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Sutures and Fibrine glue (S+F), S+F and chondrotinase ABC, S+F and electrical stimulation, S+F and chondrotinase and electrical stimulation, uninjured nerve. Video kynematic, EMG, muscle strengh and axonal count were used to asses nerve recovery at 150 days post-repair.
empty (N=5), iliac crest autograft (N=6), or PLGA/CaP biodegradable scaffold Tissue Regeneration Therapeutics Inc., ON, Canada) (N=7).
Fluorescent markers were given at different times: calcein green (six weeks), xylenol orange (nine weeks), and tetracycline (11 and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Radiography, Micro CT, and brightfield and fluorescent microscopy were used for analysis.
osteoblast-hVEGF, fibroblast-hVEGF, Osteoblasts alone, and Fibroblasts only.
The cultured cells were harvested at 1, 3 and 7 days after the transfection. The total mRNA was extracted (TRIZOL); both hVEGF and rat VEGF mRNA were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and quantified by VisionWorksLS.
gold compound was reduced in the presence of lysozyme to form Lys-AuNPs or citrate-stabilized AuNPs were functionalized with mercaptopropionic acid (MPA) to produce carboxylic acid terminated AuNPs which were mixed with lysozyme.
Both solutions were characterized with transmission electron microscopy, ultraviolet-visible spectroscopy, circular dichroism spectroscopy (CD), and enzymatic assays. Next, AuNPs were prepared on 99.5% titanium foil discs (n=32) through electroless deposition. Deposition parameters were modified to create two groups of discs with different average diameters of AuNPs, measured by scanning electron microscopy. Some discs from both groups also underwent treatment with MPA. All discs were treated with lysozyme and the adsorbed amounts and activities of lysozyme were examined with micro BCA and enzymatic assays.
no knee brace, no load, no knee brace, 15% bodyweight (BW) load, knee brace, no load, knee brace, 15% BW load.
Patellar tracking (flexion, spin and tilt; proximal, lateral and anterior translation) was assessed. Comparisons were made at 1° increments over the coincidental range of knee flexion between the no-brace and brace conditions, at no load and 15% BW load, using a paired t-test with Bonferroni correction.
combine FA and Vancomycin, and Linezolid alone in PMMA cement and characterize antibiotic elution, and to improve drug release using polyethylene glycol (PEG) and NaCl in PMMA cement.
computed tomography absorptiometry (CT-OAM) which uses maximum intensity projections to assesses peak density values within subchondral bone, and our novel computed tomography topographic mapping of subchondral density (CT-TOMASD) technique, which uses surface projections to assess both cortical and trabecular bone density at specific depths from the subchondral surface.
Average BMD at normalized depths of 0–2.5mm, 2.5–5.0mm, and 5.0–10mm from the surface were assessed using CT-TomasD. Regional analyses were performed consisting of:
medial/lateral (M/L) BMD ratio, and BMD of a 10mm diameter core identified as having the maximum regional BMD.
Each bone was assessed for OA using a modified-KL scoring system: Normal (mKL=0); Early-OA (1–2); and Late-OA (3–4).
A radio-opaque surrogate cord, with material properties matched to in-vivo specimens, replaced the real spinal cord. Sagittal plane X-rays imaged the surrogate cord in the spine during testing. Varying levels of canal stenosis were simulated by a M8 machine cap screw that entered the canal from the anterior by drilling through the C5 vertebral body. Pure moment loading and a compressive follower load were used to replicate physiologic and super-physiologic motion.
T8-L4 fusion and facet capsulotomy at L4–L5 and L5-S1; L4–L5 Maverick; L5-S1 Maverick.
Maverick total disc replacement and fusion with the CD Horizon system was performed. Repeated measures ANOVA was used to analyze changes in ROM and HAM of the L4–L5 and L5-S1 segments.
locking plate fixation alone and locking plate fixation with intramedullary allograft fibular bone peg augmentation.
lateral 8-hole 3.5 mm conventional non-locking proximal tibial plate [CP]; CP + posteromedial 6 hole 3.5 mm limited contact dynamic compression plate [CP + LCDCP]; CP + postero-medial 6 hole 1/3 tubular plate [CP + 1/3 tubular]; 8-hole 3.5mm Proximal Tibial Locking plate [PTLP]; 8-hole 3.5 mm LCP (locking compression plate) proximal tibia plate [LCP]; 9-hole Less Invasive Stabilization System [LISS] plate.
Specimens were cyclically loaded to failure or a maximum load of 4000N. Load at posteromedial fragment failure was recorded.
antibiotics were withheld until cultures obtained, at least four fluid and tissue cultures were submitted, frozen sections were obtained of any tissue grossly suspicious for infection, and the surgeons’ pre-, intra-, and post-operative suspicion for infection were recorded.
Samples were observed for growth for 28 days. All cases were reviewed at a mean follow-up of 4.2 months (range, 1–12). Comparisons were made between infection cases and “clinically Insignificant” cases, with respect to: (1) risk factors, (3) symptoms/signs of infection, (2) active range-of-motion, (2) Simple Shoulder Test (SST) scores, values of (3) WBC, (4) ESR and (5) CRP, number of positive cultures for (6) P acnes and (7) other organisms and (8) subjective pre-operative, intra-operative and postoperative suspicion for occult infection.
to define the articular injuries of PM fractures into clincially relevant groups, as complex articular injuries could require specific surgical steps; to identify clinical and radiographic parameters which would alert the surgeon to the presence of complex injuries.
an axial loading injury mechanism (.000), a radiographically captured dislocation (.006), posteromedial comminution [as defined Tor-netta] (.005) the size of the fragment (.000).
For example, axial loading would result in a complex fracture in > 85% of cases. In contrast, there was a statistically significant association between a Weber C fracture and older age and the presence of a SIMPLE PM fracture. These factors being potentially “protective” from joint comminution.
prompt surgeons to order further imaging (CT) to better delineate the lesion, and draw his/her attention to potentially malaligned fragments at the time surgery.
The anterior-posterior (AP) dimension of the end plates. Amount of subsidence. The distance between the TDA and the posterior and anterior borders of the vertebra bodies (to represent the extent of uncoverage of the endplate by the TDA). The AP dimension of the TDA metal end-plate.
The ratio between the actual and radiographic AP length of the metal endplate was calculated and utilized as the correction factor for the error of magnification on all other radiographic measurements.
determine the extent to which the American College of Chest Physicians (ACCP) guidelines for VTE prophylaxis are followed after total hip replacement (THR) and total knee replacement (TKR) and evaluate the incidence of VTE for patients receiving and not receiving prophylaxis according to ACCP guidelines (‘ACCP’ and ‘non-ACCP’, respectively).
received LMWH, fondaparinux, or VKA following surgery initiated prophylaxis within one day of surgery (for THR patients) and were prescribed prophylaxis for a minimum of ten days, or until the occurrence of major bleeding, VTE, or death. In addition, the number of DVTs and PEs occurring in ACCP and non-ACCP patients was recorded.
the number of ACL reconstruction surgeries performed on females between the ages of 13–18 inclusive in the Capital Health (CH) region from December 2000 to November 2005, and those due to soccer injuries.
Secondly, we describe factors relating to the mechanism of injury.
Age at reconstruction procedure. Indoor versus outdoor soccer playing surface. Level of play and frequency of participation.
The Alberta Soccer Association provided the number of registrants in indoor and outdoor seasons over the same time period.
C1-C2 TS on right side and C1LMS-C2PS on contralateral side C1-C2 TS on right side and C1LMS-C2IL on the contralateral side and C1-C2 TS on right side with sublaminar wire.
Valgus high tibial osteotomy (HTO) results in changes in the frontal as well as sagittal planes. Our hypothesis suggests that patellar height increases and posterior tibial inclination decreases after closed wedge (cw) HTO, whereas patellar height decreases and tibial slope increases after open wedge (ow) HTO.
Lateral radiographs of 100 knees were assessed for patellar height (PH) using Insall-Salvati (ISI), Caton-De Champ (CDI) and Blackburne-Peel indices (BPI) as well as posterior tibial slope. Measurements were done before HTO (50 cw and 50 ow), direct postoperatively and before hardware removal.
In the cw-group all three PH indices increased direct postoperatively and at removal of the hardware with changes in CDI and BPI being significant (P < 0.05). In the ow-group all three indices showed a significant patellar height decrease direct postoperatively and at hardware removal. There were no significant changes between the two follow-up measurements (P > 0.05). Posterior tibial slope showed a significant decrease of 3.1 ± 3.4° after closed wedge HTO and a significant increase of 2.1 ± 3.6° after ow HTO direct postoperatively. In cw-HTO the correlations between frontal plane correction and PH changes were moderate (CDI: r = 0.57; BPI: r = 0.64). In ow-HTO these correlations were weak (CDI: r = 0.44; BPI: r = 0.46). According to ISI there was no correlation (cw: r = 0.11; ow: r =0.16). There was no correlation between PH changes according to CDI and slope changes.
The incidence of patella infera increases after open wedge HTO, whereas the incidence of patella alta increases after closed wedge HTO. We recommend considering the PH and tibial slope before planning for HTO or TKR after HTO, also performing cw-HTO or ow-HTO with the tuberosity left at the proximal tibia in cases of patellofemoral complaint or patella infera.
There has been very little documented regarding the impact of meniscal injuries on knee proprioception. The aim of this study was to investigate the proprioceptive function of patients with meniscal tears and asses the influence that arthroscopic partial menisectomy has on knee proprioception.
One hundred subjects were recruited comprising an Arthroscopy group (50 patients) and a Normal Control group (50 subjects). The Biodex Balance SD System was used to assess proprioception. This equipment measures knee proprioception on an electronic platform. The balance of the subject is computed producing an Overall Stability Index (OSI). Lower scores reflect better proprioception. Knee stability was assessed clinically and with the Rolimeter knee arthrometer. The Lysholm and IKDC scoring systems were used to evaluate all the subjects.
Of the 50 subjects within the Arthroscopy group (all of whom had a normal ACL confirmed) 34 were found to have meniscal tears. Twenty-nine of the 34 patients with meniscal tears returned for their follow-up review 3 months post-operatively.
The proprioceptive function of the injured knee of the Arthroscopy group with meniscal tears (mean OSI 0.86) was significantly poorer compared to that of their uninjured knee (mean OSI 0.62, p< 0.001, 95%CI 0.14, 0.34) and to the Normal Control group (mean OSI 0.49, p< 0.001, 95%CI 0.21, 0.54). There was no significant improvement in their proprioceptive function following menisectomy (mean OSI 0.75, p=0.23, 95%CI −0.07, 0.28). There was a significant improvement of both the Lysholm (p=0.004) and IKDC (p=0.021) scores postoperatively.
The mean age of the patients was 11.04 years (range between 4–16). Mean follow up time for the patients after they had undergone the procedure was 16.2 months (range 3 – 34). The Mean correction achieved − 21.52 degrees (range 5 – 40). Mean correction per month − 2.05 degrees. A paired ‘t’ test showed the correction was found to be highly statistically significant (p value < 0.001).
We report the our experience of using the Sheffield intra-medullary telescoping nail system for managing recurrent fractures and deformity problems in the long bones of the lower limbs. 15 children with conditions like osteogenesis imperfecta, fibrous dysplasia and neurofibromatosis were operated from the years 1993 to 2001 and followed up for a mean period of five years nine months. The average age at the time of the initial nailing was six years. In all, 21 femurs and 10 tibiae were nailed.
A total of thirteen complications were noted in seven patients, including re-fractures with the nail-in-situ in seven bones, migration of the rods in four bones, fracture of the nail and one sub-clinical infection after femur nailing. Nine revision operations were necessary to address these problems including removal of the infected nail. All these revisions were successful. The estimated 5 year cumulative survival rate was 73% for femur and 75% for tibia. We have not experienced any evidence of epiphyseal damage after the procedure. All our patients can ambulate independently now.
Elongating intramedullary rods are ideal in children with any condition that can cause recurrent fractures or limb deformity as they improve walking capability and prevent further deformity.
Ten operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks.
Twenty-six hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. 21 further age and sex matched AP pelvis radiographs were taken from the PACS system at random. All of which had been reported as normal by a consultant musculoskeletal radiologist, these formed group C.
The Kruskal Wallis test was used to compare the 4 outcomes, in the 3 groups.
A significant difference between the groups was found for contact area (p< 0.001). There was no significant difference between the other 3 outcomes. Anterior coverage (p=0.509), posterior coverage (p = 0.135) and antirversion (p= 0.845).
A significant proportion of children with cerebral palsy (CP) are malnourished. This is particularly the case for trace elements, vitamins and minerals. Children with CP undergoing major orthopaedic procedures lose blood intra operatively leading to post operative anaemia. The aim of our study was to estimate the prevalence of low levels of serum ferritin in children with CP awaiting major orthopaedic surgical intervention.
The ferritin levels and haemoglobin (Hb) were estimated pre-operatively in 35 children with CP (CP group) undergoing major orthopaedic surgery (Hip reconstruction or Single event multi-level surgery). During the same period, we randomly identified 1000 children (Control group) who underwent Ferritin estimation as part of routine investigations. A significant proportion of children in the study group had low levels of serum ferritin in spite of having normal haemoglobin.
It is well-recognised that commencement of iron either orally or intravenously in the post-operative period does not accelerate recovery from anaemia secondary to blood loss. It is important to note that many patients who have normal Hb levels preoperatively are iron deficient. Hb estimation alone is inadequate in this group. We therefore conclude that children with cerebral palsy undergoing major orthopaedic surgery must have their ferritin levels estimated and optimised well in advance of their surgery.
We review all litigation brought against English Orthopaedic departments involving children under the age of 16 and attempt to highlight areas where they might be avoided. The NHSLA (the National Health Service Litigation Authority) is a special Health Authority responsible for handling negligence claims made against NHS bodies in England. In addition to dealing with claims when they arise, there is an active risk management programme to help raise standards of care in the NHS and hence reduce the number of incidents leading to claims. By analysing the claims data, we have had the opportunity to see trends for which Trusts have litigation brought against them, how much this costs the Health Service and most importantly how this information can aid in clinical practice.
Between 1995 until 2005/06 there were 408 cases involving orthopaedics in England that had reached a conclusion. Of those considered in our study (341), by far the most common broad category for litigation is missed or delayed diagnosis of a condition 179 cases (57% of all litigation cases) with 44% (80 cases) of those being upper limb traumatic injuries. Humeral supracondylar fractures and elbow injuries constitute 24% (44 cases) of all missed diagnoses with each having an average total payout of £27,998. Missed or poorly managed developmental disorders of the hip (DDH or SUFE) also have large total payouts. Other common causes for litigation are intra-operative errors with poor results/complications for fixation of humeral supracondylar fractures again being the most common. Complications of plasters also represent 7.3% of all claims, all with high total payouts.
In assessing these trends, we suggest highlighting the potential for error during training of juniors and taking extra care during clinical practice. There are also implications identified for the planned provision of Orthopaedic care of children.
Thirty-six patients had MRI at 2 years. Using paired t test we noted statistically significant increase in mean dural sac area in all four positions mentioned above. There was clinical improvement in 26 and some or no improvement in 10 patients. Number with increase in canal cross sectional area was 28 and that with reduced area was 8. Clinical and canal area improvement was seen in 20 (56%) patients and clinical improvement with reduced canal area was seen in 5 (14%). Some or no clinical improvement with canal area improvement occurred in 8 (22%) patients and no significant clinical or canal area improvement in 3 (8%).
Majority of patients (56%) showed clinical and cross sectional area improvement at 2 years. One patient with no clinical improvement had subsequent decompression surgery (this patient had dural cross sectional area improvement). 64% patients had similar clinical and dural cross sectional area changes but there is not a clear-cut correlation between clinical outcome and change in canal cross-sectional area.
The recent NICE guidelines on management of osteoarthritis outline weight loss as first line treatment in degenerative joint disease in the obese. There is little data surrounding the effects of obesity on the outcomes in spinal surgical interventions. Intervertebral discectomy is one treatment for prolapse of a lumbar vertebral disc. We aim to investigate the effect of obesity on outcomes for discectomy.
Demographic details including age, sex, weight and BMI were recording with a pre-operative Oswestry Disability Index (ODI). The fat thickness was measured at L5/S1 using calibrated MRI scans. Outcome measures included complications, length of surgery and change in ODI at 1 year following surgery. Obesity was defined as a body mass index of over 30. The units Serial patients undergoing discectomy were recruited into the study. Patients with bony decompression, instrumentation, revision surgery or multilevel disease were excluded.
Fifty patients with a single level uncomplicated disc prolapse were entered into the study. Sixteen patients had a BMI over 30 and so were obese, whilst 34 had a BMI of less than 30. The mean pre-operative ODI was 46.5 in the obese group and 52 in the normal group this difference was not significant (p> 0.05). The mean post operative ODI was statistically improved in the high BMI group at 28 (18.5 point improvement) and 25.2 (29.1 point improvement) in the normal group. The ODI improvement was significantly better in the low BMI group (p=0.036). There was no significant difference in operative time (p=0.24). Only a single patient had a complication (dural leak), so no valid comparison could be made.
The outcomes of spinal surgery in the obese are mixed.
We found no increase in the complication rate or intra-operative time associated with an increased BMI. However, the improvement in ODI was significantly better in the normal BMI group.
How much sway is significant for a traditional Romberg test has always been open to interpretation and debate. Prospective and detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.
Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.
The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a pro-prioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.
The Depuy Sigma Total Knee Arthroplasty (TKA) was introduced in 1997 as a modification of the Pressed Fit Condylar (PFC) TKA. It is the most commonly used TKA in England and Wales, accounting for 34.9% of all primary TKAs performed in 2006. The PFC has reported 10-year survival rates of 90–95%. This study reports the first clinical and radiological outcomes at 7–9 years following TKA using the PFC Sigma prosthesis.
Three hundred and eighteen consecutive Sigma TKAs were performed in 275 patients between October 1998 and March 2000. Patients were prospectively followed up in a specialist nurse-led clinic. Final review was performed in December 2007 or January 2008, i.e. 7–9 years post surgery. Outcome measures included American Knee Society Scores, Radiographic Scores and Oxford Knee Scores. Survival analysis was performed using the life table method.
Of 318 Sigma knees, 225 (193 patients) were alive at 7–9 years. 6 knees in 5 patients were lost to follow up. 7 knees (2.2%) were revised: 6 for infection within the first two years and 1 at 59 months who underwent isolated change of polyethylene insert. The 9-year survival was 97.7% with revision for any reason as endpoint and 99.6% with revision for aseptic failure as endpoint. The mean American Knee Society Knee score was 84/100 at 7–9 years compared with 33/100 pre-operatively. 0f 140 radiographs, 48 knees had radiolucent lines but no knee showed radiological evidence of loosening.
These results suggest that the Sigma TKA gives excellent clinical results up to 9-years.
We report a retrospective study of the major complications following one-stage and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally- invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage bilateral UKR and 80 patients (160 UKRs) had two-stage bilateral UKRs. The remainder were unilateral UKRs.
The bilateral UKR groups were comparable in age and ASA grade, but more females were in the two-staged group (p=0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep vein thrombosis (DVT) and adverse cardiac events within 30 days of surgery.
No statistical differences between the groups were found regarding operating surgeon, tourniquet time or minor complications (excepting distal DVT). Anaesthetic times were greater for the two-stage group (p= 0.0001). Major complications were significantly more common with one-stage bilateral UKR (13 patients, 8.2%) compared to two-stage bilateral UKR (no patients) (p=0.005). Distal DVT was more frequent in the two-stage group (p=0.036).
This series reports significantly higher risks of major complications are associated with one-stage bilateral UKR when compared to two-stage bilateral UKR. There is no evidence that the addition of chemical thrombo-prophylaxis would change this risk. We advocate caution before undertaking a one-stage bilateral UKR.
Arthritis may cause mild to moderate pain at rest, joint stiffness and varus or valgus deformity. This may prevent a person from working or prevent them from sitting cross-legged, squatting, climbing the stairs or walking distances. The role of osteotomy have been studied. One hundred cases were performed over a 5 year period and the results were evaluated.
There were 44 men and 56 women. The majority were sedentary workers. The majority of the patients had symptoms for between 1 and 2 years. Pain was mostly located on the medial side and there was no pre-operative feeling of instability. The pre-operative range of movement was between 90–120 degrees in 68% of cases.
In 20 cases, a dome osteotomy was performed. In 80 cases a wedge osteotomy: 75 cases were valgus osteotomy and 5 cases by varus osteotomy. All patients benefited from surgery as regards the relief of pain. Very old and obese patients showed poor results after surgery due to their inability to do the required physiotherapy. The patients having a shorter duration of symptoms showed greater radiographic improvement than those with a longer duration of symptoms.
The patients with 1–10 of postoperative valgus alignment obtained the most pain relief and a good range of motion. Over correction and failure to achieve valgus showed poor results. Overall, 52 % of patients showed good results, 35 % fair and 13% poor results.
This study presents the intraoperative findings of a cohort of 201 cases of failed Unicompartmental knee arthroplasties (UKA) from the Trent Wales arthroplasty audit group (TWAAG) register from 1990 to 2008. The main objectives of the study were to determine the common modes of failure and trends in implant systems used using sex and age matching criteria.
Results demonstrate the varying reasons for revision, use of augmentation and surgical preference in revision system. Results include survival rates and revision rates of UKA from the Trent Wales arthroplasty audit group. The average patient age at revision surgery with the average times from primary UKA to total knee arthroplasty are demonstrated. Aseptic loosening was the commonest reason for revision in both younger and older age groups, closely followed by Polyethylene wear in the younger age group versus progression of osteoarthritis in the other compartments in the older age group. The commonest implant used was Oxford unicompartmental knee system at primary surgery with the PFC implant used in almost 50% of all cases that were revised. This study demonstrates the survival rate of UKAs to be significantly higher in female patients and in those patients with primary UKAs at a younger age. The trends in revision systems have changed over the years. In the early years, over 50% used the PFC knee systems, compared to the latter eight years where the majority used revision knee systems, (e.g. LCCK and Legion). This trend is due to increased availability and ease of use of revision systems. The commonest site of augmentation was for tibial bone defects. Approximately 50% of all augmented cases required tibial blocks or wedges.
Although current thinking suggests most UKAs can be revised to a primary total knee system without difficulty, a significant proportion required revision implant systems with associated implications.
High Tibial Osteotomy (HTO) is a recognised method of correction for knee joint malalignment and unicom-partmental osteoarthritis. Long-term results of this technique have been reported and are favourable. Good results have also been reported with Autologous Chondrocyte Implantation (ACI-C, MACI). Malalignment, if present, should be corrected when ACI is performed. Although results have been reported for either procedure separately, the outcomes of combined HTO-ACI remain unreported. The aim of this study was to evaluate functional outcome in patients undergoing combined HTO-ACI procedures.
Twenty three patients undergoing a combined ACI-HTO procedure were identified retrospectively from a larger trial of patients undergoing ACI for symptomatic chondral defects. The mean age of the patients was 36 (28 – 49). The mean follow-up was 54 months (12 – 108) and mean defect size was 689mm2 (range 350 – 1200). Nine patients had ACI-C and HTO, the remainder having MACI and HTO. Pre and post-operative assessment was carried out using the Visual Analogue Score (VAS), the Bentley Functional Rating Score and the Modified Cincinnati Rating System.
The Mean VAS score improved from 7.4 (4 – 10) pre-operatively to 2.9 (0 – 6) post-operatively at the latest follow-up (p< 0.0001). The Bentley Functional Rating Score improved from 2.9 (2 – 4) to 1.8 (0 – 4), which was statistically significant (p< 0.0001). The Modified Cincinnati Rating System improved from 35.2 (20 – 49) pre-operatively to 68.7 (46 – 85) post-operatively (p< 0.0001). Fourteen patients underwent biopsy of the graft site at a mean of 13.7 months: 21% of biopsies were hyaline-like cartilage, 36% were mixed hyaline/fibrocartilage, 29 % were fibrocartilage and 14% were fibrous tissue.
Combining high tibial osteotomy with autologous chondrocyte implantation is an effective method of decreasing pain and increasing function in the short term. Further evaluation of this procedure is required.
The Cartilage Autograft Implantation System (CAIS) is being investigated as a potential alternative surgical treatment to provide chondrocyte-based repair in a single procedure for articular cartilage lesion(s) of the knee. CAIS involves preparation and delivery of mechanically morselized, autologous cartilage fragments uniformly dispersed on a 3-dimensional, bio-absorbable scaffold and fixated in the lesion with bio-absorbable staples. CAIS maintains chondrocyte viability and creates increased surface area, which facilitates the outgrowth of embedded chondrocytes onto the scaffold. A proprietary disposable arthroscopic device for harvesting precisely morselized cartilage tissue is used.
In an EU pilot clinical study involving 5 countries 25 patients were randomized and treated using a 2:1 schema of CAIS:microfracture (MFX). Subjects returned for follow-up visits at 1 and 3 weeks and then 2, 3, 6, 9, 12, 18 and 24 months and were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Outcomes at each time point were analyzed with Students t-test.
This study showed that CAIS is safe to use. During the first year, the clinical outcome data in both groups were similar. However, at 18 and 24 months we noted that selected outcome measures were different. At 18 months the Sports & Recreation values were 50.6 ± 22.70 and 21.3 ± 33.25 (p=0.016) for CAIS and MFX respectively and at 24 months 52.1 ± 27.9 and 26.7 ± 26.2 (p=0.061) for CAIS and MFX respectively. At these same time points the Quality of Life data were 43.0 ± 27.14 and 27.2 ± 29.11 (p=0.2) for CAIS and MFX respectively (18 months) and 45.1 ± 28.07 and 20.5 ± 21.47 (p=0.062) for CAIS and MFX respectively (24 months).
While some of the data are not significantly different in this pilot study, taken together they do provide evidence to support the initiation of a more robust clinical trial to investigate efficacy.
The treatment of patients with arthritis of the glenohumeral joint with an associated massive irreparable cuff tear is challenging. Since these patients usually have proximal migration of the humerus, the CTA extended head allows a surface with a low coefficient of friction to articulate with the acromion.
Between 2001 and 2006 a total of 48 patients with arthritis of the shoulder joint associated with a massive cuff tear, were treated with a CTA head. The indications for use being Seebauer Type 1a and 1b appearances on x-ray and active abduction of the arm to more than 60° with appropriate analgesia. Preoperatively, a Constant score and an ASES pain and function score were completed as well as standard radiological assessment. These were repeated at follow up. Paired t tests were carried out for all the variables. A Kaplan-Meier survival analysis was performed.
Follow up varied between 2 and 8 years. Improvements in pain, function and all movement parameters were significant at p< 0.001. There was no change in the strength component. Survival analysis showed 94% survival at 8 years (95% CL 8%) there were 2 revisions and 5 deaths. Radiological assessment at follow up revealed no evidence of humeral stem loosening. In 5 (17%) cases however there was evidence of erosion in the surface of the acromion and in 13 (45%) erosion of the glenoid. Finally one component was also seen to have subluxed anteriorly.
This head design has been in use for a number of years. To date there appears to be no reported outcome of their use. This series shows that in an appropriately selected patient a satisfactory clinical outcome can be maintained in the short to medium term. The presence of erosion of the glenoid but also the under surface of the acromion does require continuing monitoring.
The metal backed glenoid component in total shoulder replacement (TSR) has been associated with high revision rates and some authors have suspended the use of this implant.
The aim of this study was to evaluate the medium to long-term outcome of the metal backed glenoid component in rheumatoid patients.
