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View my account settingsThermal capsular shrinkage presents the prospect of reducing redundant capsule, and therefore may be a suitable method of treating capsular-type instability. A prospective study of fifty-four consecutive patients (58 shoulders) treated exclusively with radiofrequency capsular shrinkage for atraumatic instability. The mean Rowe score improved from 33.1 to 74.1 points at followup of up to 48 months. Twenty of the fifty-eight shoulders had recurrence instability. Recurrent instability was related to the type of instability: 76.9% for voluntary instability, 30.3% for involuntary instability and none of 12 shoulders for instability/impingement pain. Recurrence was related as well to previous instability surgery (70%). The outcome was not related to the direction of instability, type of radiofrequency probe used, age of patient or ligamentous laxity. Twenty-two (57.9%) of thirty-eight patients returned to their pre-instability level of sporting activity. By using repeated RF treatments for the failed thermal shrinkage cases the failure rate was reduced from (20/58) 34.5% to (13/58) 22.4% and cumulative changes were seen on electron microscopy. These results are comparable to some of the results for open inferior capsular shift for patients with multidirectional instability with substantial less morbidity. The application of the minimal effective energy is controlled according to the tissue response without any charring or burning effect to the tissue. No scar was seen in repeated arthroscopies, or in electron microscopy studies. Thermal shrinkage does not negatively affect a later open stabilisation, but rather may provide better conditions for secure open surgery. We have found significant improvement in proprioception following thermal shrinkage treatment. We believe that by re-tensioning the proprioceptors they begin to fire off at lesser degrees of movement, and that there is a greater dynamic muscular contribution to shoulder stability. When using the correct technique for the right indications, Radiofrequency thermal shrinkage is a viable alternative to open inferior capsular shift in patients with capsular type of instability.
From 1979 to 2002, 131 total hip replacement were performed consecutively in patients less than 30 years of age (13 to 30,7 mean 24;2) in 75 patients (44 in males and 31 in females. Seventy six in 57 patients could have more than 2 years follow-up and will presented hereby. Regarding the type of prosthesis, 59 stem were cemented and 16 cementless. Five different socket were implanted: 6 screw-in metal back: 8 bulky cemented, 23 bulky cementless, 13 metalback press fit with titanium mesh and 26 HA covered.
Underlying diseases were Avascular necrosis in 46, 8 inflammatory disease, 6 after infected articulation, epiphysiolysis in 4 and acetabular fracture in 3.
48 were done primarily, 28 were a revision procedure and 10 had some past history of infection.
Mean follow up was 7,84 years (range 1,13-22,9). One patient (two hips deceased at 1,1 year. One hips was lost to follow-up. 73 had complete clinical and radiological evaluation.
Nine hips were revised from 2,97-18,64 years after the index procedure (mean 8,53). In 7 only the socket was revised, in two both components. Two of these were infected (secondary infection in one). Of the remaining: 45 had no pain, 18 slight uncommon pain, 10 were classified 5 and 8 had some limp.
Radiological evaluation: 56 had no lucent lines nor subsidence, 4 had some radiolucent line none progressive and 1 had a complete lucent line: and is considered as impending failure. In no case osteosysis was documented.
With the exception of socket loosening due to non optimal design of the initial system (bulky alumina cemented or cementless) the overall results are in favor of theis material in young and active patients.
In the last decade many changes happened in arthroscopic shoulder instability treratment. As all arthroscopic procedures cause less pain and early rehabilitation. Stabilisation techniques began with very demanding transglenoid suture techniques. After innovation and developments of suture anchors, arthroscopic stabilisation becam safe and reliable operation. Bankart repair with anchors and arthroscopic knot is a well-accepted method in anterior instability. The stronger the repair is, patient can return daily and sports activities earlier and safer. Treatment of capsular laxity is still controversial. Shrinkage with radio-frequency was presented in last years for tretment of laxity in unidirectional and multidirectional instabilities. Despite its easy application, treatment principles are not clear and the long-term results are unknown yet. New capsular plication with arthroscopic suture might be alternative and more reliable method but it needs great experience in arthroscopic shoulder surgery. Some lesions such as SLAP may diagnosed and treted arthroscopically easily. Further more arthroscopic labrum repair after first traumatic dislocation is getting widely accepted in younger patients because of high recurrence rate. An overview of thermal shrinkage, multidirectional instability, associated lesions and treatment of first traumatic dislocation will be discussed in this symposium.
Unidirectional instability with or without hyperlaxity can be adressed as such; mostly traumatic changes like Bankart or capsule lesions are seen and they can be treated with the standard arthroscopic suture techniques.
Multidirectional instability (MDI) with or without hyperlaxity is quite rare. In the literature MDI is often mentioned, but most of the time it refers to multidirectional laxity with unidirectional instability. During arthroscopy often capsular redundancy is seen without obvious pathological changes. Several series have been described where arthroscopic capsulorraphy has shown to be reasonably succesfull Since the introduction of thermal shrinkage several series have been published, with poorer results compared to capsular shift: failure rates vary between 11 to 36%. The possible reason of this high failure rate is that 1) many patients with multi-directional laxity are included, 2) as well as the fact that after time the effect of the shrinkage disappears due to regeneration of the capsule. Posterior instability. In posterior subluxation, often posttraumatic, with hyperlaxity frequently as accompanying phenomenon, arthroscopic capsulorraphy has been rather successful. My personal series of 10 patients showed a failure rate of 50%. Shrinkage has been applied for this indication as well, with varying results. Since 1998 13 patients with posterior subluxations were treated in our hospital with shrinkage after the failure of extensive physical therapy. After 1 yr follow-up most of them were stable; after 18–24 months follow-up all showed recurrence of the posterior instability. The pain, often accompanying the subluxation, was however still absent at the latest follow-up.
Multidirectional instability with or without hyperlaxity is a not well defined clinical entity; for this reason the results of several treatment modalities are often not comparable. Posterior instability, especially subluxations are often posttraumatic, with some accompanying hyperlaxity. In both pathological conditions arthroscopic capsulorraphy seems to be more effective than shrinkage
Among the many ‘revolutions’ in contemporary medicine and science, the idea behind Evidence-Based Medicine (EBM) is possibly the most remarkable one. People should receive only those interventions that work (i.e. those that are most likely to do more good than harm) and physicians should try to adopt those behaviours that are most consistent with the best available scientific information.
The burden of musculoskeletal conditions is growing in most developed and third world countries. The importance of the problems we study has been recognized by the United Nations by declaring the decade 2000–2010 the ‘Bone and Joint Decade’.
Despite the many great achievements in the last century, clinical research in the field of muscoloskeletal disorders has not always been flawless: this has been already pointed out by many methodologists in the past decades, even before the outburst of systematic reviews. However, and not surprisingly, the mission statement of the Decade could have been taken from an EBM textbook: This symposium will present different aspects of EBM applied to musculoskeletal disorders. Hopefully it will serve as a source of knowledge but, even more, as a source of inspiration to continuous research in the field and, most of all, as an invitation to join the rapidly growing EBM movement.
After a first international meeting in Ferrara in April 2001 ( e_Musk1) we are setting up an e_Musk Coordinating Centre at the University of Teesside in Middles-brough, UK. It is becoming a forum for like minded people to network and interact, whose long-term goal are patient-centeredness and bringing down the professional barriers. We are organizing a 2nd e_Musk meeting for June 18th–19th 2003.
Modern oncologic treatments have resulted in an increase of the duration of life of patients with cancer; however the onset of a vertebral metastasis results in a decrease of the quality of life. The aim of surgery is to increase or restore the quality, but not the duration of life. The decision for surgery depends mainly on the functional impairment, and more incidentally on the primitive tumor, the metastatic diffusion, and the general status of the patient. Decision for operative technique depends on the anatomical patterns of the metastasis, considered with reference to the three columns classification of Denis.
The anterior column initial involvement results in instability with mechanical pain, increased by standing and coughing, decreased by supine position, similar to pain experienced with traumatic instability. The middle column involvement results in foraminal extension with radicular pain. The initial posterior column involvement is unfrequent and diagnosis is usually late as standard X-Rays are negative.
At a later stage, invasion of both anterior and middle column result in vertebral collapse with severe mechanical pain and cord compression. This is best treated by anterior approach, allowing a better tumoral resection and a better vertebral reconstruction using bone cement than by posterior approach. Middle and posterior column invasion result in canal invasion and cord compression, without vertebral collapse. Posterior column involvement requires a posterior approach, giving an easy access from C1 down to S1. In selected cases, a combined approach should be recommended because allowing a more complete resection, with less local recurrence rate.
Lastly diffuse lesions or multisegmental instability may require a posterior approach and an extensive stabilisation.
The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. The preferred techniques are easy implantable suture anchors made of titanium (Fastak). Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. From 4/96 to 10/00 we performed a prospective analysis of 242 shoulders, who underwent arthroscopic shoulder stabilization with FASTak-(n = 159) Panalok-(n = 26) and Sure-tac suture anchors (n = 57) in our clinic. The patients were re-examined with a follow-up of at least 12 months. The best results were in the FASTak-group. After 2 years 4.7% suffered a redislocation. 28.6% (2 patients) needed a revision, but none of the shoulders required a second open stabilization. The reason for redislocation or sub-luxation were traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. The Rowe score was 83.1 ± 20.9 points. There was a high satisfaction of the patients with the operative result and 60.9% could go back to their pre-op sports level. At 24-months follow-up this study demonstrates good results of arthroscopic shoulder stabilisation with FASTak suture anchors. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected.
Fracture healing complications and reoperations after internal fixation (IF) of displaced femoral neck fractures are common in spite of an improved surgical technique. The complication rate in prospective studies with a two-year follow-up is 35–50%. The long-term outcome after a unipolar hip arthroplasty seems to be suboptimal for active patients and the outcome after a bipolar arthroplasty is insufficiently reported.
In a prospective study the fracture healing complications rate at two years in patients with displaced femoral neck fractures treated with IF was 36% compared with 7% in patients with undisplaced fractures. The quality of life (EQ-5D) of patients with uneventfully healed fractures at two years was lower in patients with primary displaced fractures than in patients with primary undisplaced fractures.
In a prospective randomised trial, patients with displaced femoral neck fractures were randomised to IF or total hip replacement (THR). IF resulted in more complications than THR, 36% versus 4%, and necessitated more reoperations, 42% versus 4%. Hip function and quality of life (EQ-5D) were generally better in the THR group.
The future treatment algorithms for elderly patients with displaced femoral neck fractures would benefit from being patient-related rather than diagnosisrelated. For an elderly, relatively healthy, lucid patient with a displaced femoral neck fracture THR yielded a better outcome than IF. The indications for unipolar- and bipolar arthroplasties need to be further evaluated in randomised trials with sufficient follow-up time.
We have to deal with an increasing number of patients who are suffering from a femoral neck fracture. In Ger-many in 1996 135.000 patients with this kind of fracture were treated. These fractures are usually found in old people and have a high complication rate:
Osteonecrosis of the femoral head: 12–43% (Kyle 1994)
Pseudarthrosis: 16–28% (Rogmark 2002)
The indications for a total hip replacement are:
– age > 65years
– presence of osteoporosis (also under 65)
– daily activity possible (otherwise hemialloarthroplasty)
– comorbidity such as osteoarthritis
We have to consider several aspects:
The mortality rate is lower if we use a hip replacement (THR ~6%, osteosynthesis ~10%) The complication rate is lower if we use hip replacement (THR ~2%, osteosynthesis ~5%) In 30% of cases we have to change from osteosynthesis to a total hip replacement due to secondary complications of osteosynthesis in mobile patients If we look at this data, we must conclude that total hip replacement is the goldstandard in the treatment of femoral neck fractures (with Garden III and IV) in the population older than 65 years. Hemialloarthroplasty is only indicated for patients who are more or less immobilized.
Foot pain in children is common. The reason for the pain can usually be determined from history and physical examination, but often a radiogram is necessary. The causes for painful foot can be divided into following categories:
• Trauma (Fractures, sprains, soft tissue injuries, puncture wounds, overuse syndromes)
• Infections (Osteomyelitis, septic arthritis, ingrown toe-nail)
• Arthritis (Degenerative, juvenile rheumatoid)
• Osteochondroses (Köhler, Freiberg, Sever) • Deformities (Bunions, tarsal coalitions)
• Tumors
• Others The specific treatment depends on the diagnosis and occasionally on the age of the child.
Stereotactic principles used primarily for brain surgery have been developed further and introduced into spine surgery at the beginning of the 1990’s. The system solutions available consist of three components: the surgical object (vertebra), the virtual object (CT-image data of the vertebra), and the navigatorallowing the surgeon to localise the position of the instrument inside the surgical object in real-time. Optoelectronic systems using infrared light emitting diodes and magnetic field based navigators are in use.
Lumbar pedicle screw insertion was the first clinical application for this technique. Screws can be positioned safely following a preplanned optimal trajectory or according to the anatomic situation utilising the real-time module intraoperatively.
The effectiveness of this new technique has been shown in prospective studies (Schwarzenbach et al 1997, Laine et al 1997, 1999).
