Panayiotis D. Megaloikonomos

Scientific Misconduct (Fraud) in Medical Writing

Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176-e183].

Thromboembolism prophylaxis in orthopaedics: an update

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death. Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%. VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery. Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018

Giant cell tumor of bone revisited

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a large biological spectrum ranging from latent benign to highly recurrent and occasionally metastatic malignant bone tumor. It accounts for 4–10% of all bone tumors and typically affects the meta-epiphyseal region of long bones of young adults. The most common site involved is the distal femur, followed by the distal radius, sacrum, and proximal humerus. Clinical symptoms are nonspecific and may include local pain, swelling, and limited range of motion of the adjacent joint. Radiographs and contrast-enhanced magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosis. Surgical treatment with curettage is the optimal treatment for local tumor control. A favorable clinical outcome is expected when the tumor is excised to tumor-free margins, however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome. Local adjuvants have been used for improved curettage, in addition to systematic agents such as denosumab, bisphosphonates, or interferon alpha. This article aims to discuss the clinicopathological features, diagnosis, and treatments for GCT of bone.

Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures

Purpose: To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures. Methods: We prospectively studied 50 patients (33 women, 17 men; mean age, 80u2009years; range, 74–93u2009years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2u2009years (range, 1–5u2009years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail. Results: Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2u2009cm (range, 3–10u2009cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups. Conclusion: Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.

Fall Risk Assessment Metrics for Elderly Patients With Hip Fractures

The most common surgery performed by orthopedic surgeons likely involves that for hip fractures. The incidence of hip fractures is anticipated to rise in the coming decades. Hip fractures most commonly occur in elderly women with osteoporosis after a fall from standing position. In an effort to reduce the incidence, improve the postoperative care, and accelerate the rehabilitation of hip fractures, it is important to evaluate the fall risk of these patients, as it is an objective indication of their level of physical activity. Metrics currently available for the evaluation of fall risk in the elderly vary widely, with each having been designed to assess a specific patient population. However, their applicability has often proved to be much broader than expected. This review summarizes the metrics available for fall risk assessment of elderly patients with hip fractures, describes their individual features and efficacy, and highlights those that seem to be more reliable for the assessment of rehabilitation of these patients after hip fracture surgery. [Orthopedics. 2018; 41(3):142-156.].

Sonication Improves the Diagnosis of Megaprosthetic Infections

Limited data are available for the diagnosis of patients with tumors with infected endoprosthetic reconstructions. The purpose of this study was to evaluate whether sonication is effective for the diagnosis of infection and to compare it with tissue cultures. The files of 58 patients who underwent revision surgery for suspected infected endoprosthetic reconstructions were reviewed. Cultures were performed on 5 tissue samples obtained from each patient and on fluid obtained by sonication of the megaprosthesis. The sensitivity, specificity, and negative and positive predictive values of tissue and sonication fluid cultures were evaluated. Overall, tissue and sonication fluid cultures confirmed an infection in 42 of the 58 patients. In 36 of the 42 infected endoprosthetic reconstructions, tissue and sonication fluid cultures identified the same bacterial isolate. In 5 cases, a bacterial isolate was identified only in sonication fluid cultures, and in 1 case, a bacterial isolate was identified only in tissue cultures. The sensitivity and negative predictive value of sonication fluid cultures were statistically significantly better than those of tissue cultures, while the specificity and positive predictive value were not different between the 2 culture types. Compared with tissue cultures for the diagnosis of infected megaprostheses in patients with tumors, sonication fluid cultures are associated with a better sensitivity and negative predictive value and a similar specificity and positive predictive value. Therefore, sonication should be considered a useful adjunct for the optimal diagnosis and management of these patients. [Orthopedics. 2019; 42(1):28-32.].

