This study aims to investigate that a single dose of tranexamic acid (TXA) will reduce blood loss and transfusion rates in elderly patients, undergoing intertrochanteric (IT) or femoral neck fractures surgery. Consecutive elderly patients receiving hip fracture surgery for stable or unstable IT fracture, treated with short intramedullary nail (IMN) insertion as well as cemented hemiarthroplasty for acute femoral neck (subcapital) hip fracture, were screened for inclusion in this single-centre randomized trial.

Patients were randomly allocated to a study group by sealed envelope. One TXA dose of 15 mg/kg i.v. diluted in 100 ml N/S or one placebo dose i.v. in 100 ml N/S were administered 5 mins before the skin cut. Haemoglobin (Hb) concentration was measured at admission time and prior to surgery. Post-operatively it was measured on a daily basis until day 4, giving a total of four Hb measurements (days 1 to 4). The transfusion trigger point was determined in accordance with the French guidelines for erythrocyte blood transfusion. The transfusion trigger was 10 g/dl for patients at risk, while in all other cases, it was 9 g/dl. Information regarding the transfusions number was assessed directly by the hospital blood bank database. Blood loss was calculated by the Hb dilution method. Nadler's formula was used to calculate patients' blood volume. For calculation of total blood loss (TBL) expressed to total Hb loss and total Volume loss, the number of transfusions (55 grams of Hb per transfusion), the Hb concentration on preoperatively (Hgbi) and the Hb concentration on the last measure (Hgbe) were used. (Hb balance method).

The primary efficacy outcome was the number of transfusions of allogeneic RBC from surgery up to day 4. The secondary ones were the total blood loss from surgery to day 4 as it was calculated by Hb-balance method. After randomization, 35 patients with femoral neck fracture and 30 patients with IT fracture received TXA prior to surgery. Respectively, 30 patients with femoral neck fracture and 55 with IT fracture didn't receive TXA. The groups did not differ significantly in their basic demographics (age, gender, BMI, injury mechanism, ASA score, co-morbidities). Results showed that patients undergoing hemiarthroplasty after receiving TXA, were transfused with less allogeneic RBC and had less total blood loss than patients that didn't receive TXA, but without statistical significance. While patients treated with IMN in the TXA group received a significantly lower number of RBC units than the control group (1.28 ± 1.049 vs 2.075 ± 1.685), (P = 0.0396), had a significantly lower loss of Hb (98.59 ± 55.24 vs 161.6 ± 141.7), (P = 0.0195) and a lower total blood volume loss (951.3 ± 598.9 ml vs 1513 ± 1247 ml), (P = 0.023).

This trial confirmed TXA administration efficacy in reducing blood loss and transfusion rate in elderly patients undergoing hip fracture surgery. A TXA single dose may be a safer option, taking into account these patients' physiological status and co-morbidities.

Background

We searched -in transverse ultrasound view- the value of the difference (Delta) between -proximal to the tunnel- CSA (a) and -in the tunnel's inlet- CSA (b) for separating normal from abnormal median nerves.

Background

To investigate the new theory of hydroneurolysis and hydrodissection in the treatment of carpal tunnel syndrome (CTS). Independently of the fluid hydrodissolution works due to mechanical forces and it may have some positive effects in patients with ischemic damage caused by scar tissue pressure at the nerve's surface.

Introduction

We compared ultrasound guided methylprednizolone-lidacaine infiltrations around inflammatory area of plantar aponeurosis with systematic use of NSAID'S. Also, we investigated the reliability of the sonographic criteria (a. swelling of aponeurosis more than 20% in comparison to the healthy foot, b. effusion around aponeurosis, c. calcium deposits) most used to identify plantar fasciitis in clinically suspicious patients.

Background

To determine if double needle ultrasound-guided hydrodissolution and aspiration of intratendinous calcification is more effective treatment than blind subacromial corticosteroid injection.

Introduction

We investigated whether grey scale early ultrasonography could be used for the accurate initial diagnosis of non displaced occult scaphoid fractures.

Background

The economic crisis has significantly altered the quality of life in Greece. The obvious negative impact on the offered social and health services has been adequately analysed. We aimed to determine whether the economic crisis has influenced the quantity and quality of Orthopaedic research in Greece, as mirrored from the papers presented at the annual meetings of Hellenic Association of Orthopaedic Surgery between the years 2008–2014.

Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases.

At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05).

Reconstruction with an allograft-implant composite is a demanding procedure. However, preservation of bone stock is a major advantage.

The purpose of this study is to classify the pitfalls, obstacles and complications that occur during distraction histogenesis and also to evaluate the risk factors likely to lead to these problems.