In a a prospective randomised clinical trial one-hundred consecutive patients were randomly allocated for either conventional (Group 1) or computer assisted (Group 2) pedicle screw insertion. From the computer assisted group nine patients were dropped out. There was no statistical difference between the groups. CT-based optoelectronic navigation was used for screw insertion in Group 2. The screw position in the pedicle was assessed postoperatively by an independent observer with CT.
The pedicle perforation rate was 13.4% (37/277 screws) in the conventional group and 4.6% (10/219 screws) in the computer assisted group (P=0.006). The majority of perforations was less than 4 mm. A pedicle perforation of 4 to 6 mm was found in 1.4% (4/277) of the screws in Group 1, and none in Group 2. Intraoperatively, eleven screws were repositioned in Group 1 and none in Group 2. There were no postoperative complications related to screw placement.
We conclude that higher accuracy of pedicle screw insertion with computer assisted navigation than with conventional methods could be demonstrated under clinical conditions in a randomised controlled clinical trial.
At present CAOS Systems are used also for localisation of intraosseous pathologic processes during biopsies in spine and pelvis, sacroiliac screw fixation and vertebral osteotomies.
Refinement of the method for use in minimal invasive and percutaneous procedures is in progress.
For the hip, published literature reports approximately 50% successful outcome of operative arthroscopy in the presence of arthritis. These results are not very promising but some patients respond remarkably well. Careful patient selection is paramount to a potentially successful outcome. General parameters include: younger patients; mechanical joint symptoms; partial joint space preservation; adequate rotational motion; reasonable expectations; and failure of conservative treatment.
Arthroscopy has helped to understand the pathological process associated with various forms of osteoarthritis. We are now capable of recognizing these at earlier stages in the disease. However, it remains to be seen whether we can change the natural history of the disease process. Despite increasingly sophisticated technology with MRI, MRA, etc., radiographs remain the most important tool in assessing arthritic changes. Radiographs have traditionally been poor at detecting early degenerative disease, but with the information from arthroscopy, we are now more capable of recognizing the clinical importance associated with subtle radiographic findings.
Pedicle screws give the best bone purchase of all posterior fixation techniques of the cervical spine, which would suggest a frequent utilisation. However, the cervical pedicles are small and the potential danger of misplacing a screw limits their use. In in vitrostudies the misplacement frequency has been shown to be unacceptably high, whereas this is not seen clinically, maybe due to different insertion techniques. Fortunately a misplaced screw rarely leads to a clinical complication.
To minimise the risks, however, we now only use pedicle screws in the cervical spine where stability is critical, i.e. at the extremes of a fixation. For example: A C1–C2 fixation in rheumatoid arthritis or in fracture of the dens would utilise C2–C1 transarticular screws (i.e. C2 pedicle screws). A cranio-cervical or cranio-thoracic fixation would involve 1 or 2 levels of pedicle screws as distal anchorage, and lateral mass screws in between. A short cervical fixation with pedicle screws could be in a trauma patient where it would be desired to have a very reliable fixation with a minimum number of fixation levels.
Computer navigation is a promising technique, however, not free from misplaced screws. So far we have experience of 83 navigated screws in 18 patients evaluated with postoperative computed tomography (CT). 67 screws were in correct position, 11 had insignificant breach fractures of the pedicle wall, whereas 4 were incorrectly placed, usually laterally into the foramen for the vertebral artery, none however with a clinical consequence. The main problem with computer navigation in the c-spine seems to be to obtain a good enough CT scan to allow good matching between the virtual and real worlds.
Over the past 100 years, experimental and clinical studies have tried to accelerate fracture healing and to bring ununited fractures to union . Besides advances in surgical management, non-surgical means have been investigated. Mechanical enhancement of fracture healing using controlled micromotion has been used with some success but does not seem to have been applied to nonunions. Electrical stimulation has been found effective in hypertrophic nonunions, but less so in atrophic nonunions and in the presence of a gap; the various devices available have never gained wide acceptance for various reasons. Low-intensity pulsed ultrasound has been found effective to heal non-unions, especially hypertrophic, with a success rate around 85 % . High-energy extracorporeal shock wave therapy (ESWT) has also been found effective in non-union management, but this is still controversial and there is a need for prospective controlled studies. Biological action has also been attempted for a long time. All attempts to stimulate fracture healing using systemic drugs, diet supplementations, vitamins or hormones have been essentially unsuccessful unless when correcting a pre-existing deficiency . More recently, several molecules have demonstrated an osteoinductive capacity in animal studies; human recombinant BMP-2 is currently under investigation in clinical trials. Percutaneous injection of bone marrow into a non-union has also proved of interest, particularly following centrifugation to increase the number of osteoprogenitor cells; current research aims at selecting these cells prior to injection.
To conclude, a number of non-surgical means are currently available which may be of interest to accelerate fracture healing or to heal nonunions. Some are totally non-invasive, others are minimally invasive; early results have been encouraging for several of them, but there is still a need for clinical validation using prospective controlled studies. Some of those methods may well turn into alternate solutions to surgery in the future . Cost is currently a limiting factor, as long as it is not reimbursed by national health systems in most countries.
Tissue engineering can be defined as any effort to create or induce the formation of a specific tissue in a specific location through the selection and manipulation of cells, matrices, and biologic stimuli. The biologic concepts and the biochemical and biophysical principles on which these efforts are based have become a rapidly evolving field of biomedical research. More importantly, tissue engineering is becoming a clinical reality in the practice of orthopaedic surgery, providing patients and physicians with an expanding set of practical tools for effective therapy. The efficacy of all current clinical tools depends entirely on the cells in the grafted site, particularly the small subset of stem cells and progenitor cells that are capable of generating new tissue. The current author reviews a series of key biologic concepts related to the rational design and selection of cells in contemporary bone grafting and tissue engineering efforts. The functional paradigms of stem cell biology are reviewed and sources for autogenous stem cells for connective tissues are discussed. Finally a technique to obtain stem cells for the treatment of non unions is described.
We included 48 patients: 38 cases of posttraumatic non union (12 of them with infection); 4 non unions following arthrodesis (3 knees, 1 tibiotarsal); 4 cases with Illizarov technique; 2 patients with congenital abnormalities. The source of bone marrow was the iliac crest.
The marrow was reduced in volume (50 ml) in order to increase the concentration in stem cells by elimination of erythrocytes and polynuclear cells. The number of nucleated cells was counted in the marrow transplanted and the fibroblast colony forming cells (CFU-F) and the osteoblast colony forming cells (CFU-Ost) were cloned to appreciate the number and the activity of progenitor in the marrow transplanted.
On the first to second day after birth, equinus, varus, forefoot adduction, calcaneopedal block derotation degree, reducibility characteristics, creases, cavus and muscle condition are evaluated using the clubfoot severity scale, and a long-leg cast is applied. Casting is preceded by the Ponseti treatment: the first ray is dorsiflexed while maintaining finger pressure on the talar neck just in front of the lateral maleolus in the external rotation and abductus. Immobilization is interrupted by redressive manipulation therapy depending on the clubfoot appearance and parents’ participation. Redressive manual and casting therapies typically provide good correction of the foot; yet the equinus persists in the majority of cases. The undercorrected equinus is the major reason for one-stage surgery, consisting of postero-medial-lateral release, capsulotomies and à-la-carte tendon elongation through the modified Cincinnati incision, done at the age of 7 to 9 months. As a rule forefoot derotation and heel fixation are not necessary. There are no skin problems or oedema, and the child usually stays in hospital only for one day after surgery. The outcome, however, is unpredictable even in a fully corrected foot. After surgery, the foot is regularly checked for a potential adductus, lack of dorsiflexion and cavus, and redressive therapy is promptly instituted. Any residual deformation resistant to conservative measures is treated surgically. In the long term, children should as a rule wear ordinary shoes. A typical reoperation – medial release with sectioning of the plantar fascia – is required in approx.10% of cases. Derotation below the knee and transposition of the tibialis anterior tendon are less frequent. At this Department, complete re-correction is required in less than 1% of cases.
Five socket revisions with a radiolucent line > 2 mm in at least 1 zone had a migration and a rotation rate 2–5 times larger (broken lines) than 12 socket revisions (unbroken lines) without a radiolucent line > 2 mm. Allograft resorption in at least 2 zones was observed in all these 5 revisions but in 4 of them no progression of the radiolucent line was seen after the 2 years and there was no clinical deterioration or threat to bone stock.
In 8 of the revisions radiographic signs of trabecular incorporation or remodeling of the graft were observed. No rerevision was performed. Conclusions: Further follow-up is needed for evaluation of the clinical relevance of radiolucent lines in impaction grafting. As a consequence of these findings a RSA study using larger bone chips has been started.
Per definition we distinguish between shaft fractures of the tibia and fibula (lower leg), proximal tibial fractures, distal tibial fractures and isolated tibial shaft fractures. There are different criteria to classify a tibial fracture: 1. age, 2. soft tissue damage. Not only the terms, “open” and, “closed” but also coexistent neurovascular damage and the presence of a compartment syndrome have to be mentioned. 3. Furthermore there are well known anatomical classifications of tibial fractures (AO, OTA). Special conditions, as osteoporosis, osteopenia, pathological fractures and osteogenesis imperfecta have to be recognized.
The optimal treatment concept depends on the correct diagnosis, the manifestation of priorities, calculation of risks, management of complications and rehabilitation.
The treatment options of severe tibial fractures are: The interlocking nail in reamed or unreamed technique, the external fixator and in very rare cases plating or screw fixation.
The following principles in the treatment of severe tibial fractures should be mentioned:
The method of choice in closed and I° open tibial fractures is the reamed intramedullary nailing. If there is a coexistent fibular fracture at the same level as the tibial fracture, plating of the fibula should be performed.
The preferred method in closed tibial fractures with moderate soft tissue damage and in II° open tibial fractures is the unreamed interlocking nailing.
The closed tibial fracture with severe soft tissue damage as well as the III° open fracture are preferable treated by external fixation. The changing to intamedullary stabilization should be included in the therapeutic plan, primarily, or should be indicated later on.
Plating (ORIF) of severe tibial fractures has become a very rare performed procedure and is presently done just in some special exemptions. A complementary osteo-synthesis, including nailing and plating, is not included in our therapeutic concept. Proximal and distal tibial fractures involving the joint surface are not included in this consideration.
The indication for fasciotomy must not be too restrictive. A compartment syndrome should not prevent intramedullary nailing and a standardized protocol for second look procedures to protect bone and soft tissue has to be made.
In children the method of choice in severe tibial fractures is the external fixation The own experiences, during a three year period (1999–2001), including 208 tibial/ fibular shaft fractures are presented. We had 77% closed and 23% open fractures. Overall 90% were treated by intramedullary nailing. In the open fractures, we fixed all I° open fractures by nailing and 56% of the II° open fractures. 67% of III°a fractures, 90% of III°b and all III°c fractures were initially stabilized by external fixation.
Bone defects can be reconstructed by shortening, conventional cancellous bone grafting, bone transport or microvascular bone grafts. Each method has special indications, advantages and disadvantages.
Microvascular bone grafts provide living, solid bone to fill or bridge bone defects. They also promote bone healing and resist infection. However, microvascular bone grafting entail increased duration of the operation, a two team approach and it bears the risks of donor site morbidity. Therefore only extensive defects or poor prospect of healing warrant this method.
Iliac crest flap is mainly used to reconstruct metaphyseal or articular defects. It offers a large piece of corticocancellous bone, with an option to make an arthrodesis, if indicated.
Microvascular fibula is used to bridge long diaphyseal defects (traumatic, congenital) or to reconstruct avascular bone necrosis.
Osteomuscular latissimus dorsi flap (including the lateral part of scapula) offers a solution for bone and soft tissue defects, especially in open comminuted fractures, infected nonunion fractures or post-operative deep bone infections.
A large series of animal experiments in goats was performed in relatevely simple bone chamber models and in very realistic loaded pre-clinical models. In this paper the focuss is on two experiments. In exp 1 we analysed the effect of rinsing of allograft bone on bone ingrowth into the bone induction chamber. We found that rinsing improves the ingrowth capacity to a level that is comparable to that of autologous bone. In experiment 2 we analysed the effect of two different reconstruction methods, e.g., a mesh or a strut graft, on the revascularization of impacted allograft bone in a femoral reconstruction. We found that new vessels can enter the impacted bone through the mesh and that this promotes an early revascularization of the bone graft.
In patients we analysed 24 biopsies of 20 patients and quantitated the amount of non-incorporated graft (remnants of original material), graft in the process of incorporation, incorporated graft (=new bone) and fibrous tissue. With increasng follow up peripods after the revision operation the amount of normal bone increased upto ca 90%. The remaining 10% consists of non-incorpated bone and fibrous tissue.
Many secondary grafting procedures are performed in the treatment of tibial fractures with bone loss and soft tissue lesions. This is one of the main problems in severe open tibial fractures.
Resective distraction osteogenesis is an approach to treat some defects by primary limb shorting and secondary distraction osteogenesis from the same site.
