Aim

The aim of this prospective comparative study was to evaluate the serum levels of different cytokines in patients underwent total knee replacement (TKR) and received allogeneic blood transfusion, post-operative auto-transfusion or not transfused.

Objective: Primary reconstruction of soft tissues in acute complex lower limb injuries is often mandatory in order to protect exposed bones, nerves, tendons and/or vessels, however it may be precluded by general clinical and/or local wound conditions. Vacuum assisted closure (VAC^®) has been introduced in the management of complex wounds for its ability to remove third space fluids, improve oxygen delivery to the wound bed, while it promotes angiogenesis and granulation. This retrospective study evaluates the use of VAC^® in lower limb trauma patients unsuitable for immediate reconstruction.

Patients and Methods: Fourty-two patients, 24 males and 18 females, with 49 complex lower limb traumas were treated with VAC^® therapy for a mean of 28 days (range 15–42 days). Mean age of patients was 47 years (range 21–82). All patients included were characterized by poor general condition or adverse local wound factors. VAC^® was applied 24–48 hours after bone fixation, vascular repair and surgical debridement of non viable tissues so as to minimize the risk of bleeding and ensure viability of soft tissues in the wound bed. Wound swab cultures were obtained before the application of VAC^® and before every change of sponge. The duration of therapy, wound flora, final reconstructive technique required, outcome and follow up period were recorded for each patient.

Results: Seventeen patients were over 65 years of age, 28 were Intensive Care Unit patients, 11 had heavily exuding wounds and in 9 the viability of soft tissues after initial debridement was questionable. Patients were followed up for 60 to 395 days. Two wounds (4%) healed spontaneously, 6 (12.2%) were managed with delayed direct suture, 31 (63.2%) were managed with skin grafts, 8 (16.3%) required local flaps. Two patients died during therapy due to concurrent conditions. In all but one patient, wound bacterial flora was progressively reduced during therapy. Scars were aesthetically acceptable, however, in 7 wounds hypertrophic scars were treated with triamcinolone injections combined with silicone sheeting.

Conclusion: VAC^® is a safe and effective method facilitating delayed soft tissue reconstruction in complex lower limb traumas in high risk patients. The development of healthy granulation tissue minimizes the need for major conventional reconstructive operations and therefore postoperative morbidity.

Objectives: The aim of this study was to explore the relationship between stress fractures, bone density and factors related to bone metabolism in a comparative group matched study including male military personnel beyond basic training.

Materials and Methods: Thirty two patients with stress fractures were matched with 32 uninjured-healthy volunteers (controls), by gender, age, height, body weight and level of physical performance. A questionnaire concerning the calcium intake, alcohol consumption and smoking was completed, the values of several biochemical markers related to bone metabolism were measured from blood samples, and calcaneal quantitative ultrasound was measured by heel ultrasound for each one of the 64 patients and healthy volunteers.

Results: Statistically significant lower levels of serum Osteocalcin (p=0.012) and higher levels of Albumin (p=0.006) were found among patients compared to controls. The levels of serum Total Protein, Ca, intact Parathormone and 25-hydroxy Vitamin D were lower among patients compared to controls, but none of these differences was statistically significant (all p> 0.10). Moreover, mean values of T-scores and Z-scores were statistically significantly lower in patients than in controls (p=0.018 for T-scores; p=0.016 for Z-scores).

Conclusions: Decreased bone turnover and low calcaneal bone density may increase the incidence of lower extremity stress fractures among men military personnel.

Aims: To investigate the correlation between radiological parameters of distal radial fractures and the clinical outcome expressed by objective clinical parameters and the level of patient-rated wrist dysfunction.

Methods: A Prospective study of 30 consecutive patients with unstable fractures of the distal radius treated with closed reduction and percutaneous wire fixation followed by six-week cast immobilisation and fully assessed for a period of one year. The outcome parameters included the fracture type, radial shortening, palmar angle, radial angle, presence of postoperative intra-articular ‘step-off’, range of wrist movement, grip strength, function and pain Patient-Rated Wrist Evaluation (PRWE) scores[1].

Results: There was statistically significant differences in the range of final wrist palmarflexion according to the AO fracture type (p=0.04, Kruskal-Wallis non-parametric analysis) and final wrist dorsiflexion and PRWE function score (p< 0.01 and p=0.02 respectively, Mann-Whitney test) according to the presence or not of postoperative articular ‘step-off’. Permanent radial shortening and loss of palmar angle correlated inversely with the PRWE pain score (p< 0.01 and p=0.03 respectively with statistical correlation).

Conclusions: Permanent radial shortening and loss of palmar angle are associated with prolonged wrist pain. Residual articular incongruity correlates with persisting loss of wrist dorsiflexion and wrist dysfunction a finding that contradicts the notion that loss of articular congruity is associated with late development of articular degeneration but not with early wrist dysfunction. The study failed to show any association between the fracture type and the functional outcome as rated by the patients.

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was ≥ 3 mm.

Aim: The results of open tibial shaft fractures treated with reamed intramedullary nailing are presented. The same nail and protocol of treatent was used in all patients.