In this study we have retrospectively and prospectively studied the difficulties occurring during distraction histogenesis since 2003. We studied 74 patients (mean age 19,2 years, age range 11–60 yrs) whose 97 limbs segments were lengthened. 21 patients underwent angular correction, 42 patients limb lengthening, 17 patients both angular correction and limb lengthening and 14 non-union correction. In 46 cases, we used the Ilizarov fixator, in 38 the Taylor Spatial Frame and in 10 cases the monolateral external fix-ator Orthofix LRS. Difficulties that occured during limb lengthening were subclassified into pitfalls, obstacles, and complications. For all cases we have recorded the time of appearance of all these difficulties and have associated them with the severity of the initial deformity.

The total number of difficulties in distraction histogenesis was 20%. The number of presenting problems was estimated 5.4% and involved knee subluxation, pin breakage and malalignments. Obstacles presented in 9.5% and included cases with poor bone regeneration, peroneal nerve palsy, premature consolidation and heel cord lengthening. Finally complications were noted in 5.4% of the cases. These consisted of infection, fracture, non-union and loss of range of knee motion.

The problems, obstacles and complications that occur during distraction histogenesis can all impact on the optimal therapeutic target. Extensive surgical experience, and optimal pre-operative planning in conjunction with the type of the original deformity may all contribute in minimising these difficulties

We reported on the outcome of 84 Charnley low friction arthroplasties performed by one of us (GH), the period 1973 to 1984, in 69 patients, less than fifty-five years old, with osteoarthritis mainly due to congenital hip disease.

The patients were followed prospectively; clinically using the Merle D’Aubigné and Postel scoring system, as modified by Charnley and also radiographically.

At the time of the latest follow-up, thirty-seven hips had failed (44%). In thirty-two hips, twenty-eight acetabular and thirty femoral components were revised because of aseptic loosening (six of the femoral components were broken). Three hips were infected and converted to resection arthroplasty. In two more hips a periprosthetic femur fracture occurred three and ten years postoperatively and were treated with internal fixation. After a minimum of twenty-two years from the index operation, 37 original acetabular components and 36 original femoral components were in place for an average of 29 years. The probability of survival for both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years when 35 hips were at risk.

These long term results can be used as a benchmark of endurance of current total hip arthroplasties performed in young patients, with OA mainly due to congenital hip disease.

The purpose of this study is to present early results, common pitfalls and management in in cases of revision hip arthroplsty in patients with congenital disease of the hip.

From 2001 to 2006, 36 consecutive cemented THAs with a history of congenital hip disease were revised due to aseptic loosening (31 cases), stem fracture (3 cases), septic loosening (2 case). There were thirty patients, all females, with a mean age at revision 61.7 years (range, 40 to 76). The revision was performed after a mean 15.4 years post primary operation (range, 9 to 26). In 7 cases the cup only, in 5 cases the stem only, and in 24 cases both components were revised.

The mean follow-up was 43 months (range, 24 to 84). There were 3 intraoperative femoral fractures managed with long stem and circlage wires. Postoperatively, 5 hips were infected and sustained a 2 stage revision using a cement spacer. 3 hips were revised due to loosening.

28 cups and 28 stems remained intact for an average 45.2 months (range, 24 to 84). The probability of survival at 48 months was 76.3% (±9.7%) for the cups (12 components at risk) and 76.4% (±11.3%) for the stems (9 components at risk).

Revision of a CDH arthroplasty is difficult and non predictable. Lack of acetabular bone stock and anatomical abnormalities of the femur lead to increased intra and postoperative complication rate.

Aim: The purpose of our study is to present the survival results, clinical outcome and complications from the use of APC in cases with a history of periprosthetic infection.

Materials and Methods: Between 1986 and 1999, twenty-two patients (twenty-two hips) 11 male and 11 female (mean age 57.5 years – range 38 to 77 years) with massive bone loss (Paprosky IIIA 2 cases, IIIB 4 cases, and IV 16 cases) were included to our study. They all had a history of periprosthetic infection after an average of 3.3 (range 1 to 5) revision hip arthroplasties and were submitted to a two stage revision arthroplasty using an allograft-prosthesis composite.

Results: At an average follow-up of eleven years (range, eight to twenty years), 14 patients were alive, 7 patients died, and 1 patient was lost to follow-up. The ten year survival of the allograft-prosthesis composites was 74.9 per cent (95 per cent confidence interval 55.1 to 94.7 per cent, 4 cases remaining at risk). Seven cases presented with APC failure needing re-revision, 2 due to re-infection (4 and 23 months from revision by the same microorganism species as for the initial infection (Staph aureus to both cases), 3 due to allograft non union (at 21, 43, 79 months) and 2 cases due to graft resorption (164, 175 months post revision). Delayed healing and wound drainage occurred to 2 more cases.

Conclusion: Reconstruction of massive proximal femoral bone loss with an allograft-implant composite is a demanding procedure. Biologic means of reconstruction is a major advantage preserving bone stock for future surgery. However, high complication rate should be considered.