The radical debridement leads to a reduction of local complications such as infections.
We reviewed a series of 10 patients with tibial shaft fractures (Typ III b and c) combined with serious bone loss and soft tissue damage in a 6-year period.
Indications, operative technique and results are shown and discussed.
Unicompartmental knee replacement (UKR) is an established and effective treatment for early unicondylar osteoarthritis of the knee. However good results will only be achieved with a UKR if appropriate implants, indications and surgical techniques are used.
There are now many UKR available. The majority have been introduced recently and have no published clinical results, as a result it is not clear how well they will function. Wear is a potential problem with UKR because of thin polyethylene and small contact areas. To minimise wear we use a device with a fully congruous unconstrained mobile bearing, the Oxford UKR.
The indications for UKR are confusing. The Oxford UKR is recommended for medial compartment osteoarthritis with full thickness cartilage loss and a functionally intact Anterior Cruciate Ligament. The Varus deformity should be correctable and there should be full thickness cartilage in the lateral compartment. It is appropriate for about one in four osteoarthritic knees needing replacement. With fixed bearing devices, because of problems with wear, the indications are narrower and contraindica–tions include young patients and damage to the Patello-femoral joint. These devices can however be used in the lateral compartment. There is currently a vogue to consider UKR as a pre-TKR. Under these circumstances the indications are relaxed and worse results are achieved.
UKR are now routinely implanted through a minimally invasive approach, which decreases morbidity and aids recovery. There is concern that the small incision will compromise implantation. The techniques used range from free hand with a burr to sophisticated instrumentation. We use a mill to precisely restore ligament balance and function to normal and have shown that, with this instrumentation, the device can be implanted as precisely through a short incision as through a standard one.
If appropriate implants, indications and surgical techniques are used then UKR achieve better short term functional results than both HTO and TKR, and they can achieve a long term survival that is similar to TKR and better than HTO.
Under these circumstances we believe that UKR is the treatment of choice.
Tibial osteotomy is a time-honored procedure in the treatment of medial femorotibial osteoarthritis. However new points need to be discussed in a modern approach of this technique.
What factors have a bearing on the decision and the technique ? During this symposium will be discussed: the advantages of the tibial opening versus closing wedge; the possibility to avoid bone grafts by using bone ceramics for opening wedge osteotomies; the importance of reliable fixation technique; the importance of decreasing the posterior slope of the tibia if the osteotomy is done on a knee with an anterior cruciate deficiency.
How long is tibial osteotomy effective and what are the outcome of postosteotomy procedures after failure of the osteotomy: most of the data indicate that tibial osteotomy is very often effective and, that achieving a moderate degree of valgus is a decisive factor in the long term osteotomy survival. However since the patients are young at the tissue of the osteotomy and since the results deteriorate over the time, the subsequent procedures should be discussed. Can a second osteotomy be done after failure of the first osteotomy ? Is it possible to perform a unicompartmental arthroplasty after a high tibial osteotomy ? What are the technical problems of a total knee arthroplasty after a high tibial osteotomy ?
The HA coating yielded superior effect on bone ingrowth compared to Ti when surrounded by a gap-whereas no effect was found in the press fit situation.
Allogeneic bone graft packed around the implant enhanced the anchorage of Ti implants, but HA coating alone without bone graft offered almost the same improvement in anchorage in 2 mm defects. Only minor improvement was obtained when bone graft was used together with hydroxyapatite.
Another interesting study showed that HA coating was able to prevent polyethylene particles to migrate around the implant by creating a seal of bony ingrowth.
HA coating on a porous surface resulted in significantly stronger fixation compared with HA coating on a grit blasted surface.
A clinical study (using roentgen stereophotogrammetric analysis, RSA) on total hip arthroplasty showed that HA coated femoral components were stable 3 months after surgery whereas migration of Ti coated components continued resulting in significantly less migration of HA coated components at 60 months.
Defects of the joint cartilage are of enormous medical and socio-economic impact. Meanwhile is widely acknowledged that untreated cartilage defects lead to an early onset of osteoarthritis. Intrinsic factors for the genesis of osteoarthritis are unknown. It is wellknown however that joint cartilage has only a limited capacity of regeneration. The conservative treatment of early osteoarthritis should focus on the following principles:
The biologic approach of cell based therapies and the arthroscopic application of resorbable implants widen the indications for the conservative surgical treatment of osteoarthritis.
Since 1989 we have treated most rotationally or vertically unstable pelvic fractures operatively. An anterior extra peritoneal approach has been used to achieve access to all parts of the anterior ring. This can be combined with the lateral approach on the iliac wing or with posterior approach for the SI and sacral lesions. The extra peritoneal midline approach is created through a 10–15 cm long midline incision beginning from the symphysis. The rectus muscles are not detached. Blunt preparation along the superior ramus gives more space laterally and reveals the obturator foramen. The corona mortis vessels are ligated. The iliac vessels, femoral nerve and the psoas muscle can be gentle elevated with a long hook. The eminential area, linea terminalis as well as the quadrilateral space are then visualised. All essential fragments can be reduced and fixed with plates and screws.
Our study of 101 patients with an unstable pelvic ring (68 rotationally and vertically unstable injuries, 21 lateral compression injuries and 12 open book injuries) showed excellent or good reduction in 88, fair in 11 and poor in 2 cases. The overall functional results were excellent or good in 83, fair in 13 and poor in 5 patients. The correlation between anatomical reduction and good functional result was clear.
Our experience and new data strongly support the use of ORIF in Type C pelvic ring injuries, in Type B- open book injuries, and in markedly displaced Type-B lateral compression injuries. Good reduction and a reliable stability can be achieved. Moreover, short postoperative morbidity and hospital stay as well as full weight bearing after 4 to 8 weeks resulted after adopting ORIF in pelvic fractures. External fixation is still used by us as a temporary bleeding control device before the final operative treatment when the bleeding is considered significant.
Apart from the inflammatory reaction upon surgery itself, the immunological biocompatibility of a given material varies with factors like the site of implantation, the immunogenicity of implant constituents and the individual reactivity of the patient. Most investigations have focused on cytotoxic, osteolytic or proinflammatory effects of wear debris and corrosion products. In some patients specific immune response, e.g. allergic reactions, to the implant components may develop and lead to localized or generalized eczema, local swelling, recurrent urticaria or even implant loosening. However the number of these patients seems to be much lower than the sensitisation rates to cobalt, chromium or nickel ranging between 2–10% in the general population. To identify implant associated allergic reactions the diagnostic approach should encompass both epicutaneous patch testing and in vitro methods, e.g. analysis of T-cell reactivity in peripheral blood and perimplantar tissue. Several patients with allergy-mediated implant intolerance under the picture of eczema, swelling, seroma formation or implant loosening will be presented. Based on these cases, a new panel of patch test substances (developed by the German Contact Dermatitis Group), immunohistology and molecular biology approach to characterize the periimplantar immune response will be exemplified. As the author is actually establishing a nationwide register for implant-associated allergic reactions, more information about incidence and clinical picture of these reactions will be available in the future. Certainly, these patients profit from an interdisciplinary problem solving approach.
Compressive and entrapment neuropathies are common disorders often caused by mechanical or dynamic compression of a segment of nerve. These nerve abnormalities often occur as the nerve passes adjacent to osseous prominences, through fibro-osseous tunnels or openings in fibrous or muscular tissues.
The clinical diagnosis of nerve injury requires a detailed level of nerve anatomy, innervation patterns and an accurate neurological examination. Electromyography, motor and sensory nerve conduction and velocity studies can be utilized for the diagnosis of nerve injury in select cases, although false negative rates have been reported in as many as 30% of cases. MR imaging, with its excellent soft tissue contrast and multiplanar imaging capabilities, is the diagnostic imaging method of choice for compressive or entrapment neuropathies. It allows visualization of the nerve at the level of clinical abnormality, as well as identification of the compressive lesion. Moreover, MR imaging can also be utilized to assess the end-organ (muscle innervated) for resultant changes from nerve compression.
The purpose of the discussion will be to review the MR imaging findings of a variety of classic compressive neuropathies.
Entrapment neuropathies are chronic local nerve lesions caused compression of anatomical structures around the nerves. The entrapment neuropathies are localized to regions where the nerves pass through anatomically narrow tunnels. The best example is carpal tunnel syndrome, which is also the most common entrapment. In literature more than 60 different entrapments have been described. Only a small number of the suggested entrapments have been reported according to standards required by evidence based medicine. Examples of these doubtful syndromes are the pronator and piriformis syndromes.
The diagnosis of entrapments is based on the subjective symptoms, clinical findings and an electrodiagnostic consultation, consisting of EMG and neurography.
Needle EMG can be used to demonstrate axonal lesions of motor axons. It is quite useful in moderate or severe lesions of mixed nerves. However, in purely neurapraxic lesions needle EMG is normal. Neurography across the site of entrapment is the most sensitive method. Surface electrodes can be used in the diagnosis of carpal tunnel syndrome and ulnar nerve lesions at the elbow. The nerve lesion can be localized very accurately using short segment studies. In deeply located nerves or small nerve branches, neurography must be done using needle electrodes (Morton’s metatarsalgia and meralgia paresthetica). The sensitivity and specificity of modern neurophysiological methods are high. The syndromes with consistently normal neurophysiological findings cannot be accepted as neuropathic, other etio-logic causes must be considered in these cases.
Accurate differentiation between loosening and infection is very important in the optimal treatment of patients with painful lower-limb arthroplasty. The distinction is very difficult, time consuming and expensive. FDG-PET has shown to be a powerful tool in the diagnosis of infection and inflammation. FDG-PET is particularly valuable in the evaluation of chronic osteomyelitis, sarcoidosis, fever of unknown origin, the acquired immunodeficiency syndrome and infected prostheses and also holds promise to monitor disease activity and response to therapy.
FDG-PET is an effective modality in the diagnosis of infection associated with lower-limb arthroplasty. Overall sensitivities range from 90% to 100% and specificities of 81% to 89% have been reported. In contrast to conventional nuclear medicine and radiologic techniques (Particularly MRI), PET is not affected by metal implants used for orthopedic procedures. Bone marrow uptake is minimal in these patients who usually are elderly. Furthermore, better spatial resolution of PET compared with conventional nuclear medicine modalities allows the detection of small and subtle lesions that can go unnoticed with other tecniques. When PET imaging is used to diagnose periprosthetic infection, certain cautions should be taken into account when interpreting the scans. The criteria to be used to distinguish infection from aseptic loosening should be clearly defined. Increased FDG uptake must be present along the interface between prostheses and bone to suggest infection. Often a significantly increased FDG uptake is found around the neck and/or head portion of the prosthesis following arthroplasty. Nevertheless, without increased FDG uptake along the interface between bone and prosthesis, a diagnosis of infection can not be made with confidence. For knee prostheses this diagnostic criterion is not as optimal as in the hip prostheses resulting in more false-positive results. Surgical intervention usually results in increased FDG uptake for up to 6 months. However, nonspecific increased FDG uptake caused by uncomplicated arthroplasty persists for an extended period of time.
As a metabolic modality, FDG-PET is superior to anatomic imaging techniques in the diagnosis and treatment of patients with prosthetic infections and inflammations that rely on the presence of hyperemia and increased perfusion. Novel PET tracers are being tested that may further enhance the role of this technique.
As they pass trough fibrous, osteofibrous and fibromuscular tunnels, peripheral nerves from their origin in the spinal cord to their effector organ, risk compression, damage and impairment of their end function.
Patients present with signs and symptoms usually associated with the motor or sensory function of the involved nerve. Careful linking of these signs and symptoms can indicate a specific compressive or painful pathology commonly known as a tunnel or canalicular syndrome, and very often known as entrapment compression neuropathy. While the names may vary, according to the compressed nerve, the anatomical area affected, the motion producing the compression or the name of the describing author, these syndromes all originate from the entrapment of the nerve elements in a narrow anatomical space. Narrowing can be caused by changes intrinsic or extrinsic to the tunnel. Patients present to their physician with symptoms that can range from vague complaints of diffuse pain or numbness to specific complaints of muscle weakness or of sensory changes over localized skin areas. A careful history and physical exam must be done prior to ordering tests, scans, or electrodiagnostic studies which should be used to confirm or clarify clinical findings. MR imaging will, with an increase in resolution and a refinement in application, be of use prior to surgical exploration. Treatment of nerve entrapment syndromes, whether conservative or surgical, must address the etiology causing nerve compression. Surgical decompression (open or endoscopic) remains the resort when conservative therapy fails.
In this Symposium
Even when the bone fusion has been successful, the pain may continue to ruin the life of the patient. Two mechanisms have been identified as origin of the pain, one extra and one intradural.
The compressive extradural lesions are caused mainly by the action of progressive stenoses or by the disruption of the pedicular wall by badly placed screws.
As for defective screw’s trajectory, the most dangerous points are mainly the pedicle’s medial or inferior corticals. In the intraforaminal trajectory the dural sleeve of the lumbar root may be mangled too, suffering a mixed mechanicalbiological mismanagement. Even without laceration a burst cortical or the metal contact can be the origin of root irritation or even palsies. These lesions are present in most series in between 1 and 10% of the screws, depending of the surgical experience. The use of navigational devices finds in this technique his principal indication.
