Aim

Gram negative bacteria (GNB) are emerging pathogens in chronic post-traumatic osteomyelitis. However, data on multi-drug (MDR) and extensively drug resistant (XDR) GNB are sparse.

Aim

Data on Prosthetic joint infection (PJI) caused by multi-drug resistant (MDR) or XDR (extensively drug resistant) Gram negative bacteria (GNB) are limited. Treatment options are also restricted. We conducted a multi-national, multi-center assessment of clinical data and factors of outcome for these infections.

Introduction

Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. We review our experience to characterize its prevalence, treatment, relapse and survivorship at long term follow-up.

Aim

Bone metastases of the upper limb are a frequent complication of primary tumors. The aim of this study is to evaluate treatment and functional results of patients with prosthetic reconstruction of the proximal humerus.

Introduction

Dedifferentiated chondrosarcoma (D.C.) has a very poor prognosis. The efficacy of chemotherapy is still debated. Aim of this study was to evaluate the survival of patients with D.C. and to evaluate possible prognostic factors.

Aim

To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery.

Background

There is doubt regarding resection compared to curettage for pelvic metastases. Previous studies have reported that curettage is associated with decreased survival compared with wide resection, and have justified a radical surgical approach to achieve pain palliation and tumor control.

Aim

To present selective arterial embolization with N-2-butyl Cyanoacrylate for the palliative and/or adjuvant treatment of painful bone metastases not primarily amenable to surgery.

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

To evaluate the functional outcome after complete median nerve transaction and repair, and sensory reeducation.

We studied 40 patients, aged 20 to 32 years, with median nerve neurotmesis at the wrist. Primary epineural microsurgical repair using 8-0 single strand sutures was done in all patients, and a hand and wrist cast was applied for 4 weeks. After cast removal all patients went through physical therapy for 1 month to restore motion and reduce stiffness of the injured hand. After reinnervation was completed, the patients were randomly allocated into 2 equal groups: Group A patients were instructed to a sensory re-education program; Group B patients had no further treatment. Clinical evaluation was done at 18 months postoperatively including the localization test (locognosia), the static and the moving 2 point discrimination tests, the Moberg’s pick-up test (stereognosia), and the hand grip and the opposition strength tests.

All patients were included in the postoperative evaluation. Hand grip and opposition strength, static and moving two point discrimination were not statistically significant between the two groups (p= 0.622, p= 0.112 and p= 0.340, respectively). The localization test was statistically significant in group A (p= 0.007), and a trend to statistical significance was observed regarding the Moberg’s pick up test in group A (90% statistical significance, p= 0.063).

Sensory reeducation is essential for patients with median nerve neurotmesis and repair, as it significantly re-educates localization and stereognosia in the shortest time following peripheral nerve injury and repair

In the peripheral nervous system of rats, a wide-variety of toxins has been studied to selectively target neurons projecting through a particular nerve. We employed 54 adult male rats to create a neuroma-in-continuity and to evaluate the effect of the immunotoxin OX7-saporin to inhibit neuroma-in-continuity formation. Materials and Methods: The left common peroneal, tibial or sciatic nerves were crushed by one 10-second application of a microforceps. At 3 and 6 weeks after nerve crush, the respective nerve was cut distal to the site of nerve crush, and microinjection of 2 μl of natural saline or 2 μl of the OX7-saporin was done.

In all nerve specimens of the control group and the saline-injection experimental subgroups, gross observation showed a thickened area at the site of nerve crush. Histology showed features consistent with a neuroma-in-continuity. In 11 of the 14 nerve specimens of the OX7-saporin injection experimental subgroups, gross observation showed a narrowed area at the site of nerve crush. Histology showed prevention of neuroma-in-continuity formation as seen by wiping out of almost all nerve fibers, leaving an empty tube encasing by connective tissue.

This study supports the hypothesis that intraneural injection of the OX7-saporin may inhibit neuroma-in-continuity formation

Aim: We prove the importance of the medial ligamentary system of the elbow for its stability and the usefulness of the ligamentoplasty by palmaris longus tendon as reconstructive technique.