Thirty-nine patients (46 shoulders) with a mean age of 55 years (35–86 years) received a TSR with a screw fixed porous coated metal-back glenoid. Ten were lost or died before 8 years follow-up, of which none were revised. Twenty-nine patients (36 shoulders) were followed up for a mean of 132 months (96–168 months). A Constant score was measured preoperatively and annually from time of surgery, and independently at last follow-up. Radiographs were assessed for lucency, loosening and superior subluxation of the humeral head.
The Constant score improved by 12.9 points (p=< 0.001). Implant survivorship at 10 years was 89%. Five were revised: 3 for pain secondary to superior subluxation, one for infection and one for aseptic loosing. All patients with lucent zones around the glenoid (four) had superior subluxation of the humeral head two to four years prior to their development. Survival rate however at 10 years was reduced, if judged by the development of superior subluxation on radiographs (33%).
The uncemented glenoid performs well in the rheumatoid shoulder, giving pain relief and improved functional outcome. The survivorship is comparable to previously reported studies.
From 1993 to 2008, 44 DELTA III prostheses were implanted for 33 three-part and four-part displacements and 11 fracture-dislocations, in 3 males for 41 females, with an average age of seventy five years. The results were estimated with AP and profile X-rays.
Ten patients died and and three moved. Thirty one cases were reviewed with a mean follow-up of 6.3 years, range 1 to 15. The radiographs showed:
two 2-mm thick borders on the glenoid at four and eight years. one aseptic loosening of the base plate at twelve years with a broken polar inferior screw. nineteen inferior scapular notches at a mean occurrence time of 4.6 years: the longer the follow-up, the more severe the notch with two distinct patters of notches: mechanical, stable, because of an impingement between the humeral component and the pillar and biological, progressive in size, evolving over time with proximal humeral bone loss (five medial resorptions and three bone-cement interface medial borders) because of polyethylene disease. fourteen inferior spurs, stable after emergence at a mean occurrence time of 2.5 years. one joint ossification at 6 months and stable at 6 years. one septic humeral loosening at 2 years.
In elderly patients with trauma, when attachment of the tubercles on the classical orthopaedics devices is impossible, the use of a RSA leads to precocious worrying and progressive images but with only one re-intervention for an aseptic loosening of the base plate at a twelve year evolution. New developments in design and bearing surfaces, new surgical techniques of implantation and a more long term results will probably provide more durable utilization of the reverse concept for this indication.
The correlation between the results of NCS and the subsequent outcome from surgery Compare these results with a similar group of patients that underwent decompressive surgery without NCS.
It is difficult to estimate the true cost to the Trust for a cancelled case. Each cancelled case is a ‘slot’ on an operating list that has not been filled. There are regular Waiting List Initiative (WLI) Lists – the number of these have increased. Could an empty slot on a regular list have been filled by a WLI case? Would the cost of the WLI case theoretically performed in the empty slot be the cost of the cancelled case? The model is basic and has many assumptions. Patients are allocated a slot on a WLI list for a variety of reasons, however with enough numbers and across enough time, the true cost must be somewhere near these figures.
The total number of WLI cases in the same period and the total cost of those cases.
Cases Cost: £3,234,000 (£2,065 per case)
Orthopaedics, internal medicine and general practice were the future specialty interest of 6%, 29% and 36% respectively. Only 15% had any Foundation Programme exposure to Orthopaedics and only 13% felt they had been given adequate exposure to musculoskeletal medicine.
In the feedback from UKITE 2008, 85% of trainees felt it was better quality than 2007. The trainees wanted more questions on clinical situations. Those approaching the FRCS examination are interested in using the database towards preparation for the real examination. Some enthusiastic trainees would like the facility to submit questions early. We aim to improve on these in 2009.
In 2009 we also aim to open the examination for other surgical specialties and international trainees through elogbook.org.
The use of shoulder ultrasound in clinic is a way of decreasing the time patients have to wait til definitive treatment is started. Although ultrasound is used in clinic by some surgeons, we are not aware of anyone specifically looking at the total cost implications and the impact on waiting times.
We therefore prospectively assessed the outcome of a one-stop shoulder assessment service set up by a new Consultant Orthopaedic Surgeon in a busy unit. All new patients were assessed by the Consultant, who then performed an ultrasound if indicated. Treatment or further investigation was then instituted based on the findings. The time taken and accuracy of the scans, the number of patients seen, impact on waiting times, total savings and patient satisfaction were assessed. We based cost calculations from data that included capital, structural, maintenance and staffing costs gained from the Department of Health and the hospital management.
We found that 65% of all shoulder patients required ultrasound, and these were performed in an average of 2.7 minutes, with no significant overrunning of the clinic. The sensitivity for the detection of full thickness rotator cuff tears was 88% and specificity was 89%. Four patients needed further ultrasonography by a specialist musculoskeletal radiologist. All patients reported high satisfaction rates. We calculated the cost saving over a year of two shoulder surgeons performing ultrasound in a similar setting was between £200,000 and £500,000 depending on the figures you used.
We believe ultrasound is a quick, easy, cheap imaging process for the diagnosis of soft tissue shoulder diseases. When performed at the first consultation by the surgeon it offers the advantages of high patient satisfaction rates, shorter waiting times, and significant cost savings. Should all shoulder surgeons be performing ultrasound in clinic?
Management of hip osteoarthritis in young active patients is made more challenging by the longevity required of the prostheses used and the level of activity they must endure. The aim of this study was to compare the functional outcomes and activity levels following hip resurfacing (HR) and uncemented total hip arthroplasty (UTHA) in young active patients matched for age, gender and activity levels.
255 consecutive hip arthroplasties performed in a teaching hospital were retrospectively reviewed from which were identified 58 UTHA patients and 58 HR patients, matched for age, gender and pre-operative activity level. Mean age of patients within UTHA was 58.5 years (34 – 65) and in HR was 57.9 years (43 – 68).
No patients within the study were lost to follow-up. Mean follow-up was five years.
Within each group there was a statistically significant improvement in the mean UCLA score following surgery (p=0.00). In the HR Group, mean UCLA score improved from 4.2 (1–8) to 6.7 (3–10) while in the UTHA group the mean UCLA score improved from 3.4 (1–7) to 5.8 (3–10). Mean OHS improved from 44.4 (31–57) to 16.6 (12–31) in the HR group and from 46.1 (16–60) to 18.8 (12–45) in the UTHA group, p = 0.00 each group.
This study found no statistically significant difference in the levels of function (p= 0.82) or activity pursued (p= 0.60) after surgery between UTHA and HR in a population of patients matched for age, gender and pre-operative activity levels.
This study has shown comparable outcomes with hip resurfacing and uncemented THA in terms of both functional outcomes and activity levels in a group of young active patients. The potential complications unique to hip resurfacing may be avoided by the use of uncemented THA. In addition, uncemented THA has a longer track record.
There have been marked changes in the management of Juvenile Idiopathic Arthritis (JIA) over recent decades, mainly with earlier use of methotrexate (MTX). Our aim was to describe orthopaedic interventions in a large group of adults with JIA followed up over several decades.
This was a retrospective observational study of adult JIA patients attending a teaching hospital clinic, with information collated on JIA subtype, disease duration, orthopaedic interventions and exposure to MTX.
The study included 144 patients with median disease duration of 19 years. Survival analysis showed that joint surgery was observed in the majority (75%) of patients with disease duration over 40 years with a trend for less joint surgery in patients with oligoarticular JIA. In total 41 patients (28.5%) had received joint surgery and 17/41(41%) have required multiple procedures. Of those who have required joint surgery, 20/41(48%) had started MTX in their adult years, with only 5/41 (12%), starting MTX prior to first joint replacement and none within five years of disease onset. Of the patients who have not had joint surgery to date, most (46/103, 45%) were receiving MTX or another immunosuppressive agent, in the majority of cases MTX was started within two years of disease onset.
Many adults with JIA require joint replacement surgery and ongoing immunosuppressive treatments, emphasising that JIA is not a benign disease. Many patients who have had joint replacement surgery have had exposure to MTX albeit after many years after disease onset; it remains to be seen whether patients who have received MTX therapy early in their disease course will ultimately have less requirement for joint surgery.
Metal on metal hip resurfacing (MMHR) is a popular procedure for the treatment of osteoarthritis in young patients. Several centres have observed masses, arising from around these devices, we call these inflammatory pseudotumours. They are locally invasive and may cause massive soft tissue destruction. The aim of this study was to determine the incidence and risk factors for pseudotumours that are serious enough to require revision surgery.
In out unit, 1,419 MMHRs were performed between June 1999 and November 2008. All revisions were identified, including all cases revised for pseudotumour. Pseudotumour diagnosis was made by histological examination of samples from revision. A Kaplan-Meier survival analysis was performed, Cox regression analysis was used to estimate the independent effects of different factors.
The revision rate for pseudotumour increased with time and was 4% (95% CI: 2.2% to 5.8%) at eight years. Female gender was a strong risk factor: at eight years the revision rate for pseudotumours in men was 0.5% (95% CI 0% to 1.1%), in women over 40 it was 6% (95% CI 2.3% to 10.1%) and in women under 40 it was 25% (95% CI 7.3% to 42.9%) (p< 0.001). Other factors associated with an increase in revision rate were, small components (p=0.003) and dysplasia (p=0.019), whereas implant type was not (p=0.156).
We recommend that resurfacings are undertaken with caution in women, especially those younger than 40 years of age, but they remain a good option in men. Further work is required to understand the patho-aetiology of pseudotumours so that this severe complication can be avoided.
Metal-on-metal arthroplasties are being inserted in increasing numbers of younger patients due to the increased durability and reduced requirement for revision in these implants. Recent studies have raised many concerns over possible genotoxicity of MoM implants. This is a prospective study of patients who have undergone elective total hip replacement, they were selected and then randomised into two groups. Group A received a MoP implant and group B received a MoM implant. Patients are reviewed pre-operatively (control group), at 3 months, 6 months, 1 year and 2 years post-operatively. On each occasion blood tests are taken to quantify metal ion levels (chromium, cobalt, titanium, nickel and vanadium) using HR-ICPMS method and chromosome aberrations in T lymphocytes using 24 colour fluorescent in situ hybridisation (FISH).
Fiffty three patients have been recruited to date, 24 of whom had MoP prosthesis and 29 a MoM. 25 of these have had their one-year follow-up with blood analysis. Cobalt and chromium concentration increased during the first 6 months in both MoM and MoP groups, in the MoM group the chromium levels were twice that of MoP group and 12x that of the preoperative samples. There was no difference with the levels of titanium, nickel and vanadium. Chromosome aberrations occurred in both groups. At 6 months both the MoM and MoP groups showed increase frequency of aneuploidy aberrations with further increases after one year. Structural damage in the form of translocations occurred in the MoM group after one year, but not in the MoP group.
Preliminary results of this study show that the levels of chromium and cobalt are significantly higher in the MoM group compared to the MoP group. This corresponds to increases in chromosome aberrations between the groups particularly in translocations present in the MoM group at 1 year.
In our independent centre, from 2002 to 2009, 155 BHRs (mean F/U 60 months) have been implanted as well as 420 ASR resurfacings and 75 THRs using ASR XL heads on SROM stems (mean F/U 35)
During this period we have experienced a number of failures with patients complaining of worsening groin pain at varying lengths of time post operatively. Aspiration of the hip joints yielded a large sterile effusion on each occasion. At revision, there were copious amounts of green grey fluid with varying degrees of necrosis. There were 17 failures of this nature in patients with ASR implants (12 females) and 0 in the BHR group. This amounts to a failure of 3.5% in the ASR group.
Tissue specimens from revision surgery showed varying degrees of “ALVAL” as well as consistently high numbers of histiocytes. Particulate metal debris was also a common finding.
The mean femoral size and acetabular anteversion and inclination angles of the ARMeD group/all asymptomatic patients was 45/49mm (p< 0.001), 27/20°(p< 0.001) and 53/48°(p< 0.08). Median blood chromium(Cr) and cobalt(Co) was 29 and 69 μg/L respectively in the ARMeD group versus 3.9 and 2.7 μg/L in the asymptomatic patients (n=160 with ion levels). Explant analysis confirmed greater rates of wear than expected.
Lymphocyte proliferation studies involving ARMeD patients showed no hyper reactivity to Cr and Co in vitro implying that these adverse clinical developments are mediated by a toxic reaction or a localised immune response.
Our overall results suggest that the reduced arc of cover of the fourth generation ASR cup has led to an increased failure rate secondary to the increased generation of metal debris. This failure rate is 7% in ASR devices with femoral components _47mm.
Four hundred and twelve patients were included in the study. The mean Harris, VAS and HSS were significantly different between the failed and well fixed groups. However there was no statistically significant difference between the mean Oxford and MDA scores. ROC analysis demonstrated the Harris (0.97), VAS (0.98) and HSS (0.77) score to have good prediction of outcome.
Radiologically, 15 showed component subsidence, 9 demonstrating radiolucency around one or both components. In one case where the patient had not undergone reoperation component fracture was seen on x-ray. Clinically, in patients who had not undergone subsequent fusion, 15 had less than 36 degrees of movement, 9 had between 36–45 degrees, 4 were in the 46–60 range and only one had more than 60 degrees. There were no cases of infection.
Classification of osteoarthritis of the hip is fraught with difficulty Although different patterns of disease are recognised, there is no accepted classification or grading system. We aim to develop a classification system that reflects both the radiological changes, and the local disease process within the joint.
After ethical permission and consent tissue was taken from 20 patients undergoing primary hip replacement surgery. Intra-operative tissue samples were taken from each patient and the steady state gene expression of several cytokines (TNF-α, IL1-β, IFN-γ, IL-6, RANKL and OPG) measured quantitatively using Taqman RT-PCR. Relative expression was calculated for each sample using standard curves and normalised to 18S expression. The technique was consistent with high correlations for repeated measures from the same tissue type (κ=0.99) and from different tissue types in the same joint (κ=0.92). Intra-observer (κ=0.93) and inter-observer (κ=0.89) reliability for the technique were also found to be high.
Preoperative radiographs were scored by two independent observers and joint space narrowing, cysts, osteophytes and sclerosis noted in each of the DeLee-Charnley zones on the femoral and acetabular side. Based on these scores patients were then classified to either lytic or sclerotic type and subclassified into either hypertrophic or atrophic.
Subgroup analysis of cytokine expression by radiographic type was performed. There were statically significant differences in expression of macrophage stimulating cytokines (IL-1γ and OPG) in the lytic group as compared to the sclerotic group (p< 0.05). Conversely, the sclerotic group expressed significantly higher levels of IL-6. Individuals with atrophic subtype demonstrated significantly higher levels of IL-1β and IL-6, but lower levels of IFN-γ
Our results demonstrate greatly differing patterns of disease within osteoarthritic hip joints. These changes are reflected in radiographic appearances of osteoarthritis. Our proposed classification system can be used grade and classify osteoarthritis in a manner that reflects the disease process.
There was a statistically significant differences in their score between type-2 surgical and conservative groups (P=0.0006), and between type-3 surgical and conservative ones (P=0.04), but no significant difference between type-2 and type-3 surgical groups.
At medium-term follow-up, the scores for type-2 and type-3 surgical groups were 77.06 and 63.66 respectively, with significant increase in type-2 while type-3 remains similar comparing to two-year scores. There were 7 deep, 5 superficial infections and 32 metalwork removals in total.
In this series, contrary to published articles, there was a better outcome at two years with surgical treatment than conservative treatment.
Hind foot arthrodesis through traditional lateral approach in patient with severe valgus deformity carries a significant risk of wound breakdowns, infection and the risk of sural nerve damage. It is also difficult to fully correct a severe valgus deformity through the lateral approach. To overcome some these problems a medial approach has been recommended. Few authors have reported good results in a small series of cases.
We present a retrospective review of 18 consecutive patients with valgus hind foot deformity who underwent hind foot arthrodesis via a medial approach. There were 10 male and 8 female with an average age of 55 years (range 28–75years). The indications included osteoarthritis in 13; post traumatic OA in 3 and rheumatoid arthritis in 2. The mean pre-op subtalar valgus angle was 32o (range 12 – 49) and mean post op valgus angle was 17 (range 10 – 25). All the wounds healed primarily and there were no incidence of wound breakdown or infection. None of the patients developed neuro-vascular complications. The average time for fusion was 5.6 months (range 3–9). Two patients needed further surgical intervention, one for FHL tethering at the fusion site and one for non-union of subtalar joint in a chronic smoker.
The medial approach not only allows a safe and fantastic access to subtalar joint making correction of valgus deformity easier but is also extendable to include talo- navicular and naviculo-cunieform fusion and FDL transfer as additional procedures through the same approach as and when indicated
In conclusion we recommend the medial approach for performing subtalar arthrodesis in valgus hind foot deformities
Ostoearthritis of the trapeziometacarpal (TMC) joint, the key joint in thumb opposition, is one of the most common diseases involving the hand, especially among middle-aged and elderly women, and can seriously impair overall hand function.
A Jamar dynamometer was used to assess the grip and pinch strengths which showed a 63% of recovering of the grip strength. Overall survival after a mean follow up of 36 months was 93%. At final follow up mean Quick DASH score was 27.4 Radiological review of the surviving joints showed subsidence of trapezial component in 4 joints and further lucencies in 3 joints. However, these patients had good hand function and grip strength. No sign of osteolysis was seen in any of the cases. We found that the radiological findings did not correlate with clinical findings. Satisfaction rate was 26 good to excellent, with 5 fair and 3 poor.
Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio.
We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury.
One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population.
Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender
Long-term follow up after replacement arthroplasty has become established as a “Gold Standard”, providing information that can aid optimisation in future prosthetic design and use. In less mainstream joint replacements however, the evidence for use of prostheses, and in particular long-term outcome, is scarce.
A cohort of 71 patients (93 implants) was reviewed in 1997 having had a De la Caffinière prosthesis implanted between 1980 and 1989. The conclusions of the study included the findings that the replacement was generally well regarded by recipients, pain was improved and survivorship was comparable with data from the best hip replacements.
Ethical permission was obtained to review the same cohort ten years on (16 – 26 years post-op). Similar outcome measures were employed as in the original study but in addition formal grip strength measurements were taken, along with newer outcome scores including the DASH (Disability of arm, shoulder and hand) and EQ-5D (a European quality of life measure). Radiographs allowed assessment of radiological failure using the criteria from the original study.
We found a significant mortality rate in the interim period since the original review (27 patients, 36 implants). A further 8 implants in 8 patients had been removed and were not clinically reviewed as per patients’ wishes. However, 39 implants in 26 patients were available for follow up at a mean 19 years (SD 6.3) leaving a “lost to follow up” rate of 10 patients (10 implants). Survivorship at 26 years was 73.9% (95% CI 61.2, 86.6) with the end-point as revision. Our data also demonstrated continued patient satisfaction without pain, satisfactory power and thumb mobility.
Such information may be used to counsel future patients requiring surgery that there is a functional alternative to excision arthroplasty (trapeziectomy).
We found a positive correlation between age and time to union/graft incorporation (R2 = 0.47). The mean time to graft incorporation was 16 weeks. All of the patients treated with iliac crest structural graft progressed to union. Only 2 of the 4 patients treated with HA graft achieved incorporation, while the other 2 have required revision surgery.
Conclusions: At a midterm follow-up, reconstruction of the MPFL with rerouting of the semitendinosus tendon is an effective method with improved function in all patients. Maximum improvement was achieved within the first six postoperative months. Heterogeneity of our population may have affected some of our results.
The HA coated implants remained asymptomatic. Three uncoated components required revision for migration. No evidence of accelerated UHMWPE wear was seen on retrievals or radiographs. Histological analysis of the retrieved HA coated specimens showed excellent bony fixation, uncoated cups showed predominantly fibrous tissue.
This large randomized study unequivocally shows for the first time that, compared to a 28 mm articulation, a 36 mm articulation in THR is efficacious in reducing the incidence of dislocation in the first year following THR.
For validating the classification system, six surgeons reviewed 14 hip arthroscopy video clips. All surgeons were provided with written explanation of our classification system. Each surgeon then individually graded the cartilage lesion. A single observer then compared results for observer variability using kappa statistics.
The Olympia has only been used at 3 centres until the 10 year clinical and radiographic results were available. The results at 10 years justify further evaluation. It is crucial that meticulous detail to cement technique is adhered to in the operative technique. The ease of insertion and natural anteversion has given confidence to surgeons in training.
Patient demographics were similar between both groups. There was no significant difference in intra-operative blood loss between both groups. The early post-operative blood loss and total blood loss were significantly less in the tranexamic acid group. This effect of tranexamic acid was more significant in females who showed a dose-related relationship between tranexamic acid dose and blood loss. Fewer patients in the tranexamic acid group required blood transfusion. There was no increased incidence of DVT in the tranexamic acid group.
The use of a single pre-operative 1g bolus of tranexamic acid administered before surgery is a safe, cost-effective method of reducing post-operative blood loss following total hip arthroplasty. The effect is more significant in females at this dose.
no treatment (control); administration of alendronate (ALN) from 14 days after osteotomy; ALN from the time of osteotomy. Fracture repair was assessed weekly with the use of standardised radiography, DEXA scan and in vitro peripheral quantative computed tomography (pQCT). The rats were sacrificed 42 days post-osteotomy and the femora underwent mechanical testing.
Radiologically, BAC-MS and cartilage thickness at three months had no significant difference between treatment and placebo groups (p-value = 0.81 and 0.88 respectively). The change in BAC-MS and cartilage thickness at 3 months was also not significant (p-value = 0.09 and 0.41 respectively).
31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries.
32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients.
41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test).
There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test).
Hypothesis: That IRI can be attenuated using established antioxidant medications (ascorbate and n-acetyl-cysteine) in the controlled setting of elective knee arthroscopy.
We have demonstrated that simple targeted changes can make a significant difference to wait till surgery after hip fracture.
2pm to 5pm weekday trauma lists were extended from 2pm to 7pm two days a week.
Priority for one hip fracture case first thing on the CEPOD emergency list each day.
Fortnightly morning ‘day case’ trauma list for minor cases.
The mean time to return to training post operatively was 34 days (24–54) and to playing was 41 days (29–72). Significant correlations were found between the length of symptoms and the number of pre operative injections (Spearman’s rank correlation coefficient = 0.806. p< 0.001) and the length of symptoms pre-operatively and return to training (Correlation coefficient = 0.383. p=0.048) and return to play (Correlation coefficient = 0.385. p=0.048). Return to training was significantly faster after soft tissue debridement with FHL release than after bony surgery (p=0.046 Kruskal-Wallis test). There was one surgical complication in the form of a persistent portal leakage. This was successfully treated by resting the ankle in a boot for 2 weeks. One patient had recurrent symptoms 3 months after surgery; this was successfully treated with an ultrasound guided injection. There were no infections and no neurovascular injuries.
All except 1 joint in one patient had clinical and radiological fusion of their joints. 1 patient needed removal of metalwork and 4 had delayed wound healing. Average satisfaction score was 7/10. 86% Patients would recommend it to a friend and 91% would have it again.
We calculated age-related incidence of hip fracture in the local population and noted the first significant increase at the interval between 40–44 and 45–49, rather than the age of 50, which is when the onset of screening of hip fracture patients for osteoporosis occurs in most health areas. Lag screw fixation was the most common method of operative fixation. General complication rates were low, as were reoperation rates for cemented prostheses. Intracapsular fractures are an interesting subgroup. When displaced, 39% (61/158) had lag screw fixation and 61% (97/158) were treated by arthroplasty. Kaplan-Meier implant survivorship of displaced intra-capsular fractures treated by reduction and lag screw fixation was 82% at two and 71% at five years.
A second stage reconstruction was performed after 4–6 weeks, using a free vascularised fibular graft, fixed using internal and/or external fixation.
Patients gained an average of 46° forearm rotation (range 0–105°) with wrist or elbow motion significantly improved in 3 patients. At last review, all patients had a pain-free stable forearm with unhindered hand functions of grasp, hook and pinch. SF-36 assessment showed varied results, although mean values for the physical components of the survey were lower than general population values, while mental/emotional scores were as good.
Complications included: Superficial infection (1), deep infection (1); Recurrence 2; Improper cementing (2); Neuropraxia [radial nerve] (8); Subluxation of prosthesis head (8); Post radiotherapy skin necrosis and contracture (1); 4 patients died.
The theoretical benefit historically attributed to rota-tionplasty lies in the provision of a functional and durable hinge joint, however these results suggest that this advantage has been negated by modern endoprostheses, probably due to improvements in surgical experience and prosthesis technology.
In Europe wide exhibition on ancient diseases in skeletal and mummified remains are scarce. In the last Congress of the EBJIS held last year in Barcelona a small sample of old infection diseases were showed. Until now, only in the specifically meetings of paleopathology it is possible to see some examples of this archaeological pieces. The knowledge of the frequency, prevalence and evolution of the most important infections that use to affect at bone across the time could be important to evaluate the health status of the population.
From February to August 2009 is been open in the Egyptian Museum of Barcelona a wide exhibition of archaeological pieces that shows a wide range of abnormalities and diseases in skeletal and mummified remains. More than 150 pieces belongings at 35 different institutions around the World are shows to the public. Among theses, 58 pieces are present in the Infection Area; they cover a wide range of time in the Mankind History, from the Neolithic Period to the end of the XIX century. We present a sample of the most important pieces of this ambit as poliomyelitis, Hanssen disease, treponematosis, tuberculosis, brucellosis, pyogenic osteomyelitis in diaphysis of long bones and in the spine, hidatidic cists. The diagnoses of some of them are evaluated by molecular evidence. We also shows the mummies of two children, one with tuberculosis and the other with triquinosis, and an adult mummy from the Tiwanaku Culture possible affected of treponematosis.
Direct observations have shown that the bacteria and fungi that cause device-related and other chronic infections grow in well developed biofilms on the surfaces of biomaterials and of compromised tissues. This mode-of-growth confers on the microorganisms an inherent resistance to host defenses, and antibiotic therapy, and makes these infections very difficult to detect because biofilm bacteria do not produce colonies when plated on the agar media used in routine cultures. We have initiated two comprehensive studies of total joint prostheses, and of non-unions secondary to trauma, in which we use DNA-based (Ibis and 454) methods for the detection of bacteria and an iterative process in which we locate and visualize biofilms using FISH probes and confocal microscopy. The DNA-based detection system confirms culture results, but detects more organisms and determines their sensitivity to antibiotics, and appears to be useful in the management of both types of infection. The use of confocal microscopy and FISH probes to visualize and map biofilms, in relation to orthopedic hardware and affected tissues, confirms the Ibis data and provides useful insights into the etiology of orthopedic infections.
Post-operative surgical site infection following total joint arthroplasty occurs at rates between ~ 0.2–5 %, depending on the joint and the surgeon volume, as well as various patient risk factors. Given that an estimated over 700,000 knee and hip arthroplasties are performed in the US each year this translates to thousands of patients that are affected by this serious, costly and traumatic complication. In addition, it is now recognized that clinical culturing underestimates the infection rate and that a number of aseptic loosenings might actually have an infectious etiology. We have used a combination of non-culture based molecular methods to detect bacteria associated with hardware, antimicrobial impregnated cement, reactive tissue and pus collected during revision surgery in a total elbow arthroplasty (TEA) case and a total ankle revision (TAR) case. Confocal microscopy showed live cocci in biofilm cell clusters, and fluorescent in situ hybridization (FISH) demonstrated S. aureus biofilms. Reverse transcriptase (RT)-PCR, and multiplex PCR coupled with electrospray-ionization mass spectrometry (Ibis T5000) to identify S. aureus, S. epidermidis and genes for methicillin resistance. Together our complimentary techniques comprise compelling evidence that viable biofilm bacteria played an important role in the refractory infections in these cases.
