICLE2020-12-31T00:00:00.000+00:00A case report of blunt liver trauma in times of COVID-19 pandemic<abstract> <title style='display:none'>Abstract</title> <p>The liver is one of the most affected organs in abdominal trauma mostly because of its considerable dimensions, the fragility of the liver parenchyma.</p> <p>We present the case of a 29-year-old patient who sustained an abdominal trauma after an accidental fall from a 3 m height. The patient tested positive at RT-PCR for SARS-CoV-2 at admission, without any symptoms of viral infection. The emergency CT scan revealed a blunt liver trauma with an expanding hematoma (grade III). The patient was initially hemodynamically stable but shortly after admission became unstable and required surgical treatment that initially consisted of damage control and liver packing. Reintervention was decided 36 hours later, after reevaluation unpacking and hepatorrhaphy were done. The postoperative evolution was uneventful. The case indicated the importance of continuous monitoring of the traumatic patient. In liver trauma, hemodynamic instability guarantees an emergency laparotomy. The time of operations in trauma patients with SARS-CoV-2 must be reduced to the maximum both as an objective of damage control and also to minimize the risk of contagion.</p> </abstract>ARTICLE2020-12-31T00:00:00.000+00:00Orthopedic surgery related infections; study of the importance of associated comorbidities in relationship with septic evolution<abstract> <title style='display:none'>Abstract</title> <p>The current socio-economic development has improved the standard of living of the general population. Technological evolution has led to the use of an increasing number of motor vehicles. Associated with the growing violence observed globally, orthopedic surgery involves frequent use of osteosynthesis materials and prostheses. Therefore, an increasing number of patients live with these implants, having a higher risk, compared to the general population, to develop complications. Although technological developments have increased the quality of life, it must not be forgotten that these foreign materials come with certain risks, the most feared being the associated infections.</p> <p>We conducted an epidemiological study on infections identified in patients treated in the Orthopedics and Traumatology Department of Bucharest Emergency University Hospital, from 01.01.2016 to 01.06.2019. We were able to extract data about patients without neglecting their confidentiality.</p> <p>The information sought, primarily involved the pathogen causing the infection, but at the same time we tried to build a more accurate history of each patient in order to determine the cause of infection and the risks posed by various associated pathologies. During these 4 years we were able to identify 139 patients who suffered an infection in the musculoskeletal system. In most cases we identified mono-microbial infections, but there were 7 cases in which two pathogens were identified.</p> </abstract>ARTICLE2020-12-31T00:00:00.000+00:00Ruptures of mesentery- a silent posttraumatic injury (Case Report)<abstract> <title style='display:none'>Abstract</title> <p>The mechanism of mesenteric injury in blunt abdominal trauma involves compression and deceleration forces which result in a spectrum of injuries that range from contusions to tearing of the bowel wall, tearing of the mesentery, and loss of vascular supply. Hemoperitoneum is a major sign of severity in abdominal trauma, which, in most cases, requires emergency surgery.</p> <p>Our patient showed that the diagnosis of mesenteric injury should be considered even in patients who sustain only minor abdominal trauma. In this case the patient’s symptoms were suggestive only for the orthopedic lesion and not for the hemoperitoneum.</p> <p>Trans-scapho-lunate dislocation fracture is a rare lesion that may go unnoticed at initial assessment in a polytraumatized patient. A delay in the diagnosis and treatment of a scaphoid fracture may alter the prognosis after consolidation.</p> </abstract>ARTICLE2020-12-31T00:00:00.000+00:00Challenges in treating pleomorphic bone sarcoma in elderly patients: a case report<abstract><title style='display:none'>Abstract</title><p>Pleomorphic sarcomas or spindle cell sarcomas of the bone are rare malignant tumors that affect the adult. Fracture in the affected bone is the most frequent first symptom. Multimodal treatment is similar to the one for osteosarcoma, but the benefit is less evidence-based, due to the rarity of this sarcoma subtype. The present paper is a case report of a 73-year-old patient, who presented with a comminuted fracture of the distal third of the femur after a fall on ice. Differential diagnosis of bone metastasis was made. After the histopathological confirmation, the surgical team decided to amputate, with prior patient consent. The tumor was staged pT1NxMx, R0. Immunohistochemical studies confirmed the histopathological diagnosis. A lytic lesion in the stump bone appeared on post-operative MRI and was interpreted as skip metastasis. No other metastatic sites were detected. The multidisciplinary team decided for adjuvant chemotherapy (3 courses) and then radiotherapy. He was unable to receive the total planned dose of radiotherapy due to local toxicity. Even so, he is free of recurrence on long-term follow-up.