Purpose: Fractures of the distal tibia are high energy fractures, associated with marked soft-tissue trauma. Management of these fractures is challenging. The purpose of this study is to present our experience on the treatment of these fractures using hybrid external fixation, with or without open reduction and minimal internal fixation of the fibular fracture.

Patients and Methods: Forty eight patients with a distal tibial fracture were admitted to the authors’ institution since 2005. There were 33 men and 15 women. According to AO there were 24 A, 10 B and 14 C fractures. The mean age of the patients was 45.6 years. Eight patients had an open pilon fracture; according to the Gustilo classification, 1 patient had a grade I, 5 patients had a grade II, and 2 patients had a grade III open fracture. In all patients, the pilon fracture was treated using hybrid external fixation; in 18 patients, open reduction and minimal internal fixation of the fibular fracture using plate and screws was also done.

Results: Mean follow-up was 14 months (range, 9 to 36 months). In all patients, the mean duration of the application of the external fixation was 2.85 months, followed by the application of a below-knee cast. In 42 patients, radiographic evidence of union was observed at 3,6 months (range, 3 to 9 months). Time for union was different between patients with closed and grade I open fractures compared to patients with grade II and grade III open fractures (union at 3.5 and 6 months, respectively). There were 5 non-unions (10,4%) with 3 of them septic (6,25%). All three deep infections were low grade and occurred in open fractures.Delayed union was observed in 3 patients; in these patients, solid union of the fracture was observed at 7 months (range, 6 to 9 months). Pin track infection was observed in 7 patients (14.6%).

Conclusion: Based on the present study, hybrid external is associated with satisfactory results for the management of distal tibial fractures with acceptable complications.

Background: Massive bone loss from the proximal femur is a complex problem, occurring in multiple-revision hip arthroplasties, and malignancy. Allograft prosthetic composites (APCs) are used to restore bone loss and provide better function of the limb.

Material and Methods: Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss due to an average of 2 previous revisions, had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases.

Results: At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Minor complications occurred in 13 other cases. Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05).

Conclusion: Reconstruction of massive proximal femoral bone loss with an allograft-implant composite is a demanding procedure. Preservation of bone stock is a great advantage of this biologic means of reconstruction. Specific technical issues should be known and followed so to avoid failure and need for early re-revision

The purpose of this study was to evaluate the clinical and radiological findings in patients with avascular necrosis of the femoral head after implantation of a porous tantalum implant combined with autologous growth factors (AGF).

The study included 40 hips in 30 patients. Of the 40 hips, 1 hip was stage I, 9 hips were stage II, 22 hips were stage III, and 8 hips were stage IV, according to the Steinberg classification system. Follow-up was 2 to 4 years. The porous tantalum (diameter of 10 mm, length ranging from 70 –110 mm) was implanted in the center of the necrotic area under fluoroscopic control.

Clinical evaluation using the Harris hip score showed an increase from 66 to 96 points preoperatively to postoperatively in hips with stage II disease, from 60 to 85 points in hips with stage III, and from 60 to 80 points in hips with stage IV (p< 0,001). Of the 40 hips, the radiological stage in 20 hips (50%) remained stable, 17 (42.5%) progressed to an advanced stage and 3 hips (7.5%) underwent total hip arthroplasty (p< 0,001). Of the 17 hips that progressed, 7 were stage II, 7 were stage III, and 3 were stage IV. No material damage or implant migration was observed.

Although failures are still observed with the use of porous tantalum, the minimal invasive technique and short operative time make tantalum a reasonable alternative in the treatment of AVN of the femoral head.

The purpose of this study was to compare the clinical and radiological findings in patients with avascular necrosis of the femoral head after management with vascularized fibular graft (VFG) compared to porous tantalum implant.

The study included 60 hips in 50 patients, who were followed prospectively for 2–4 years. 28 patients (30 hips) were treated with VFG and 22 patients (30 hips) were treated with a porous tantalum implant. The two patient groups were matched for age, gender, etiology, pre-operative stage and Harris Hip Score (HHS). Of the VFG group, 14 hips were stage II and 16 were stage III, while of the tantalum group, 1 hip was stage I, 11 hips were stage II and 18 hips were stage III, according to Steinberg classification system. Mean operative time was 3 hours for VFG and 30 min for porous tantalum.

At final follow-up, there was no significant statistical difference in the radiological stage (p=0.246), and radiological progression of the disease (p=0.329) was observed between these two groups. Using HHS, the mean clinical results improved in the VFG group from 61 points preoperatively to 90 points at final follow-up, while in tantalum group HHS improved from 63 to 81 points (p=0.022). Three hips from each group underwent total hip arthroplasty.