First generation molecular diagnostics based on PCR suggested that the routine culture of bacteria was inadequate for the detection of many pathogens, particularly after antibiotic treatment or when associated with chronic infection and biofilm growth. These techniques, however, suffered from their own problems. False negative results were caused by inhibitors of the PCR process and by the overly specific nature of most simplex assays which require an a priori assumption on the part of the investigator as to which species to test for. False positives resulted from contamination, or carryover, of amplified DNA. Recently several new technologies have been developed and have resulted in “next generation” tests that overcome the problems associated with the earlier methods. We will provide an overview of two of these technologies and present our experience in their application to the diagnosis of orthopedic infections associated with arthroplasties and external fixations. 454-based deep 16S rDNA sequencing provides for a comprehensive and quantitative analysis of all bacterial species present in clinical specimens regardless of whether the species present have been previously identified. The results of this test can be used to improve the specificity of other tests such as the Ibis Universal Biosensor. The Ibis Universal Biosensor T-5000 system uses a highly multiplex PCR front end which is coupled to a highly sensitive electron spray ionization (ESI) time-of-flight (TOF) mass spectrometer (MS) which provides for the exact base composition of the amplified DNA permitting species and even strain-specific identification of bacterial and fungal pathogens through an interface with a massive DNA sequence database. This system therefore provides both great breadth of coverage, with exquisite specificity. Moreover, this system can identify multiple species within a specimen providing a rapid analysis of polymicrobial infections.
Implant-associated osteomyelitis is caused by persistent bacterial infections, predominantly by staphylococci species forming biofilms on implants or osteosynthesis – materials. In the majority of patients the systemic immune response appears to be inconspicous with only minor upregulation of activation-associated receptors on the polymorphonuclear neutrophils (PMN). We found, however, evidence the activation of T cells, apparent as the expansion of CD4+ and CD8+ T cells bearing the activation-associated receptor CD11b. These cells also lacked the co-stimulatory molecule CD28, which is a further indicator for T cell activation. Moreover, small populations of T cells expressing Toll-like receptors (TLR)1, TLR2 or TLR4 were detected in the patients, while in healthy donors less than 1 % of T cells express TLR. A preferential association of TLR1- and TLR2-expression with CD28-CD11b+ cells was seen, compatible with the fact these cells represent an activated phenotype. In addition to the peripheral blood we also analysed leukocytes recovered from the infected site during surgery for removal of the implant. Predominantly PMN were found, highly activated as judged from their surace recpetor pattern, but also CD4+ and CD8+ T cells. As expected, these T cells represented an activated phenotype, and particularly the CD8+ cells expressed CD57, a receptor identifying end-differentiated T cells. The T cells recovered from the infected site, but not the peripheral blood T cells, produced interferon gamma, a cytokine known to support the function of phagocytic cells. In conclusion our data provide evidence that in response to local, persistent bacterial infections T cells are activated to acquire – among others – receptors selective for bacterial products, which in turn might modulate the T cell function and hence the host defence.
P. aeruginosa produce N-3-oxododecanoyl homoserine lactone (3OC12-HSL), a so-called “quorum-sensing molecule” that provides signals for the production of virulence factors and for bacterial biofilm formation in a paracrine manner. We now found that 3OC12-HSL, but not its 3-deoxo-isomer or acyl homoserine lactones with shorter fatty acids, is also able to activate human polymorphonuclear neutrophils (PMN) in vitro: 3OC12-HSL enhanced the phagocytosis of opsonised bacteria in vitro; up-regulated the surface expression of phagocytosis-related receptors, and was chemotactic for PMN. Because induction of chemotaxis implies the polarisation of the cell by receptors expressed on the surface, we performed uptake studies with radiolabelled 3OC12-HSL. At 4° C we found saturable binding of the radiolabelled 3OC12-HSL, which could be inhibited by an excess of unlabelled 3OC12-HSL, indicating specificity of binding, and hence expression of a distinct surface receptor. By use of selective inhibitors, a signalling pathway, comprising phosphotyrosine kinases, phospholipase C, protein kinase C, mitogen activated protein kinase C was delineated, but in contrast to the well-studied chemokines C5a and interleukin 8, the chemotaxis in response to 3OC12-HSL did not depend on pertussis toxin-sensitive G proteins. Selective surface receptors for 3OC12-HSL have been identified in various bacteria species, but scrutinising a human gene bank did not reveal homologous structures. While the characterisation of the surface receptor awaits further studies, the functional consequence of the cross-kingdom signalling is obvious: by recognising and responding to 3OC12-HSL PMN are attracted to the site of a developing biofilm, and thus may prevent its progression and by that persistent infection.
28 sera were collected from controls (patients with uninfected joint prosthesis, as judged from clinical, laboratory and radiological data) and 25 sera were obtained from patients with known SOIRI, sustained by S. aureus or coagulase-negative Staphilococci (CNS) (positive joint aspiration and/or intra-operative cultural examination).
Implants are highly susceptible to infection [
host-defense mechanisms around implants [ risk of hematogeneous infection of extravascular devices [ efficacy of prevention or antibiotic treatment [ correlation between efficacy of treatment in vivo and in vitro [
Taken together, these experiments showed that an agent acting on slow-growing and adhering microorganism is needed to eradicate device-associated infection. This requirement is only fulfilled by rifamycins in staphylococcal infection and by fluoroquinolones in infections caused by gram-negative bacilli [
In conclusion, the favorable role of rifampin has been proven in vitro, in animals and in human studies. Also the newest antistaphylococcal agents must be given in combination with rifampin in order to eliminate infection without removal of the device.
Implant-associated infections do not spontaneously cure. The reason for persistence in device-associated infections is the biofilm, a specialized form of bacterial growth on surfaces. The biofilm represents a survival form of bacteria which is highly resistant against most antibiotics, and can persist over months or years as low-grade infection. Bacteria in biofilms enter a metabolically inactive state, embedded in an amorphous substance, called biofilm matrix. Together they form a complex three-dimensional structure with rudimentary communication and circulation systems.
As a rule, only a combined surgical and antimicrobial management can eradicate biofilms and cure implant-associated infection. In selected patients, implant infections can be cured without implant removal with early debridement and long-term antibiotic treatment acting against biofilms. In this presentation, common pitfalls and reasons for treatment failure will be outlined and discussed.
In conclusion, using the proposed diagnostic and treatment algorithm (
Biofilm formation (BF) in wounds and on biomaterials is a severe complication in trauma and orthopaedic surgery. Maggot therapy is successfully applied in wounds, that are suspected for BF. This study investigated BF by Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella oxytoca, Enterococcus faecalis and Enterobacter cloacae on polyethylene, titanium and stainless steel and tested the effect on BF by maggot excretions/secretions (ES). Comb-forming models of the biomaterials were made to fit into a 96-well microtiter plate. In the wells, a suspension of 2.5 x 105 bacteria/ml and nutrient medium was pipetted. Combs were placed in the wells and incubated for 3, 5, 7, and 9 days at 37°C. The formed biofilms were stained in crystal-violet and eluted in ethanol. The optical density (OD 595 nm) was measured to quantify BF. Then, maggots excretions/secretions (ES) were collected according to a standardized method, added in different concentrations to (non-stained) mature biofilms (7 days), incubated another 24 hours and at last stained and measured. The results showed biofilm reduction by ES on all biomaterials. Biofilms formed by S. aureus were reduced to minima of 40% on PE and SSS (p< 0.001) and 50% on TI (p=0.005). The biofilm reduction for S. epidermidis was even greater on PE, SSS and TI with respectively minima of 8% (p< 0.001), 32% (p< 0.001) and 38% BF (p< 0.001). The quantity of BF by S. aureus and S. epidermidis had a comparable strength (p=ns) and was for both bacteria the greatest on polyethylene and the lowest on titanium (p< 0.001). Klebsiella oxytoca, Enterococcus faecalis and Enterobacter cloacae formed weak biofilms on all materials. Mature BF was reached between 5 to 7 days by S. epidermidis and between 7 to 9 days by S. aureus. Our previous research showed biofilm inhibition and breakdown of Pseudomonas aeruginosa by ES. This study showed that maggot ES also reduce biofilms formed by S. aureus and S. epidermidis which are frequently isolated from biomaterial-associated infections. There may be pharmacologic agents that could be developed from maggot ES. While BF on orthopaedic materials is an increasing problem, this experimental study could indicate a new treatment for BF on infected biomaterials
For the surgical reconstruction of bone defects there are several options:
Gradual distraction stimulates active bone regeneration and due to increased vascularisation also healing of the chronic infectious process. The mechanical lengthening device must insure stability.
As soon as both bone ends get into contact a docking manoever has to be performed to remove soft tissues between the bone ends and to stimulate healing by drilling of the bone ends with a k-wire and eventually adding cancellous bone grafts.
The external fixator is kept in place until full bone consolidation is accomplished.
Segmental bone transport can be performed by using monolateral fixators, by intramedullary nails (e.g. fit-bone) and by circular frame fixators like the conventional Illizarov or the new Taylor Spatial Frame.
Our preferred technique is the Weber cable technique with TSF which allows an ideal guidance of the segment to the docking site without cutting through the skin.
In all but 2 cases fusion and healing of chronic infection of bone and soft tissues could be achieved. In the 2 cases which could not be treated successfully an amputation had to be performed.
Also, five cefazolin and vancomycin solutions were used to impregnate bone chips and to make dose-response curves. Furthermore, 1 gram bone chips was impregnated with 5ml cefazolin or 5ml vancomycin solution.
Infection of bone represents a major challenge in orthopaedic surgery. Chronic cases are distinguished by necrosis of parts of the osseos structures. It is generally accepted, that sequestered bone comprises bacterial colonies that show inherent resistance to both host defence mechanisms and antimicrobial chemotherapy, leaving thorough removal of all necrotic tissue a prerequisite for cure. The resulting dead space needs to be filled – defects require reconstruction. Bone grafting is a well established procedure with well documented success, however, autologous bone is available only in limited amounts and recurrence rates are still high. Availability of allograft bone is unlimited but rarely used in florid osteomyelitis since surgeons fear grafts being at risk to become a focus of ongoing infection. Fresh frozen allogeneic bone contains bone marrow consisting of fat and necrotic cells. Fat is eliciting an inflammatory response that together with immunological reactions against cell membranes may create an environment promoting bacterial growth with the necroses as a growth medium. Removing bone marrow lowers the risk of infection. When using allograft bone in sites with high risks of infection it therefore should be free of all components of bone marrow.
Highly purified allograft bone, consisting of collagen and minerals as autologous bone, is unlikely to initiate or nourish a florid infection; however, the matrix surface may represent a substratum for adherence of bacteria with formation of biofilms. To avoid bacterial adhesion the matrix may be loaded with antibiotics. It has been shown that purified bone is capable of storing huge amounts of antibiotics for prolonged periods of time. This capacity offers the possibility to use allograft bone not only as a filler but the same as a carrier for antibiotic delivery.
In chronic osteomyelitis our most obstinate opponents are not the familiar planktonic pathogens but their phenotypically different sessile forms embedded in biofilms. Those require up to 1000 fold higher concentrations of antibiotics for elimination than their planktonic forms. Debridement removes the predominant amount of bioburden but some colonies disrupted from the biofilm during manipulation may find new habitats in niches of the site and cause recurrence after an indefinite period of time. Levels reached by systemic antibiosis or local therapy with commercially available antibiotic carriers mostly are not effective in eliminating biofilm remnants. Bone impregnated with high loads of vancomycin or tobramycin may provide for high local antibiotic concentations for several weeks (> 1000x MIC) that are likely to eliminate not only planktonic bacteria but also detached biofilm clusters. Allograft bone may be impregnated both in cancellous and cortical form, morsellized or structural. Indications for their use are all forms of chronic bone infection, including osteomyelitis, infected pseudarthroses, deeply infected diabetic feet and infected total joint replacement.
Osteomyelitic lesions and pseudarthroses of long bones may successfully be treated using antibiotic loaded allograft bone, providing dead space management, antibiotic delivery and reconstruction of deficient areas at the same time. As long as local antibiotic levels are higher than the dosage required for eliminating biofilm fragments no contamination of simultaneously implanted alloplastic material needs to be feared.
The main causes of segmentary bone defects at the knee, appear after high energy injuries, tumoral resections and after infected total knee arthroplasties. Nowadays the treatment of these lesions, supposes a challenge to the orthopaedic surgeons due to the difficulty of the bone and soft tissue lesions.
Initially we used the prosthesis FINN model (BIOMET©) on 11 cases, while we have used the RHK model (BIOMET©) on the remaining 24. We followed the two-stage reimplantation using antibiotic PMMA spacers either manual or preformed depending on the defect’s size. Exposure of the stiff or ankylosed knee can be especially difficult when preoperative flexion is limited, so in these situations we use the Whitesides technique (tibial tubercle osteotomy). We used platelet derivated growth factors (inductors) associated with hydroxiapatite (conductors) with the goal to obtain the best possible osteo-integration.
For decades the treatment of chronic posttraumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopedic surgery. “Sterilization” of the osteomyelitic site, that is radical debridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the debrided area was closed with skin grafts, which were removed in a further stage, when the infection was ceased; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time requiring several-stage treatment.
We performed a retrospective study on 9 patients treated for chronic osteomyelitis of the upper limb (6 forearm – 3 arm) by means of free fibula vascularized bone graft, between 1992 and 2003 (7 male 2 female). All patients had been more than 2 previous surgical attempt with conventional treatment (sterilization and bone graft). In most of them (7 cases) a two-stage treatment was performed (resection and sterilization, eventually with muscle transfer, in the first stage and bone transfer in the second one); in other 3 cases a one-stage treatment was performed. Two cases required a composite tissue transfer with a skin pad to cover the exposure. The length of bone defect after extensive resection of necrotic bone from septic pseudoarthrosis ranged from 5 cm to 12 cm.
In all cases there was no evidence of infection recurrence in the follow-up period. The mean period to obtain radiographic bone union was 4.1 months (range 2.5–6 months). In 2 cases secondary procedures have been carried out due to an aseptic non union in one site of synthesis (cruentation and compression plate). Functional results were always satisfactory although in the forearm a complete range of motion has never been achieved (plurioperated patients with DRUJ problems).
Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius, ulna and humerus of sufficient length to reconstruct most skeletal defects. The vascularized fibular graft is indicated in patients where conventional bone grafting has failed or large bone defects, exceeding 5 cm, are observed. The application of microsurgical fibular transfers for reconstruction of the extremities allows repair of bone and soft-tissue defects when shortening is not possible with good functional results.
Our work is based on the analysis of 104 patients with suppurative posttraumatic osteoarthritis of the ankle joint.
By prolonged septic arthritis with degradation of articular surfaces of ankle and shin bones we used necrectomia with osteoarthrotomy and compression arthrodesis in the mechanism of external fixation, which allows to radically sanify the nidus of infection and eliminate the inflammatory process all together. This operation was performed for 68 patients.
Surgical treatment for 18 patients with septic arthritis of the ankle joint with considerable involvement of ankle joint metaepiphysis was performed in the following way. We performed segmental resection of the shin bone distal part, put in external fixation mechanism with the possibility of defect building, and then we performed the osteotomy of the shin bone in its upper one-third. On the 10th day we started performing building of defect by Ilizarov.
For six patients with ankle joint septic arthritis with considerable involvement of ankle bone we performed its subtotal resection and compression arthrodesis in the external fixation mechanism. For patients with total overall affection of the ankle bone we performed ankle bone excision and tibialcalcaneal fusion. For three patients we performed ankle bone excision with tibialcalcaneal fusion and external fixation. For nine patients where it was not possible to perform a single-stage fusion of shin and heel bones we used external fixation mechanism with the possibility to move the shin bone fragment. Then we performed open fusion of shin and heel bones.
The result was considered to be position (92% of patients) in case of extremity support ability recovery, suppurative process elimination and bony ankylosis achievement.
Original ankle joint injury nature and localization are very important in selecting the necessary surgical treatment variant.
Differential surgical treatment tactics selection for patients with suppurative ankle joint osteoarthritis together with adequate usage of conservative therapy allow to eliminate active purulo-necrotic process and restore the extremity support function for most patients.
Based on the analysis of Rittmann and Matter the AO advocated to leave stable implants after osteosynthesis in place and to remove them only when a sufficient bridging of the fractured would have happened. In opposition it generally became accepted to remove instable implants to be replaced by an external fixateur. Using local antiseptics such as Lavasept (Willlenegger) and intravenous antibiotics efficient against the proven bacteria one was able to cure the infection. Additional measures of osteoinduction (mainly cancellous autograft and decortication) favoured bridging of the non-union area. With the help of callus distraction after segmental resection of dead bone areas using more sophisticated external fixateurs marvellous reconstructions of big bone areas became possible.
On the other hand we have to realize, that in the upper extremities external fixation is frequently a clumsy installation inhibiting function. Because of delay of union not unfrequently secondary stabilazation of non-union or refracture areas had to be stabilized with secondary internal fixation. This was possible because the infection was already cured.
The knowledge of implant related infection did learn us, that the elimination of bacteria linked to a biofilm, which are at rest, frequently are resistant against antibiotics otherwise successful against planctonic bacteria of the same species. Be it by higher concentrations, be it by the use of antibiotics efficient against resting bacteria such as Rifampin ant once other possibilities are developed to be able to treat infections even in presence of internal osteosyntheses. When the success rate of intramedullary nails as they were used by Klemm was distinctly lower compared with external fixateurs at that time, today it becomes possible to us internal fixation in infections with bacteria with a known antibiotic treatment in presence of implants. This opens important doors for the combination of internal fixation, vascular bone grafts and antibiotic treatment accelerating the treatment of infected non-union in adequate cases.Stepwise it became possible to get to better functional results within a shorter time in adequate cases.
Surgical treatment of infected bones with vascularised bone grafts is well established as an efficient strategy since several years. Nevertheless orthopaedic and trauma surgeons seem to apply vascularised bone grafts as the last treatment option only.
Two strategies exist for treatment of chronically infected bones with vascularised bone grafts. First: Complete resection of the infected, often non-united part of the bones and reconstruction with large vascularised bone grafts, mostly fibular grafts. Second: Augmentation of the kept and intact parts of the bones with vascularised bone grafts. Two small series of patients are presented to illustrate both techniques and to show the results and outcome.
Resection of big parts of the tibia and reconstruction with mostly ipsilateral fibular grafts – single barrel in children and double barrel in adults – led to uneventful healing in all cases. Augmentation of radius, femur and calcaneus with vascularised grafts from the iliac crest or the scapula was followed by primary healing, too. All patients were disburdened from infection up to now and regained full extremity function.
The presented vascularized bone grafts did not only salvage the extremities but also could maintain their functionality. The procedure is demanding, but reliable and safe at a low rate of complications. Thus vascularised bone grafts should not only be used as ultimative salvage procedures, but as early as possible whenever standard treatments for osteomyelitis fail.
We must remove the implant:
If the fracture has healed. If the fracture has not healed and the implant does not provides stability.
Follow-up information was available for eight patients after a median of 19,5 months (range: 3 to 61 months). Seven of them did not show signs of recurrent infection.
Infection of a total joint replacement (TJR) is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. Usually at least two surgical interventions and antibiotic treatment within a period of several months are estimated being required for a favourable outcome. It is undoubted that one stage exchange, if successful, would provide the best benefit both for the patient and the society. Still the fear of re-infection dominates the surgeons’ decisions and directs them to multiple stage protocols. However, there is no scientifically based argument for that practice. Successful eradication of infection with two stage procedures is reported to average 80% to 98%, whereas there are no significant differences between revisions with or without antibiotic loaded cement, with short or long term antibiotic therapy, with or without the use of spacers and other differences. On the other hand a literature review of Jackson and Schmalzried (CORR 200) summarizing the results of 1,299 infected hip replacements treated with direct exchange (almost exclusively using antibiotic loaded cement), reports of 1,077 (83%) having been successful. For total knee replacement Jaemson et al. (Acta 2009) could show that the overall success rate in eradication of infection was 73–100% after one-stage revisions. It may be calculated, that adding a second one stage procedure for treating the failed cases the overall result with two operations may improve to > 95%, an outcome which is at least as good as the best results after two stage revisions, while requiring only one surgical intervention for the majority of cases.
Spacers have been proven to be useful for improving final functional results compared to temporary resection; however, concerning infection control no benefit could be shown. Dead space management is performed comparably effective by a new prosthesis as with a spacer. In addition a definitive prosthesis is providing increased stability, which a spacer does not. As long as protection against colonization is granted by high local antibiotic concentrations a prostheses is likely to provide better functional results than a spacer.
These results suggest, that the major factor for a successful outcome with traditional approaches may be found in the quality of the surgical debridement and dead space management. Failures in all protocols seem to be caused by small fragments of bacterial colonies remaining after debridement, whereas neither systemic antibiotics nor antibiotic loaded bone cement (PMMA) have been able to improve the situation significantly.
One stage exchange provides marked reduction of patients discomfort and costs but is performed only rarely due to a multitude of risks and disadvantages, related to the mandatory use of antibiotic loaded cement for fixation. Cemented revisions generally show inferior long term results compared to uncemented techniques; the addition of antibiotics to cement reduces its biomechanical properties. The release of antibiotics from cement is too short-lived and concentrations are too low for reliable eradication of eventually remaining pathogens, especially when they are embedded within biofilms. PMMA has been shown to be the ideal substrate for bacterial attachment and replication of sessile bacterial phenotypes. Aging cement releases antibiotics in subinhibitory amounts, leading to antibiotic resistance of adherent bacteria even years after implantation. Whenever a new prosthesis is implanted into a previously infected site the surgeon must be aware of increased risk of failure, both in single or two stage revisions. Eventual removal therefore should be easy with low risk of additional damage to the bony substance in such a case. On the other hand it should also have potential of a good long term result in case of success. Cemented systems seem to be less likely for that purpose since efficient cementing techniques will result in tight bonding with the underlying bone. Eventual removal such will be time consuming and possibly associated with further damage to the osseous structures.
Allograft bone may be impregnated with high loads of antibiotics using special incubation techniques. The storage capacities and pharmacological kinetics of the resulting antibiotic bone compound (ABC) are more advantageous than the ones of antibiotic loaded cement. ABC provides local concentrations exceeding those of cement by more than a 100 fold and efficient release is prolonged for several weeks. The same time they are likely to restore bone stock, which usually is compromised after removal of an infected endoprosthesis. ABC may be combined with uncemented implants which in case of a failure markedly facilitates their removal. There is reduced risk of creating resistances since the stored antibiotics are eluted completely and elution is terminated after several weeks.
Based on this technology new protocols for one stage exchange of infected TJR have been established, both for hips and knees. Bone voids surrounding the implants are filled with antibiotic impregnated bone graft; uncemented implants are fixed in original bone. Recent studies indicate an overall success rate of more than 90% without any adverse side effects. Incorporation of allografts appears as after grafting with unimpregnated bone grafts. The favourable results have initiated extension of the technique to simultaneous reconstruction of large septic defects using impregnated bulk allografts.
Antibiotic loaded bone graft seems to provide sufficient local antibiosis for protection against colonisation of uncemented implants, the eluted amounts of antibiotics are likely to eliminate biofilm remnants, dead space management is more complete and defects may be reconstructed efficiently. One stage revision such should be at least comparably save as multiple stage procedures, taking advantage of the obvious benefits for patients and economy.
Two-stage revision is the most widely accepted and performed intervention for chronically infected joint prosthesis. The choice of this option relies on the following considerations:
higher antibiotic concentrations may be used in the spacers, compared to the cement used for prosthetic fixation in a single-stage procedure, since high dose antibiotic-loaded cement may be too fragile for long term prosthesis fixation (Bucholz, 1986); the frequent occurrence of bone loss and the smooth cortical bone surface, encountered at revision may prevent effective cementing; two-stage revision allows the use of uncemented modular stems, useful for intra-operatively balancing legs’ length, offset and muscular tension; distal fixation allows to overcome proximal frequent bone loss; bone grafts, eventually plus growth factors, may be safely added; a second debridment may enhance the possibility of eradicating the infection; there is a large and growing international literature evidence in support to this option.
Two-stage reimplantation using an articulated interval spacer of antibiotic-impregnated bone-cement has been previously investigated and proved as an effective Method:
to adequately fill the void created by the implant removal, to prevent limb shortening and soft-tissue contracture, to allow a better function, to provide local antibiotic therapy, to eradicate infection, to facilitate reimplantation.
However a considerable variation in the form and function of interval spacers exists. A spacer may in fact be commercially made, or it may be custom-made in the operating room. It may be made entirely of polymethylmethacrylate cement, or it may be a cement-coated metal composite. Favorable results have been reported with each of these types of spacers.
Preformed antibiotic-loaded spacers (InterSpace® Hip and InterSpace® Knee, Tecres SpA, Verona, Italy – Hexactech Inc. Gainesville, Florida) offer:
known mechanical resistance; predictable antibiotic release; reduced surgical time; joint function preservation and partial weight bearing; standardized technique. In particular, as to concern the hip, their most peculiar feature is their availability in short and long stem shapes, that allows to overcome frequent proximal femoral bone defects Acceptable costs (<
5% of the total costs for a two-stage procedure).
The Liestal algorithmus for the treatment of infected total joint arthroplasties proposes the abovementioned three groups for revisions with exchange.
One stage exchange is executed in the presence of a adequate soft tissue situation and in absence of bacteria difficult to treat.
Two stage revision with spacer and a interval of 2–3 weeks until re-implantation is indicated in bad soft tissue situations
Two stage revision without spacer, a curative intravenous antibiotic treatment period of 6 weeks, a break of 2 weeks followed by reimplantation is indicated in the presence of bacteria difficult to treat.
All patients of group 1 and 2 were treated with antibiotics for 3 months – the first two weeks intravenous.
The ones of group 3 only, if during reimplantation positive tissue cultures were harvested.
We analysed 72 episodes of ITHA, 22 with 1-stage exchange, 29 with 2-stage exchange with spacer, 21 with 2-stage exchange without spacer. All 16 cases but 1 with bacteria difficult to treat were included in the last group. In this presentation only cases are included following the algorithm completely as published. All patient had an overall treatment with antibioticsIn all patients the index operation was done more than two years prior to the latest control. Two patients died shortly after the operation, the result remaining unknown. Another 3 died between 1 and two years after the operation. They were regarded as probably cured. Only one case of group 2 suffered of a relapse being caused by a coagulase negative staphylococcus being resistant against Rifampin. 2-stage exchange without spacer was then successful. One case of reinfection with another bacterium happened in the group 1.
Two-stage revision is the most widely accepted and performed intervention for chronically infected joint prosthesis. The choice of this option relies on the following considerations:
higher antibiotic concentrations may be used in the spacers, compared to the cement used for prosthetic fixation in a single-stage procedure, since high dose antibiotic-loaded cement may be too fragile for long term prosthesis fixation (Bucholz, 1986); the frequent occurrence of bone loss and the smooth cortical bone surface, encountered at revision may prevent effective cementing; two-stage revision allows the use of uncemented modular stems, useful for intra-operatively balancing legs’ length, offset and muscular tension; distal fixation allows to overcome proximal frequent bone loss; bone grafts, eventually plus growth factors, may be safely added; a second debridment may enhance the possibility of eradicating the infection; there is a large and growing international literature evidence in support to this option.
Two-stage reimplantation using an articulated interval spacer of antibiotic-impregnated bone-cement has been previously investigated and proved as an effective Method:
to adequately fill the void created by the implant removal, to prevent limb shortening and soft-tissue contracture, to allow a better function, to provide local antibiotic therapy, to eradicate infection, to facilitate reimplantation.
However a considerable variation in the form and function of interval spacers exists. A spacer may in fact be commercially made, or it may be custom-made in the operating room. It may be made entirely of polymethylmethacrylate cement, or it may be a cement-coated metal composite. Favorable results have been reported with each of these types of spacers.