The CAT usually diagnoses the misplaced screws. The artefacts caused by stainless steel are the reason of banning this metal for spinal devices. When doubt the pain origin can be proved by electromyographical analysis. The electrical stimulus of the screw with a 0.2 millisecond pulse of 5 – 10 mA DC signals a violated pedicle wall. The treatment of these lesions is always the removal of compressive hardware. When a non-union compounds the root compression a TLIF with cage plus posterolateral fusion with posterior instrumentation, allows the liberation of the root without entering the compromised canal.
The compression of the dural sac by recurrent stenosis was frequent in posterior fusions. The lamina thickens by the transmission of charges through this bony continuum. Nowadays it can be yet seen with lamina decortication and bone grafts stocked between the rods and the base of the spinous process. The CT myelogram shows the lesion. The extraction of the hardware and resection of the redundant bone inside the canal, can resolve the compression. The most fearful lesions are the peridural and the intradural fibrosis caused by the operative mishandling of the dural sac or by septic epidural episodes. The neurologic lesions are often irreversible. The treatment is the most difficult and the outcomes the gloomiest of the spinal surgery. The best treatment is the prevention by delicate handling of the dural sac. Suture with titanium micro-clips must be done in all the dural wounds. Disc resection adjoining articular fusion in the treatment of stenotic canals must be avoided, to prevent a cicatricial circle. Abstention of foreign bodies inside the canal, use of bipolar cautery and soluble haemostatic substances to stop the intra-canalar bleeding, are the means of preventing the peridural fibrosis. Corticoids locally or covering the dura with a thin layer of anti-adhesive gel is a good prevention of adherences. The wounds of the dura can produce too a leakage of CSF leading to a compressive myelomeningocele if intracanalar. Wear titanium particles can be found in defective constructs. The motion between rod and screws can produce them. If the particles enter the canal they can produce both compression and fibrosis.
In the case intradural adherences blocking the roots in bundles, little can be done. Once secured the immobilisation of the level by a good extracanalar bone-fusion, the use of electrical interference electrodes in contact with the affected roots is the only solution. Some aid can be expected with the use of antiproliferative cytokines as interferon gamma or reverse-transcriptase inhibitors as Suramin, administered after a surgical cleaning of the fibrosis. With all the inconveniences of these treatments yet they allow a modicum of hope.
The analysis of failed spinal fusion usually always proves that either biomechanical or biological basic principles have not been observed. We find this in both fractures and tumors, but particularly also in degenerative changes within the region of the lumbar spine.
One must be aware of the fact that lumbar fusion which includes the lumbosacral hinge can have considerable impact on the entire sagittal profile of the spine. In particular in fusion over several in multisegmental fusion within the lumbar region this must be considered as in the case of an unfavorable position of the lumbosacral hinge and in fusion over several segments, no possibility remains for compensation of the malposition within the region of the lumbar spine.
It is obvious that an unfavorable sagittal profile with displacement of the gravity line anteriorly (lumbar kyphosis) results in an unfavorable distribution of the forces at the lumbosacral hinge so that a fusion is always jeopardized by the occurrence of higher bending moments and shearing forces.
Under this aspect, the restoration of an optimal sagittal profile with proper position of the sacrum above the hip joint should be given special attention. We know that the pseudarthrosis rate is significantly lower in correct position of the sagittal profile as in cases of potentially existing flattening of the lumbar spine in terms of a lumbar kyphosis.
There is a close link between the biomechanics and the biology of a fusion.
Particularly in older patients, these two parameters must be given considerable attention if fusion of the lumbar spine is intended, particularly if the lumbosacral hinge is included.
Acute trauma and repetitive nicrotrauma connected with certain athletic activities are oftenmentioned when describing the etiology of nerve entrapment syndromes. According to the literature it is obvious that nerve entrapment syndromes in athletes are not as rare as they were once considered to be. Certain sports or physical activities have been mentioned that lead to specific nerve entrapment syndromes – for example, cyclist’s palsy and bowler’s thumb. Unlike nerve entrapment syndromes, vascular and neurovascular syndromes in athletes seem to be more common and have been described in greater detail, while nerve entrapment syndromes in athletes have been reported only recently. To support this contention, I present currently available information about nerve entrapment syndromes in athletes. For each syndrome possible cause of compression, clinical symptoms and signs, and the most effective treatment is presented. On the upper extremity are described: spinal accessory nerve, thoracic outlet syndrome, brachial plexus, long thoracic nerve, suprascapular nerve, axillary nerve, musculocutaneous nerve, lateral ante-brachial cutaneous nerve, radial nerve above the elbow, radial tunnel syndrome, Wartenberg’s disease, distal posterior interosseous nerve, ulnar nerve at the elbow and in Guyon’s canal, median nerve at the elbow and in carpal canal, anterior interosseous nerve and digital nerves. The syndromes described on the lower extremity are: groin pain, piriformis muscle syndrome, pudendus nerve, meralgia paresthetica, sural nerve, common peroneal nerve, superficial peroneal nerve, deep peroneal nerve, tarsal tunnel syndrome, the first branch of the lateral plantar nerve, medial plantar nerve (jogger’s foot) and interdigital neuromas (metatrsalgia.
In conclusion I stress that nerve entrapment syndromes must be considered in the diferential diagnosis of pain in athletes.
Four cases of scoliosis were operated as an average 5 times by posterior approach (3 – 9 times), all of them suffered fistulised non-unions recidivating after every one of the previous operations. 4 times the germ xas a Staph. Aureus Met. resist (1 associated with a streptococcus and 2 of them with an enterococcus). Three patients presented severe radicular pain.
Six posttraumatic cases underwent a surgical extraction of the posterior instrumentation. All of them presented a non-union with total loss of the initial angular correction. In one case the septic destabilisation affected the level proximal to the fixation. The germ responsible was every time a Staph. Aureus Met. Res. with an enterococcus associated in one of the cases.
Two inveterate fistulae were operated before. The grafts were performed on 1 to 4 levels without a new posterior fixation but in one case (5 thoracolumar approaches, 5 on lumbosacral fusions, external support by a 3 points corset between 4–6 months). The postoperative antibiotherapy has been maintained for 4 months in average (3–12 mos). The fusion was appreciated by the graft aspect on CT scan with a mean follow-up of 22 months (12 months minimum).
Lumbar spine fusion has increasingly been used as a lumbar pain treatment. Its frequency is of 0.03 to 0.6% fusions in the population over 65 years of age. The first factor of this increase is the use of more accurate non-invasive diagnostic mediums as CAT or MRI.
The second increasing factor has been the pedicular fixation introduced by Roy-Camille. Recently the use of interbody cages has made easier the correction of disc collapse, instability and sagital deviations. Both posterior and anterior fixation is used with different sort of approaches, according to the particular patient or training of the surgeon. The systematic use of fluoroscopy and navigational devices rends accurate the use of internal fixation. The third factor increasing the frequency of spinal fusion is the raising demography of well-trained spinal surgeons’ perhaps one of the most influential reasons of the higher success rates.
Notwithstanding those advances, it remains a number of failures. The rate of reoperations after fusion has been assessed to be 17.4% over 4 postoperative years. The advances in the knowledge of cellular signals and factors of ossification can diminish the failed bone fusions. The use of different sorts of bone-grafts, bone-substitutes and bone enhancers has rendered easier the postoperative regimes. The rhBMP’ use with specific carriers as sole fusion initiator has been successfully introduced and inhibitors of bone growth as nicotine or NSAIDs identified.
But the same factors of control of vertebral motion are the cause of errors than can be the origin of root lesions. The bulky hardware is a co-operative factor in the onset of septic failures. And the surgeon’s demography origins a higher number of borderline indications.
Autologous chondrocyte transplantation is a two-stage procedure for treating full-thickness chondral and osteochondral joint lesions. It has been used in more than 1200 patients in Sweden and 8000 outside of Sweden.
No serious general complications have been seen, no deep infections, no deep thrombosis.
Relevant serious complications are graft delaminations, especially in partial or total loss of attatchment. These can be a result of inadequate surgical technique, too aggressive rehabilitation or too early return to competitive highimpact sports. They often occur 6–12 months postop. Marginal delaminations can be handled by debridement and microfracture. Partial and total graft delaminations need retransplantation. This can be performed with good result. More common complications are periosteal delamination and hypertrophy of the periosteal flap causing catching, pain and swelling. If symptoms does not disappear with a change in rehabilitation an arthroscopic debridement is necessary.
Arthrofibrosis with limited R.O.M. is treated with intensified physical therapy. If that fails arthroscopic debridement is needed. Other relevant complications like infection and thrombosis could usually be prevented.
Autologous chondrocytes transplantation (ACT) was first used in humans in 1987 and is based on a surgical technique where cells are injected under a periosteal flap. Due to the sometimes tricky surgical isolation and suture of the periosteum and complications with hypertrophy of periosteal tissue (5 – 10% of the cases) that in some cases requires a second arthroscopic trimming ‘easier’ transplantation techniques based on cells cultured on scaffolds and membranes have been suggested. However, the standard ACT technique creates a unique in vivo bioreactor where chondrocytes and periosteum form a unique local environment. If live periosteum and chondrocytes are transplanted to a defect in the rabbit patellae a cartilage repair tissue is formed in contrast to treatment with ‘dead’ periosteum and live chondrocytes were no repair tissue is demonstrated. The unique environment formed by the periosteum and chondrocytes might be responsible for the unique in vivo induction of early embryological development patterns seen in limb formation in the foetus: We have found that the transplanted chondrocytes are expressing early developmental genes e.g Sox 9 and wnt14 and fibroblast growth factor 3 receptors (FGFR3), a marker of chondrocytes progenitor cells. Furthermore, we have found that the articular chondrocytes are able to demonstrate a phenotypic expressivity with an additional ability of bone and adipose tissue formation. Changes to the transplantation procedure must address these unique features of the ACT technology in order to maintain the long term clinical outcome.
The fractures of the humerus shaft and of the proximal humerus in childhood turn off less than 1% of all fractures. Healing is unproblematic, according the literature the non operative treatment is the treatment of choice.
Under the influence of the ESIN (Elastic Stable Intramedullary Nailing) the readiness to operate children’s fractures has changed completely. The reasons for it are multiple. According to this trend, also is to recognize a change in the treatment of the humeral fractures in childhood obviously.
The presentation on hand shall show the reasons of this paradigm change more nearly. The classic indications for the operative therapy of humeral fractures were: 3∞ open fractures, comminuted fractures, secondary complications.
We have asked whether, today, this concept is still valid in Europe. The tendency towards more operative treatment becomes apparent in the documentation of children’s fractures that has started by the international working group for children’s trauma in collaboration with the AO – Doc in 1991.
We think every unstable humerus fracture should be stabilized today. We posit in the rest, that if a general anaesthesia for reduction of humeral fracture is indicated, we aim at a definitive, stable and save fixation, i.e. potentially unstable fractures should be reduced in the OR. In our hands and relying on our experience we prefer to stabilize humeral fractures with ESIN.
For a long time treatment of all forarm fractures was coservatively in principle. Retrospective analysis of more than 1000 fractures showed that 97,8% were treated orthopedically, 22% finished consolidation with an axial malalignment of more than 10∞ and 6,9% showed bad functional results 3–13 years later. Most bad results were found in shaft fractures of both bones on the same level or in oblique fractures with convergent displacement.
The introduction of elastic stable intramedullary nailing (ESIN) gave the opportunity to stabilize instable diaphy-seal fractures with less [Aufwand], with an implant adequate for children and with the possibility of immediate postoperative movement. Within three years, 161 diaphy-seal forearm fractures were managed by cast (27%), reduction (32%) or osteosynthesis (41%). In 14 cases (8,7%), secondary osteosynthesis took place because of secondary or re-displacement during orthopedic treatment. The functional results following ESIN are very good.
In radial neck fractures with severe displacement of more than 60° an open reduction and fixation by K-wires was the preferred method for a long time. After open reduction, radial head necrosis was the result in a significant part of cases independent of the quality of reduction. Closed reduction with the tip of the nail without touching the fracture region improved the results extremely. Seldom a transcapsular reduction manoever is necessary.
In a multicentric study of proximal radius fractures including 67 cases, 27 fractures with a relevant displacement were managed surgically (24 ESIN, 3 K-wire). 3 [Verplumpung] of the radial head, two of them combined with premature closure of epiphyseal plate, and one radial head necrosis took place, but only in one case with ESIN, whereas all cases with open reduction and K-wire use showed problems during the healing course.
Despite progress in surgical methods, the clinical results of spine fusion are still not satisfactory, although success rate is certainly higher than in the past, some patients require multiple surgeries to treat a spinal disorder.
There are many reasons for which a revision surgery may be necessary: for failure of spinal previous fusion, as pseudarthrosis, for junctional failure or for decompensation of previous fusion.