Methods and patients: 9 patients aged between 17 and 58 (17,18,28,32,35,38,40,56,58,), 6 male, 3 female suffered the following injuries:1)elbow luxation or sub-luxation with rupture of the medial collateral elbow ligament, associated with: 1)Forearm bone fractures, 2)Ulnar nerve pulsy, 3)fracture of the coronoidal process, 4)Fracture of the radius head, 5)fracture of the humerus with radial and musculocutaneous nerve pulsy. The lesions happened since 2 week, 2 month and 2 yrs respectively. The 17 yrs old young man was injured during a weightlifting championship game and the next 4 suffered traffic and work accidents, while the 18 yrs old last one suffered an iatrogenic ligamentary lesion, the rest of the lesions have been caused to work accidents or to motor vehicle accidents

All patients were operated by ligamentoplasty with palmaris longus by medial incision, fenestration of the medial epicondyl and olecranon and transoseus pivoting of the palmaris longus which was enforced by 2 anchor sutures.

An elbow flexion-extension functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint was removed 2 months postoperatively, while full rang of motion has been obtained.

Results: Follow up was between 6 and 18 month. The 16 yrs old boy return in full sport activity and obtained at the elbow joint full range of motion. the second –young man-patient presents an extension defect of 15 degrees and the 56 yrs old women has a 25degreed deficit of both extension and flexion but she continues the therapy program.

Conclusion: The medial ligamentary system lesion with elbow instability must be repaired by medial ligamentoplasty and the well done technique followed by correct therapy program improved results.

Six patients underwent wide segmental resection and limb salvage surgery for primary or metastatic bone tumors involving the diaphysis of the femur, the tibia and the humerus using a modular intramedullary diaphyseal segmental defect fixation system. There were 4 men and 2 women with a mean age of 62 years (range, 40 to 77 years).

Histological diagnosis included adamantinoma, dedifferentiated synovial sarcoma attached to the tibia, multiple myeloma, and metastatic renal cell carcinoma, myeloid carcinoma of the thyroid gland and metastatic adenocarcinoma of the stomach.

The mean follow-up was 16 months (range, 11 to 24 months). At the latest examination, 5 patients were free of local or distant disease; one patient had deceased with distant disease, without evidence of local recurrence. Revision surgery was necessary in one patient because of mechanical loosening of the proximal fixation of the prosthesis. The mean increase of the Enneking rating from the pre to the postoperative status was 87.82%.

The intramedullary diaphyseal segmental defect fixation system used herein is associated with a satisfactory functional and oncological outcome after wide resection of diaphyseal bone tumors.

Purpose: To present a series of 49 patients which underwent single or two staged complete spondylectomy, vertebral body reconstruction and segmental spinal stabilization due to spinal tumors.

Materials and Methods: From 1992 to 2002, 49 patients with primary or metastatic spinal tumors were treated. There were 36 females and 13 males with mean age at operation of 53.5 years (19 – 80). The preoperative classification was Frankel E in 17 cases, B – D in 31 cases and A in one case. Five patients had nerve root dysfunction and one, classified as Frankel E, had sphincter inadequacy. The parts of the spine involved were lower cervical in 7 cases, thoracic in 10, thoracolumbar in 15 and lumbar in 17 cases. The operations were two staged in 36 cases and single staged in 13 cases. In the cervical spine, titanium cylinders filled with methylmethacrylate were used. For the rest of the spine, the most commonly used instruments were the Kaneda device, followed by the Miami–MOSS system. Bone graft was used in five benign tumors. Mean follow – up was 62.3 months.

Results: One patient died during the anterior procedure and in another it had to be interrupted, whereupon he died one week later. Two patients died due to their underlying pathology in the 6th post–operative month. Complications included wound healing problems in 9 patients and local recurrence in one patient. There were no neurological deteriorations or instrument failures. The majority of patients experienced improvement in their neurological status, reduction of pain or both. Most patients were functionally improved and spinal alignment was maintained in all.

Conclusion: Spinal tumor resection and spinal reconstruction provide stability, early weight bearing, symptom remission and neurological improvement.

Purpose: To describe the diagnostic planning and treatment modalities of six patients with this rarest of sacral fractures. Due to the low incidence of these injuries, there is no literature evidence concerning their management.

Materials and Methods: Six patients with a transverse fracture of the sacrum with anterior displacement. All patients were admitted with bowel and bladder dysfunction, perineal anesthesia, sensory and motor deficits at the lower extremities. Prompt diagnosis of the sacral fracture was obtained in five of the six patients.

Results: Operative treatment including extensive lumbosacral laminectomies, spine instrumentation and fusion was performed in all cases. Neurological recovery was almost complete in one patient, partial in 4 patients and absent in one patient.

Conclusions: A more favorable clinical outcome can be achieved when operative treatment is implemented using lumbosacral decompression by laminectomy, dural repair and posterolateral instrumented fusion with bone grafting. Although reduction of the fracture was not ideal in many of these patients, long term clinical and radiographic follow – up as well as neurological improvement were rewarding.