Preformed antibiotic-loaded spacers (InterSpace® Hip and InterSpace® Knee, Tecres SpA, Verona, Italy – Hexactech Inc. Gainesville, Florida) offer:
known mechanical resistance; predictable antibiotic release; reduced surgical time; joint function preservation and partial weight bearing; standardized technique. In particular, as to concern the hip, their most peculiar feature is their availability in short and long stem shapes, that allows to overcome frequent proximal femoral bone defects Acceptable costs (<
5% of the total costs for a two-stage procedure).
I wish to present my experience with 521 patients with infection around hip arthroplasty and 262 with infected knee arthroplasty. The management in each case depends on circumstances such as the period since surgery, the patient’s symptoms, severity of illness and general health, and the condition of the remaining bone stock.
One hundred and thirty hips and 94 knees were managed conservatively i.e. without surgery.
Nine knees and 11 hips had debridement and irrigation without removing the arthroplasty. Infection persisted in 2 knees and 3 hips.
Nine knees were exchanged in one stage. infection persisted in 5. Forty three hips were exchanged in one stage. Infection persisted in 18.
Fifty knees were exchanged in two stages. Infection persisted in 11. One hundred and ninety eight hips were exchanged in two stages. Infection persisted in 28.
Arthrodesis was performed in 77 of the more severely infected and destroyed knees. Infection persisted in 32.
One hundred and eight of the more severely destroyed hips were left as excision arthroplasties. Ten remained infected but comfortable.
Five patients required amputation above the knee and three through the hip.
Two patients sustained serious vascular complications during surgery at the hip and one at the knee.
Four patients in this series died during treatment
Preoperative determination of the causative organism its sensitivity to antibiotics Radical debridement surgery and cement spacer with PerOssal implantation Appropriate IV antibiotic therapy for 6 weeks and postoperative clinical evaluation and monitoring of inflammation markers After a six-week antibiotic free interval and if inflammation markers had return to normal second stage surgery took place: Medullary canal reaming, intraoperative cultures, thorough wound irrigation with 10L NS and prosthesis implantation Postoperative antibiotic therapy until culture results; IV antibiotic treatment for 6 more weeks if they were positive. FU evaluation at 3, 6, 12, and 24 months.
After the first stage a 10-week antibiotic course was administered according to the sensitivity of the isolated bacterial strain. The second stage procedure was carried out after 4,9 months.
We evaluated the results of surgical one stage versus two stage exchange of patients diagnosed positive for prosthetic infection following total hip replacement in correlation with a classification described by Mc Pherson.
This technical choice constitutes an effective solution for all those cases where, due to the infective damage, the radical surgical debridement needed or in presence of a septic pseudoarthrosis, there is a relevant loss of bone stock in the proximal femur.
As a treatment for these specific clinical patterns oncological prosthetic implants can be used, to overcome the amount of bone loss.
Sometimes acetabular prosthetic implantation, or reimplantation, is also needed because of its septic mobilization, otherwise a bicentric endoprosthesis can be implanted.
The main issue for the surgeon is the gluteal muscular deficiency, caused often by the loss of the great trochanter, a severe condition often worsened by the damage on muscles and soft tissues given by previous surgical procedures and debridements.
The offset itself, really often not sufficient for the limited amount of sizes and lengths of the oncological designed prosthetic implants, represent a key issue of this treatment with a high luxation risk, with a higher rate in those cases when an arthroprosthesis has been performed.
In this article are described 4 cases, all four treated with a two-stage surgical approach and a definitive oncological prosthetic system to overcome the severe bone loss of the proximal femur.
The cases are examined about the surgical indication to this prosthetic choice, the postoperative period with the related complications (1 case of recurrent luxation) and with a minimum follow up of 6 months (maximum 36 months).
In all the cases at the follow up the infection is solved.
At the end the specific rehabilitation program for the range of motion and the muscular strength regain, that we developed in our Operative Unit is described; in this program we occasionally used for the immediate post surgery period a jointed hip brace.
The length of the rehabilitation could not be standard, but should be customized and variations of the program could be done during the follow up.
In the immediate post-surgical period the rehabilitative goals are maintaining the correct posture in bed and regaining the passive articular range of motion.
In the longer period the main goals are regain strength of the gluteal muscles, proprioception and gait, even if claudication (Trendelemburg), hyposthenia a recurrent dislocation can be let.
The weight bearing is allowed usually at the eight week after surgery, but only after clinical and x-ray evaluation.
We want to show our results of infected THR in the years from 2006 to 2008. We use an algorithm similar to Mc Phersons’s:
In early cases with not affected surrounding tissue we prefer the one stage procedure:
When there are no radiolucent lines in X-ray und the Scan does not show any tracer enhancement we perform synovectomy and replacement of the poly liner.
If soft tissue does not have an inflammation and only the bony bed is affected, we perform a one stage procedure with use of antibiotic augmented morcelliced bone graft. We use freeze-dried cancellous bone granula from a commercial tissue bank which are bathed for 30 minutes in a combination of Tobramycin and Vancomycin which is placed into the interface of implant and bony bed.
In chronic cases with affected soft tissue we treat the patient with a two stage exchange by use of a so called intermediate spacer and the definite revision after 3 months. The intermediate spacer contains a stainless steel rod coated by Gentamicin bone cement (Tecres company) in the shape of a prosthesis. This provides the release of antibiotics into the surrounding tissue.
We treated 36 patients:
18 patients were treated by use of a single procedure and 15 could be healed in 5 cases we could heal the patients by synovectomy and change of the poly liner. 10 cases could be healed by a THR revision with antibiotic augmented morcelliced bone graft in two cases a two stage treatment was necessary after a synovektomie and change of poly liner one patient was treated by synovektomy first, after persistent inflammation a THR Revision with antibiotic augmented morcelliced bone graft was performed and finally she could be healed by a two stage procedure 20 patients were treated by a two stage THR with an intermediate spacer 17 patients could be healed (three cases included from failed single procedure group) 3 patients are changed to a Girdlestone Hip (one died by reason of neoplasma, one could not be healed despite 4 revision with spacer, one could not be operated as he had chronic cardiac disease and ~prostatae) 1 patient get a permanent head-spacer as the femur prosthesis (Lord) could not be revised based on cardiac and pulmonary disease
Using Mc Pherson’s algorithm we could be successful with a single stage procedure in 15 from 18 cases. The remnant three patient could be healed by a two stage procedure. Only 4 patient could not be healed by a two stage procedure which was performed for 20 times. As we were successful too in three cases by treating chronic periprosthetic hip infection with a single procedure by using antibiotic augmented bone granula, investigation are requested to prove if this procedure could be postulated for all chronic periprothetic infections too.
Objective of this study was to analyse results of two stage revisions in infected megaprostheses in lower limb.
Infection occurred in 80 cases (7.7%) at mean time of 4 yrs (min 1 month, max 19 yrs) in 18 KMFTR®, 47 HMRS®, 5 HMRS® Rotating Hinge, 10 GMRS®. Sites: 51 distal femurs, 21 proximal tibias, 6 proximal femurs, 1 total femur and 1 extrarticular knee resection. Most frequent bacteria causing infection were: Staphilococcus Epidermidis (39 cases), Staphilococcus Aureus (17) and Pseudomonas Aeruginosa (5). Infection occurred postoperatively within 4 weeks in 9 cases, early (within 6 months) in 12 cases, late (after 6 months) in 59 cases.
Usual surgical treatment was “two stage” (removal of implant, one or more cement spacers with antibiotics, new implant), with antibiotics according with coltures. One stage treatment was used for immediate postoperative infections, only since 1998.
Functional results after treatment of infection were assessed using the MSTS system.
In 3 cases an amputation was primarily performed, to proceed with chemotherapy.
Revisions for infection were successful in 63 pts (79%), while 17 pts were amputated (21%).
Functional results evaluated in 53 revised cases were good or excellent in 43 (81.1%).
Based on these results, 25 knees (76 %) were rated excellent, 5 knees (15 %) were rated good, 2 knees (6 %) were rated fair and one patient (3 %) had a poor result. Complications were one temporary peroneal palsy, one luxation of the spacer due to insufficient extensor mechanism and one fracture of the tibia due to substantial primary metaphyseal bone loss.
S. Epidermidis and S. Aureo were the most frequent bacteria causing infection (45%). Two stage treatment of infection was chosen: removal of the implant and temporary substitution with cement spacer with antibiotics (usually vancomycin) until infection healed. But a new prostheses was actually implanted in 3 cases only (at mean time of 5.7 mos), while in 17 the spacer was never removed by patients choice due to the acceptable result with the spacer. Systemic antibiotics were associated according to cultural results. Infection healed in all patients.
We classified septic revision surgeries following total knee according to a classification published by Mc Pherson. Eradication rate of one stage versus two stage exchange was compared.
Regarding Mc Pherson’s systemic grades classification the eradication rate for two stage exchanges was 85,7% in group A+B and 60%% in group C. One stage procedures achieved 0% eradication rate in group B and 60% in group C. Regarding Mc Pherson’s local extremity grade classification eradication rates within two stage revisions were 84% in group 2 and 75% in group 3. One stage revision achieved 40% and 0%.
The infected total shoulder arthroplasty is not a frequent finding at the present time, the necessity of treating this complication may become more urgent with the continually increasing number of arthroplasty procedures performed.
From 1992 till the beginning of 2005, eleven patients were treated for infected total shoulder arthroplasty. An acute infection occurred in one patient (9 %), subacute in three (27 %) and late in seven patients (64 %). The average period between the primary operation and infection manifestation was 19.3 months.
The group of 181 patients operated on for shoulder replacement between 1992 and 2005 was evaluated, and a deep infection of total shoulder arthroplasty was found in 11 patients (2.2 %).
An antibiotic therapy alone was sufficient to eradicate the infeciton in only 20 % of the infected patients, but these showed good Constant scores (average, 42 points). Revision surgery, debridement and irrigation drainage had a low success rate (33 %) and good Constant scores (average, 45 points) in the cured patients. A two-stage exchange was 100 % successful but had a poor outcome, with an average Constant score of 26 points. However, a two-stage exchange involving a spacer had both 100 % success rate and a good outcome with an average Constant score of 49 points. On statistical evaluation using the unpaired t-test, there was a significant difference in the Constant scores (T 4.35 p=0.005) between the patients undergoing exchange arthroplasty with (n=40) and without (n=4) the spacer.
Poor function scores after resection arthroplasty are not surprising, because a sharp residual proximal humerus is likely to irritate soft tissues and, in addition, it is not possible to reconstruct a rotator cuff to match it.
Comparing the results of one-stage with two-stage reimplantation is a complex issue. Attention should be paid to a relationship between the methods routinely used to treat an infected total shoulder arthroplasty and those preferred by the given hospital for treatment of other joints. If the therapy is well established in that hospital and gives good long-term results, it is optimal to use it also for the treatment of infected total shoulder arthroplasty.
The method of treating infected total shoulder arthroplasty is not different from other big joint therapies. The use of a spacer will allow us to remodel soft tissues satisfactorily even after extensive debridement. The functional results of treatment involving a spacer are significantly better.
3462 knee prosthesis were implanted between 1.1.1998 and 31.12.2008 (11 years). There were 491 Unis in this group, but infection ocurred only in Total Knee Replacement (TKR) group. We treated 24 patients (0,69 % infection revision rate) with infected TKR in this time period. The follow-up was from 126 to 7 months. The infection agens was diagnosed by preoperative joint aspiration (Staph.aureus 40%, koagulaseneg.Streptococci 20%)
We compared 3 methods of treatment: the first group was open debridement + inlay exchange. In this group we treated 10 patients (37%). There was infection recurrence in 20 %.
The second group was one-stage exchange: 5 patients (18%) with infection recurrence 60% and two complications (spin-out and component loosening).
The third group was two-stage exchange: 12 patients (44%) without infection recurrence (0%) and no complications. Two stage-exchange was performed with custom-made cement tibialspacer and resterilized explanted femoral component which was reimplanted with [[Unsupported Character – & #8222;]]poor“ cement technique as originally described by A.Hofmann. Post-op partial to full-weight bearing with brace 0–90 degrees was allowed. For reimplantation a non- or semiconstrained revision prosthesis with mobile bearing after cca 6 weeks period was used. The prothesis‘ stems were not cemented.
Based on our experience we recommend two-stage revision in mostly cases. Use of mobile spacer keeps excellent mobility after revision and prevent excesive scarings which complicate the reimplantation and causes limitation of movement if fixed spacer was used. On the other side we could show that use of mobile spacer do not increase infection recidiv rate in septic knee surgery. A meticulous debridement is, in our opinion, the most important part of surgery, but it was possible in all cases to save the collateral ligaments and to prevent use of constrained revision prosthesis with increased revision rates because of loosening. Debridement + inlay exchange should be limited only for acute cases with short disease history.
Endoprosthetic replacement following oncological conditions has shown to be at higher risk of sceptical complications due to the use of implants of unusual size, major soft tissue loss and immunsupression.
373 patients have been treated at our institution for malignant tumours of the bone or soft tissue around the knee with a modular tumour-prostheses of the knee joint since their availability from 1978. Infection or septic complications were identified in 78 patients (20.9%).
In 15 cases of superficial wound healing disturbances with a fistula simple excision and revision of the wound was performed. In 48 cases of deep periprosthetic infections patients underwent one-stage revision with explantation of the total prosthetic material except femoral and tibial stems, extensive debridement of the wound and replantation of the disinfected prostheses throughout one operation. In 8 patients two-stage revision of the prostheses was performed, using an antibiotic impregnated cement spacer and Steinmann nails. In 5 patients amputation of the affected limb was indicated, whereas 2 patients could be treated conservatively. Out of the patients treated by one-stage revision 16 developed recurrent infection and had to undergo consecutive surgery. After two-stage surgery 4 patients showed signs of septic recurrence.
According to our results deep periprosthetic infection of tumour-prostheses primarily can be treated by one-stage revision, in recurrent infections, however, two-stage revision should be performed. We additionally suggest the use of local or pedicled muscle flaps to obtain better soft tissue coverage of the prostheses after infection.
This infrequent complication occurs with a frequency ranging from 0,6% to 1,1% depending series, and in Revision cases it may rise up 20%.
We expose our experience in the treatment of infection associated with THR using the two-stage procedure with hand-made partial hip spacers.
There were 5 men and 4 women, with an average age of 65 years, ranging from 35 to 76. 3 patients had previous surgery before presenting to our hospital.
The infecting pathogen was Gram positive in 6 out of 9 patients (66,7%), Gram negative in 2 patients (22,2%) and in the remaining patients the pathogen was not detected.
No clinical signs nor radiological findings suggested septic loosening of the femoral component, except in one patient.
The partial spacer consisted on a ball of acrylic cement with antibiotics (usually an aminoglycoside i.e. gentamicin) which is manipulated by the surgeon in order to be placed in the acetabulum. In 8 out of 9 patients femoral component was not removed.
All the patients received systemic antibiotic treatment with two or more antibiotics for more than 6 weeks after the first stage, on the basis of the antibiogram.
The average between the first and second-stage operations ranged from 8 to 24 weeks (mean 15,7 +− 2.1). During this period of time most patients had tolerable pain in the hip.
Success rates in terms of recurrence of infection after Revision surgery was 11,1%.
One patient presented a fistulae one year after second time surgery, and fistulectomy was carried out.
The use of a hand-made device offers some advantages with respect conventional hip spacers. Easier implantation, preservation medullary canal and preservation of bone stock not requiring an extended throcanteric osteotomy for the removal of an infected long stem, especially in older patients with important associated morbidity.
Antibiotic-loaded PMMA spacers are used with increased frequency in two-stage revision arthroplasty. The release of aminoglycosides and vancomycin, the most commonly used antibiotics, is prompt, and concentrations are inhibitory. The release kinetic from PMMA bone cement shows a biphasic profile, consisting in an initially high and rapid drug release followed by a slower but sustained phase.
However, this general profile of drug release kinetics from PMMA spacers in vitro may have great variability in terms of drug amount, modality, and duration of elution. Initial drug concentration, cement surface area and porosity are essential and well-known factors in determining the drug release. Moreover, viscosity, vacuum-preparation and the different technical characteristics of commercially available spacers are additional factors of variability. Industrial preformed spacers are considered superior to custom-made devices because of uniform mixing and standardized procedures.
Spacers produced by different manufacturers vary in their mechanical properties and antibiotic elution characteristics. Small changes in the formulation of a bone cement can also affect these properties.
Similar bone cements produced by various brands release different amount of drugs. Gentamicin diffuses from Palacos in a larger amount and for a longer period than from Simplex and CMV. Spacers produced in France (Synicem™) and in Argentina (Subiton™) elute less total amount of gentamicin than those produced in Italy (Spacer G™) and show a delayed peak drug release. The low initial release of antibiotic can contribute to unsatisfactory antimicrobial effect and to the risk of selection of resistant bacteria. Some spacers release gentamicin for longtime (months), while others release antibiotic for only two weeks.
In the last years an evolution of PMMA spacers production occurred and modifications in the polimerization process of cement can increase cement porosity and antibiotic elution from spacers.
The current commercial preformed spacers for 10 days elution (Spacer G™, prepared with Cemex HP) release more gentamicin (34.1 mg) than previous models, which were prepared with Cemex SP (16.4 mg). Furthermore, they maintain a high elution rate (1.4–1.6 mg/day after one month).
The combination of Gentamicin and Vancomycin mantains an elution pharmacokinetic profile that is superimposable to that of Gentamicin and Vancomycin alone, with synergistic effects against multiresistant bacteria in prosthetic infection site.
In conclusion, the antibiotic release from PMMA spacers of various brands is not equivalent. The old elution data are no longer valid for new preparations. Consequently, this additional factor of variability should be considered in clinical practice and literature data utilisation.
Early and late infections are the most uneventfull complications after tumor resection and implantation of a maegaendoprosthesis. Therefore, silver-coating was introduced by our department years ago with successful reduction in infection rates. After promising results in animal and Phase exclusion of side effects in our Phase I trial, we would like to share our knowledge about latest research, especially the actual results of the Phase II study. We included the results off all implanted silver-coated Megaendoprosthesis since introduction in our department. Implantation had to be more than 12 months ago to guarantee a acceptable minimum follow up for calculation of the infection rate. Actually our infection rate lies at 3,1% (N=131) in the prevention group (no previous infection in medical history) and at 19% (N=36) in our “Highest-Risk” and previous infection group. Still no side-effects could be noticed. In one case we examined retrieved samples of three silver-coated Megaendoprosthesis. Macroscopically a leopard shaped figures could be noticed on the silver-coated surface in shiny and dark areas after being implanted in an infected region. Electron microscopy pictures show still intact surface and remaining silver with dark staining. Biofilm formation coulod not be noticed, though some few dead single bacteria could be found without any signs of proliferation or matrix production after adhesion. Signs of biofilm couldn’t be seen anywhere. Despite the discoloration silver is still intact in these areas without any loss of antibacterial properties. Blisterings or even flaking off the silver coating cannot be noticed. The thickness of the silver was not thinned in a significant way leading to a breakdown after a few years.
Up to these days we have no experience in covering the whole prosthesis including the stem in human beings. Concerning osteointegration of silver-coated stems, our animal trial could not prove their effectiveness in comparison to titanium. Pull-out tests showed high significant discrepancies in osteointegration between titanium and silver coated stems in a dog model after a period of 12 months after implantation.
Summarizing we recommend silver as a safe adjuvant therapy in patients undergoing endoprosthetic reconstruction after tumor resection. Intramedullary use of silver can be done only in experimental cases and needs further changes in the technical design of the coating.
The rate of infections in primary and revision surgery (hip and knee) The success rate in treating those infections Long term survival rate of revision arthroplasties
Considering an infection free arthroplasty as the goal, the overall success rate of treatment was under 48% (30/69). The success of treating infections with debridement and retention of components was even lower (29%). Further analysis revealed a higher success of this approach (45%) when considering more appropriate candidates (short term infections). An interesting statistically significant difference was found favoring this approach in the knee.
Two-stage revision strategy was successful in achieving revision arthroplasty in 43% (20/46) of the cases. Most patients were never considered candidates to the second stage procedure. Knee joint and resistant microorganisms were found to be predictors of bad prognosis.
There was a 90% (18/20) survival rate of revision arthroplasties after two years average follow-up. There were only 2 cases of relapsing infection both controlled without prosthetic removal.
Postoperatively a final diagnose was made based on microbiological testing, which in addition to routine culture, included sonication of the prosthesis and nucleic acid based diagnostics (PCR). Data from the preoperative examination was evaluated in relation to the final diagnose (chi-square test and Student’s t-test), and the sensitivity and specificity for diagnosing a septic loosening was calculated for each preoperative finding.
At our institution, periprosthetic hip joint infections are treated according to a previously defined treatment algorithm. Each patient is evaluated regarding risk factors such as duration of clinical signs and symptoms, stability of the implant, condition of the soft tissue, and antimicrobial susceptibility of the microorganism. Depending on these factors, either debridement with retention, one-stage exchange, or two-stage exchange with spacer (short interval, 2–4 weeks), or without spacer (long interval, 8 weeks) is performed. Very rarely, resection arthroplasty or lifetime suppression is necessary. All surgical procedures are combined with an antimicrobial therapy for 6 or 12 weeks, depending on the surgical pathway. For infection due to staphylococci, whenever possible, rifampicin is used in combination with a fluoroquinolone. From 2002–2006, 89 patients with 95 episodes (3 patients with 2 independent episodes, 3 patients with bilateral infection) of periprosthetic hip joint infection have been treated at our hospital. Five patients died within 2 years after revision, one of them with septic shock related to the periprosthetic hip joint infection. One patient is living abroad. All other patients (n=83) had consecutive follow-up visits at least until 2 years after infection treatment without recurrence. Debridement with retention has been performed in 18 episodes, one-stage exchange in 25 episodes, two-stage exchange with temporary spacer for 2–4 weeks has been performed in 26 episodes, and two-stage exchange without spacer and an interval of 8 weeks in 19 episodes. In 4 cases, immediate resection arthroplasty was performed and 3 patients received long-term suppression therapy. After debridement with retention, 3 recurrences and one event of death occurred (4/18=22.2%), 3 of them did not fulfil the criteria of the algorithm. No failure was observed after one-stage exchange (0/25). Treatment with two-stage exchange was followed by one failure in the group with spacer and short interval (1/26=3.8%), as well as one in the group without spacer and long interval (1/19=5.3%). No recurrence occurred after resection arthroplasty or suppression therapy. All 5 patients with relapse could be cured with a one- or two-stage exchange and remained without recurrence. Comparing one-stage versus two-stage exchange, one-stage exchange is known to have better functional results. It is associated with better patient acceptance, shorter hospital stay, and therefore lower economic burden.
In conclusion, one-stage exchange implies no increasing risk of recurrence provided that the standards of our algorithm are considered.
In the 2-stage group (n = 50) results were lower but not significantly, with 80, 30% and 28% respectively, and 2 stems and 1 cup were revised due to aseptic loosening.
One case (after one stage) developed an infection with a different pathogen and one case (after two stage exchange) had a relaps of infection.
My X-rays and scars literally show my life-story. What they show is a destroyed right hip bone due to Osteomyelitis at the early age of 4 days and, 18 years later, a length difference between my feet of approximately 6 inch. But what they do not show is me.
The fragile infant who became a little girl, turned into a teenager, and eventually grew into a woman. A woman who, throughout this process, was forced to set her personal hopes and dreams aside in order to be (the) patient. Why is it that when you get sick you simultaneously seem to vanish as a person? It feels like your individuality becomes second to your medical status. Moreover, you are expected to stick to the rules of your role to serve the hospital system. But I am a human being after all, not a numb, genderless puppet.
Once the patient, you are trapped and challenged by the obstacles of a life that is no longer in your hands. Lying in a hospital bed, childlike and deprived of your gender, often not even capable of choosing when to act according to your personal needs, you just never know when to feel safe within yourself.
Exposure, shame, and pain become a daily routine, as your handicap is put into the spotlight of men, without any space left for privacy. This vicious circle can lead into self abandonment and depression. You break under the pressure of getting healthy and your self-imposed control. Dependency on strangers, adapting to hospital rules, waking up in a changed body after surgery and losing your self-worth are some of the consequences you have to face along the way. Pain is not the problem, your soul, adapting to the changes that are made on your body, is.
Please note, that the patients’ soul is not visible on an x-ray. Take a closer look at the bravely smiling patients, who are sitting in your offices, scheduling their next surgeries without hesitation, because they finally want to get well. The system has to be individually adapted for all parties. It is teamwork after all. As for me, I stood up for myself, got to be part of my surgical team and are now, 28 years later, living my freedom, the “normal” life, so to say. I am safe for now.
to assess how patients viewed their infections, to see if infection with methicillin-resistant Staphylococcus aureus (MRSA) was different to non-MRSA infections, and to explore the emotional associations of these infections.
According to the International Classification of Psychic Disturbances (ICD 10) accidents are among the traumatic incidents in a person’s experience and can lead to acute or persisting post traumatic strain reactions. During the primary medical treatment and care the patient first of all has to come to terms with the consequences of the accident. If an acute osteomyelitis occurs later on, this will be a further strain on the patient’s convalescence. At this point in time the extent of this infection is not foreseeable, neither for the team treating the patient nor for the patient him/herself. While the accident itself is to be seen as an acute trauma, the development of a chronic infection is a creeping and uncertain process. On the one hand the patient is confronted with the psychic effect of the accident and its consequences and on the other hand with the psychic effects of drawn-out treatment.
Apart from functional restrictions and cosmetically straining outcomes the patients suffer under the social effects, such as loss of work and threats to finances, changes, or loosing a partner and the social surroundings and restrictions in leisure activities. The psychological effects of chronic strain are a depressive attitude, loosing control when acute pain occurs, a decrease in sexual needs, alcohol or medication abuse and not rarely a permanent change in personality. Added to this are worries about the future, fear that the infection can “flare-up” again or the necessity of an amputation. According to the literature the existence of chronic pain is the most serious influential factor on a patient’s quality of life.
The question which personality factors contribute to the development of chronic osteomyelitis has not been answered to date. Investigations only show a connection between patients with psychiatric illnesses and a higher liability to be ill. Klemm et al. (1988) specified that for a small group of patients psychosomatic factors are involved in the “definition” (but not the cause) of chronic osteomyelitis.
The psychological treatment deals with the results of the accident and the effect of the drawn-out treatment.
Starting point is a detailed psychological and social requirement and problem orientation with an active analysis of problems and to look for resolutions. A subjective appraisal of the illness, the psychic resilience, intellectual abilities, cognitive handling strategies, personal and social resources all have a decisive effect on the progress of the therapy.
I studied 1191 patients with known or suspected bone or joint infection. I divided patients with acute onset infection into three groups based on the speed of onset and the intensity of the infection. I divided the patients with known chronic infection into four groups according to the intensity of the infection. I used clinical and radiological parameters to determine the groups. There was a fifth group of patients with suspected infection who turned out to have other related or similar pathology but who were actually free of infection. The laboratory tests studied were all the parameters constituting a full blood count (CBC), tests of inflammatory activity (erythrocyte sedimentation rate, C-reactive protein, plasma viscosity and procalcitonin). I also studied the iron profile (serum iron, iron saturation, transferrin and ferritin). The same tests were used to monitor the patient’s progress as they responded to treatment – or not.
At the Orthopedic Hospital Vienna Speising 7.857 surgeries were performed in 2008.
2.211 of these surgeries required implants. The number of performed Total Hip Arthroplasties (THA) was 836.
All of these surgeries were elective. Approximately 0,5% of the patients who underwent a surgery at our institution had a postoperative infection, 0,8% were admitted because of an already existing infection, which required treatment at our department.