This is a review of 54 patients who underwent revision spine fusion between ’96 and 2000: they were 20 males (37%) and 34 females (53%), in 9 (17%) cases was interested cervical segment, in 9 (17%) thoracic, in 10 (18%) thoracolumbar, in 26 (48%) lumbar; in 29 (54%) patients, previous fusion was performed for a fracture, in 23 (42%) for degenerative pathology (in 17 (31%) was made a postero-lateral fusion, in 4 (7%) cases postero-lumbar interbody fusion and in 2 (3%) cases anterior fusion), in 1 (2%) case for degenerative scoliosis and in 1 (2%) case for a tumour excision. Revision surgery had to be performed in 28 (52%) patients for a mechanical complication, in 14 (26%) for instability of device, in 7 (13%) for wound infection and in 5 (9%) for pseudoarthrosis. Revision procedures were in 37 (68%) cases a new spinal fusion (17 (31%) postero-lateral, 7 (13%) postero-lumbar interbody, 7 (13%) anterior fusion and in 6 (11%) cases both anterior in 7 (13%) removal of mechanical devices, in 7 (13%) cleaning of wound and in 3 (5%) elongation of devices.
We have performed a clinical and radiological evaluation with al least 2 years of follow-up. From our analysis of results of the present study, it appears that the rates of improvement after a second operation is lower than that after an initial operation and the rates of complication are significantly higher. This is probably relates to the greater complexity of revision surgery, the more invasive nature of procedure and the longer duration. and posterior fusion).
A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion.
Fractures of the shaft of the humerus are usually easy to treat, irrespective of the personality of the fracture.
The blood supply is abundant that union is rapid. There is no tendency to over-riding; on the contrary, the only danger is that the fragments may be allowed to distract by the weight of the limb and cause delayed union. The middle third is the most vulnerable in relation to delayed or non-union. This is because the main nutrient artery enters the bone very constantly at the junction of the middle and lower thirds or in the lower part of the middle third. The radial nerve is another structure at risk from fractures or operations on the humerus. It does not travel along the spiral groove of the humerus next to the bone as is commonly described; instead along most of its course it is separated from the humerus by a variable layer of muscle, and lies close to the inferior lip of the spiral groove.
In general treatment of the fractured shaft of the humerus is not usually difficult. The fractured ends can be readily aligned with the patient sitting, when the weight of the forearm on the distal fragment will usually achieve an acceptable position. Support of the wrist a collar and cuff or narrow sling, allowing the elbow to lie free and unsupported may be all that is required. In the early stages when there is considerable pain a well padded plaster of Paris U-slab passing from the region of the acromion down to the olecranon and up the inner side of the arm to the axilla and bandaged in place is very effective in relieving discomfort. After two weeks the collar and cuff bandage can be replaced by a functional orthosis type Sarmiento for another four to six weeks. A “ hanging cast” popularized by Caldwell is no longer recommended because it may distract the fracture and produce delayed union.
Lower limb fractures in children are common. These fractures can be managed in a variety of ways, and the method chosen depends on a number of factors including:
Age of the child.
Site of fracture.
Whether the fracture is open or closed.
Associated injuries.
Surgeon’s expertise and experience.
Parental wishes.
The retrograde Marchetti-Vicenzi humeral nail consists of four or five flexible branches. At one end these branches are fixed into a solid L-shaped cylinder and at the other, they are held together with a locking wire. The nail is inserted in a retrograde way through a cortical window proximal to the olecranon fossa. Once passed the fracture, removing the locking wire allows the branches to spread in the metaphysis providing proximal stability. Distal locking is achieved through screw fixation.
The Marchetti-Vicenzi nail presents several theoretical advantages. Its flexible branches facilitate nail insertion and might favour fracture healing. Distal locking is performed under direct vision from posterior to anterior and additional proximal locking is not required, preventing iatrogenic neurovascular damage. Distal locking avoids nail migration and retrograde nail insertion spares the rotator cuff. Early mobilisation is often possible. This leads to an equally good elbow function, but with a better shoulder function compared to antegrade nailing.
On the other hand, limited rotational stability, especially in transverse fractures, can cause non-union and hardware failure. In the initial design, the bulky L-shaped end made a large supracondylar insertion and removal window mandatory, increasing the risk of fracture in this area. In the later version, the angle of the L-shaped cylinder has therefore been modified.
In our opinion, the use of the Marchetti-Vicenzi nail is not advisable in comminuted or transverse humeral fractures, in fractures extending in the distal third or in patients (young ladies) with a narrow medullary canal. Nail removal should only be considered if absolutely necessary.
Ten year results of 100 primary lower limb reconstruction prostheses implanted between 1982 and 1989 were analysed. In a Kaplan-Meier estimate there was a 85% three years, a 79% five years and 71% ten years survival rate. Most common reason for implant failure was aseptic loosening in 27% of patients (11 patients; range 10–121 months) after initial operation. Other reasons for revision surgery were implant failure (4) and infection (4). Early repair of prostheses-related minor complications, was polyethylene bushings destruction. After a median followup of 127.5 months after the initial surgery, 51 patients had died and eight patients were lost to followup. Forty-one patients were evaluated clinically and radiologically using the MTS score and the radiologic implant evaluation system of the International Symposium on Limb Salvage. 41 patients had a mean of 80% (range, 40%–100%) of the normal functional capability.
The wrist is one of the main targets of rheumatoid arthritis. The classic pattern of deformity and destruction shows involvement of the radio-carpal and the radio-ulnar joint with destabilization of the carpus, resulting in a ulnar sliding of the wrist. With ongoing disease a radial tilting and a carpal supination is observed. Although considered as a uniform systemic disease of immunogenetical background the patients show various courses of this disease. The recognition of the pattern of progression may have implications on the management and also on the surgical treatment of the patients. Most currently used classifications of wrist deformity include mainly the actual destruction of the carpal joints but do not include the different possible pattern of progression. For optimal surgical treatment of rheumatoid wrists it seems mandatory to recognize the type of destruction if possible already at early stages of the disease. Based on radiological long-term analysis, Simmen et al. proposed a new classification of rheumatoid wrist involvement considering the type of destruction and possible future development with direct consequences for surgical decisions. Three pattern of destruction are distinguished, based on the morphology of destruction and the course over the duration of the disease. Serial radiographs allow the classification in either type I, II or III wrists. Type I rheumatoid wrists show a spontaneous tendency for ankylosis type II wrists remain stable and show a destruction pattern which resembles osteoarthritic changes and type III wrists show a disintegration with progressive destruction and loss of alignment. Type II is further subtyped in III a with more ligamentous destabilization and type III b shows bony destruction with finally complete loss of the wrist architecture. The classification into the different types of the natural course of the disease at wrist level is based on serial radiographs and measurement of carpal height ratio and ulnar translation. A change in the carpal height ratio of more than 0.015 and/or an increase of ulnar translation of more than 1.5 mm per year classifies a wrist in the type III category. Type I and II wrists have a low probability undergoing radiocarpal dislocation.
Therefore surgical treatment including wrist and tendon synovectomy and usually ulnar head resection, gives satisfactory results also in the long-term. In contrast type III wrists, because of ligamentous and/or bony destruction, require a procedure which provides realignment and stability.
Performing a total knee arthroplasty in a patient with a flexion contracture or recurvatum deformity requires from the surgeon an adequate knowledge of the principles of flexion – extension space balancing.
In the standard TKA procedure, adequate balancing between the flexion and extension space is usually easily achieved, leading to an equal and symmetrical space both in flexion and extension, which results in a stable knee and maximal range of motion after implantation of the prosthetic components. The situation is different in the knee with a flexion contracture or recurvatum, where the extension space is relatively smaller (flexion contracture) or greater (recurvatum) than the flexion space. In both of these situations, the flexion and extension space should be balanced by the surgeon in order to avoid an important deficit in range of motion or an instability problem. Several surgical techniques are available for this.
In the knee with a flexion contracture, the extension space is relatively too small. Adequate removal of posterior osteophytes will increase the extension space, and this should be the first step in the flexion – extension space procedure (1). Next, the collateral structures should be balanced, with release of the tight structures that are effective in extension only (2).
These are predominantly the iliotibial band in the valgus knee, and the posterior oblique ligament in the varus knee. If these 2 steps are not sufficient, proximalisation of the femoral component by 2 to 3mm may be required (step 3), or a formal release of the posterior capsule from the posterior femoral condyles (4). When an anterior reference system is used, the surgeon can also decide to use a slightly larger femoral component with a slightly increased tibial resection to equalise the gaps (5).
In the knee with a recurvatum deformity, the extension space is relatively too large. In this situation, distalisation of the femoral component by removing 2 mm less distal femoral bone, will decrease only the extension space without altering the flexion space (1). In case of anterior referencing, the use of a slightly undersized femoral component will further equalise the gaps (2). Just using a thicker tibial insert to fill up the extension space, while increasing the flexion space by resecting the PCL or increasing the tibial slope, may be another option in the modest recurvatum knee (3).
The computer and telecommunications revolution has barely begun, although it has already profoundly changed our daily lives. But health care is still regrettably unplugged compared with other industries. Why? There are several obvious answers. For one thing, modern medicine is both complex and fragmented. And the medical profession has a long tradition and a strong ethos, not easily influenced by IT nerds. Also, security and patient integrity as well as other legal aspects put limits on what is feasible and desirable. The collapse of the dot.com business and the numerous accounting scandals have certainly not increased the profession’s confidence of internet.
Yet, documentation in today’s health care is obsolete: at the same time redundant and insufficient. Access time for paper documents are often measured in days or weeks rather than in milliseconds. This slow communication technology is bad for our patientsòat a time when the sheer magnitude of information necessary for medical decision-making is increasing exponentially. Another aspect is research and quality control. No manager of a manufacturing industry would keep his/her job without keeping the board happy with hard data on the quality of what is produced. How about medicine?
This symposium aims at giving a smorgasbord of IT applications in orthopaedic care, quality control and research. We will also discuss perhaps the most important question: what do we want the new technology to do for our patients and for orthopaedic surgery? Complications of limb salvage
The MP joint is the key joint for function of the fingers. Rheumatoid arthritis involvement of this joint is frequent (1/3 of patients), and results in severe painful deformity and functional loss. The factors leading to the classic ulnar drift and volar luxation are multiple but the permanent pathophysiological element is synovitis of the joint. No deformation will occur in the MP joint without synovitis.
Etiopathogenesis: The causes of MP joint deformity in Rheumatoid arthritis are anatomical, pathological and indirect.
The asymmetry of the metacarpal heads with a slight ulnar tilt induce the deformation in this direction. The weakness and the length of the radial collateral ligaments compared to the ulnar collateral ligament makes the laxity to occur on the radial side of the joint. The obliquity of the extensor tendons pull the fingers ulnarly with a tendency of dislocation over the MP joints.
Synovitis is at the origin of elongation, rupture or destruction of the ligaments, attrition of the cartilage and bone resorption. The distention of the extensor hood predominate radially and accentuate the extensor tendon obliquity. The destruction of the A1 pulley of the flexor tendon participate to the volar luxation of the joints. The ulnar sliding and radial tilt of the carpus, the tension of Abductor Digiti Minimi and the contracture of the intrinsic muscle participate indirectly or aggravate the deformation. The thumb force in pinch grip and the ulnar deviation of the finger in heavy prehension participate also to the deformation.
Classification: Without prognostic factor the following classification gives information on the stage of the deformation and the treatment that can be proposed.
synovitis without deformation, normal radiographs
synovitis with ulnar deviation, normal radiographs
synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with almost normal cartilage
ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and more or less bone erosion on radiographs
Synovectomi with stabilization and realignment procedures can only be used in stage 1 and 2. In stage 3 and 4 arthroplasty is more appropriate.
Treatment: Indication are pain, loss of function and cosmesis.
Synovectomy. The prophylactic effect of synovectomy is still subject to debate. The almost impossible total synovectomy, the difficulties to control the effect of the procedure and the different stage in disease of each patient make the synovectomy unpredictable as a real prophylactic procedure.
Stabilization and realignment procedures has always to be part of a synovectomy. If the destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed. For this purpose different techniques can be used. Suture of the extensor hood on the radial side enables reorientation of the extensor tendons. The radial collateral ligaments can be strengthened or their attachments reinserted, the Abductor Digiti Minimi or the intrinsic tendons can be divided. Some tendon transfers (intrinsic, Extensor Indicis Proprius) can also be proposed.
Arthroplasty. The choice of the procedure depends most of the surgeon preferences. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand with very good results on the aspect of the hand and on pain. The mobility of the MP joints is variable and depends of the mobility of the finger joints. The bone erosion and the rupture of these devices are in favor of autologous interposition arthroplasties which, on the other hand, gives lesser mobility and stability. For these reasons silicon and interposition arthroplasties are often indicated late in the MP joint destruction process. More recently, new non constrained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function. If the preliminary results are confirmed in the long term, these non constrained devices will have a good indication as early MP joint replacement in the active young rheumatoid patient.