Patients and Methods: Twenty patients (mean age 25.2 years, s.d.: 6.0) with open tibial shaft fracture. The fractures were classified according to Gustillo classification (grade-I: 7, grade-II: 6, grade-IIIA: 7), and the comminution according to Winquist-Hansen classification (stable: 7, unstable: 13). All patients were treated within 6 hours from the injury, the wound was left open, followed by wound inspection and re-debridement (if needed) after 48 hours. A delayed primary suture or wound coverage was applied within 4–6 days.

Results: Eighteen fractures united with no need for additional operation. Non-union developed in 2 grade IIIA fractures (1 fracture healed after exchange nailing, and 1 fracture required an alternative method of treatment. The mean union time was 22.7 weeks (grade I: 20.2 weeks, grade II: 20.3 weeks, grade IIIA: 26.3 weeks). There was no infection. Dynamisation was applied in 7 fractures.

Conclusion: The results in this small series of open tibial shaft fractures treated with reamed intramedullary nailing are satisfactory and in accordance with the results of large larger-scale studies published (the recent years) recently in the literature.

Aim: The aim was to study the blood loss and the need for transfusion in patients with fracture of the upper end of the femur.

Patients – Methods: In a prospective study we included 50 patients with intertrochanteric fractures (Group 1) and patients with fractures of the femoral neck (Group 2). Patients with other concomitant injuries or fractures were excluded. The blood loss and the need for transfusion were studied using as lower limit for transfusion Hb 10 gr./dl.

Results: The average age of the patients was 80.2 years (s.d. 8.3). Patients of the Group 2 (mean 73, s.d. 10) were younger than patients in Group 1 (average 82, s.d. 5.6).

Two thirds of the patients were women, with higher proportion of women in Group 1 (women: 81.3%, men:18.7%) than in Group 2 (women: 66.7%, men:33.3%).

In Group 1 the average blood loss (3.4 units) as well as the average need for transfusion (1.9 units) was higher than in Croup 2 (average blood loss 2.8 units, average need for transfusion 1.6 units). The average Hb admission in Group 1 was 11.4 and in Group 2 was 11.8.

In patients that were operated on within the first 24 hours after the injury, the average blood loss was lower than in patients who were operated on later.

Conclusions: In patients with intertrochanteric fractures the blood loss as well as the need for transfusion was higher than in patients with femoral neck fractures. Early surgical treatment led to less blood loss.

Aim: The aim of this presentation is to present a new fixation device in ACL reconstruction using Hamstrings (Semitendonosous and Gracilis tendons) and the early clinical results.

Material – Methods: The new technique has been applied in ten patients.

Technique: Arthroscopic technique using a single skin incision. Four stand graft from the Semitendonosous and Gracilis tendons was used.

Femoral fixation: A Suspensory device -Endoflip- was used. Tibial fixation: A bioabsorbal screw -Bilok-was used. Postoperative regime: Early knee mobilization, partial weight bearing using crutches.

Results: The learning time for the femoral fixation was short. Second skin incision on the femoral site was necessary in the first two patients. There were no intraoperative or postoperative complications. The early clinical results are encouraging.

Conclusion: The early clinical results indicate that the above-mentioned technique is a reliable one for graft fixation in ACL reconstruction.

Aim: This study investigated the causes of meniscal tears in an unselected adult population. No epidemiological study of this type has been undertaken since the advent of arthroscopy and MRI.

Method: The notes of all patients (1236 cases) who underwent arthroscopic surgery under the care of one knee surgeon working in a District General Hospital between 1992 and 1998 were scrutinised. 392 patients aged between 18–60 years, with normal X-rays, no previous knee injury, surgery, or arthritis, and arthroscopically proven meniscal tears, form the basis of this study.

Results: Sports injuries (Group 1) occurred in 32.4% patients. Non-sporting injuries (Group 2) accounted for 38.8% patients, 71.9% of which happened in normal daily activities. Half occurred on rising from squatting position. No Injury (Group 3) was identified in 28.8% of patients. Average age of sports group was 33 years, non-sporting group 41 years & no injury group 43 years. Male:Female = 4: 1.

Age v cause: In patients under 20 years of age meniscal tears occurred mainly in sports. In patients 20–29 years, 64.5% were related to sports, 25% to non-sporting activities & 10.5% no specific injury. Between 30–39 years, distribution was about equal in each group. In patients aged 40–49, & 50–59 years sports related tears dropped below 20%, whilst non-sporting and spontaneous tears rose to 45% and 35% respectively.

A detailed analysis of: i) the tears in relation to different sports, ii) the nature of non-sporting injuries, iii) the pathological types and distribution of tears, and iv) the associated intra-articular injuries will be presented.

Conclusions: Approximately two thirds of meniscal tears in the general population occurred during normal daily activities and in the absence of sporting injury. In nonsporting injuries the mechanism of the tears was often unrelated to loading in flexion. Tears occurred in the absence of definitive injuries even in early adulthood and middle years. Degenerative change may contribute to the pathological mechanism of meniscal tears at an earlier age than generally appreciated. Ascent from the squatting position is an important common mechanism of injury not generally described or emphasised.