In order to achieve a basis for international compatibility and to meet the legal postulations the Orthopedic Hospital Vienna Speising actively participates in ANISS (Austrian Nosocomial Infection Surveillance System)/HELICS (Hospital in Europe Link for Infection Control through Surveillance).
In 2008 a survey on incidences for Total Hip Arthroplasties was started. So the possibility of specific measures is given when interventions should be necessary.
The stuff unit for Hospital Hygiene gathers data from clinical records and conducts an evaluation by means of a standardised (equivalent surgeries) and stratified (differentiation of the patients after ASA-score- American Society of Anaesthesiologists, duration of the surgery, etc) procedure. Three times a week the stuff unit for Hospital Hygiene visits the wards and collect selected indicator-surgeries, which are entered in a specific program for registering infections. By finding noticeable problems, a detailed analysis is continued with the examination of microbiologic, histological and radiologic data as well as questions to the surgeon or attending staff and ward rounds for inspecting for instance changes of dressing.
The infectdiagnoses, based upon CDC (Center of Desease Control) definitions for nosocomial infections, are encrypted and sent to the control center quarterly. In turn our hospital receives an analysis and feedback once a year. A biannual exchange of experiences on behalf of the active members including an interpretation of the data allows to settle discrepancies and dubieties in evaluation.
This data on surveillance allows a detailed analysis of information gathered in recent years as well as a discussion with authorities.
As a result specific consequences could already been deducted like written guidelines for surgical management, recommendations for antibiotic treatment, preoperative shaving of the surgical area as well as preoperative screening for staphylococcus in Total Hip Arthroplasties.
History of surgical wounds drainage is long-lasting. In our research we focused on the debated issue of safety and effectiveness of drainage.
In the period 2006–2008 we were examined 198 samples of patients after arthroplasty, or one-stage exchange for aseptic loosening and and 202 patients with infected artrhoplasty. For all patients was performed a prospective study of drain contamination using PCR methods.
Research has confirmed that the Redon drainage is a safe method that provides a clear benefit for the pacient. Based on the results of this study is recommended to keep drains 2 days after surgery.
Negative factor for the colonization of the drain are higher postoperative blood loss.
Continuous irrigation drainage can be clearly classified into standard operating procedures in the treatment of infectious diseases in the orthopedic. The use of irrigation drainage brings benefit over risk.
Prolonged irrigation drainage did not remove the contamination from the drains. Handling with irrigation drainage systems and dressing exchange did not a risk factor of contamination.
For infected knee joint is recommended to leave irrigation drainage about 100–112 hours, follow sucktional drainage and further 12 to 24 hours to remove the drains.
An important finding is the frequent presence of pathogenic fungi in the DNA material from arthroplasty area.
There were no incidences of wound infection at 6-week follow-up.
In bone infections, it is of fundamental importance to wrap any orthopaedic surgical procedure in healthy vascularised soft tissue, in order to allow good healing and to prevent infection recurrence.
Vitality of soft tissues around the knee joint can be easily jeopardized in patients undergoing multiple surgical operations as in case of infected arthroprostheses. In addition, there are very few local options in the soft tissue reconstruction of this area, due to the fact that the vascularisation of skin and subcutaneous tissue is based on the genicular arteries’ axes which prohibits the use of random skin flaps.
Preoperative planning of cutaneous incisions and reconstructive procedures is mandatory for a correct surgical treatment.
We analyze retrospectively a series of 8 patients who underwent soft tissue reconstruction of the knee area with local flaps, considering criteria and indications in the choice of each surgical option.
Main variables considered in decision-making were size and location of soft tissue defect, planned orthopaedic surgical procedure, likeliness of the need for further surgery, age, local and general condition of the patient.
Flaps employed have been medial gastrocnemius muscular flap, reverse ALT fasciocutaneous flap and the “propeller” freestyle perforator flap.
Main complications observed have been partial flap necroses and recurrence of the underlying bone infection.
In this work, the authors want to emphasize the importance of a multidisciplinary treatment of bone and prosthetic infections, where the antimicrobial therapy chosen by the Infectious Diseases Specialist must be synergic with an “orthoplastic” surgical procedure, in the effort to reduce the risk of infection persistence or recurrence and to obtain the best possible functional result and quality of life for the patient.
In these cases the soft tissue coverage has a particular importance.
In the most cases the defect site was closed by primary would healing, additional procedures (excision of skin necrosis, mesh grafting) were necessary in 8 cases. In one case we saw a complete loss of the muscle flap.
Patients included 44 females and 38 males, ranging in age from 14 to 74 years. Mean follow-up was 9.5 years (min. 3, max. 27). Histopathological findings included chordomas in 55 cases and giant cell tumor (GCT) in 27. Most pts. had iv antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection, surgery of GCT was intralesional excision. In 6 sacral resections a miocutaneous transabdominal flap of rectus abdominis was used for posterior closure.
Mean surgical time was 14 hours for resections and 6 hours for excisions.
No significant difference was found comparing deep wound infections with levels of resection (15/33 resections proximal to S3-45% and 8/19 resections below or at S3-42%), previous intralesional surgery elsewhere (4/9 patients previous treated elsewhere-44% and 19/46 primarily treated patients-41%) and age at surgery.
The purpose of this study is to present the surgical and functional results of a partial and total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus.
The older literature (1960–1982) partially supports this assumption and iodine contrast agents have been modernized considerately.
Is the effect the modern contrast agents have on the micro-organisms the cause of the fault negative culture results?
Staphylococcus aureus Staphylococcus epidermidis Enterococcus faecalis Streptococcus pyogenes Bacillus cereus Escherichia coli (E. coli) Pseudomonas aeruginosa Candida albicans Corynebacterium jeikeium Propionibacterium acnes
Three different techniques were used: a disk diffusion test (classical resistance determination) and time-killing curves tests with a high inoculum (1,5*108 cfe/ml) and a low inoculum (10*3 cfe/ml) at 0, 2 and 24 hours.
The high and low inoculum tests: only the combinations Telebrix with both P. aeruginosa and E. coli showed any growth inhibition but a non-significant (p = 0.07) growth inhibition of log-1. This however, did not impede the detection of these bacteria.
And with all other combinations there was no significant inhibition compared to the saline control and in every combination the percentage surviving number of bacteria was always higher than 30%.
Septic arthritis induced by Staphylococcus aureus causes a rapid destruction of joint cartilage and periarticular bone. The mechanisms behind this phenomenon are not fully understood. Toll-like receptors (TLRs) are essential in host defense against pathogens by virtue of their capacity to detect microbes and initiate the immune response. TLR2 is seen as the most important receptor for gram-positive bacteria. TLR2 signaling can lead to the activation of NF-kB through myeloid differentiation factor 88 (MyD88) dependent pathway. The purpose of this study was to examine the catabolic role of TLR2 mediated by the NF-kB pathway in human septic arthritic chondrocytes.
Septic arthritic (SA) chondrocytes (n=7) and fibroblast-like synoviocytes (n=7) infected by gram-positive bacteria, mainly Staphylococcus aureus, as well as chondrocytes from healthy individuals (n=5) were used for this study.
The expression of TLR2 in septic articular cartilage and normal cartilage was analyzed by real time reverse transcription polymerase chain reaction as well western blot analysis. Production of matrix metalloproteinase MMP- 13 and IL-1b was evaluated by enzyme-linked immunosorbent assay. MyD88 protein expression levels and NF-kB activation were evalutated by western blot analysis. Downregulation of TLR2 expression was achieved after transfection with specific siRNA against TLR2 using liposomes.
We observed that TLR2 mRNA and protein expression was significantly up-regulated in septic arthritic cartilage. Also MMP-13 and IL-1b production were significantly increased in septic arthritic chondrocytes compared to normal. Blocking TLR2 in septic chondrocytes resulted in significant reduction of MyD88 and NF-kB protein levels as well as reduction in MMP-13 and IL-1b expression.
It could be suggested that stimulation of TLRs by microbial components may represent the initial signal promoting a pro-inflammatory environment that will enhance degeneration of articular cartilage and the surrounding synovial cells. Targeting NF-kB signalling pathway through TLR2 gene silencing may be of potential therapeutic value in treatment of joint diseases.
Nevertheless, it is not clear that it is necessary or desirable as a routine means in primary total knee arthroplasty.
Some European studies demonstrate that the use of antibiotic-impregnated cement, shows to be effective in the prevention of early to intermediate deep infection following primary total knee artrhoplasty
Two groups were established:
A group of 296 patients with a primary total knee arthroplasty cemented without impregnated antibiotic. In the second group of 346 patients a primary total knee arthroplasty was performed with the use of gentamycin-impregnated antibiotic in all cases.
The mean follow up was 12 months.
We analyze the differences in the infection rate between the two groups, within the first year of follow-up
10 postoperative deep infections were found in the antibiotic non-impregnated cement group (3.3% of infection) 3 postoperative deep infections were found in the antibiotic-impregnated cement group (0.09% of infection)
A comparative analysis was performed which showed to be statistically significant.
The second group is classified as “Difficul osteomyelitis”. The bone involved presents with multiple erosions-cavities and there is no clear sequestrum on X-ray film. This category also includes those cases where surgery under tourniquet is impossible. Blood for transfusion must be available. Despite treatment, this type of osteomyelitis often recurs and further surgeries are often needed. All the cases of multiple osteomyelitis are included in this group as well. The third category covers “Complex Osteomyelitis”, whereby chronic osteomyelitis is associated with a pathological fracture or septic arthritis. There is axial deformity, bone loss and non-union. Some sort of reconstruction is always required.
Joint prosthesis infection after post-surgical intervention is an emergency. Infection development and progression are inherently dependent on the process of angiogenesis. Many immune disorders are associated with circulating natural antibodies, which bind self-protein as angiogenin (ANG). Biomarkers as anti-ANG IgA show a predisposition for infection development and must be attended by the strategies for therapeutic interventions.
To determine the relationship between the serum levels of anti-ANG IgA and risk of post-surgical joint prosthesis infection (JPI).
We have developed a ELISA, in which ANG coupled to high-molecular weight matrix (polyphenylacrylate) was coated on microtiter plates. Human serum samples were incubated in the plates, after which bound anti-ANG IgA was detected with mouse anti-human IgA-HRP. The optimal sensitivity and specificity of the assay was 91% and 84%. The specificity of ELISA was confirmed by the immunoprecipitation/immunoblotting control experiments. Serum levels of anti-ANG IgA in a cohort of healthy donors differed by more than a hundred-fold, whereas the fluctuation of anti-ANG IgA levels in individuals over time was small (coefficient of variation 6%). The study began in October 2005 and finish December 2008. For first study samples were collected from Department of Hip and Knee Articular Reconstruction. In this period we have operated 1290 patients with joint prostheses implanted. A second study examined specimens collected in Department of Bone Infections from 119 patients with JPI. In both studies, detection of anti-ANG IgA in sera by ELISA. JPI was defined as acute clinical sings of infection during the first 3 months after the placement of the prosthesis. Serum samples were obtained from 500 healthy adults.
IgA antibodies, reacting with ANG tested, were present in the sera of all patients as well as in the sera of normal individuals. Serum levels of anti-ANG IgA are significantly low in 19.1% patients with pre-surgical total joint replacement than in healthy individuals (m±SD: 385±101 versus 121±98; P< 0.001). Very low serum levels of anti-ANG IgA, as occur in primary immunodeficiency syndromes, are associated with significantly increased risk of infections (r=0.85; P< 0.005). Increases in serum anti-ANG IgA to normal/higher levels in patients before surgery associated with good response after gammaglobulin replacement therapy (m±SD: 385±101 versus 587±189; P< 0.001).Risk of JPI was dependently associated with secretory anti-ANG IgA antibody responses. Very low the expression of anti-ANG IgA in sera seem to be potentially useful as angiogenic biomarkers of risk JPI.
To analyze the relationship between functional outcome and tissue quality after arthroscopic rotator cuff repair.
One hundred and forty-five patients who had undergone arthroscopic repair of rotator cuff tear, during the period of 2003–2008, were evaluated. All operations were performed under the same surgeons. The mean follow-up period was 2.4±1.2 years (range, 0.5 to 5 ys). The patients were devided in two groups:
patients with good tissue quality and patients with poor tissue quality.
As good tissue quality is defined the tendon with enough mass for suturing (thickness> 3mm) and good elasticity (the footprint is covered properly under tendon traction with tissue grasper). The independent variable studied here was the tissue quality of rotator cuff tendon. Clinical outcomes preoperatively and postoperatively, were assessed with use of ASES, CONSTANT and UCLA scores. Statistical analysis was performed by using STATA 8.0.
Good tissue quality was identified in 119 patients (82%) and poor tissue quality in 26 (18%) patients respectively. At the follow up the patients with good tissue quality achieved Constant score: 86.85±12.49, ASES score: 84±3.4, UCLA score: 28.7±1.9 and the patients with poor tissue quality achieved Constant score: 62.35±13.85, ASES score: 61.49±8.9, UCLA score: 21±3.2. Significant difference between the two groups concerning the clinical outcome was observed after adjusted the data for age. Besides high correlation was noticed between old age and increased rate of poor tissue quality (r=0.88).
Better clinical outcomes are expected in patients associated with good tissue quality, adjusted for age. So the tissue quality is positively correlated with the final functional outcome.
Simple posterior elbow dislocations are often being treated with strict immobilization after reduction. We performed a study in order to investigate if a functional protocol of rehabilitation, allowing early motion, would be more effective.
We prospectively followed twenty five consecutive patients for simple posterior elbow dislocation in a non-randomized study. Patients were divided in two groups. Group A (twelve cases) was treated with immobilization using a cast in 90 degrees of flexion and neutral rotation for three weeks. Group B (thirteen cases) was treated according to a functional rehabilitation program that allowed early controlled mobilization starting on the 2nd post-traumatic day, consisting of immediate flexion from 90° and gradual extension after the 2nd week. Follow-up of the patients was recorded at six weeks and three months. The functional scores used were Mayo Clinic Performance Index, Liverpool Elbow score and Broberg and Morey.
None of the patients had an incident of redislocation. Patients of group B had statistically significant better (p< 0.05) functional scores at six weeks and better no statistically significant in three months: group B/group A: Mayo: 91.6/65.5, Liverpool: 8.8/6.1, Broberg and Morey: 89.1/73.3.
It seems that a functional rehabilitation program gives the same result in terms of stability offering at the same time patients a better range of motion and functional score at least at six weeks and three months.
The purpose of this study is to evaluate the long-term results of the surgical treatment of cubital tunnel syndrome by comparing the in-situ decompression and release of the ulnar nerve with or without partial medial epicondylectomy and the anterior transposition and release respectively.
17 patients were lost to follow-up. 108 patients were clinically assessed. Comparing the results among different surgical procedures, an improvement of at least one McGowan grade was obtained in 26 of 30 patients treated with simple decompression, in 29 of 35 patients treated with release and anterior transposition of the nerve and in 38 of 43 patients treated with release and medial epicondylectomy.
The results of this study show that the possibility for complete recovery is inversely related to the initial neuropathy grade. Partial medial epicondylectomy is a valuable surgical procedure for treating grade I to IIB ulnar neuropathy because is an anatomic method with minimal nerve manipulation preserving regional blood supply.
One hundred and twenty-four patients who had undergone arthroscopic repair of rotator cuff tear, during the period of 2006–2008, were evaluated. All operations were performed under the same surgeons. The mean follow-up period was 1.1±0.4 years (range, 0.5 to 2 ys). The patients were devided in three groups:
patients underwent complete repair (n=104), patients underwent incomplete repair (n=8) and patients underwent medialized technique repair (n=12).
Clinical outcomes preoperatively and postoperatively, were assessed with use of ASES, CONSTANT and UCLA scores. Statistical analysis was performed by using STATA 8.0.
Postoperative functional scores were better than preoperative ones, in all patients (p< 0.05).The patients underwent complete repair achieved preoperatively Constant score: 58.15±3.26, ASES score: 55±3.6, UCLA score: 22.3±1.2 and postoperatively Constant score: 92.65±4.15, ASES score: 92±2.4, UCLA score: 32.1±1.3. The patients underwent incomplete repair achieved preoperatively Constant score: 46.18±3.12, ASES score: 44.2±3.4, UCLA score: 18.1±3.3 and postoperatively Constant score: 76.35±4.22, ASES score: 72±5.4, UCLA score: 24.1±2.3. The patients underwent medialized technique repair achieved preoperatively Constant score: 52.3±1.12, ASES score: 51.9±2.4, UCLA score: 20.4±1.3. and postoperatively Constant score: 86.15±2.22, ASES score: 85.4±4.4, UCLA score: 28.24±2.3. Significant difference was observed between (a) and (b) groups (p< 0.05, CI1: 0.83–0.97, CI2: 0.86–0.95, CI3: 0.81–0.97).
Functionality improvement after arthroscopic repair of rotator cuff tear, with complete, incomplete or medialized repair either, is evidence.
To evaluate the incidence of early complications and operative events during shoulder arthroscopy.
A prospective study of 134 consecutive shoulder arthroscopies, performed using lateral decubitus position, by the same team, with 6 months minimum follow up. During 11 months period we performed 80 shoulder arthroscopies in male and 54 in female patients with mean age 48.6 years (15–82 years). Shoulder pathology that we treated was: 74 rotator cuff repair, 37 shoulder instability, 11 frozen shoulder, 9 calcifying tendonitis, 2 SLAP lesion and 1 debridement. We have well-placed 476 anchors and 63 side to side sutures.
We experience 4 early complications in total (2.98%): 1 anterior interosseous nerve paresis, that fully recovered 6 weeks post op, 1 motor and sensor ulnar nerve paresis that has not fully recovered 4 months post op, 1 sensor ulnar nerve paresis that has not fully recovered 5 months post op and 1 septic shoulder arthritis that was treated with arthroscopic lavage and intravenous antibiotics and has not shown recurrence 11 months post op.
Operative events: 5 (1.05%) anchor slippage, 3 (0.63%) anchor breakage, 5 (0.53%) suture slippage from anchors, 5 (3.73%) instrument breakage, 5 (0.53%) knot loosening or suture breakage.
Shoulder arthroscopy is a quite safe but technically demanding operation. Early complications occur in low rate, but due to technical difficulties operative events occur more frequently, without affecting the final outcome of the operation. Although axillary nerve is believed to be prone to injury during shoulder arthroscopy, in this series other neurological lesion occurred more frequently.
We present a case of a 19-year-old white female patient with neurofibromatosis type I who, 10 years ago, underwent free vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius.
An external fixator was applied for gradual distraction and correction of the deformity of the pseudarthrosic site for five weeks. Wide resection of pseudarthrosis with surrounding fibrotic and thick scar tissue and bridging of the gap with a free vascularized fibular graft followed. Four months postoperatively, union was established in both graft ends. At the last follow-up, 10 years postoperatively, the patient has excellent function with full wrist flexion-extension and forearm pronation-supination.
Free vascularized fibula transfer is considered the treatment of choice for congenital radial pseudarthrosis. It allows complete excision of the pathologic tissue and covering of the gap in one operation. Due to the vascularity of the free vascularized fibular graft both sides of fibula unite easily with no additional intervention.
Fractures of metacarpals and phalanges are common in hand injuries. The goal of treatment is the immediate mobilization of the fingers and restoration of the hand anatomy thus avoiding contractures of the metacarpo-phalangeal and phalangophalangeal joints and hand dysfunction. The aim of this study is the comparison between two methods of fixation of these fractures.
Between 2000–2007, 74 patients who suffered meta-carpophalangeal fractures were treated by K-wires and 62 patients were treated by mini external fixation. Parameters recorded were the operating time, postoperative range of motion, cost and complications. The surgical time was lesser with the use of K-wires, the operative technique much simple and the cost minimum as compared to mini external fixators. The postoperative range of motion was inferior with the external fixation. However, there was no statistical difference between the two groups. 2 patients with the external fixation and 1 patient with K-wires developed pin-track infection. There were 3 failures of fixation in the external fixator group but no failure occurred with the use of K-wires. The majority of the fractures healed within 6 weeks.
K-wires seem to be the ideal method of treatment considering the fractures of metacarpals and phalanges. The use of mini external fixation presents many disadvantages and probably is restricted to the treatment of the open and comminuted hand fractures.
Aim of this prospective, randomized study is to introduce and compare a new technique of reduction of the anterior dislocation of the shoulder with the “Hippocrates” and “Kocher” methods, as far as its efficacy, safety and intensity of the pain felt by the patient during the reduction, are concerned. This is the first reported prospective, randomized comparative study of three reduction techniques of anterior dislocations of the shoulder.
154 patients suffering from acute anterior shoulder dislocation participated in the study. Patients were randomly assigned to one of the three study groups (New, “Hippocrates” and “Kocher”) and underwent reduction of their dislocation performed by residents orthopaedic surgeons.
The groups were statistically comparable (age, male/ female ratio, mechanism of dislocation, mean time interval between injury and first attempt of reduction).
Reduction was achieved with the “Fares” method in 88.6%, with the “Hippocrates” in 72.5% and with the “Kocher” in 68% of the patients. This difference was statistically significant, favoring the new method (p=0.033). The mean duration of the reduction (p=0.000) and the mean reported by the patients VAS with the new method (p=0.000) were also statistically significantly lower than those of the other methods. No complications were noted in any group.
The new method seems to be more effective, faster and less painful method of reduction of the anterior shoulder dislocation, when compared with the “Hippocrates” and the “Kocher” methods. It is easily performed by only one physician and it is not more morbid that the other two methods.
To show the role and effectiveness of semi-constrained total elbow arthroplasty in restoring elbow function in severe, irreversible post-traumatic osseous and chondral injuries.
Eighteen patients, aged 19–80, 11 male and 7 female, suffering from serious, irreversible anatomical and functional lesions of the elbow joint due to previous severe untreated or inadequately treated fractures (T-type transcondylar, trochlear-condylar, open fxs with large bony defects, severe osteochondral, heterotopic ossification in ICU fracture patients). Postop follow up was 9–57 months.
All patients were treated with modular, cemented, semi-constrained linked total elbow arthroplasty. A functional brace was used post-operatively, and motion was permitted on the 3rd post-op day. The patients were allowed a full range of motion at 1 week post-op and they were subjected to vigorous physiotherapy.
Post-op results were evaluated by using Mayo, DASH, quick-DASH scores and measuring grip strength and range of motion. Our results ranged from satisfactory to excellent in 16 patiens, with good strength and wide motion arc (with up to 15o extension-flexion deficit). One old female patient suffered a severe cerebral stroke with a bad outcome. In another young male patient the motion arc reached only 40% of the normal (spasticity, ICU patient with brain injury).
Semi-constrained linked total elbow arthroplasty proves to be an effective method of treatment in severe, irreversible, intraarticular post-traumatic elbow injuries with chondral destruction and grave functional deficit, provided the proper technique is employed and a vigorous rehabilitation program is followed.
The aim of the study was to investigate, firstly, the force distribution between scaphoid/radius and lunate/radius in the normal wrist and in the presence of a scaphoid fracture, secondly, how stresses and strains at the fractured area change during the healing process and thirdly, how the direction of the applied forces affects load transmission.
A 3D finite element model of the normal wrist was initially developed. Two typical scaphoid fractures B2 and B3 according to Herbert’s classification, were investigated. The fractured areas were modeled with a range of modulus of elasticity to resemble the various stages of the healing process. Furthermore, three different directions of the externally applied loads were examined.
The applied compressive vertical load in the normal joint was transmitted to the radius through the radioscaphoid and the radiolunate articular surfaces at a ratio equal to 56:46 respectively. The ratio was equal to 54:48 and 53:49 for the B2 and the B3 fracture respectively. The load direction resembling an ulnary deviated wrist caused the appearance of a significantly higher strain field at the fractured area. The maximum developed stresses at the fractured area for scaphoid fracture B2 were approximately 37%–58% higher than those of B3, for all three loading directions.
Based on our results, the onset of osteoarthritic changes in a wrist with a scaphoid fracture is due to carpal collapse and scaphoid deformity. The recorded maximum developed strains for both B2 and B3 scaphoid fractures suggested intense bone remodeling activity. Among the examined three different load directions, the one simulating an ulnary deviated wrist corresponded to the most severe effects.
The objective of this study was to evaluate the functional outcome of the elbow joint in patients with heterotopic ossification of the elbow joint who underwent surgical excision of pathologic bone.
From 5/1994 to 12/2006, 24 patients (33 joints) with heterotopic ossification of the elbow joint were evaluated. All patients were attended in the Intensive Care Unit (ICU). The patient\’s age ranged from 19–48 years (mean; 32 years) The median ICU hospitalization was 3 weeks. In nine patients both elbows were affected. Unilateral involvement was equally noticed to the right (seven cases) and the left elbow (eight cases). The DASH SCORE and the range of motion were used for the evaluation of the results. All patients underwent surgical treatment in order to extract heterotopic bone and to improve the range of motion of the affected elbow joint.
Postoperatively 18 out of 33 operated elbow joints (54.54%) demonstrated improvement of the range of motion, whereas no improvement was observed in the remaining 15 elbow joints (45.45%). Higher DASH SCORE was obtained in 19 out of 24 patients (79.17%). Surgical excision of the ectopic bone around the affected elbow significantly improves the range of motion of the joint providing better use of the upper extremity and therefore a superior quality of life in these patients.
To assess the outcome of Wilson’s osteotomy of the first metatarsal to correct Hallux Valgus.
Two hundred and forty feet in 172 patients who had surgery for pain were reviewed clinically and radiologically. Age ranged from 28 to 82 years (mean 55 years) and duration of follow-up ranged from 2 to 15 years (mean 6 years). A mini external fixation was used to stabilize the osteotomy.
The average AOFAS score improved from 51.6 to 89.5 points at the last follow-up. In 96% of the cases, the final outcome was satisfactory as far symptomatic improvement was concerned. A 4% only was dissatisfied with the outcome of the surgery due to metatar-salgia, restricted first metatarsophalangeal joint motion or lack of correction. There were no cases of avascular necrosis of the metatarsal head. We had five cases of delayed union but they didn’t need further surgery.
The average preoperative HVA and IMA were 34.80 (range: 180–540) and 15.10 (range: 100–290), while the average postoperative HVA and IMA were 16.10 (range: 70–280) and 7.20 (range: 30–90) respectively.
Wilson’s osteotomy as a method of treatment of Hallux Valgus is technically straightforward, effective and with a predictable outcome. We believe that the external fixation offered increased stability at the osteotomy site and could be the reason why patients had a very low incidence of postoperative metatarsalgia and returned to their normal activities faster, thus giving a higher satisfaction rate.
To analyze the results in proportion to the type of talar fracture.
Eighteeen talar fractures(8 of the body and 20 of the neck)in 28 patients(24 men and 4 women, between 22 and 60 years, of average age 42 years) were treated in our department in the period 1981–2007. 24 fractures were closed and 4 were open (2 B and 2 C1 grade). The Hawkins classification for the fractures of the neck is: 10 type I, 6 type II, 4 type III. The fractures of the body were: 1 type A, 4 type B, 3 type E. The most common mechanism of injury was fall from a height in 16 cases and car accidents in 12 cases. 18 patients had associated injuries. The fractures managed within 6 hours. Time of follow up ranged between 2 and 9 years.
All type I fractures of neck were treated conservatively with excellent results (Hawkins score). All type II were operated and healed with results ranging from very good ones to medium ones. From type III, one had a very good result, one medium and 2 manifested osteonecrosis. From the fractures of the body all (except three: 1 type A, 1 type B and 1 type E) manifested osteonecrosis. The time of union ranged between 2,5 and 4,5 months. There was no deep infection and 9 complications were observed.
Our results agree with those of international bibliography for these rare fractures. The fractures of the body and the type III of the neck have the worst prognosis.