Current concepts for the evaluation and management of diabetic foot ulcers

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates. More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation. Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010

Rare diseases of bone

Non-Langerhans cell histiocytosis (N-LCH) summarizes a group of rare diseases with different clinical presentations, pathogenesis and morphology. These include primary cutaneous N-LCH, cutaneous N-LCH with systemic involvement, and primary extracutaneous systemic forms with occasional cutaneous involvement. The juvenile (JXG) and non-juvenile xanthogranuloma (N-JXG) family of histiocytoses are N-LCH: the JXG family consisting of the JXG (cutaneous), xanthoma disseminatum (cutaneous and systemic) and Erdheim-Chester disease (ECD; systemic); and the N-JXG family consisting of the solitary reticulohistiocytoma (cutaneous), multicentric reticulohistiocytosis (cutaneous and systemic) and Rosai-Dorfman disease (RDD; systemic). ECD is a clonal disorder from the JXG family of N-LCH; RDD is a reactive proliferative entity from the non-juvenile xanthogranuloma family of N-LCH. ECD and RDD N-LCH are rare disorders, which are difficult to diagnose, with multi-organ involvement including bone and systemic symptoms, and which respond to therapy in an unpredictable way. The key to successful therapy is accurate identification at tissue level and appropriate staging. Patients should be observed and monitored in a long-term pattern. Prognosis depends on disease extent and the organs involved; it is generally good for RDD disease and variable for ECD. Cite this article: EFORT Open Rev 2018;3:381-390. DOI: 10.1302/2058-5241.3.170047

Harvesting, Isolation and Differentiation of Rat Adipose-Derived Stem Cells

BACKGROUNDnAdipose tissue is one of the most attractive sources of stem cells because it can be easily harvested and yields a greater stromal cell density. The multilineage potential of adiposederived stem cells (ADSCs) demonstrates their significant impact within the field of tissue engineering, with studies successfully demonstrating the ability to produce a range of tissue types. However, although a broad spectrum of applications has already been suggested, many important scientific and medical questions remain unanswered before the clinical application of ADSCs in humans. Importantly, clarification of the biology and identification of the differences of ADSCs from various areas of the body is required. In this continuous endeavor, research in rat models plays an important role in the development of new knowledge.nnnMETHODSnA literature review was done to summarize all information regarding harvesting, isolation, expansion, cryopreservation and differentiation of rat ADSCs. A Wistar rat model was also used to describe harvesting sites of adipose tissue, and to characterize the ADSCs using Fourier-transform infrared (FT-IR) spectroscopy and phase contrast microscopy.nnnAIMSnTo discuss all relevant considerations for harvesting, culture, differentiation and phenotypic characterization of ADSCs, to provide a comprehensive roadmap of this process, to identify the differences between ADSCs obtained from various adipose tissues of the rat, and to provide FT-IR spectroscopy marker bands that could be used as fingerprints to differentiate the types of adipose tissues.

Dual head screw hip nailing for trochanteric fractures

Introduction: There are limited information and inconclusive results for dual head screw intramedullary hip nails for trochanteric fractures. Therefore, we performed a prospective study to evaluate the healing of fractures, and survival, function, and complications of patients operated with this implant. Methods: We prospectively studied 79 patients (61 women and 18 men; mean age: 84.7 years; range: 65–96 years) with a low-energy trochanteric fracture, treated with a dual head screw intramedullary hip nail from 2013 to 2016. The mean follow-up was 2.1 years (range: 1–3 years); seven patients were lost to follow up. This left 72 patients for further analysis. We evaluated the healing of fractures, and survival, function, and complications of patients. Results: Fracture healing was evident in 70 patients (97.2%) at 2–3 months postoperatively. One patient experienced cut-out and z-effect phenomenon of the head screws. Another patient experienced a periprosthetic femoral diaphysis fracture at the distal tip of the nail. A third patient experienced an acute postoperative superficial skin infection that was treated successfully with wound dressing changes and a course of antibiotics. Sixteen patients (22.2%) deceased within 12 months postoperatively. In the remaining patients, the Harris Hip Score (HHS) at 12 months postoperatively was excellent in 16 (28.6%), good in 23 (41.1%), fair in 10 (17.8%), and poor in 7 patients (12.5%). The function declined after the patients’ fracture. Fair and poor results were related to age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types. Conclusion: The dual head screw intramedullary hip nail is associated with high healing and low complication rates for intertrochanteric fractures. The function of the patients is good or excellent in most cases; however, it declines, especially for those patients with age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.