The management of localized soft tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumor bed during surgery.

Ten patients over a 4-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was done postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60–65 Gy.

After a median follow-up period of 30 months, the 4-year local disease-free survival rate was 80%. The 4-year actuarial survival rate was 85%. There were no failures within the high-dose region of the implant. No patients had locoregional failures. One patient developed distant metastases. No serious side effects were noticed. Pro-phylactic intramedullary nailing was done in 1 patient. Pathological fractures occurred in 2 patients. All patients had good cosmetic and functional outcomes.

Intra-operative implantation of the tumor bed in combination with tumor resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.

The purpose of this study was to propose a new classification based on the structural, anatomical and biomechanical properties of the odontoid process, to evaluate the outcome and to suggest the adequate treatment in relation to the specific fracture type.

The files of 97 patients with odontoid process fractures admitted to our institution were reviewed. The external and internal anatomy of the axis has been studied. The fractures were classified according to the proposed new classification. The method was tested for reliability and validity. Mean follow-up was 14 years.

Intraobserver and interobserver agreement was excellent with intraclass correlation coefficients at levels of 0.98 and 0.85 respectively. Four types of odontoid process fractures are distinguished; type A fractures are avulsion fractures involving the tip of the odontoid; type B fractures are fractures of the neck between the lower edge of the transverse ligament and the line connecting the medial corners of the upper articular facets of the axis; type C fractures involve the area between the previously mentioned line and the base of the odontoid process (type C1) or extend to the body of the axis (type C2); type D fractures are complex fractures involving more than one level of the odontoid process.

Classification of odontoid process fractures has to be reconsidered as novel imaging technology has shown new patterns of fractures. Computed tomography scan with image reconstruction is mandatory. The analysis of the imaging data in the present study justifies the new classification.

Intraarticular osteoid osteomas account for approximately 13% of osteoid osteomas. The hip is the commonest location of intraarticular osteoid osteomas.

We present 16 patients with intra-articular osteoid osteomas of the hip treated with RFA. These were 13 men and 3 women, with a mean age of 27 years (range, 16–48 years). Eight osteoid osteomas were located in the femoral head, 6 in the femoral neck, and 2 in the acetabulum.

The approximate mean duration of the procedure was 82 min (range, 50–125 min). The mean hospitalization time was 8.7 h (range, 6–12 h). All patients had pain improvement within the first 24 h. Five patients had pain relief within the first 3 days, 9 patients within the first week, and 2 patients within 2 weeks post-procedural. Twelve patients continued to have some restriction of their physical activities up to one month after the operation. All patients returned to their previous status of physical activity within the first 2 to 3 months post-procedural. At the latest follow-up, there were no residual or recurrent symptoms. Five patients complained for mild pain, which was probably due to hip synovitis that resolved within a week. One patient experienced transient paresthesias and pain in the buttock at the site of the trocar and electrode insertion.

Intra-articular osteoid osteomas have clinical and imaging features significantly different from those seen in extra-articular lesions. CT-guided percutaneous RFA is a simple minimally invasive, safe and effective method for most intra-articular osteoid osteomas.

The purpose of this study is to present the clinical and radiological evaluation of 632 resurfacing total knee arthroplasties of Foundation-Solution type, performed in 550 patients (437 women and 113 men), from 1994 to 2003. In the majority of cases (569 knees) the operation was performed because of degenerative osteoarthritis. Cement-free implantation was performed in 209, cemented in 117 and hybrid implantation in 306 procedures. We were able to retrospectively review 442 (80.4%) of the patients (498 knees), for a follow-up time of 6 months to 10 years. The Knee Insall Rating Scale was improved from 60 points (34–70) preoperatively, to 92 points (74–100) postoperatively. The range of flexion at the latest follow-up was between 75 to 130 degrees (mean 98 degrees). Extension lag more than 10 degrees was found in 3 patients (0.68%). The radiological evaluation was performed according to Knee Society Röentgenographic Evaluation and Scoring System. Partial periprothetic radiolucent lines (< 1mm) were observed in 35 knees (7%), with no statistical significant difference between the three groups and no progression during the follow-up. No further clinical and radiological evidence of mechanical failure and no significant loss of the mechanical axis were noticed. There was a case of fatal pulmonary embolism, and a case of peroneal nerve palsy that fully recovered. Three knees were revised as a result of septic loosening.