Grice-Green subtalar arthrodesis was initially reported to correct valgus hindfoot deformities in patients with poliomyelitis. Nowadays, the indications of the Grice-Green arthrodesis have been significally broadened. The aim of this study is to analyse the indications of treatment and evaluate the results of the Grice-Green arthrodesis in children.
During the period 1986–2006, 17 children with valgus hindfoot deformities were treated in our department. In 12 of them the procedure was performed in both feet and in the rest (5 patients) unilaterally. The mean age at operation was 8.8 years. The most common group of patients suffered from cerebral palsy (10 patients), followed by the patients suffering from myelomeningocele (4 patients), 2 patients suffered from overcorrection following treatment of congenital equinovarus and one patient from Charcot Marie Tooth disease. In neine patients the operation was combined with Achilles tendon lengthening, capsulotomies, tendon transfers, tendonotomies, and Evans arthrodesis. In all operations bone graft from the tibia or the fibula was used. Postoperatively a balow knee non weightbearing cast was applied for 8 weeks followed by a weightbearing cast for 4 weeks. The results were avaluated according to Alman and Zimbies criteria. The mean follow up of the patients was 4.2 years. The results in 24 feet were considered excellent and in 5 cases satisfactory. In all cases subtalar arthrodesis was achieved.
Grice-Green arthrodesis is a very useful operative technique for the correction of severe valgus hindfoot deformities in children. The results of the technique are usually good and the operation does not influence the normal growth of the foot. An accurate preoperative planning and a good surgical technique is neccesary for good results.
Pilon fractures present a unique challenge to the patient and orthopaedic surgeon. Care for the soft tissue envelope is as important as management of this articular fracture. Assessment of the degree of energy causing the fracture and careful planning of the joint reconstruction will lead to acceptable results in most cases.
Forty-five patients (AO-ASIF classification) treated between 2003 and 2008 were examined clinically and radiologically at an average of 24 months after injury. The patients were treated in three different ways: primary internal fixation with a plate following, which was reserved for patients with closed fractures without severe soft tissue trauma; one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with long-term transarticular external fixation of the ankle for at least eight weeks and hybrid external fixation. Objective evaluation criteria were infection rate, pseudarthrosis, amount of posttraumatic arthritis, range of ankle movement.
In 65% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication.
The complication rate depends mainly on the type of fracture, the soft tissue damage and the type of treatment. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the hybrid external fixation. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires
Is to present our clinical experience in how we evaluate ankle fractures as unstable and the use of syndesmosis screw in their treatment.
Since 2004–2008, 85 ankle fractures treated surgically. Of them 31 were evaluated as unstable according to:
preoperative x-rays findings intraoperative tests, and syndesmosis screw was used.
We used AO-Weber classification: 14 cases type B(7 cases of B2 and 7B3), 16 cases type C(4 cases of C1 and 12 C2). Twenty-one of them were females and 10 were males. Their age rage was from 17–61 years old (Mean 42,5).The follow-up was from 6 months to 4 years(Mean 2,5 years). Syndesmosis screw was removed afters six weeks. Postoperative results were evaluated according the scoring system of Olerud and Malander. Postoperative there were 2 ankle O.A.(6,45%) due to false surgical technique. They treated by arthrodesis.
The proper evaluation of the first x-ray findings of the fracture is of great importance for the proper treatmet. The syndesmosis screw is obligatory in unstable ankle fractures, in which, in combination with proper osteosynthesis preserves the ankle’s stability and viability. Ligament and bone lesions are responsible for ankle stability
There have only been a few studies in the literature which reported on the outcome of ankle arthrodesis in patients with hemophilia, furthermore the number of patients is usually low and the operative technique is not uniform. The aim of this study is to evaluate the outcome of surgery in hemophilic arthropathy of the hindfoot, using internal fixation.
From 1983 to 2006, 20 fusions were performed in 13 consecutive patients due to advanced hemophilic arthropathy of the hindfoot. There were 11 ankle fusions, 1 isolated subtalar fusion and 8 ankle and subtalar fusions, 3 of the latter on a second operation. The mean age at operation was 38.7 years and the mean followup was 9.4 years. Preoperativelly the mean modified Mazur score was 47.7. In the majority of cases the ankle fusion was achieved by two crossing screws, while, for the subtalar fusion either staples were used, or the tibiotalar screws were extended to the os calsis.
Arthrodesis of the ankle was successful in all but one patient, who was revised and progressed to fusion. The mean postoperative modified Mazur score was 94.9. There was also one painless incomplete union of the subtalar joint which did not need revision. There was no recurrent bleeding, and no deep infection.
Arthrodesis with cross screw fixation and staples is a quick, simple and effective method for fusion of the hindfoot in patients with hemophilia.
This study concerns an epidemiological analysis of foot and ankle injuries during the Athens Olympic Games 2004.
An epidemiological survey was used to analyse injuries in all sport tournaments over the period of the Games. During the Athens Olympic Games 2004 in the period from August 1st to September 1st, 624 patients presented to the Foot and Ankle Department for treatment. The mean age of athletes was 24 years (range 21 to 32). Among the patients there were more males, 358 (58%) than females, 266 (42%).
In 525 (84.1%) patients there was only a soft tissue injury and in 99 (15.9%) patients there was bone involvement. Regarding specific diagnoses, tendinitis was the most common reason for a visit, followed by ankle sprains, nail infections/injuries, lesser toes sprains, and stress fractures. Sixty-nine (11%) required emergency transfer to the hospital.
Our experience from the Athens Olympic Games will inform the development of public health surveillance systems for future Olympic Games, as well as other similar mass events.
The assessment of the long –term outcome (5 years) of patients treated with arthroscopic stabilization for acute traumatic patellar dislocation.
From September 2004 until April 2009 we treated 29 patients (25 male, 4 female) with a median age of 18 years (range 14–23 years), two of them had suffered from traumatic dislocation of the patella of the other knee joint in the past. The median range from injury to our surgical intervention was 20 days (7–29 days). The return in sporting activities, the possible redislocation or joint instability and the subjective assessment of the symptoms of the patients, were evaluated in a 5 years follow-up. After 5 years, 23 patients (20 males, 3 females), were re-evaluated.
After the arthroscopic medial retinacular repair all the patients return to sporting activities. All the patients presented chondral lesions at the medial facet of the patella and to the lateral femoral condyle and hemarthrosis too. The functional outcomes were evaluated with Kujala scoring scale, with Visual analog scale and Tenger scale the range of results was good.
The acute arthroscopic repair of the medial retinacular ligaments, protects the patient from redislocation or subluxation, allows the evaluation and stabilisation of the chondral lesions, the removal of free chondral bodies, as well as the evaluation of the possible damage to the menisci or ACL, PCL ligaments.
All the patients returned to normal sporting activity avoiding further injury, or the development of osteoarthritis of the knee joint
To compare the early functional and clinical results, between single (SB) and double-bundle (DB) of Anterior Cruciate Ligament (ACL) reconstruction with hamstrings (HS).
Thirty-six patients from 17 to 36 years old (average age 23), 22 ♂ and 14 ♀, from January 2006 to May 2008, were randomly allocated for ACL reconstruction with HS (SB – DB). Eighteen patients underwent a 4-stranded SB reconstruction (group A) and the remaining 18 underwent an anatomic, 2-stranded DB ACL reconstruction with 2 tibial and 2 femoral tunnel technique (group B), by using the Smith & Nephew instrumentation system. The follow-up was from 8 to 22 months (average 16 months) for both groups and included clinical evaluation (pivot-shift test, anterior laxity test with KT-1000 arthrometer and Lysholm knee score) and radiographs.
There were no statistically significant difference in the results between the 2 groups with regard to the pivot-shift test and the Lysholm score (SB: mean 91, DB: mean 89) (Mann-Whitney test, T-test). The anterior laxity was not significantly different between group A (mean, 2.2mm) and group B (mean, 0.9mm), according to KT-1000 measurements. Rotational stability, as evaluated by pivot-shift test, was better in group B than in group A, but statistical analysis showed no significant difference. The average operation time was longer in DB (110 min) compared to SB (80 min). There were no infections, though one patient of each group was found to be complicated with fixed flexion and extension lag > 5°; and underwent arthroscopic lysis.
Our study shows no statistically significant advantage of DB versus SB ACL reconstruction, concerning the clinical evaluations and the complications
The purpose of this retrospective study was to report the results using scarf, first metatarsal osteotomies, in correcting Hallux Valgus deformity with H-V angle > 35°.
During the period 2003–2008 we did 23 scarf, first metatarsal osteotomies in 15 patients (8 bilateral).In order to evaluate the effectiveness of this operation, patients were clinically (aofas score) and radiologically (X –ray in 4, 8, 12 weeks) assessed.
Mean follow up was 32 months. The results evaluated with the aofas score in order to study the function, the pain and the overall satisfaction of the patients. We had excellent results in 13 %, very good in 48 % good 32% and poor 7 %.There was only one complication and no one infection.
According the above results it seems that scarf osteotomy is quite reliable surgical treatment of severe Hallux – Valgus deformity with an increased IM angle.
The assessment of graft stability in ACL reconstruction with two different techniques (endobutton vs. crosspin) and the comparative evaluation of the results of the two techniques.
From October 2005 until May 2009, 69 patients underwent ACL reconstruction with the above-mentioned techniques by two surgeons; follow-up examinations took place after a minimum of two (2) years. Postoperative radiographic and clinical assessment were carried out and Lysholm, Tenger and IKDC scores were obtained at 3, 6, 12 and 24 months; stability was checked by KT-1000 arthrometer. Clinical evaluation by Lachman and pivot shift was normal or near-normal in 65 patients. No significant differences were found both as regards the KT-1000 (1.0 mm less with the cross-pin technique) and as regards the subjective variables (the endobutton having a slight advantage). Mean postoperative IKDC evaluation was 87.4 vs. 85.3, while Lysholm was 89 vs. 86. Two patients underwent revision after a new traumatic incidence and one displayed a new meniscal lesion, which was treated accordingly. The vast majority of the patients returned to their previous occupational activities and social life (overall patient satisfaction was at 88.2 vs. 85.4).
Both the endobutton and the crosspin techniques proved to be reliable fixation methods for the treatment of ACL ruptures using the hamstrigs tendons; both methods provided safe fixation even in cases when back wall blow had occurred
Forefoot involvement in rheumatoid arthritis (RA) is extremely common and the majority of the patients with RA have active foot symptoms and signs of the disease. This rertospective study was undertaken to assess the outcomes and complications in the surgery of the forefoot RA.
Seventeen patients (27 feet) with RA underwent surgical correction for the forefoot deformities. Antero-posterior and lateral weight bearing radiographs of all feet were taken preoperatively. The forefoot deformities seen with RA varied and included hallux valgus with subluxed metatarsophalangeal (MTP) joint in 23 feet, hallux valgus with dislocation of the MTP in 4, hammer or claw toes in 12 and 8 feet respectively. In addition, all 27 feet presented with variable levels of intermetatarsal deviations or widening. All the patients with hallux valgus underwent first MTP joint arthrodesis with various techniques. Deformities of the lesser toes were treated in all but 3 cases with resection arthroplasty, while the remaining 3 feet received a Weil osteotomy. Postoperatively the toes and the MTP joints were stabilised with K-wires for 6–8 weeks.
All patients have been studied for a minimum follow up of 9 months. Twenty six patients were satisfied by the outcome of the surgical treatment. Only one patient complained of persistent metatarsalgia postoperatively. The surgical complications included 2 cases of delayed union, 5 cases of delayed wound healing, 2 cases of wound infection, and 4 cases of plantar callosity. Overall, 4 patients required reoperation.
Even though complications occur in patients with RA who undergo surgical correction of the forefoot deformities, most of these complications can be treated successfully. Thus, the overall outcome of the surgical treatment is good leading to satisfactory correction of the forefoot deformities and to pain elimination
We describe the treatment of traumatic anterior shoulder instability complicated with Hill-Sachs lesion, using a combined arthroscopic technique of anterior & posterior capsular fixation and infraspinatus tenodesis by means of suture-anchors, in order to fill the humeral head bone defect (i.e. “remplissage”).
We use 2 posterior portals introducing the arthro-scope through the upper one. A double-armed suture-anchor is inserted through each portal piercing the infranspinatous tendon & posterior capsule in an extra-articular mattress mode. The humeral head bone defect is filled with the aforementioned tissues.
18 patients with well established anterior instability were subject to this technique between March 2005 and December 2008. The follow-up time was 6 to 36 months (average 18 months). All were evaluated using the Rowe protocol for shoulder instability which assess stability, ROM & shoulder functionality.
In 13 patients the outcome was assessed as excellent, in 4 good & in 1 average. In one patient, post-op stiffness was developed which managed successfully with conservative means.
The arthroscopic technique of “remplissage” is an innovative choice in the armamentarium of treatment of anterior traumatic instability with concomitant Hill-Sachs lesion. The results of this technique are excellent regarding the recurrence rate of anterior instabiliy (in our series there was none episode of recurrent instability during the study period).
Since 1987, autologous chondrocyte implantation (ACI) has been performed in Gothenburg, Sweden in more than 1600 patients. Out of the first 442 patients operated with ACI, 153 (35%) had patella lesions and 91 (21%) had trochlea lesions. Forty two patients (9.5%) had kissing lesions of the patellofemoral joint.
The aim of the study was to evaluate the current clinical status of operated patients. Lysholm and Tegner-Wallgren self-assessment questionnaires were used. The patients were requested to compare their current status to previous states and to report whether they would do the operation again. Concomitant realignment procedures of the patellofemoral joint were also recorded and preoperative scores were also assessed from the medical files.
Patients were divided into groups according to the location of lesion. All the groups showed a significant improvement compared with the preoperative assessment. Over 90% of the treated patients were satisfied with the ACI and would have undergone the procedure again.
It seems that correcting the coexisting background factors with realignment, stabilizing or unloading procedures is improving the results over time. Despite the initial controversy about the results and indication for ACI in patellofemoral lesions, it is clear that ACI provides a satisfactory result even for the difficult cases with concomitant patellar instability. Our study reveals preservation of the good results and of high level of patients’ activities, even 10 to 20 years after the implantation.
The purpose of this study is to determine the influence of knee flexion angle for drilling the posterolateral (PL) femoral tunnel during double-bundle anterior cruciate ligament (ACL) reconstruction via the anteromedial (AM) portal on resulting tunnel orientation and length. Methods: In nine fresh cadaveric knees, the ACL was excised and 2.4 mm guide wires were drilled through the PL bundle footprint via an AM portal. We compared knee flexion angles of 90, 110, 130 degrees. AP-, lateral- and tunnel view radiographs were measured to determine tunnel orientation, o’clock position, and direct measurement to determine intra-osseous tunnel length
On AP view, increased flexion resulted in more horizontal tunnels. The angles were 31.9 ± 7.1°, 26.4 ± 8.9° and 23.0 ± 8.1° for 90°, 110° and 130°. The pin orientation was significantly different when comparing 90° and 130°. On lateral view, increased flexion resulted in more horizontal tunnels. The angles were 68.9 ± 19.9°, 50.4 ± 11.6°, 31.3 ± 12.3° for 90°, 110° and 130°. On tunnel view, pin orientation was 22 ± 8.2°, 28.3 ± 6.7° and 35.9 ± 6.2° for 90°, 110° and 130°. Mean o’clock position was 09:00 ± 0:12. Intra-osseous length of the pins did not significantly change with knee flexion. The exit of the pins on the lateral femur with regard to femoral attachment of the LCL was proximal. The distance was 0.1 ± 6.6 mm, 6.4 ± 6.4 mm and 9.2 ± 2.4 mm for 90°, 110° and 130°. This was significant when comparing 90° and 130°. The shortest distance between the exit and the posterior femoral cortex was 4.0 ± 1.8 mm, 9.7 ± 3.5 mm, and 13.2 ± 2.8 mm for 90°, 110° and 130°. All values were significant. Conclusion: At 110°, exit of the PL pin is close to the attachment of the LCL. 90° flexion risks damage to the LCL and posterior cortex blow-out. Thus we recommend drilling the PL tunnel at 130° of knee flexion
Acetabular chondral delamination is a frequent finding at hip arthroscopy. The cartilage is macroscopically normal but disrupted from the subchondral bone. Excision of chondral flaps is the usual procedure for this type of lesion. However, we report 19 consecutive patients in whom the delaminated chondral flap was re-attached to the underlying subchondral bone with fibrin adhesive. We used the modified Harris hip score for assessment of pain and function.
Improvement in pain and function was found to be statistically significant six months and one year after surgery. No local or general complications were noted. Three patients underwent further surgery for unrelated reasons. In each, the area of fibrin repair appeared intact and secure.
Our results suggest that fibrin is a safe agent to use for acetabular chondral delamination.
The assessment of the arthroscopic findings in patients suffering from impingement syndrome and partial tear of the supraspinatus tendon, staged as type 1& 2 under Ellman, Gartsman, Snyder, that were treated by acromioplasty, debridment and repair of the supraspinatus tear.
Thirty four patients,(20 male, 14 female), with a median age of 52 years, (48–64 years old), underwent shoulder joint arthroscopy. All were evaluated by two physicians and subjected to plain films (AP& Y views) as well as to MRI.
Clinically, the differencies in the evaluation of patients with type 1& 2a lesion were insignificant. Type 2b had a better outcome, but in comparison to type 1, that were subjected only to acromioplasty, variations involving range of motion, pain and scoring (Constant & Oxford scores), were observed, from the first stages of rehabilitation, with no further improvement. The comparative method in relation to the clinical trials was in favor of those patients treated with repair of the tear.
After a 29 m follow up, we suggest only acromioplasty, in stages 1& 2a, although the daily activities of each patient can change the approach. In type 2b lesions, irrespective of age, we suggest the repair of the tear
To present our preliminary results in fully arthroscopically performed 3-dimensional autologous cartilage transplantation (ACT-3D) for medium to large focal chondral defects at the knee.
We treated operatively in our Dept., 35 symptomatic patients between March 2007 and May 2008. The mean age was 32 years old. The mean area of cartilage defect was 6.75cm2 (2.2–10cm2) and all the cases were classified as grade III(16) and IV(18) according to Out-erbrigde scale. 18 of the cartilage lesions were located in the weight-bearing surface of the medial femoral condyle, 8 in the lateral one, 6 in the trochlea area and 2 in the lateral facet of the patella. We performed 15 applications of ACT3D as single procedure. Apart from that, we performed 11 ACL reconstructions combined with the 3D-spheres. Preop. and postoperative evaluation of patients was done using the Modified Cincinatti (MC) Rating System(0–100), the VAS (visual analogue pain score) (0–10), IKDC Knee examination score and Patient Outcome Function score.
All the cases were performed uneventfully. No major complications were seen. All cases followed a specialized rehabilitation protocol. In MC Rating System the result rose from 41.5 to 72.5 and in VAS, pain significantly reduced from 6.1 to 1.8 in 12 months time. The Patient Outcome Function score showed 81% better, 18% same and 1% worse results. The follow-up using MRI showed adequate filling of the defect without significant bone swelling.
Arthroscopically performed chondrocyte implantation (ACT) is an innovative technique with early results very promising. It’s surgeon demanding, although it’s fast performed technique and well tolerated operation. A greater number of cases and further mid and long term follow-up has to be studied in order to prove the efficacy of the method.
The goal of this study is to analyze the surgical management of proximal humerus fractures in medial age patients (50–65 years of age).
From 2003–2008 were treated 49 patients, 14 male and 35 female with mean age of 61 years. All patients had a proximal humerus fracture classified by the AO Universal Classification. The fractures were treated with either open reduction internal fixation (ORIF-21 patients) or with shoulder hemiarthroplasty (HSA-28 patients) under general anesthesia.
Among the patients that were treated with ORIF or HSA we did not observe statistical significant differences in the days of hospital stay, the change of pre and postoperative hemoglobin, the need of blood transfusion and the acute postoperative complications. On the contrary there were statistical significant differences in the level of acute postoperative pain, the clinical results and the range of shoulder movements after a period of 3,6 and 12 months (constant score).
ORIF seems to have better clinical results for younger medial age patients in comparison with HSA that seems to have poorer results. On the contrary HSA seems to have better clinical results for older medial age patients.
To evaluate humeral and glenoid bone loss in patients surgically treated for shoulder instability as factors of recurrence.
During the period 2000–2008, 114 patients (103 men and 11 women) with mean age of 28 yrs underwent arthroscopic treatment for shoulder instability by the same surgeon. Mean age of the 1st shoulder dislocation was 20,89 yo and the average number of dislocations per patient was 17,14. Glenoid bone loss was found in all patients (16 Large, 59 Medium, 29 Small), as well as Hill Sachs lesions (66 Large, 23 Medium, 8 Small) or both. Thirteen (13) patients had an “inverted pear” glenoid shape. Seventy five (75) were into sports and for 57 (76%) of them this involved Overhead/Contact activities. Also 20 patients presented joint hypermobility. Complete follow up existed for 92 patients and it ranged from 4–108 months (Mean=44). The recurrence of instability and the functional outcome were evaluated post-op using the Rowe Zarins Score.
Recurrence of instability was noted in 5 patients (4,38%). All of them presented Hill Sachs lesions and glenoid bone loss (2 Large, 2 Medium, 1 Small) but without an “inverted pear” glenoid shape or joint hypermobility. All 5 of them were into Overhead/Contact sports activities (2 Professional: Mean=15hr/w and 3 Amateur: Mean=2,5hr/w). The post op Rowe Zarins Score ranged from 80–100 (Mean=95,11).
From the evaluation of our data, it seems that humeral and glenoid bone loss do not significantly contribute to the recurrence of arthroscopically treated shoulder instability.
The treatment of radius head comminuted fractures remains controversial. The radius head excision and the radius head arthroplasty have been proposed as the main treatment methods.
We present 13 cases, 6 men and 7 women aged 25–68 years old with radius head comminuted fractures Mason type III during 2005–2006. Elbow dislocation was also present in 3 patients, ulnar comminuted fracture in 1 patient and ipsilateral cubitocarpal comminuted fracture in another patient.
All patients were managed operatively with radius head removal and cementless monopolar metallic prothesis placement. The others musculoskeletal injuries were managed at the same time. The average hospitalization was 6.8 days without complication postoperatively.
12 cases were followed up and the average follow up period was 26 months.
In 6 cases the results were excellent, in 3 cases the results were moderate and in 3 cases the results were bad.
We believe that the arthroplasty is the acceptable method in radius head comminuted fractures management especially in cases were complicated elbow damages are present.
Posterior interoseous nerve (PIN) syndrome is an entrapment of the deep branch of the radial nerve just distal to the elbow joint. It may result in the paresis or paralysis of the fingers and thumb extensor muscles.
We present a review of 26 cases of PIN entrapment syndrome, diagnosed an treated over a ten years period form 1996 to 2005. Their ages ranged form 12 to 57 years, they were 18 men and 8 women. The interval between, the onset or paralysis and operation ranged from 4 months to 1 year. All the patients were diagnosed preoperatively as having PIN palsy from physical examination and electromyographic (EMG) studies of the posterior interoseous innervated muscles and all were treated by operation.
The cause of compression was, ganglia in four cases, fascia thickening at the arcad of frohse in six cases, the radial recurrent vessels in three cases, lipoma in four cases, dislocated head of the radius in two cases, infamed synovium in four cases, tumour in two cases, and Intraneural Perineurioma in one case. The periods of postoperative observation were from 1 to 10 years. The paralysis recovered completely by the six postoperative months in all cases except one girl with intraneural peri-neurioma.
Three patients developed mild reflex sympathetic dystrophy which resolved with physiotherapy and auxilary blocks. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve which recovered in a few weeks.
Having arrived at a diagnosis of PIN syndrome, it is important to select the correct level for the release of the radial nerve. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury.
We prove the importance of the complete osteoligamentary elbow reconstruction and the usefulness of the liga-mentoplasty by palmaris longus combined with other procedures in complex elbow unstable injuries.
17 patients aged between 17 and 72 suffered elbow luxation or subluxation with rupture of the medial collateral ligament, associated with:
Fracture of the radius head, fracture of the coronoidal process(terrible triade),1) olecranon fractures.
In 3 compaound injuries we had open fractures with Brahial artery lesion, Ulnar nerve pulsy, radial nerve laceration, Brahial plexus injury.
The lesions happened between 2 hours and 2 yrs pre-operatively, caused to work accidents or to traffic accidents with a follow up between 8–62 months. 10 of the injuries were operated almost in emergency by ligamen-toplasty with palmaris longus, coronoidal process fixation with screw or ancor, radial head osteosynthesis or prosthesis. The vascular injuries urgently operated while the nerve lesions left for secondary repair. A functional splint was applied postoperatively, initially fixated between 110–85 degrees. The splint removed 2 months postoperatively, while full rang of motion obtained.
We performed both Mayo clinic, DAS scores and grasp strength force and Range of Motion measurement evaluation procedures
Satisfactory to excellent results have been obtained in 11 cases with stable joints and range of motion with 20 degrees extension-flexion deficit while in I case the instability persited, in another one arrived 50% of the normal range of motion.
The complex elbow injuries with ligamentary instability are effectively treated if except fractures we always repair The medial-anterior ligaments lesion with liga-mentoplasty and ancors.
The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after surgery and whether these phenomena were clinically significant and would influence the final outcome.
12 unstable, displaced metacarpal fractures in 10 patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with the Inion® OTPSTM Biodegradable Mini Plating System. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m). For patients without appearance of foreign body reaction the minimum follow-up time was 24 months
Patients were examined both radiologically to evaluate fracture healing, and clinically by completing the DASH-score and a visual analogue scale for pain assessment. Grip strength, finger strength and range of motion of metacarpo-phalangeal and interphalangeal joints were measured.
Fracture healing occurred uneventfully in all patients within six weeks. The most important complication was a foreign body reaction observed in 4 of our patients more than a year postoperatively. All were re-operated and had the materials removed. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction.
Although internal fixation of metacarpal fractures by using bioabsorbable implants is a satisfactory alternative fixation method, patients should be advised of this possible late complication and should be followed postoperatively for at least one and a half year, possibly longer.
To estimate the prevalence of clavicular fractures, number of cases required operative treatment, and whether removal of the implant is a frequent necessity.
Between November 2005 and Nov 2007 all patients presenting in our institution with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Retrospective review of clinical notes and radiographs. Demographic details, mode of injury, treatment protocol, operative procedures performed, time to union, complications post-surgery stabilization, and the number of cases that required implant removal were documented and analysed in a computerized database. The mean time of follow up was 24 weeks (12–48).
Out of 16,280 adult fractures that presented to our institution, 200 (1.23%), (137 males) patients met the inclusion criteria with a mean age of 43 years (19–95) and a mean ISS of 9 (4–38). There were 4 of the medial, 153 of the middle and 43 of the lateral clavicle fractures (3 were open). 178 (89%) patients were treated non-operatively and 22 (11%) operatively. Indications for surgery included open fracture, bony spike/skin threatened, grossly displaced/comminuted fracture, polytrauma and non-union. Mean time to radiological union was 14 weeks (5–38 weeks). Out of the 200 patients 12 (6%) developed non-union. Out of the 22 operated patients, 7 (32%) required plate removal and 1 had screw removal. Indications for removal of implant included, periprosthetic fracture (1), prominent metal work through skin (3), pain in shoulder (2), pressure symptoms (1). Post removal of implant, 6 (75%) patients claimed improvement in symptoms. Functional outcome was excellent/good in 90% of cases.
The incidence of clavicular fractures was 1.23%. A small number of patients (11%) required operative treatment out of which one third had metal work removal. The majority of clavicular fractures can be treated non-operative with good functional results.
The aim of this study was to evaluate the severity of pelvic fractures, to emphasize the appearance of major complications and to record the possible permanent damage of these patients.