Conclusion: MP joint deformity in rheumatoid arthritis is complex. The Etiopathogenesis will guide the treatment most appropriate in each patient. However some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure. The ulnar deviation can be reduced and corrected by ligaments and tendon procedures. The volar subluxation/luxation indicates an advanced deformity of the MP joint that requires arthroplasty.
Synovitis of the pip joint with separation of the lateral bands from the central slip allows the lateral bands to sublux forwards to lie anterior to the axis of rotation thus the intrinsics which extend the proximal and distal joints of the finger come to act as flexors of the proximal joint and continue to act as extensors to the distal joint. The patient will use the intrinsic muscles and they now have a flexion force upon the PIP joint and hyperextension force on the DIP joint, causing a boutonnière deformity. Volar subluxation of the middle phalanx draws forwards the lateral bands and defunctions the central slip creating the same imbalance. Scarring of the volar plate as is seen in volar plate injuries with the production of a pseudo-boutonnière deformity is sometimes seen in psoriatic arthropathy.
In a boutonnière deformity the PIP joint is flexed and the DIP joint is extended. With the joints in this position, the origin and insertion of the intrinsic muscles are closer together, and as a consequence, with the passing of time, the muscles fibres will remodel in a shortened position, creating a lateral band tightness.
The patient has a passively correctable flexion deformity of the PIP joint, and can actively flex the distal interphalangeal joint.
The anatomical alterations are the following: elongation of the sagital fibres and volar displacement of the lateral bands but no secondary shortening of musculo-tendinous system.
The patient cannot actively or passively flex the distal interphalangeal joint, when the PIP joint is passively corrected. Secondary shortening of the intrinsic/lateral band system because the intrinsics have remodelled in a shortened position.
There is no passive correction of the deformity but the joint surfaces are sound. The patient can not passively extend the PIP joint nor flex the DIP joint.
In these cases, stiffness of the PIP joint is not only due to soft tissue remodelling but mainly to joint destruction.
In this type, destruction of the joint cartilage should be added to the previously described anatomical deformities. X-ray examination is needed to confirm the diagnosis.
Along with prosthetic components, a bone allograft is a major option to be considered in reconstructing a segmental bone loss after a primary malignant bone tumor resection.
In most cases of primary bone tumor surgery, segments of long bone will be used as allografts. These are sterilely procured in operating theatre after an organ procurement. To facilitate the reconstruction, the periarticular soft tissues along with the cartilage are also dissected free during the harvest.
Bone or osteochondral allografts can be implanted alone with osteosynthetic material or combined with a prosthesis. The allograft can be used as an osteoarticular end, an intercalary construct with or without arthrodesis or be implanted with a prosthesis.
The main indication for using bone allograft in 2003 are the intercalary bone loss, an osteoarticular defect at the upper limb, at the proximal tibia and femur if tendon insertions are to be resected and at an anatomical location where no reliable prosthetic material exists such as the scapula or distal fibula.
A risk of disease transmission and a high rate of fracture and nonunion are the main disadvantages of this material.
An anatomical reconstruction of the skeleton, the possibility to reinsert tendon insertion, the biologic anchorage of the graft with a bony callus, the absence of bone reaction to wear particles and the possibility to recreate a stable joint are among the advantages of using this bone grafting materials. With a bone allograft, virtually any segmental bone loss can be reconstructed.
Bone allografts remain a sound material to work with when dealing with a bone tumor. The surgeon must however anticipate the potential complications by performing an appropriate reconstruction.
Hip fractures have increased in most western countries during the end of the last century. This increase will continue mainly because of an increasing number of elderly persons and also due to an increase in the risk of hip fractures in the oldest. This constitutes a threat to resources for medical care. Practise differs concerning choice of operation method and principles for rehabilitation throughout the world. A national registration of the outcome after hip fractures in the elderly started in 1988 in Sweden to compare different methods of surgery, mobilization and rehabilitation. This project has attracted great international interest and several centres have participated with prospective registration. With support from the European Commission a project was started in 1995 called Standardised Audit of Hip Fracture in Europe (SAHFE). The project aims to encourage centres in Europe to participate in a hip fracture audit with a defined data set consisting of a core of 34 questions which includes outcome measures at 4 months from operation. Printed forms are distributed to the participants as well as a computer program designed for the project. In addition there is a large number of optional questions. Each participating centres collects its own data and registers for own analysis. The data are then sent to the project centre in Lund. Hospitals wishing to participate in these international comparisons are welcome. The SAHFE project will promote comparisons of demographic features, surgical technique and rehabilitation methods to facilitate the dissemination of the best practise of hip fracture surgery and rehabilitation throughout Europe. Further international participation will widen the spectrum and facilitate improvements of the hip fracture treatment of benefit both to the patients and the society which has to provide health care to the increasing number of elderly.
In Scandinavia registers of locomotor system disease and trauma were developed in the mid 1970’s. In Sweden since then there exists registers of hip and knee arthroplasties and some years later similar registers were developed in Norway, Finland and Denmark. In 1988 a register on the treatment and rehabilitation of hip fractures started in Sweden and also since 1993 a spine register has been in use. The arthroplasty registers contain parameters concerning age, sex, diagnosis and technical factors for the operation. The outcome parameter is survival of the prosthesis e.g. if it has been revised or not. The real need to perform a revision arthroplasty has been considered a sufficiently well defined parameter to register. The hip fracture registration contains also background parameters as well as rehabilitation outcome including functional outcome parameters above all walking capacity and place of living. Functional outcome and patient rated quality of life are also included in the spine register. The arthroplasty registers have been very useful to separate better from not so well performing models as well as showing the importance of good cementing technique, type of cement as well as the influence of age, sex and diagnosis in a more rapid and reliable way because of the large-scale magnitude of the study. The hip fracture register has shown the importance of optimised operation and rehabilitation, which saves considerable resources in this increasing group of elderly patients. The symposium will exemplify performance, spread and results of orthopedic registers, which is an efficient way to evaluate on a large-scale everyday orthopedic practise. This way of registration has attracted great interest and is now spreading internationally. For hip fractures a European project has started called SAHFE (Standardised Audit of Hip Fractures in Europe).
Lumbar spine surgery has been registered on a national basis in Sweden since 1993 but the register became widespread after 1998 when the protocol was made patient-based and a support function for participating units was created. The surgeon completes data on diagnosis, type of operation, implant, hospitalisation time and complications. All pre- and postoperative data are completed by the patients, including pain on the VAS scale, pain drawing, and the SF-36 and EuroQol questionnaires. Data are presented yearly in an aggregated form while individual departmental data are reported to the individual departments. A participation rate exceeding 85% of lumbar spine surgery in Sweden was calculated for 2002 and the one-year follow-up rate from the previous year was almost 85%. The national registration provides a basis for evidence based lumbar spine surgery, documenting indications for surgery, variation over time and region, complication reporting as well as patient reported outcomes. The mean reduction of VAS pain for the individual diagnoses (disc herniation, lateral and central spinal stenosis, spondylolisthesis and disc degenerative pain) demonstrates the outcomes of surgical treatment for these diagnoses to be favourable. Current projects are expansion of follow-up to 5 and 10 years postoperatively, the creation of a web based protocol version and the development of a cervical spine register.
The growing amount of tissues transplanted every year challenges the bookkeeping of tissue banks to guarantee prompt and reliable traceability. The task is even harder when the tissues are procured, stored and transplanted in diffenrent hospitals. The problems faced us during the years led us to seek a solution from the new electronic possibilities.
The Tampere University Tissue Bank is collecting tissues and data from 9 different units. The tissues have been transplanted mostly in Tampere University Hospital but delivered also to 10 other hospitals for transplantation. A Microsoft Access based program was used for bookkeeping. We had to do double work when bringing the data from papers to tha Access database. To ease the work we started to develop a Web-based program, which could discuss between the different units.
An up-to date Web-based program has been created and it has been testdriven from the beginning of September 2002. The tissue-harvesting and tissue-transplanting units can fill the electronic forms ready in Web. The central bank sees the up-to-date information in the central registry in the Web. For the sake of patient security the forms are planned so that every box in the form has to be filled or otherwise the program does not progress and you are not able to continue. We have managed to minimize the mistakes of tissue bookkeeping caused by human errors. We have also managed to speed-up and standardize the whole bookkeeping process of tissue-harvesting and tissue-transplanting dramatically. It is also very easy to generate different kind of research reports by thisWeb-based system. The security of the data is guaranteed by encrypted connections and fault-tolerant server clusters situated in high-security hosting centres.
We have been able to remove the overlapping paper work. There are no more missing or wrongly filled data. The several paper-vision files of tissue on different stages during the laboratory checking is now replaced only with one final file, which is printed for archive when the tissue has been used and also the data or recipient has been filled. The forms and the whole program are easy to modify and all users can utilize the new up-to-dated versions immediately. It makes the database very flexible and every user has the possibility to improve the program. Because of these improvements the safety and the possibility for quick traceability have been increased.
In the past decades the use of allografts has increased rapidly in the field of orthopaedic surgery. In particular in revision hip arthroplasty allografts are frequently employed. Several reports in the past decades on the transmission of HIV and hepatitis have, however, raised concerns on the safety of allografts. These reports have led to a revision of the standards for tissue banks. The screening of donors’ medical and social history was improved and rigorous testing methods were implemented. Processing methods introduced by tissue banks have further reduced the risk of transmission.
Despite these precautions, however, a recent report of the CDC has again caused for concern regarding the safety of allografts. After receiving allografts from a common source one patient died and another developed a serious infectious complication. These cases make it clear that the use of allografts is still not without risks. Orthopaedics should be aware of these risks but should also be familiar with the measures taken by tissue banks to reduce these. Only then can the surgeon decide whether he should use an allograft for a specific indication and more important which graft he should select.
This presentation will provide an overview of measures that may be taken by tissue banks to reduce the risk of disease transmission. Also, suggestions are made for orthopaedic surgeons for the selection of an appropriate graft from a safety point of view.
Osteoporosis is one of the most common diseases. It occurs in 11% of population and in 31% of women above the age of 50. Familial occurrence, aging, menopause, low calcium diet and smoking are the predominate risk factors of osteoporosis occurrence. Due to prevalence of bone resorption over osteogenetic processes, bone mineral density (BMD) decreases and deterioration of bone microarchitecture follows. Whether BMD loss will reach fracture threshold depends from the primary peak bone mass ( achievable at the age of 25 yrs) but it is determined by genes.
Bone fractures consist of great meaning of osteoporosis in clinical practice. Life risk of any fracture in 50-year-old women is 39.7%. Spinal fractures affect 21% of women at that age and 80% at the age of 70. Proximal femur fractures (PFF) are the most difficult and problematic. 20% of women will die during the first year after fracture and 50% of those surviving will become disabled. There were 1.700.000 PFF worldwide in 1990. Population aging will lead to more then 3 fold increase in 2050 giving 6.300.000 PFF fractures.
Fracture prevention is based on early diagnosis and treatment. DXA measurement of spine and hip BMD are the golden standard for diagnosis. According to WHO criteria osteoporosis is ascertained at level of −2.5 T-score. Treatment of osteoporosis should combine pharmacoterapy and fall prevention programme.
The term of hip dysplasia means an abnormality of shape, size or spatial configuration of the acetabulum. It also concerns the femoral head, with mutual relationships, proportions and alignment between the femoral head and the acetabulum the most crucial factors. The reason of any symptoms in hip dysplasia is the dysplastic acetabulum and its disproportion in relation to the femoral head. Dysplasia of the acetabulum appearing at puberty has been attributed to secondary “absorption” of bony acetabulum. The presence of fatigue fractures at a later age has been considered as resulting from trauma. However, the fragments of the acetabular rim should be ascribed to overloading of the rim in dysplastic hips, causing fracture and separation of its segment. They are sometimes associated with cysts in the acetabular roof. Limbus tears with or without an associated bony fragment are known to occur after traumatic dislocation of the hip but also without any history of injury. There is no explanation of their cause or their relation to acetabular dysplasia. Limbus tears have been diagnosed by arthroscopy, arthrography and CT scans.
Vertebral fracture (VF) is a common complication of osteoporosis. Patients with osteoporotic VFs are often without symptoms and many of these fractures are detected by chance. Only one third of VFs is clinically diagnosed. However, osteoporotic VFs may also be very painful and cause severe discomfort during several weeks. In both genders low bone mineral density (BMD), prevalent VF and increasing age are strong predictors of VF. About one fifth of the patients with a VF suffer a new VF during the following year.
Clinical consequences of VF include acute and chronic back pain, decreased quality of life and increased mortality. The care of patients with VF includes proper pain management and early rehabilitation. The use of elastic lumbosacral brace reduces pain when mobilising patient after VF. Calcitonin has been shown to have an analgetic effect. Sometimes the vertebral fracture causes a diagnostic problem and reasons other than osteoporosis should be ruled out (e.g. myeloma, lymphoma, metastases, other malign diseases). If feasible, the diagnosis of osteoporosis should be confirmed by BMD measurement. Osteoporotic VFs are seldom unstable requiring operative treatment. In case of neurological complications operative decompression and stabilisation should be considered. Impaired bone quality causes problems in pedicle screw fixation. Cement augmentation and special anchorage screws may provide increase in holding power in osteoporotic bone. Percutaneous vertebroplasty and balloon kyphoplasty are mini-invasive procedures that provide immediate and long lasting pain relief in VF patients. These techniques are technically demanding and require careful patient selection. Recent, prospective, randomized studies have shown that antiresorptive drugs can prevent new fractures in patients who had experienced previous fractures.