</p></abstract>ARTICLE2018-04-26T00:00:00.000+00:00Management of bimalleolar fracture in pregnancy<abstract><title style='display:none'>Abstract</title><p>Ankle fracture is one of the most common fractures in adults and among pregnant women. In pregnancy, the treatment must be prompt because of the risks and complications that could involve both mother and fetus. In this article, we reported the management of a patient with a bimalleolar fracture in pregnancy, its treatment, and evolution.</p></abstract>ARTICLE2018-04-26T00:00:00.000+00:00Pelvic reconstruction with bone cement and total hip prosthesis after resection of chondrosarcoma. Case Report<abstract><title style='display:none'>Abstract</title><p>Introduction. Chondrosarcoma is a malignant tumor of cartilaginous origin representing approximately 20-30% of all bone malignant tumors and occupying the second place in terms of their incidence. It usually affects adults between 40 and 60 years old, but can be encountered at older ages as well.</p><p>Materials and methods. We report the case of a 55-year-old male patient who presented to our department with 2 weeks-long right hip pain and partial loss of functionality in right limb. We performed X-rays, magnetic resonance imaging, computed tomography, bone scintigraphy, and angiography, which established the diagnosis of pelvic tumor. Biopsy of the tumor was performed by iliofemoral approach and its result showed moderately differentiated chondrosarcoma. Orthopaedic surgery was performed, with tumoral removal within oncological limits, pelvic reconstruction using acrylic bone cement impregnated with Vancomycin and total hip arthroplasty.</p><p>Results were assessed using the Musculoskeletal Tumor Rating Scale and a score of 23 out of 35 was obtained (the higher the better). Postoperative complications consisted in flap-skin necrosis that resolved within 2 months after surgery.</p><p>Conclusion. Bone defects repair using antibiotic impregnated cement drastically reduced the rate of postoperative infections, thus decreasing both morbidity and mortality. In spite of technological advancement, long-term prognosis remains reserved in chondrosarcoma, due to its specific aggressivity, resistance to chemo- and radiotherapy and high rate of recurrence.</p></abstract>ARTICLE2018-04-26T00:00:00.000+00:00Non-Hodgkin lymphoma as primary bone tumor in a patient with B hepatic viral infection - case report<abstract><title style='display:none'>Abstract</title><p>Diffuse large B cell lymphoma (DLBCL) is the most common form of non-Hodgkin lymphomas, which has shown an increasing incidence in the past decades. 7% of primary bone tumors consist of non-Hodgkin lymphomas. The etiology of this type of lymphoma is still unclear. Our aim was to study the latest research papers; to highlight the importance of cooperation between different medical specialty departments, in rare cases like NHL as PBT with associated HBV infection.</p><p>Case report: We present the case of a 39-year-old male patient, who presented to the orthopedic department of the University Emergency Hospital of Bucharest, with moderate pain, swelling, and a palpable mass of the right lower limb.</p><p>Management and Outcome: The patient underwent several investigations, whose result was DLBCL and an associated HBV infection. Due to the aggressive form of DLBCL, chemotherapeutical treatment has to be initiated as soon as possible to prevent further growth of the tumor. An antiviral therapy had to be initiated to prevent the hepatic failure, which could appear after chemotherapy and in the acute phase of viral infection.</p><p>Discussion: Our case raised the question regarding what kind of relationship could be identified between the HBV infection and NHL, and how this condition influenced the outcome of the treatment.</p></abstract>ARTICLE2018-04-26T00:00:00.000+00:00An update on osteoporosis<abstract><title style='display:none'>Abstract</title><p>With the growth of the aging population worldwide, osteoporosis represents a serious health problem, which implies higher morbidity and costs, despite the continuous advances in treatment options. It involves both sexes, although menopausal women are mainly affected. This article is a brief review of literature on current osteoporosis treatment options.</p></abstract>ARTICLE2018-04-26T00:00:00.000+00:00en-us-1