The results of the present study suggest that although the management of AVN with VFG appears to show better results compared to the use of porous tantalum using clinical evaluation Methods: (eg HHS), further controlled studies with larger patient groups and longer follow-up are required.

The incidence of periprosthetic knee infection is generally low (0.5%–2%) but the economic impact is great. The rates are higher for rheumatoid arthritis and revision knee surgery. Treatment of periprosthetic knee infection takes into account the acuteness of the infection, the overall immune/medical status of the patient, and the local factors at the site of infection.

Evaluate the results of two-phase exchange arthroplasty with the use of articulating spacer in III-A-1 and III-B-1 periprosthetic knee infection.

From 1990–2005, 24 patients with minimum (< 2) systemic and no local compromising factors were treated for chronic periprosthetic knee infection. These patients staged as III-A-1 or III-B-1 according to MSIS staging system. Diagnosis was clinical, radiological, laboratory and from knee aspiration cultures. Two-phase exchange arthroplasty was performed. Initially, there was removal of the prosthesis, surgical debridement and placement of a PMMA spacer impregnated with antibiotic. The spacer was shaped as a knee joint permitting motion. In 6 cases a hybrid spacer was used (PMMA and TECRES® spacer). Intravenous antibiotic therapy according to intraoperative cultures followed for 6–8 weeks. Re-implantation was always done after the completion of the antibiotic therapy and on the ground of normal CRP, ESR and negative aspiration cultures. All patients received antibiotics after the re-implantation.

Staphylococcus aureus was the most common pathogen followed by Staphylococcus epidermidis and Pseudomonas aeruginosa. No infection recurrence was noted over a 2–15 years follow-up. All patients returned to normal everyday activity. A custom-made prosthesis was placed in one patient and there was a rupture of the extensor mechanism in another.

Patients with periprosthetic knee infection, staged as III-A-1 and III-B-1, when treated with two-stage exchange arthroplasty combined with antibiotic impregnated articulating spacer and i.v. antibiotics can have excellent results.

The mini exposure in THR is currently a very trendy issue in reconstructive surgery.

Purpose: We present our initial experience with the posterior mini exposure.

Materials and method 32 patients from February to August 2004 have been submitted to mini THR.

23 patients were female and 9 were male, with mean age 64 years (34 – 72 years).

The exposure was posterior; the incision length was at a mean of 8 cm (7 – 10 cm). In 30 cases we used the SYNERGY THR, in 1 case the ZIMMER and in 1 case the DURALOC-SUMIT (DePuy) THR. All cases were without cement.

Special retractors for mini procedures were used in 26 out of the 32 operations, whereas classic retractors were used in the rest.

Results: We observed a substantial reduction in morbidity with less postoperative blood loss in the drains (a mean of 200 cc), fewer analgesics were used than usual and mobilization of the patients was faster.

All the patients were mobilized by the 2nd postoperative day and released from the hospital by the 4–6th day postoperative day. Radiologically there was no case of components malpositioning.

Conclusion: The mini posterior exposure THR is feasible for the experienced hip surgeon; it has many advantages while none of the technical problems and disadvantages of the minimal two incision exposure.

The upper and lower thirds of the tibia are areas of peculiar anatomy and pose a lot of problems in their treatment.

Purpose We present a method of hybrid external fixation used in a wide variety of these fractures.

Material and method: Between 2000 and 2004, 29 patients with fractures of the tibia (16 fractures of the lower third and 13 fractures of the upper third) were treated with hybrid external fixation ORTHOFIX. Most of the fractures involved the adjacent joints, 12 fractures of the tibial condyles and 9 pilon fractures. Among the patients, 5 had septic non-union 2 of who were submitted to bone transport with the attachment of a lengthening system. All patients were called for monthly follow up till union.

Results: In all cases except one (septic non-union – bone transport of the lower third) there was successful union by 3 to 7 months postoperatively. There was no malalignment, no deep infection or other major complication.

Conclusion: The rational use of the hybrid external fixation offers a valuable solution in the treatment of the complex fractures in the upper and lower third of the tibia.

Purpose: The 7–10 years follow-up of a series of 165 consecutive hybrid total hip arthroplasties performed by the same team of surgeons and with the same technique is presented.

Materials and method: Underreaming and pressfitting of the cup was performed in all cases. Screws were used supplementary in 8 of the cases. For the fixation of the stem second generation cement technique was performed in 77 hips and the third generation technique in 88.

Results: After a mean follow-up of 8 years (range 7 to 10 years) the average Harris hip score increased from 36 points (range 7 to 63 points) preoperatively to 93,5 points (range, 75 to 100 points). Revision was performed in one patient, no radiographic loosening or osteolysis and no infections.

Conclusion: The medium to term results are very encouraging and seem extremely promising for the long term (at least a decade).