Microsurgical techniques have become useful in reconstructive surgeryn of the hand. Toe-to-hand transplantation is currently the procedure of choice for thumb loss reconstruction, as well traumatical as congenital. For a successful outcome meticulous planning is imperative and presumes a thorough knowledge of pertinent anatomy and surgical technique
The method of thumb reconstruction must be individualized and is dependent on the patient’s functional needs, age, and the level of the amputation. Postoperatvely, diligent nursing care is essential in assuring a positive outcome.
From Nov. 1979 to Dec. 2001 53 second toe-to-hand transfers were performed at Center of Replantation of Limbs in Trzebnica/Poland. Mean age was 27 years. Males (79%) and manual workers (91%) dominated the series
The rate of failure was 5,5%. The transfer gave functionally acceptable thumb with 8–12 mm two poin discrimination, on average 55% of strength in pinching (compared with unaffected side), 35 degrees of range flexion (but with flexion contracture)and poor cosmesis. Second toe transfers are preferable in cases with proximal thumb amputations, and in children. Their main advantage is the minimal morbidity of the donor site.
Radius fracture is the earliest and one of the most common symptoms of osteoporosisò1/6 of fractures seen in the emergency roomòand many patients with distal radius fractures would benefit from osteoporosis treatment to prevent future fractures. Nearly 80% are women, most frequent between 60–70 years of age; men have a more flattened incidence curve.
As to classification, distal radius fractures span a wide spectrum, but the sheer bulk of them calls for a simple and robust classification with a low interobserver error. Older’s classification gives an indication of the risk for redislocation, and perhaps the presence/localisation of comminution in the distal/metaphyseal areas are more prognostic than the dislocation per se in unstable fractures.
Despite improved surgical treatment, most series still report dissatisfaction rates around 20% with significant complications. One reason is that the population of patients with fragility fractures is so heterogeneous in terms of autonomy, cognitive function, and functional demands. Although anatomy does correlate with function, a stratification in background factors seems to be reasonable. The chronological age of the patient and the radiological classification grade of the fracture are often not the most important factors in terms of functional outcome, health-related quality of life and patient satisfaction in the long run.
The indications for reduction and external/internal fixations are still unclear, but there has been clear trend towards a more active approach, and a combination of different surgical techniques. But since it is still unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes, there is a need for evidence for the management of these fractures in terms of efficacy (clinical trials) and effectiveness (general practice).
Hand – the stability and MP motion in 14 case were satisfied. The sensibility, except one case, in 2 points discrimination test was between 14 mm – 20 mm. Pinch and grasp reached 40–60% of hand’s opposite site. Remodelling processes were satisfactory except one case of limited bone graft resorption which required supporting by cancellous bone.
Foot – function of the foot was outlined by podoscope and pedobarography (before and after operation). Podograms in all cases revealed limited deficits in loading pulp of toe. Pedobarograms in 6 cases revealed lateralised trajectory of loading. In these cases there were no chance to weight-bear of forefoot. In the rest cases only deficits in loading surface of the toe’s tip were presented on pedobarograms. The notices to vascular complications like twisting pedicle, constriction by tight skin closure or kinking pedicle were mentioned too.
PV is also indicated in patients complaining with severe back pain related to metastatic lesions or myeloma involving vertebral bodies if the lesion is not associated with neurological signs or epidural involvement. PV can be performed before radiation therapy or reserved for patients who have already received maximal dose radiation. PV induced complications are more frequent in these indications and that treatment should be considered after a multidisciplinary discussion.
PV is the treatment of choice in painful and or aggressive vertebral hemangiomas. Association with injection of absolute ethanol is suggested in aggressive forms of that pathology.
Author’s experience in surgical treatment of aplasia of the thumb according to the Buck-Gramcko procedure introduced by this author in 1971 is reported.
Inidcation of the pollicization of the index finger according to Buck-Gramcko is aplasia of the thumb in the 3rd, 4th and 5th stages (Blauth’s classification).
The surgical technique is particulary complex because of knowledge of microsurgery and soft-tissue reconstruction necessary. The different surgical phases may be schematically divided into a cutaneous stage which calls for the reconstruction of the web space, a vacular stage, a skeletal stage in which the reduction of the trapezium radial I metacarpal is reduced and a miotendinous stage.
Surgery is carried out on patients of at least one year of age as it is necessary their cardial-pulmonary system be adequately mature, development of the endostal circle, thicker vascular walls and a suitably developed bimanual grasp, as well.
The revision of these cases treated is especially significant because an average follow-up of the 17 years puts in good light the functionality of the hand, both from the points of view of strength and movement (Percival’s classification).
After a revision of the case studies with a long term f.-u. we may affirm that the pollicization of the index finger according Buck-Gramcko, to achieve the development of the first finger in opposition, is the best-choice surgery in the reconstruction of the aplasial thumb and owes its effectiveness to the association of microsurgical techniques for preparing an island pedicle composite-tissue flap to the cardinal principles of articular reconstruction and of tendon transfers.
The Act for Patient Injuries came into force on May 1987 in Finland. This Act covers all medical treatment, both public and private care in Finland including examination, surgical and non-operative treatment, physiotherapy, rehabilitation as well as patient transportation. The Finnish Patient Insurance Centre handles all claims in Finland, about 6.000 cases yearly, of which about 1.700 will give compensation to the patients. So far, operative treatment in orthopaedics and traumatology has produced most injuries. The Centre is supervised by an independent Patient Injury Board stated by the Ministry of Health. The injuries are divided into three subgroups: 1. treatment injuries, 2. injuries caused by infection and 3. true traumatic accidents. In addition, there is a special pool for medicine induced side effects or injuries which is organized in cooperation with pharmaceutical companies selling drugs in Finland.
All evaluation of each individual case is based on probability. If there is more than 50% probability between the suspected treatment phase and injury the precondition for compensation is present.
Moreover, the evaluation is concentrated to the case itself and the personnel involved will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has guaranteed that most of the injuries have been reached and evaluated by the Patient Insurance Centre. All the 18 hospital districts in Finland covering both common health services and hospital care have their own policyholder status. Total expenses, both compensation and administrative, will be charged from the districts with a non-profit principle. Private hospitals and smaller units have their own contracts with insurance companies, and medical and dental unions have contracts of their own for individually working physicians and dentists.
The prerequisite for compensation is that there has to be an objectively recognised and measurable harm to the patient due to a diagnostic or treatment procedure. In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means e.g., that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare. These are for example all injuries caused by broken medical equipment, falling of the patient during examination or treatment etc. However, it does not cover falling of the patients if this occurs during the hospital stay while no medical treatment is given.
The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.
Negative outcomes, accidents and complications are unavoidable. In surgery as in aviation a major role is played by human factors contributing to 30 to 90 per cent of accidents. However in aviation accidents and near-accidents are investigated and all errors are reported.
Surgical errors and near-accidents are never reported nor investigated and no lesson can be learned.
Minimal-invasive augmentation techniques have been advocated to treat osteoporotic vertebral body fractures (VBFs). Kyphoplasty is designed to address both fracture-related pain as well as the kyphotic deformity usually associated with the fracture. Previous studies have indicated the potential of the technique for immediate pain relief and reduction of vertebral height, but whether this is a lasting effect, has not been well investigated. The current prospective study reports on our experience and the one-year results in 27 kyphoplasty procedures in 24 patients with PMMA for osteoporotic VBFs.
Pain was assessed on a 0–10 VAS. Deformity and reduction of the vertebral body was measured as the angulation between the two endplates on standing lateral radiographs. All parameters were taken pre-op, one day and two months post-operatively and after one year. Multiple regression analysis was conducted to determine the importance of independent factors as predictors of the achieved fracture reduction.
All but one patient experienced pain relief directly following the procedure with a lasting effect after 2 months and also one year in 25 cases. An average vertebral kyphosis reduction of 47.7% was achieved with no loss of reduction after one year. Pain relief was not related to the amount of reduction. The potential for reduction was related to pre-op kyphosis, level treated, and fracture age, but not to the age of the patient.
In this series, kyphoplasty was an effective treatment of VBFs in terms of pain relief and durable reduction of deformity. However, whether spinal realignment results in an improved long-term clinical outcome remains to be investigated.
Every surgical act could be considered a criminal offence, were it not for the patient’s consent. The latter formerly used to be considered implicit but it now has to be made explicit, which may include signing an informed consent document. In case of litigation, the surgeon may be required to provide evidence that the patient received full information and was in a position to give informed consent. Every adult individual is supposedly able to understand and to recall technical information on any specific operation; we know how unrealistic this is. The information should be complete, including on complications least likely to occur; it should also be made understandable to the patient. Assuming this would be possible, the surgeon may be requested later on to provide evidence that such information was provided. How to prove this remains an unsolved problem. A stereotyped informed consent document will be no obstacle to a determined lawyer. Unless every patient receives a customised information booklet written with assistance from a lawyer, the surgeon will always have difficulties in providing evidence that the patient was fully informed. Litigation will often end up with patient and surgeon presenting two irreconcilable versions. One of the reasons is poor retention of information by the patient. A number of studies all showed that retention of basic information is poor and falls down to 50 % after one week and 18 % after 6 months; besides, any “unpleasant” information will be selectively forgotten. In countries that do not have a no-fault compensation system, the only way for some patients to obtain compensation for a disability or financial harm following surgery is to sue the surgeon for malpractice. Lawyers have found out that it was easier to plead the absence of informed consent. We have no real possibility to prevent this, and the quest for absolute security would be hopeless and would result in a paranoid behaviour on the part of the surgeons. Judiciary insecurity has become part of our everyday life and we must cope with it; no-fault compensation systems may improve this but only to some extent. It is best to treat only patients with whom a confident relationship appears possible, as we know that they will usually not quite understand what is going on and will anyway forget most of the information provided.
With the increasing number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system, it is essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.
The Bone and Joint Decade initiative was developed around the core issue of improving the health related quality of life for those afflicted with a musculoskeletal condition. It was recognised that at most levels within the health care system or within society, the impact of these conditions today and for the future were underestimated both regarding number and regarding consequences; disability, handicap, societal implications or costs. The increasing population of elderly, reaching above 20% within the next 20 year, will further augment the problem within Europe, as these conditions also increase with advancing age.
In order to make a change, strategies needs to be developed addressing a number of issues: what is the incidence and prevalence of these conditions today, what is burden in terms of economic and societal costs, what is the impact on the individual and what is the outcome for the individual with optimal care but also with sub-optimal care. From systematic reviews of evidence-based interventions and collation of guidelines, recommendations for strategies including multiprofessional approaches have been developed. The evidence for interventions is identified in terms of effectiveness in dealing with symptoms, tissue damage, activities and participation. Policies can than be based on what is achievable and what is needed after local adaptation.
The menisci function within the knee as load distributors, shock absorbers and secondary stabilisers. The medial meniscus has been shown to carry as much as 50% of the load across the medial compartment, and the lateral meniscus 70% of its compartmental load. After total meniscectomy, joint contact areas decrease by approximately 75%, and peak local contact stresses increase by as much as 235%. Meniscectomy may lead to a 14 times increase in the risk of arthritis at 20 years.
Axial load across the knee is converted into hoop stresses along the circumferential collagen fibres within the meniscus. Strong and stiff attachment of both meniscal horns, via the insertional ligaments, to the tibia is essential. Disruption of the circumferential fibre arrangement will defunction the meniscus. Preservation of meniscal tissue, where possible and appropriate, is now accepted practice.
Most techniques for meniscal repair have been validated in vitro by testing radial pull-out strengths. However, meniscal tissue is highly anisotropic, with little strength in the radial direction, perpendicular to the circumferential collagen fibres. Physiological forces in the radial direction, across the menisci, are probably only very small. Therefore, mechanical evaluation of radial pull-out strengths is probably of little clinical significance.
The role of different repair techniques, and the significance of gapping across repair sites under cyclical loading will be discussed.
Sutures are the strongest and the only time proven technique for meniscal repair. Sutures are safe and without surprises as long as the peroneal and the saphenus nerves are protected and avoided. Sutures can be placed via arthrotomy or under arthroscopic view. In pure suture techniques a sling holds the meniscus parts together or refixes the meniscus to the capsule. The orientation of the sling can be vertical, horizontal or oblique, but should always either catch the circumferential fibre bundles of the meniscal tissue or part of the densely woven meniscal surface. Suture related techniques make use of a thread but do not strive to form a sling. The earliest of these was the knot-end technique, the latest one is the Fastfix? repair. Either absorbable or non-absorbable material has been recommended but most would favour non-absorbable threads of 0 or 1–0 USP sizes. Depending on the course of the needle inside-out, outside-in and all-inside techniques have been described. For repair of intrasubstance tears the sutures have to be supplemented by measures to enhance healing as trephination of the meniscal periphery or addition of a fibrin clot to the repair side.
