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
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
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
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 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.
With use of CAD-CAM the lesion is located and a custom-made metallic aiming device is manufactured. This aiming device is then used to place the graft in its optimal position in the center of the lesion. This group was compared with 20 patients with conventional targeting.
This study describes the clinical features and treatment of the 53 patients with primary tumors of the hand. A review of primary tumors of the small bones of the hand during a 9 year period (1991–2001) was done. There were 14 enchondromas, 1 malignant fibrous histiocytoma, 15 ganglions, 5 haemangiomas, 1 haemangioma of median nerve, 4 giant cell tumors of tendon sheath, 4 osteoid osteomas, 1 lymphangioma, 1 exostosis, 1 dermatofibrosarcoma, 1 neurilemoma, 2 neurinomas, 1 glomus tumor, 1 benign fibrous histiocytomas and 1 papillary endothelial hyperplasia. There were 34 males and 19 females with an average age 37.7 years. The mean follow-up was 6y (1–8y). There were 33 lesions in the fingers, 3 in the metacarpals, 13 in the carpus and 4 in the palm. Swelling and localized tenderness were the most common presenting complaints. One patient died of metastatic disease. 3 patients were seen initially with locally reccurent lesion. All the patients were treated surgically. The material was analyzed in terms of diagnosis, localization, surgical management and post-operative complications. Primary tumors of the hand are rare. The cases in these series are similar to that of other reports. As in other musculoskeletal neoplasms, a treatment plan must be formulated based on the location, size and biologic behaviour of the lesion.