We studied the clinical presentation of 105 patients with solid or multiple fractures during the period 2000–2007. Thirty one patients presented with acetabular fracture (5 of which showed dislocation of the corresponding hip), 52 patients presented with pelvic ring fractures and 22 patients presented with ischio-pubic and sacral fractures. The demographic data and patient history were recorded. The patients were re-evaluated in out-patient department.
There were several major complications. Pulmonary embolism occurred in 6 patients, 15 days following the fracture. One patient had a myocardial infraction, 19 days after the fracture and 1 stroke victim, 10 days following fracture. Five patients had urinary bladder rupture. Fourteen patients presented severe injury of the sciatic nerve. Three patients had a permanent urinary tract catheter and one had penile erectile dysfunction. In 13 patients there were minor complications such as numbness of limbs, groin pain and limping during gait. We needed, on average, 3.8 units of blood.
We conclude that pelvic fractures, solid or multiple, are very severe injuries. They require high level of observation due to major complications, of which increase morbidity and mortality.
The evaluation of our results from the use of transscalen block in shoulder surgery.
During September 2008 – March 2009, in our institution 25 patients underwent different types of shoulder surgery. Fifteen patients were male and ten female with mean age 56 y.o. Shoulder pathology included fractures, rotator cuff tears, subacromial decompression. Two of the patients received general anaesthesia because of anatomic variations to the neck and the rest twenty three of them underwent a transcalen block as method for anaesthesia. For the block all the patients received 20 ml Naropeine 7.5% and 10 ml NaCl 0. Two out of twenty three patients received, during the beginning of surgery, general anaesthesia because of pain. There were no other complications, regarding the anaesthesia, during the surgery. The postoperative analgesia was 8.5 hours in average. None of the patients received postoperatively any strong analgetics.
We believe that the use of transcalen block is a safe and secure method of anaesthesia for the shoulder surgery with excellent analgetics results.
This paper aims to evaluate the Remplissage arthroscopic technique as described by Eugene Wolf used in patients with traumatic shoulder instability that present glenoid bone loss and Hill Sachs defects.
In our study 28 patients (5 women and 23 men) with mean age of 31 yrs underwent arthroscopic stabilization of the shoulder by the same surgeon during 2007–2008 period. All patients presented Hill Sachs lesion, 11 of them had medium or large glenoid bone loss, 10 had an “inverted pear” glenoid shape, 4 had been revised for stabilization in the same shoulder and 14 presented joint hypermobility. Mean age for the age of 1st dislocation was 20,1 yrs and our follow up ranged from 5–28 months (Mean=18). The recurrence of instability and the functional outcome were evaluated pre-op and postop with the Rowe Zarins Score. The post op rehabilitation was performed by a specialist.
None of the patients presented recurrent instability. The Rowe Zarins Score raised from a mean pre op score of 23,33 (15–60) to a mean post op score of 97,11 (75–100) (p< 0.05). All the patients that were into sports activities before the presentation of shoulder instability began training again and our post op evaluation of the shoulder’s ROM showed a decrease in the external rotation from 0°–15°.
The infraspinatus tenodesis and posterior capsulodesis in patients with humeral bone loss seems to offer so far excellent post op results despite the slight decrease in the external rotation of the shoulder.
This study compares the endoscopic carpal tunnel release with the conventional open technique with respect to short and long-term improvements of functional and clinical outcomes.
We assessed 72 outpatients diagnosed with carpal tunnel syndrome. Thirty-seven patients underwent the endoscopic method according to Chow and 35 were assigned to the open method. Improvement in symptoms, severity and functionality were evaluated shortly preoperatively (at two days, one week and two weeks) and one year after using the Symptom Severity Scale, Symptom Severity Status and DASH questionnaire. Changes in clinical outcomes (grip strength, key pinch and two-point discrimination test) were evaluated one year postoperatively. Complications were also assessed.
Both groups showed similar improvement in all but one outcome one year after the release; increase in grip strength was significantly higher for the endoscopic group. The endoscopic method was also associated with a significantly faster short-term improvement. Separate analysis of the questionnaire components referring to pain reveals that the delay of improvement in the open group is due to the persistence of pain for a longer period. Paresthesias and numbness decrease shortly after the operation with comparable rates for both groups.
Correcting a malunited distal radial fracture usually requires osteosynthetic material applied on the dorsal side of the radius. However, contact of the material with the extensor tendons often produces irritation and rupture problems. The aim of this study is to evaluate the effectiveness of the specific osteosynthetic material (Trimed) in treating malunion of intra- or extra-articular fractures of the distal radius, after a corrective osteotomy.
We examined 11 patients (7 females, 4 males), with average age of 42 years (ranging from 21 to 69 years old), 10 of which presented with symptomatic malunited distal radial fracture of a mean duration of 2.85 months (2–7 months). In one patient the malunited fracture was 30 years old. In 7 patients the malunited fracture was extra articular whereas in 4 patients it was intra articular. A corrective osteotomy was performed in all cases, followed by application of the special osteo-synthetic material by Trimed on the dorsal side of the radius. In seven patients iliac crest bone graft was used, whereas in four allografts were applied. Furthermore, five patients had to undergo additional surgical procedures. More specifically, shortening osteotomy of the ulna in 3 patients, radio-scapho-lunate fusion in 1 and excision of scaphoid with carpal tenodesis in 1 patient.
After a mean follow-up of 15 months (6–27 months) the results were evaluated based on (Fernadez 2001), pain, range of motion, and grip strength. Excellent results (18–20 points) were observed in three patients, good results (15–17 points) in five patients and fair results (12–14 points) in two patients.
We conclude that the use of this particular material provides satisfactory stability on the corrective osteotomy and because of its low profile it can be applied on the dorsal side on the radius without interfering with the extensor tendons.
In this study we try to evaluate the results of intramedullary nailing in the treatment of fractures of diaphysis of humerus.
During the time period of 2002 to 2006 46 patients were admitted in our clinic with fracture of the diaphysis of the humerus and 23 patients were treated surgically with intramedullary nailing. 14 patients were directly submitted to intramedullary nailing, 6 patients after unsuccessful conservative treatment and 3 patients due to nonunion after internal fixation. Average age was 51 years old. In 5 patients open reduction was applied while bone grafts were not used in any case. In all cases bone healing was obtained within 6 to 20 weeks (average 11 weeks). Final functional outcome was evaluated with Constant Score and according to it 10 patients demonstrated excellent score (> 75), 7 satisfactory (50–75) and 6 poor(< 50). Postoperative evaluation was based on clinical findings such as pain, range of motion and rehabilitation. As far as complications are concerned 2 cases with severe stiffness of the shoulder were observed and 1 case with malunion. There were no cases with non-union, sterile necrosis or neurological impairment.
Intramedullary nailing shows significant advantages such as limited damage to soft tissues, satisfactory retention of osteoporotic fractures, immobility of complex fractures and allows immediate postoperative mobilization.
Anterior elbow dislocations often occur as a fracture-dislocation in which the distal humerus is driven through the olecranon, causing either a simple oblique fracture of the olecranon or a complex, comminuted fracture of the proximal ulna. The purpose of this study was to characterise the morphology and to evaluate the surgical treatment of this injury.
Thirteen patients (8 women and 5 men) with a mean age of 42 years were included in this study. Four patients had a simple, oblique fracture of the olecranon and 9 a complex, comminuted fracture of the proximal ulna. Six patients had an associated fracture of the coronoid process which was detached as a large fragment and 7 an additional fracture of the radial head. In all cases the collateral ligaments were found intact. All fractures were treated by open reduction and internal fixation through a midline dorsal approach. Simple fractures of the olecranon were treated with tension-band wiring while comminuted fractures were fixed with a plate and screws. Fractures of the coronoid process were stabilised by interfragmentary screws or small plates. The concomitant radial head fractures were treated by excision of small fragments, internal fixation or radial head replacement.
The average follow up was 71 months. According to the functional scale of Broberg and Morrey, the results were excellent in 8 patients, good in 2, and poor in 3. Mild arthritis was observed in one patient.
Transolecranon fracture –dislocation of the elbow is often misidentified as an anterior Monteggia lesion or a simple fracture of the olecranon. Differential diagnosis between these lesions is imperative. Consequently, anatomical restoration of the trochlear notch in cases of transolecranon fracture –dislocations can be achieved leading to good long-term results.
Fractures of the distal tibia metaphysis comprise a challenge for the orthopaedic trauma surgeon because of the poor blood irrigation they do not heal very easy leading sometimes to pseudarthrosis and many times arise problems with the skin.
We compare the following techniques: LC-DCP and LCP plates, MIPO, External fixators (hybrids or simple one), intramedullary nailing with multiple screws at the distal end.
94 cases of distal tibia fractures from all AO types were treated during last 3 years (2005–2008) with the following techniques:
16 ORIF with LC-DCP plates 9 ORIF with LCP plates 19 MIPO 35 External fixators 15 intramedullary nailing
The simple oblique or spiral fractures which treated with the 1st and 2nd method (ORIF), they do not seem any remarkable difference in healing but both methods demonstrate a delay in fracture healing over 5 months. The 3rd method display faster healing 2,5 months average in simple fractures with no skin wound at all. The 4th method display 3 pin track infections and dealt with removal of the material and 2 pseudarthrosis which encountered with ORIF and bone grafting from the iliac. The 5th method display 2 malunions but because of the small angle in varus we do not perform any treatment. Every technique has its own position on those type of fractures, depending of the personality of the fracture and the skill of the surgeon.
We evaluated the use of unreamed expanding nails in prophylactic stabilization of impending fractures in patients with multiple bone mets.
During 2004–2008 we treated 25 impending fractures due to metastasis (11 male, 14 female patients) with so-called expanding intramedullary nails. All they had multiple bone mets and signs of impending fracture due to extensive osteolysis. We stabilized 6 impending humeral fractures, 15 femoral and 1 tibial with antegrade nailing and 3 pertrochanteric with cephalomedullary nailing. Fluoroscopy was used to check the nail entry-point. No medullary reaming was performed. The nails were not interlocked at the mid-shaft but fixed rather firmly within the medullary cavity after introducing normal saline under pressure that expands its walls. The operation time ranged from 12min (humerus) to 25min (pertrochanteric). No blood transfusion was necessary. On follow-up (8–41 mos) all patients were reviewed. In all cases the risk of impending fracture was remarkably decreased. The patients with humeral fractures regained function quickly. The patiens with lower limb fractures were mobilized immediately post-op and were allowed to walk with TWB.
Surgery of impending fractures of long bones in patients with multiple bone mets is palliative. It aims in safer patient’s mobilization, fracture risk reduction, pain control and function restoration in order to render the patient capable to continue the treatment for the main disease. The expanding nailing is indicated in selected cases as it can be inroduced quickly and effectively with minimal blood loss and morbidity.
We present our clinical experience in treating atrophic non-union of long bones by injecting, percutaneously, autologous bone marrow aspirate concentrated as a source of progenitors stem cells
Bone marrow aspirated from the iliac crest contains progenitor cells that can be used to obtain bone-healing of non-union. However, its efficacy appears to be related to the number and concentration of progenitors in the graft. The last three-year period, 11 patients (8 men-3 women) with established atrophic non-union were treated in our department. In all cases, the gap between the fragments was smaller than 5 mm. A constant volume of 60+60 ml of marrow were aspirated from both iliac crests and centrifuged for 15 minutes aiming at the increase of concentration of progenitor-mononucleotide cells. An average volume of 20 ml (+/− 2) concentrated bone marrow was injected percutaneously, under C-arm, at the site of non-union. The graft contained an average of 272.64 x 10(6)/ ml mononucleotide cells. The evaluation of treatment was based on the clinical and radiological findings after 3, 6, 9 and 12 months. However, prior to administration of bone marrow stem cells, there was no case with evidence of ongoing deep sepsis.
Bone union was obtained in 10 out of 11 patients (full weight bearing, callus formation in 3 out of 4 cortices). In one case a second operation was needed due to impaired indications of treatment. However, in all cases, there were no signs of local or systematic complications.
Percutaneous concentrated bone marrow grafting is an efficient and safe method, for treating atrophic non-unions, with a minimal invasion technique. Contraindications for the above technique are a gap larger than 5 mm and a preexisting angular and axial deformity.
Ankle fractures are among the most common injuries treated by orthopaedic surgeons, and surgical treatment is often required to optimise the results. This retrospective study was undertaken to assess the effectiveness of the TRIMED ankle fixation system in the treatment of malleolar fractures.
During the last ten months, fifteen patients with an average age of 63 years underwent open reduction and internal fixation of a bimalleolar ankle fracture with the TRIMED fixation system. A standart surgical approach was used for both the medial and lateral malleolus. Regarding the lateral malleolus, a TRIMED Sidewinter plate which requires no additional interfragmentary screw was applied. Based on the morphology of the fracture of the medial malleolus, either interfragmentary screws or the sled- like medial malleolus fixation system was applied. One patient underwent in addition open reduction and internal fixation of the posterior malleolus.
All fractures proceeded to uncomplicated union in an average healing time of 6 weeks. Excellent functional restoration of the ankle joint, comparable to the ipsilateral ankle, was achieved.
The TRIMED ankle fixation system represents a good alternative method in malleolar fracture fixation which simplifies the fracture reduction and obliterates the need for a lag screw, thus preserving the biology of the fracture site. Furthermore, it can be used for the reconstruction of distal fractures of the lateral malleolus. However, further long-term studies are recommended to evaluate the success of the TRIMED fixation system.
Periprosthetic fractures are rare complications (0.3%–2.5%) of total knee and hip Arthroplasty. Purpose of this study is to present our experience and the mid-term clinical results of periprosthetic fracture care.
Between 2005 and 2009 nineteen femoral periprosthetic fractures were treated in our department. Seven patients with TKA had supracondylar fractures, type II according to Lewis and Rorabec classification. Twelve patients with THR had type B2 fractures according to Vacouver Classification. Seven patients were men and 12 women with average age 78.15 years. Femoral shaft fractures were treated with ORIF and DCP 4.5mm femoral plate in 8 cases, revision THR in 3 cases and 4.5mm plate with wires in one case. Supracondylar fractures were treated with ORIF abd LCP plate 4.5mm in 5 cases, Ilizarov fixator in one case and DCS plate in the last case. The average follow up was 22 months postoperatively.
Fracture healing observed in 16 patients at an average of 6 months postoperatively. No infection or non union complicated our treatment goal. Three patients died at an average of 2 months postoperatively. One should point out that mobilization and return to previous activity level is very difficult for these patients, despite fracture healing. Best clinical results observed with DCP and LCP 4.5mm plates.
Periprosthetic fractures are serious and complex complications of an arthroplasty that require stable osteosynthesis and primary patient mobilization.
Restoration of an anatomical hip centre frequently requires limb lengthening, which increases the risk of nerve injury in the treatment of Crowe 4 Developmental Dysplasia of the Hip (DDH). Prospective evaluation of the use of subtrochanteric derotational femoral shortening with a cemented Exeter stem.
15 female patients (18 hips – 3 bilateral) with a mean age at time of operation of 51 years followed-up for a mean of 114 months (range 52 to 168). 16 cemented and 2 uncemented acetabular components were implanted. Exeter cemented DDH stems were used in all cases. No patient lost to follow up. All 18 Crowe IV hips reviewed. Charnley-D’Aubigne-Postel score for pain, function and range of movement were improved from a mean of 2-2-3 to 5-4-5 respectively. One osteotomy failed to unite at 14 months and revised successfully. Clinical healing was achieved at a mean of 6 months while radiological evidence of union at a mean of 9 months. The mean length of the excised segment was 3 cm and the mean true limb lengthening was 2 cm. 3.5mm DCP plate with unicortical screws was used to reduce the osteotomy, and intramedullary autografting performed in all cases. Mean subsidence was 1 mm and no stem was found to be loose at the latest follow up. No sciatic nerve palsy was observed and there were no post-operative dislocations.
Cemented Exeter femoral components perform well in the treatment of Crowe IV DDH with when a subtrochanteric derotational shortening osteotomy (SDSO) was necessary. A transverse osteotomy is necessary to achieve derotation and reduction can be maintained with a DCP plate. Intramedullary autografting prevents cement interposition at the osteotomy site and promotes healing.
In selected patients in-cement revision of the total hip arthroplasty components is an attractive option. Recommended roughening of the primary mantle surface remains controversial. Aim of the study was to investigate the influence of the cement surface roughening on the strength of bilaminar cement interface.
Flat, laboratory model of bilaminar cement interface was used. Prior to its creation, modeled primary mantle surface was machined to the roughness of either smooth surface observed after removal of a highly polished stem (Ra=200nm) or that following roughening (Ra=5μm). Two viscosities of interfering fluids (water and bone marrow) were also used. 6 variants (smooth or rough, both stained with water, bone marrow or with no fluid) with 7 repeats were exposed to single shear to failure.
No significant difference in resistance to shear was observed between the groups with dry smooth (16.82MPa) and rough surfaces (16.96MPa), and those stained with large volume of low viscosity fluid. In the presence of water, roughening did not significantly influence the interface (smooth – 17.04MPa and rough – 16.25MPa respectively).
In the smooth variant with large volume of viscous fluid, ultimate stress value dropped to 5.53MPa, and 9.87MPa in the roughened group with the same amount of viscous fluid (p< 0.05).
Extra roughening may offer some benefit when performing in-cement revision in the presence of large volume of viscous fluid only though in-cement revision would not be then recommended. In the presence of low viscosity fluids (blood, irrigation fluid) benefit of roughening is dubious.
The purpose of this study was to investigate the outcome after surgical therapy of patients suffering from HO of the hip after treatment in ICU.
We retrospectively examined 39 patients with heterotopic ossification of the hip (18 bilateral and 21 unilateral). All patients have had history of ICU treatment for several reasons, such as craniocerebral injury (35 patients-90%), 2 patients with Guillain-Barre syndrome (5%), 1 patient with pulmonary druse (2.5%), and 1 patient with inflammatory bowel disease (2.5%). They all underwent surgical removal of HO and postoperative irradiation therapy. On the basis of plain radiographic findings, we evaluated the recurrent ossification after an 18-month follow-up period.
The evaluation of the average 18-months follow-up period showed relief of pain and clear improvement of range of motion in most of our patients. Specifically, improvement in the range of movement was observed in 41 hip joints (71.93%) in contrast to 16 hip joints (28.07%) that did not show any alteration post-operatively. No lesion re-occurrence was observed. There was only one complication of peroneal nerve paresis following HO excision.
The majority of our patients that were treated with surgical excision of the ectopic bone around the hip joint significantly improved their range of joint movement and were relieved from pain. Surgical excision seems to provide a superior quality of life in these patients, as they have a high risk for major complications due to their poor level of mobility.
To determine the gross structural alterations of the nailed bone (femur or tibia) after the removal of an intramedullary nail (IMN).
Eighteen patients (14 femoral and 4 tibia nail) underwent an IMN removal from their femur or tibia. Every patient had a spiral computed tomography scan and a plain X-ray study, immediately after the nail removal and also at their latest follow-up (24–30 months). The 4 patients with a tibia nail were additionally examined using a peripheral quantitative computed tomography study at their latest follow-up. All patients were asymptomatic.
An intramedullary shell of compact bone was demonstrated around the nail track. This new bone was apparent on plain radiographs in all of the patients. Peripheral quantitative computed tomography study revealed that the density of the bony ring was similar to that of subcortical bone. The histologic examination of the intra-medullary shell of one of our patients suggested that the bony ring was made of cortical bone.
Intramedullary nailing may enhance new cortical bone formation within the bone marrow cavity. This “cortical bone” still exists more than 2 years after implant removal. Nail insertion also causes thickening of the normal cortex at the sites of nail–cortex contact where loads are transferred from the nail to the cortex. This new finding could probably lead the research of intramedullary nailing biomechanics toward new directions as to understand the body’s reaction to IMNs.
The treatment of the displaced proximal humerus-fracture with solid osteosynthesis is complicating by coexistence of osteoporosis and simultaneous degenerative changes of the rotator cuff. These specific problems, as well as the usage of primary endoprosthetic replacement should be reduced through the introduction of locking-screw-plate-systems.
From April 2006 to March 2008, 70 patients received the clinical application of a newly developed locking-screw-plate (Winsta PH) in a prospective study. 48 of 70 patients were subjected to re-examination after averagely 15 months (1–3 years), 34 women and 14 men. The average age was 68.7 years. The classification of the fractures occurred after Neer. Concerned are 12 two-fragment, 21 three-fragment and 15 four-fragment fractures. The functional result after surgery was rated according to the Constant- and Dash-Score.
The average absolute Constant-Score was 63% and the Dash-score 18.3. Patients with accurate anatomical reduction achieved a significantly better score. Secondary loss of correction occurred in 3 patients with collapse of the humeral-head and perforation of the screws. An early metal removal combined with subacromial decompression took place in 3 patients, because of post-traumatic impingement. In a Neer VI-fracture-case, an early revision to hemiarthroplasty occurred due to a postoperative dislocation. One postop-wound discharge was surgically debrided.
Modern locking-screw systems like Winsta-PH plate allow a safe treatment of complex fractures of the proximal humerus, diminishing the need for primary endoprosthetic replacement significantly. Anatomic reduction is essential for the locking screw plate system to form the pillar for a successful outcome.
The evaluation of the middle term behaviour of the Wagner-type stems in dysplastic femurs and the presentation of the technical and surgical differences with the implantation of a Wagner stem.
Between 1997 and 2008 we implanted 64 Wagner stems in 58 patients. Average age at the time of implantation was 64 years. 52 patients was operated because of DDH, and 12 had had previous osteotomy. All patients were prospectively evaluated radiographically and clinically at annual intervals. Functional outcome was assessed with Harris Hip Score and Oxford Score.
Mean follow-up of these series was 4 years (11-1)One stem was revised because of fracture of the lesser trochander and two more patients were re-operated for open reduction. With the re-operation as end-point and 95% Confidence Interval survivorship rate was 98, 5%. There were no progressive radiolucent lines. Stem migration was at an average 2mm (1–6) during the first two years and remained stable thereafter. There was no deep infection in these series. After the second year a dense zone is evident in all Gruen zones at the implant –bone interface with a width of 2–3 mm.
Dysplasia of the proximal femur may pose significant technical problems during THA due to the distortion of the geometry and the narrowing of the femoral canal. The sort, conical Wagner type stems can offer a very good alternative is such patients. They allow control of the anteversion and they are able get a good press-fit despite the metaphyseal/diaphyseal mismatch and the femoral bowing.
Wagner type stems are a reliable alternative when performing THA in patients with dysplastic femurs.
This study reports the results of hybrid stem fixation in difficult revision hip arthroplasties where proximal femoral bone stock loss was severe.
Twenty-six revision arthroplasties (21 women and 5 men, aged from 58 to 86 years), were performed between 1998 and 2008. The indication for surgery was aseptic loosening. In all cases, stabilization of the stem presented problems because of severe proximal femoral bone stock loss (due to extensive periprosthetic osteolytic defects), or because of iatrogenic defects or surgical procedures (attempts to remove the stem and cement with fenestration or extended osteotomy). The average follow-up was 48 months (range 16 to 120).
Primary stability is necessary for the successful definite fixation of a cementless implant by bone. When this was not possible (because of proximal cortical insufficiency), we used a modular distally cemented long stem, bypassing the area of bone defect for at least 6–7 cm. Proximally bone defects were grafted and osteotomy was closed with cerclage wires.
Four stems (15%) had an asymptomatic subsidence (3 stems subsided less than 3–4 mm and 1 stem about 15mm). No stem was revised to date. Major complications did not occur. The mean Harris hip score improved from 32 points preoperatively to 82.3 points (at the most recent evaluation).
Hybrid fixation offers the advantage of initial and secure stability of the cemented stem on the short term, until stabilization of the entire implant by bone occurs. Thus early subsidence and loosening is avoided and on the long term benefits of the cementless fixation are attained. Our results support the method of hybrid fixation in patients with severe femoral bone loss (and consequently problematic stabilization), when primary stability is needed.
We reported on the outcome of 84 Charnley low friction arthroplasties performed by one of us (GH), the period 1973 to 1984, in 69 patients, less than fifty-five years old, with osteoarthritis mainly due to congenital hip disease.
The patients were followed prospectively; clinically using the Merle D’Aubigné and Postel scoring system, as modified by Charnley and also radiographically.
At the time of the latest follow-up, thirty-seven hips had failed (44%). In thirty-two hips, twenty-eight acetabular and thirty femoral components were revised because of aseptic loosening (six of the femoral components were broken). Three hips were infected and converted to resection arthroplasty. In two more hips a periprosthetic femur fracture occurred three and ten years postoperatively and were treated with internal fixation. After a minimum of twenty-two years from the index operation, 37 original acetabular components and 36 original femoral components were in place for an average of 29 years. The probability of survival for both components with failure for any reason as the end point was 0.51 (95% confidence interval, 0.39 to 0.62) at twenty-five years when 35 hips were at risk.
These long term results can be used as a benchmark of endurance of current total hip arthroplasties performed in young patients, with OA mainly due to congenital hip disease.
Two-stage revision procedure is the gold standard in management of periprosthetic infections. Cement spacers have long been used to preserve the space created during resection procedure and to release antiobiotics within the created dead space. However, the problems related to cement as an antibiotic carrier are well recognised (thermal necrosis, random porosity, unspecified antibiotic delivery rate).
To present the concept of using PerOssal as a canal filling spacer and local antibiotic delivery system in two-stage revisions of hip and knee infected arthroplasty.
8 patients (6 females, 2 males) with infected arthroplasty (4 TKRs, 4 THRs) were managed with two-stage revision procedures during the years 2006–2008 (minimum FU: 12 months). Our protocol consisted of:
Preoperative determination of the causative organism Radical debridement surgery and cement spacer with PerOssal implantation Appropriate IV antibiotic therapy for 6 weeks, postoperative clinical evaluation and monitoring of inflammation markers After a six-week antibiotic free interval and inflammation markers normalization second stage surgery took place: Medullary canal reaming, intraoperative cultures, thorough wound irrigation and prostheses implantation Postoperative antibiotic therapy until culture results; IV antibiotic treatment for 6 more weeks if they were positive. FU evaluation at 3, 6, 12, and 24 months.
We had 7 cases with eradication of infection, 2 with delayed wound closure, and 1 late recurrence of disease.
We think that PerOssal can offer a very useful additional and genuine support in managing infected joint arthroplasties with so far good clinical results.
We present the results of 15 patients revised with a Compress® prosthesis secondary to failure of other distal femur reconstruction.
One prosthesis had to be removed because of deep infection. Three patients needed a second surgery due to a vertical crack proximal to the anchor plug at the level of a cortical bone defect. At last follow-up, radiologic evaluation of the entire series showed a mean bone growth ratio higher than did preoperative radiographs. All patients had mainly good or excellent MSTS functional results.
Distal femoral prosthetic replacement with a Compress® implant in severe cases of bone loosening and instability provides a reliable reconstruction alternative that promotes bone formation. Patients with cortical defects proximal to the anchor plug should be protected with extracortical supports.
Total Hip Arthroplasty (THA) is one of the most important procedures in the fields of Reconstructive Orthopaedics. This study aims to present the preliminary results of the clinical and radiological evaluation of patients who have undergone THA with metal bearings, modular necks and big femoral heads and to correlate them with the results of the Finite Element Analysis. In the period from 1/1/2006 until today 90 patients (33 men and 57 women) with mean age 62,4 years have undergone primary THA. The patients were clinically and radiographically evaluated preoperatively, as well as postoperatively, in regular time intervals (1st, 3rd, 6th, 12th month and every year afterwards). The clinical assessment was based on two scales, Harris Hip Score (HHS) and Merle d’ Aubigne (MDA) score, whereas the radiographic on Engh criteria. The mean follow up was 16 months. The mean preoperative HHS and MDA score were 45 and 10,3 respectively, whereas 89 and 16,74 at the last evaluation. The mean Engh score was 16,12. No incidence of dislocation, infection and cup or stem adverse effect occurred. We demonstrate extensively, with respect to the used combination of neck and femoral head, the radiographic findings in the zones of Grün and Charnley, in the areas of the tip of the stem and the calcar, as well as the resulting clinical manifestations. The early clinical and radiological data are in line with the increase in the stresses and strains on the upper part of the femur, which are revealed through the Finite Element Analysis.