There are regions of the menisci that are close to impossible to reach for the suture cannulas. For these it seems better to do a non-suture reconstruction with some of the innovative devices compared to leaving them alone or do meniscectomy instead of repair. Hybrid meniscal rapair, combining the advantages of sutures and new repair devices are in frequent use.
The critical role that the meniscus plays in the knee along with the advantages of preserving as much of the meniscus as possible have both been well documented. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears.
Despite the benefits associated with successful meniscal repair there is a potential risk of complications.
The nature of arthroscopic repair does carry a certain risk.
Meniscus refixation with bioabsorbable arrows is considered reliable but shows other complications that must be kept in mind.
Despite the numerous complications discussed in the literature, virtually all of these have resolved spontaneously or had satisfactory outcomes after appropriate treatment.
Several precautions should be included in the surgical technique to minimize the likelihood of complications.
Meniscus repair is now an accepted procedure, but many questions remain, regarding the results, indications versus meniscal resection. How to assess the results of meniscal repair?
Clinical results doesn’t allow to assess the healing rate. Some failure of healing can be asymptomatic. There is thus a need for an objective assessment of the healing process: by arthroscopy (but it is invasive); by MRI but the hypersignal in the meniscus area is difficult to interpret. The best way seems to be arthro CT, even if it is a quite invasive technique.
1. Location of the lesion.
In case of lesions in the red-red zone or red-white zone: the healing potential is good ameniscectomy would be total and would lead to secondary degenerative changes. it is thus the best indications for meniscal repair
In case of lesions in the white-white zone: the healing potential is poor the meniscectomy would be partial with usual good long term results.
Indications for meniscal repair should be very selective in this occurrence
2. Etiology
2.1. ACL Tears Meniscectomy is the key of degenerative process after ACL rupture. ACL reconstruction is able to preserve meniscal status
We must thus preserve the menisci as much as possible: by doing a meniscal repair in case of unstable extended lesions by abstention if he meniscal is table.
In all the cases, ACL should be reconstructed.
Results of meniscal repair in this context are good both in terms of clinical results and healing rate
Isolated meniscal repair should be only considered in presence of 4 criteria: symptomatic meniscal lesion, no functional instability, non repairable meniscal lesion, low demanding patient
2.2. Stable Knees
Meniscectomy remains the most frequent procedute in this condition with good functional results. But, according to the long term FU results (> 10year) (multi-centre study of the SFA 1996), the rate of asymptomatic knees is only 60% on the medial side, and 50% on the lateral side. The rate of joint line narrowing is 28% on the MM and 40% on the lateral side. The recovery after lateral meniscectomy is often long with a high rate of rearthroscopy (14%). There is a specific complication on the lateral side: rapid chondrolysis by young patients.
Meniscal repair should be thus proposed as often as possible
The best indcation is a peripheral vertical lesion by a young patient.
The rate of secondary meniscectomy is about 10% but the rate of complete healing is only 50 to 60% according to the literature.
Prognostic factors are: time to surgery: recent lesions have a better prognosis (12 weeks ?) extension of the lesion side of the lesion: lateral lesion is better than medial one.
Intrameniscal horizontal cleavage grade 2 lesion by young patients is a specific indication which gives good results and avoids a total meniscectomy.
Meniscal repair should be recommended for red-red or red-white zone to preserve the meniscus and thus the cartilage, specially on ACL unstable knees, lateral side, young patients (children+++).
But many questions remain: which strength do we need ? what about shear forces is there any secondary degenerative changes of the meniscal tissue with an increasing risk of iterative tear which long term results with the new devices ?
Juvenile hip instability is associated with many conditions. Most of them belong to the group of neuromuscular diseases. Generally following categories can be enumerated: 1. Cerebral palsy, 2. Myelomeningocele, 3. Spinal cord injury, 4. Paraplegia following spine surgery, 5. Poliomyelitis, 6. Inflammatory hip disease, 7. Idiopathic instability, 8. Recurrent post-traumatic hip instability. In the groups 1–5 a chronic muscle imbalance is the reason of the displacement of the femoral head. Inflammatory joint disease produces displacement through cartilage and bone destruction and increased intra-articular pressure. Very rare idiopathic instability is usually associated with generalised hypermobility. For the early diagnosis a careful clinical examination is necessary involving range of motion, testing of the hip stability by the Palmén’s test in the same way like in new-borns. Routine x-ray screening at least once per year is mandatory. For the groups 1–5 a muscle imbalance has to be corrected first. Elimination of muscles contractures or muscles transfers respectively, showed a high efficiency if these surgical corrections were performed early. Femoral osteotomy alone does not provide reliable results. Any form of pelvic osteotomy is necessary to correct acetabular insufficiency. For the inflammatory hip disease early active surgical treatment is best prevention of displacement. Idiopathic hip instability has to be differentiated from common snapping hip. No treatment is necesary. Recurrent hip dislocation can be cured by a posterior capsulorrhaphy.
Bone impaction grafting of the femur is associated with more complications when segmental defects are present. The effect of segmental defect repair on initial stem stability was studied in an in vitro study with fresh frozen goat femora. A standardized medial segmental defect was reconstructed using a cortical strut or a metal mesh. As controls we used intact femora and femora with a non-reconstructed defect. In all four groups impacted bone grafting was performed in combination with a cemented Exeter stem. Each group contained five femora. Reconstructions were dynamically loaded up to 1500N. Migration was measured with Roentgen Stereo-photogrammetric Analysis. All cases with a non-reconstructed segmental defect failed into excessive varus rotation. None of the femora with a reconstructed defect failed. Cortical struts and metal meshes were equally effective in creating a stable stem construction (varus rotation 2.89±2.27 and 2.27±0.57, respectively). Reconstructions with a metal mesh were more reproducible, although the obtained stability was significantly lower (p< 0.01) when compared to impaction grafting in an intact femur (varus rotation 0.58±0.36).
Besides, structural grafts may negatively influence the revascularization of the underlying impacted grafts in contrast to an open wire mesh. So, an in vivo study of 12 goats was done. A standardized medial wall defect was reconstructed with a strut or a mesh in six goats per group. In all femora impaction grafting was performed in combination with a cemented Exeter stem. After six weeks the femora were harvested. A high rate of peri-prosthetic fractures was found (43% and 29% for the strut and mesh groups, respectively). Histological and micro-radiological examination showed different revascularization patterns for both reconstruction techniques. In the strut group revascularized graft was found at the edges of the defect. In the mesh group fibrous tissue and blood vessels penetrated through the mesh and a superficial zone of revascularized grafts was found. Segmental defect reconstruction with a strut reduced the amount of revascularized grafts medially behind the strut (p=0.004). This may interfere with the stability of the stem in the first period after surgery and the incorporation of the impacted grafts on the long-term.
We would recommend segmental defect reconstruction with a mesh. A regime of unloading and long-stem prostheses should be used, irrespective of the reconstruction technique
Neurological problems such as cerebral palsy, myelomeningocele and others may lead to unstable hips in children and juvenile patients. Major problems may arise due to the inability to treat the underlying condition. Patients may suffer from spasticity, reduced muscular tone, bone loss or bony deformity. Despite these problems several tactics are used to gain long-term reduction of unstable hips.
Femoral osteotomies are done alone or in combination with pelvic osteotomies, and/or muscular procedures. The indication of the femoral osteotomy alone is the unstable hip with a normal pelvic anatomy shown in the three-dimensional computed tomography (CT). Long-term follow up (11 to 18 years) of patients with intertrochanteric femoral osteotomy alone resulted in hip centration if patients were younger than four years of age at the time of surgery. In older patients hip centration always improved but femoral osteotomies alone did not result in sufficient coverage of subluxated or dislocated hips. Therefore in these patients with pelvic deformity we perform an intertrochanteric varusderotation and shortening osteotomy to correct the femur deformity in combination with a Pemberton type peri-acetabular pelvic osteotomy, an open reduction of the hip joint and a capsuloraphy.
All stems migrated distally and most of them also migrated medially or laterally and posteriorly. Migration was still observed in one third of stems between 1.5 and 2-year follow-ups. At 2 years stem subsidence averaged 2.5 mm, medial or lateral migration averaged 1.2 mm and posterior migration averaged 2.9 mm. No correlation to the preoperative bone stock deficiency was observed. Between 2 and 5 years only marginal migration occurred in 11 of the 15 stems followed for 5 years.
No differences in the migration pattern were detected when free weight bearing was allowed immediately after revision in hips without intraoperative skeletal complications as compared to when restricted weight bearing was practiced. No rerevision was performed.
The clinical success of revision THA combined with impaction morcelised bone graft is completely dependent on healing of the bone graft. Both the platelets inside a fibrin clot contained in the graft bed, and the row bone surfaces of bone graft pieces leak bone morpogenetic proteins essential for healing.
Pre operatively in the state of aseptically loosening when osteolysis is the predominant metabolism, there are also a bone healing activity present in the endosteum, as could be visualised studying Flouride-uptake in a Positron Emission Tomography scan.
One day after revision THA using a Lubinus SP II stem with impacted morcelised fresh frozen and fat reduced allografts, no bone healing activity could be detected using PET.
8 days after the same kind of surgery an intense bone healing activity detected as an elevated Flouride-PET uptake was seen.
3 weeks after the same kind of surgery, histological analyses of human biopsies from the graft beds surrounding femoral stems revealed an intense state of healing. A fibrin clot, invaded by inflammatory cells, predominantly granulocytes, was surrounded the necrotic graft pieces. Fibroblasts creating a granulation tissue with newly formed capillaries were also seen in the graft bed. This is the healing scenario normally seen at periostal callus formation. Occasionally bone formation with osteoide was seen in the periphery of the graft beds at this early stage.
3–4 months after surgery histological analyses showed the fibrous healing to have reached 3–5 mm inside the graft beds. Bone healing was somewhat slower; it had reached 2–4 mm.
At this stage a continuously high bone healing activity could be confirmed using PET.
6 months post operatively the fibrous and bone healing had advanced further 2–3 mm.
10 months after surgery, the superficial 3-mm of the graft beds were mainly bone healed as seen by histology. Also the deeper layers of the graft beds were now in an intense state of bone healing. The secondary stage of bone healing, creating new Haversian canals and trabeculares in the direction of load, visible in plain radiographs, is not yet present at this time.
1 year compared to 1 week after surgery PET scans revealed the maximal bone forming activity to have advanced from the surface of the graft beds (which is in the interface to the endosteum) to the deep graft area close to the cement mantle surrounding the stem.
1 1/2 year after surgery is the earliest stage, to my knowledge, when new trabecular formation inside the graft bed can be detected at plain radiographs. Predominantly first visible in the most loaded Gruen zones. If new trabecular formation is not detected after 3 years it is unlikely to become present at al. Cortical repair however may be detected after half a year.
The course of healing described here is to my knowledge predominant. Less good healing scenarios do however occur. Whole or parts of the graft bed may remain necrotic, as has been described in the literature. In case of non-healing, the stem and the cement mantle is bound to a slow but continuos subsidence. Pain is not likely to occur until the tip of such a stem is in contact with the cortex.
310 patients (23%) had to be revised after an average duration of eight years. In 233 cases only the cup was revised, in 35 cases both components were revised and in 14 cases only the stem was revised.
In 222 of the 233 cup revisions (95%) the Endler cup had failed. In the 35 cases with revision of both components the Endler cup had failed in 28 cases. In the 14 stem revisions only in two cases an Endler cup was involved. The Endler cup resulted in a significant increase of stem revisions. The ten-year survivorship of all hips was only 82% due to the high failure rate of the Endler cup. If only the stem was analysed the ten-year survivorship increased to 96%.
A prospective trial of proximal femoral nail versus dynamic hip screw for unstable intertrochanteric fractures of the femur.
We report our experience in the use of the TGN in the treatment of extracapsular fractures of proximal femur.
Measuring the the angle of external rotation of the tibial component preop helped to determine the extent of external rotation of the tibial component intraoperatively.
A significant decrease of the postop Q angle was noticed in all patients.
Diabetic foot is a disease with social, familiarly and economic charge.
Usually the patients with neuropathic diabetic foot have a compromise in large vessels of the calf that invalids most of the techniques of Plastic Surgery for reconstruction for skin losses of the foot.
The authors describe the utilization of little fragments of skin (proximally 4 mm diameter) draw under local anaesthesia in the tight. The receptor area due not have infection and clean of necrotic tissue. Tendons have also due excised or recovered of granulation tissue With this technique they have treated 4 patients; 3 have total recuperation of the lesion and in one, with a scar in the hallux, all the skin has lost. The largest area of the lesion treated has 8 x 6 cm, and time o healing has 12 weeks.
The reconstitution of the donor area is complete at 4 weeks with no scars.
The authors conclude that this technique is valid for dorsal loss of skin due to neuropathic diabetic foot.