Simultaneous compression of the median and ulnar nerve at the elbow is rather uncommon. The aim of this study was to describe 10 such cases which have been treated in our unit.
The patients presented with a combination of ulnar neuritis symptoms at the elbow with a pronator syndrome. Five patients were female and 5 male with an average age of 33 years. All patients were manual workers. Regarding the cubital tunnel syndrome, all patients complained for hypesthesia in the ulnar nerve’s distribution in the hand and 6 for additional night pain in the medial aspect of the elbow. Regarding the pronator syndrome, the patients complained for mild tenderness or pain at the proximal forearm as well as hypesthesia or paresthesias at the digits. Nerve conduction studies were positive only for the ulnar nerve compression neuropathy. Six patients were treated by decompressing both nerves at the same time through the same medial incision, creating large medial flaps. The ulnar nerve underwent a simple decompression. In one case that the symptoms were initailly attributed to ulnar nerve, a second operation for medial nerve decompression was required.
In all patients symptoms subsided following surgical decompression. Four patients developed an ugly scar and 2 a hematoma. All returned to their previous occupation. Clinical tests and nerve conduction studies were performed postoperatively to evaluate the results; all of them turned out negative for ulnar and median nerve compression neuropathy.
Simultaneous compression of the median and ulnar nerve at the elbow is rather rare. Careful evaluation of the patient’s symptoms as well as thorough clinical examination are the keystones for the correct diagnosis. Although decompression can be performed through the same medial incision, extensive dissection may be required.
In Essex-Lopresti injuries, the prevailing concept, according to which the stability of the forearm can be restored after fixation of the fracture or replacement of the radial head by a metallic implant, is disputable. The aim of this study is to evaluate the midterm results in 12 patients with an Essex-Lopresti injury who were treated operatively.
We studied 12 patients, with comminuted fracture of the radial head, either isolated (4 patients) or with injury of the ipsilateral (4 patients) or the contralateral (4 patients) arm. Initially, 10 patients were treated with excision of the radial head whereas 2 underwent internal fixation of the radial head and pinning of the DRUJ. Eventually, everyone developed a subluxation of DRUJ and had to be treated for an established Essex-Lopresti injury, 1–7 months after the initial injury. Six patients were treated with equalization of the radioulnar length (ulnar shortening osteotomy with or without a distractor-external fixator) and restoration of the TFC, while six patients underwent replacement of the radial head with a titanium implant, equalization of the radioulnar length and restoration of the TFC.
The results were evaluated after a mean follow-up of 4 years (1–12 years), based on radiological and clinical criteria. The six patients in whom the titanium radial head implant was used presented with good results, even though two of them reported forearm pain during activity. On the contrary, in the rest of the patients the radioulnar incongruity reappeared in varying degrees. However the poor radiological result was not consistent to the clinical one.
We conclude that in cases of complete rupture of the interosseous membrane, internal fixation or replacement of the radial head with a metallic implant will not probably provide us with a good long-term functional result.
The revision of the hip surgery belongs to the major orthopaedic surgery and the purpose of our research is the presentation of our experience.
During the period 2004–2008, revision in surgery of the hip was performed in 15 patients, while most of them were women with average 73 years. 190 subcapital fractures were revisioned in 7 patients, 277 pertrochanteric fractures in 3 patients, 75 total arthroplasties in 5 patients and all of them were bipolar arthroplasties and osteosynthesis with DSH plate. The average interval between the primary operation and revision arthroplasty was 28 months, revision of the acetabular was performed in 3, revision of the femoral in 1 and regarding to the other patients both types of revision were performed. According to Paprosky classification we noted lesions of type I and type II and in 13 cases operation was made in a time. Early complications appeared in 6 patients (mostly postoperative infections). For the stabilization of the acetabular we used supporting rings with bone grafts or press fit acetabulars without cement, while for the femoral, according to the injury extend and the bone quality, the stabilization of the stem was made with cement. The average follow-up time was 20 months, we re-examined 14/15 patients and chronic complications appeared in 2 patients. The final result was satisfactory, according to Harris-Hip score with the radiological evaluation.
Conclusively, hip revisions are difficult and demanding operations, accompanied by serious complications. For their success good preoperative planning, experience and complete material-technical supporting are required with use, most of the times, of custom made prosthesis, supporting rings of the acetabular with bone graft.
Total hip arthroplasty is nowadays a common treatment for a large number of pathological cases regarding the hip joint and is considered as the most successful orthopedic operation. With the mean age of patients constantly decreasing and the more intense way of life, the need for versatile implant designs has arisen. Currently modular hip implant systems are used extensively in order to compensate for difficult occasions, where offset and version correction are required. In addition to this femoral heads of bigger diameter have been introduced to deal with issues such as dislocation and impingement, although their influence on the mechanical behavior on the bone – implant assembly is not widely documented. Towards this direction a finite element model was generated. Computed tomographies of a cadaveric femur were used as raw data and processed, a Profemur-E system with variable heads was digitized, thus leading to a complete assembly consisting of the femur, the stem, the necks and the femoral heads in the commercial CAD software Solidworks. For typical loading scenarios – the stance phase of the gait cycle – the finite element analysis was performed in ANSYS Workbench. The results showed that the implementation of BFH and the neck version produced an increase in strains and stresses with respect to a normal head of 28mm and a straight neck in areas of clinical interest such as the calcar, the greater trochanter area and the stem tip region, considered responsible for thigh pain.
Chronic distal biceps tendon rupture is a relatively uncommon situation with difficulties in treatment. Surgical treatment with allograft has been described in the literature with varying results. The purpose of this study was to describe 9 cases of chronic distal biceps tendon rupture which have been treated in our unit with local soft tissue as a graft.
All patients were male with an average age of 54 years. The mean interval between tendon rupture and reconstruction was 11 months. In all patients a flap from lacertus fibrosus was used in continuation with the remnants of the tendon. The flap was entubulated and advanced to the bicipital tuberocity. The biceps was released and mobilized as necessary. In addition, 3 patients underwent a fractional lengthening of the muscle. All procedures were performed through a single anterior approach. Anchors and anchor sutures were used to stabilize the tendon to the tuberocity.
The mean follow up was 3 years. No complications were encountered except for a superficial infection which resolved with oral antibiotics. All patients returned to their previous occupation. Furthermore, they all achieved 5/5 muscle strength regarding flexion and supination on manual testing. According to the Mayo Elbow performance score, the results were excellent in 8 patients, and fair in one.
We believe that the aforementioned technique is useful in treating chronic biceps ruptures. It requires no additional cost and also the risk, even if marginal, of transmitting diseases with allografts, such Achilles tendon is avoided. Furthermore, the possibility of rerupture is minimal compared to the techniques using allograft or free autografts, since a revascularisation process during which the risk for failure is high does not take place as in other types of allografts.
Elbow contracture is a well recognised sequel of neuromuscular disorders and can be a rather debilitating condition. Non operative treatment, such as physiotherapy and splinting, results in an improved range of motion, but since musculoskeletal pathology in neuromuscular diseases is progressive, an open surgical release of the elbow is often required. Therefore, the purpose of the present study was to assess the results of surgical treatment of elbow stiffness in patients suffering from neuromuscular disorders.
Between January 2000 and October 2008, 11 patients with neuromuscular diseases underwent surgical treatment of elbow contracture. The mean age of the patients was 21 years. Eight patients had cerebral palsy, 2 arthrogryposis and 1 brachial plexus palsy. Pre-operatively the lag of elbow flexion and extension was 45° and 38° respectively. In 6 patients releases were performed through a lateral approach, while 3 required an additional medial incision. In 2 patients the pathology was addressed through a posterior approach.
The mean follow up was 26 months. Postoperatively one patient developed skin necrosis which was treated conservatively. Furthermore, another patient developed transient ulnar neuritis, and finally one more presented with medial collateral ligament insufficiency. All patients had an improved functional arc of motion. Namely, the lag of elbow flexion and extension was reduced to 22° and 10° respectively. At the final follow up the patients maintained 90% of the range of motion that was achieved immediately postoperatively.
Open release of the elbow contracture in neuromuscular diseases yield satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion.
Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.
Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.
Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.
Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.
Radial head fractures are the most common fractures occurring around the elbow and are often associated with other fractures or soft tissue injuries in the elbow. The purpose of this study was to characterise the morphology and to evaluate the outcome of the surgical management of radial head fractures in complex elbow injuries.
Nineteen patients with this pattern of injury underwent surgical treatment in our unit. In addition, seven patients had posterior dislocation of the elbow, 2 medial collateral ligament rupture, one capitellar fracture, 3 posterior Monteggia, 1 Essex-Lopresti lesion and 5 coronoid fracture plus posterior dislocation. Non comminuted radial head fractures were treated by open reduction and internal fixation or simple excision of small fragments. Patients with comminuted, displaced radial head fractures underwent radial head replacement.
The average follow up was 44 months. Two patients developed post-traumatic elbow contractures, one elbow instability and 2 mild arthritis. Overall, according to the DASH Outcome Measure, the results were excellent in 12 patients, fair in 3 and poor in 4.
In complex injuries of the elbow the characteristics of the radial head fracture and in particular the comminution, the fragment number, the displacement as well as the age of the patient should determine the appropriate surgical technique which will lead to satisfactory long-term results. Anatomical restoration and maintenance of elbow stability will allow early mobilisation of the elbow joint and should be the goals of surgical management.
Hinged external fixators of the elbow joint can be a valuable tool in managing complicated trauma associated with instability, instability after contracture release, and distraction interposition arthroplasty or distraction arthroplasty alone. This retrospective study focuses on the performance of the device in acute and chronic elbow instability associated with complex injuries around the elbow.
Thirteen hinged external fixators were applied in 13 patients with an average age of 46 years. All fixators were applied for various types of fractures around the elbow joint associated with elbow dislocation. In 12 patients prior to the application of the fixator, a formal open reduction and internal fixation was performed so as to neutralise the whole construct and permit early mobilisation of the joint. In one patient with a minimally displaced fracture which required no internal fixation the fixator was used to permit early mobilisation. A circular multiplanar frame was used in 4 patients and a unilateral one in the rest of them.
Eight out of 13 patients with fracture-dislocation had an uneventful outcome. Three patients required a revision surgery to correct a fracture malalignment and a subluxation of the joint. The results were evaluated according to the Mayo Elbow Performance score. Complications included 4 cases of pin tract infection and 2 of transient ulnar neuritis.
Despite the complexity of its application and the complications that may follow such device, an articulating external fixator can be a valuable tool in treating complex elbow instability.
Among the most popular techniques for the management of radial nerve palsy is the transfer of the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB), of the Flexor Carpi Radialis (FCR) to the Extensor Digitorum Communis (EDC) and of the Palmaris Longus (PL) to rerouted Extensor Pollicis Longus (EPL). This retrospective study was undertaken to assess the outcome of flexor carpi radialis transfer in the treatment of radial nerve palsy.
Twenty patients with a mean age of 36 years were included in this study. Surgical management, as described above, was decided since all patients had irreparable damage to the nerve. Parameters that were assessed included range of wrist motion, dynamic power of wrist flexion and extension, and radial and ulnar deviation and function.
The average follow-up was 4.5 years. Compared to a control group of 10 volunteers of similar characteristics, all patients achieved a functional range of motion and satisfactory power of wrist motion. All patients returned to their previous occupation.
Transfer of Flexor Carpi Radialis tendon for irreparable radial nerve palsy yields satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion as well as an adequate strength of motion.
Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.
Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.
Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.
Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.
The aim of this study is the presentation of the midterm results of the radial head replacement with pyrocarbon head prosthesis (MoPyc).
Thirty two patients (20 males and 12 females) with a mean age of 54 y.o. (32–68 y.o.) were subjected to replacement of the radial head with a pyrocarbon head prosthesis. Twenty of them had a comminuted radial head fracture(15 Mason IV type and 5 Mason III), two had a malunion and ten had a complex elbow injury (ligamentous rupture and comminuted radial head fracture with/without coronoid process fracture). In 22 patients the fracture was on the dominant side. The mean follow up time was 27 months (21 – 46 months).
The post-operative results were:
The mean range of motion in flexion-extension was 130° (105° to 150°), while in pronation and supination was 74° (60°–80°). The mean grip strength was 96% of the contralateral side. There was no clinical laxity in the varus or valgus stress test. According to the Broberg-Morrey score the good and excellent result were 77%, while according to the Mayo Clinic Elbow Performance Score (MEPS) good and excellent results were up to 97% of the total.
Pain was evaluated with a visual analogue scale. Finally there was also a radiographic evaluation of the patients (that yielded six cases of loosening or osteolysis without any clinical manifestation)
Replacement of the radial head with the specific prosthesis leads to very satisfactory results when performed under specific indications.
The aim of this study was to compare accuracy of an image guided percutaneous core needle biopsy (PCNB), using ultrasound or computed tomography, to PCNB without image guidance in the diagnosis of palpable soft tissue tumors.
One hundred forty patients with a suspected soft tissue sarcoma underwent a percutaneous core needle biopsy with or without image guidance. One hundred eleven patients had subsequent surgical excision. The accuracy of guided PCNB and blind PCNB was calculated by comparing the histological results of the needle biopsy to the surgical specimen.
The diagnostic accuracy of blind percutaneous core needle biopsy was 78% (36 of 46 biopsies) and significantly lower (p ≤ 0.025) in comparison to image guided percutaneous core needle biopsy which was 95% (62 of 65 biopsies).
We suggest that image guidance improves the diagnostic accuracy of PCNB especially for small size deep sited suspected soft tissue tumours.
The purpose of this study is to compare the healing progress in cases with wound healing complications with or without VAC assistance.
From 2005 to 2008, 32 patients with a mean 56 years of age had wound healing complications necessitating for further operative intervention. 26 cases were classified as stage III and 6 cases were classified as stage IV according to the National Pressure Ulcer Advisory Panel. The mean extent of wounds was 7cm2. 17 cases (group A) were treated with repeated removal of necrotic debris. In 15 cases (group B) the VAC device was applied (75mmHg). The 2 groups were compared on the basis of total hospital stay, need for additional operation, and re-infection rates.
Mean hospital stay was 25.2 days in group A and 16.5 days in group B (p< 0.05). 7 cases needed re-operation in group A comparing to 2 in group B (p< 0.05). Re-infection appeared in 5 cases of group A comparing to 1 case of group B (p< 0.05). 1 patient of group B used VAC therapy in lower negative pressure (50mmHg) 6 days post application due to unrelenting pain.
Negative pressure wound therapy is safe and effective. It minimises the total hospital stay, it is associated with lower recurrence, re-infection and re-operations rates, and lowers total cost of therapy.
To present our experience and evaluate functional results on endoprostethic reconstruction of extremities with bone tumors after tumor resection.
47 patients (15 females, 32 males; mean age 55 years; range 13–85 years) who underwent tumor resection and cemented endoprosthetic replacement using the TMTS (Turkish Musculoskeletal Tumor Society) prosthesis for bone tumors of the extremities were analysed. Thirty patients (63.8%; mean age 63 years) had metastatic, 17 patients (36.1%; mean age 53 years) had primary tumors. The femur (70%) was the most frequent tumor location site. Functional assesments of the patients were made using the Musculoskeletal Tumor Society (MSTS) scoring system on the follow-up period. The mean follow-up period was 18 months, being 36.3 months for primary, and 7.3 months for metastatic tumors.
Postoperative complications were seen in 9 patients (19.1%). 22 patients died due to tumoral causes during follow-up period, distant metastases exists in 4 patients, and 21 patients are tumor-free. Survival rates found significantly better in patients with primary tumors. All the patients were able to walk without crutches in the postoperative period. The mean MSTS score was 58.7% in survivors, which was 71% for primary tumors, and 53.1% for metastatic tumors.
Reconstruction with cemented modular endoprostheses is an appropriate surgical alternative in the treatment of extremity tumors, with satisfactory functional results particularly in primary tumors.
Presentation of two cases of pelvic periacetabular sarcoma, which were treated with wide resection of the tumor, pelvic reconstruction and lower limb salvage.
Two patients, one male 23 y.o. with chondrosarcoma and one female 75 y.o. with chondroblastic osteosarcoma, were treated in our clinic. Both tumors were stage II according to Enneking’s classification. Both tumors were treated with Enneking type II internal hemipelvectomy due to their periacetabular localization. After wide resection of tumors, pelvic deficit was reconstructed with allograft, which was internally fixated, and total hip replacement with constrained prosthesis.
Clinical evaluation showed absence of pain and satisfactory function of the limb. Imaging evaluation with x-ray, 3D-scan kai MRI showed satisfactory position and condition of allograft and internal fixation without evidence of loosening. Non weight bearing mobilization commenced 3 weeks postoperatively.
Internal hemipelvectomy requires precise preoperative planning and surgical knowledge because it is technically demanding due to complex structure of the pelvis, the great number of muscular attachments and the presence of important vessels, nerves and pelvic viscera. Wide pelvic resection and reconstruction with allograft for periacetabular sarcomas is a challenging procedure, which offers the opportunity of limb salvage associated with functional outcome.
To compare usual practices against published guidelines of Perioperative Antimicrobial Prophylaxis (AP), which is an established method to reduce the risk of postoperative infection in TJR.
We prospectively evaluated AP in 616 patients, who underwent TJR of the hip and the knee in an ongoing cohort study. Teicoplanin was administered once perioperatively (10mg/kg iv) in one group A (n=278), while in the other group B (n=338) AP was administered according to the usual practice (various antibiotic combinations, including hemisynthetic penicillins/penicillinase inhibitors, cephalosporins, aminoglycosides and quinolones for 2–10 days). An evaluation form and personal examination were used for data collection and monitoring. Patients were followed up for 2 years minimum.
The two groups did not statistically differ (p> 0.05) regarding overall postoperative infections. Superficial soft tissue infection developed in 9/616 pts. 1/278 in group A (0.4%) vs 8/338 in group B (2.4%) (p< 0.05). Deep SSI was rarely seen, 4/616 pts (0.6%). 2/278 in group A (0.7%) vs 2/338 in group B (0.6%) (p=NS). Mean duration of AP was significant higher in group B [6(IQR: 5–8.25)], p< 0.001 Mann-Whitney test. Only in group B, MRSA-MRCNS postoperative infections did appear. The duration (days) of glycopeptide antibiotic usage, therapeutic (group B) or prophylactic (group A), was comparable in both groups (p> 0.05).
Glycopeptide antibiotic prophylaxis for TJR leads to less postoperative infections compared to other antibiotic prophylaxis, but similar duration of overall glycopeptide usage (prophylactic and therapeutic) in both groups.
To present the oncological outcome of eleven patients with stage-3 GCT of bone.
Thirty-nine cases of GCT who were treated the past nine years at our department were reviewed. Five tumors were classified as stage I, twenty-three tumors as stage II and eleven as stage III tumors.
In stage I or II tumors we proceeded to an intraoperative biopsy (frozen biosy).In cases where the intraoperative pathological findings confirmed our diagnosis of GCT we proceeded to operative management. In cases where the intraoperative pathologist’s findings were not clear as well as in cases of stage III tumors we performed only a traditional open biopsy proceeding surgery in a second stage. In stage III tumors we aimed wide margins. Ten of these patients underwent wide surgical excision and limb salvage, while in one patient curettage with cementation was the treatment of choice in order to obtain a fair functional outcome.
With a minimum follow up of 3 years, we had no case of local recurrence in cases treated with wide excision and limb salvage. One stage III GCT treated with curettage recurred. Two stage III tumors metastized to the lung. The average interval from initial operation to lung metastasis was six months.
Treating GCT with the above management minimizes diagnostic failures. Literature shows local recurrence rate as high as 50% in stage III GCTs. The present study shows that recurrence rate can be significantly reduced and good functional outcome can be achieved by carefully planning approach and wide excision of the tumor.
Patella recurrent dislocation and patellofemoral pain syndrome instability many young people and especially athletes. In the present study we present the results of the extension mechanism realignment through the Fulkerson oblique osteotomy of the tibial tuberosity and soft tissue balancing.
During the last two years 10 patients (7 men, 3 women, mean age 29.3/ range 20–39) were treated operatively for recurrent dislocation of the patella using the Fulkerson procedure. All patients underwent knee arthroscopy for the treatment of potential chondral damage or loose bodies and for lateral retinacular release. After that we performed oblique tibial tuberosity osteotomy, medialization and internal fixation with 2 cortical screws. This oblique osteotomy allows also the anteriorization of tibial tuberosity as we move it medially. In addition, we performed medial placation. All the patients used functional knee brace locked to 0° right after the operation and with gradual ROM increase till the 8th p.o. week.
The patients had no initial or long term complication. During their last follow up examination had a painless knee with full ROM and marked improvement of the patella tracking. The mean Lysholm score was 90.5. No patella dislocation was referred.
Our findings show that the Fulkerson osteotomy procedure, with an additional intervention on the lateral and medial patella retinacular, is an excellent option for the treatment of recurrent patella instability and relief of the patellofemoral pain.
To compare the effects of botulinum toxin injection with and without electromyographic (EMG) assistance for the treatment of spastic muscles.
In a prospective comparative study, botulinum toxin was injected intramuscularly into 17 patients with spasticity due to CNS damage (CP, SCI, head injury, stroke). All patients were evaluated using the modified Ashworth scale and the score was 2–4. In 9/17 patients, group A (53%), the injection was given with EMG assistance, while in 8/17 patients, group B (47%), without, always from the same injectionist. The follow-up period ranged from 4 to 24 months.
Average spasticity decreased in all injected muscles and new scores were 1–2 grades less according the modified Ashworth scale. No complications or side effects were noted. The average reduction of spasticity reached 1.66 (SD 0.5) in group A and 1.25 (SD 0.46) in group B. The average reduction of spasticity was statistically more pronounced in group A (p< 0.001).
The effectiveness of botulinum toxin injection for the treatment of muscle spasticity in patients with CNS damage increases when used with EMG assistance and this is attributed to the appropriateness of points for injection.
Complex limb-salvage surgical techniques and reconstruction with sophisticated massive endoprostheses prove to be excellent tools for effective bone tumour management.
We treated 34 bone tumours (osteosarcoma, chondrosarcoma, plasmatocytoma, Ewing’s, osseous lymphoma, histocytosis-X, MFH, mets). We excised the lesions on oncologically safe surgical margins (wide excision inclunding anatomical barriers to tumour spread) and we reconstructed the defects with 29 modular and 5 custom designed and manufactured massive endoprostheses. Intramedullary stems were all cemented and they were supplied with hydroxyapatite collars that favour callus formation and extramedullary stabilisation. We did 12 proximal femoral tumour reconstructions, 17 distal femoral and proximal tibial tumours with rotating metal or polyethylene fixed-hinge knee implants and 1 total femur. In upper limb we did 2 proximal humerous with reverse polarity shoulder endoprostheses. In 1 humeral shaft case we did subtotal excision and reconstruction with two joint-saving endoprosthesis. In 1 distal humerus tumour we used custom constrained endoprosthesis of distal humerus and elbow. If tumours did not extend too close to the cartilage we applied joint-saving techniques. Function was restored with proper implant size selection and rearrangement of muscle remnants. On follow-up (4–58 months) average TESS score was 83%. There was no local recurrence and no aseptic loosening, dislocation or implant failure. Three patients with metastatic disease DOD. One case presented with late DVT and one with late deep infection.
New surgical methods and sophisticated implants with evidence-based design contributed greatly to successful limb salvage surgery as well as in overall patient prognosis and survival who enjoy better function.
The objective of this study was to compare the results of two consecutive series of patients with either intra-medullary uncemented stems (UCS) distal femoral endoprosthetic replacement or the Compress® (CMP) distal femoral implant.
Patients were divided into two groups: those who received UCS prosthesis (Group-1: 54 patients) and those who received CMP prosthesis (Group-2: 42 patients).The most frequent diagnosis was osteosarcoma. Age and gender were similar both groups.
In Group-1, at a mean follow-up of 144 months, 37 prostheses were still in place. The overall Kaplan-Meier prosthetic survival rates were 79% at five and 62 % at ten years. Most of failures were long term complications. Aseptic loosening was the primary cause of late prosthetic failure. On Cox regression analysis, prosthetic stem diameter under 13mm was a significant negative prognostic factor for prosthetic survival (p=0.016).
In Group-2, at a mean follow-up of 84 months, 36 prostheses were still in place. The overall rate of CMP prosthesis survival was 86% at 5 years. All complications were during the first postoperative year, being femoral fracture the main revision cause.
The patients who retained the prosthesis had mainly good or excellent MSTS functional results in both groups.
Total knee arthroplasty (TKA) disturbs patellar blood flow, an unintended accompaniment to TKA that may be a cause for postoperative anterior knee pain. We compared patellar blood flow before and after medial parapatellar arthrotomy to pre- and postoperative anterior knee pain scores to ascertain whether disrupted patellar blood flow correlates with anterior knee pain following TKA. Blood flow measurements were performed at full extension and at 30°, 60°, 90° and 110° of flexion prior to and after medial arthrotomy in 50 patients (21 male, 29 female; mean age 73.1±8.6 years) undergoing TKA. Anterior knee pain was assessed using the pain intensity numeric rating scale. A significant decrease in blood flow was detected at 60°, 90°, and 110° of flexion (p values: 0.00314,< 0.0001,< 0.0001 respectively). The medial arthrotomy did not have a statistically significant influence on patellar blood flow in the Students’ t-test (margin of significance p& #61603;0.05) Nineteen patients exhibited an average 14% (range 1%–54%) increase in patellar blood perfusion at knee flexions of 90° and 110° after medial arthrotomy (p value: 0.32) Prior to TKA, 16 of the 50 patients (32%) complained of anterior knee pain (average NRS 7.12, range 5–10). At 6-month follow up, 4 of the 16 patients (25%) complained of moderate anterior pain (average NRS 5.7, range 5–6), while 8 of 16 (50%) patients reported discomfort (average NRS 3.5, range 2–4) around the patella. No statistically significant correlation was found between intraoperative findings on patellar blood flow and the presence of anterior knee pain
Bloodless field in limb musculoskeletal tumours’ surgery has great value as it facilitates resection and reconstructions without excessive bleeding.
40 large bone or soft tissue tumors located in upper (n=4) and lower limbs (n=36) were resected and reconstructed in bloodless surgical field achieved by a new device, an elastic silicone ring (S-Mart, OHK Medical Device). Proper size of it is chosen between items of different diameter, length and elasticity depending on their measurements and BP. Our goal was safe and sufficient blood pressure for bloodless operation. In tumours, esh-mark and any pressure on the mass results in microscopic spread. We rolled the ring along the limb, starting from digits and exsanguinated the limb raising it above the tumour to avoid crushing it. If tumours extend too proximally to hip and shoulder we cannot use tourniquet because cuffs are wide enough to allow proximal extension of the incision. The elastic ring we used, is too narrow (Φ< 20cm) and proved of utmost importance in large, bleeding growths helping tumour elimination and limb salvaging. The ring was applied from 18–120 minutes created completely bloodless surgical field thus facilitating and speeding up the operation. The time needed for application was shorter than for pneumatic tourniquet (< 10sec). After removing the elastic ring we noticed neither BP drop nor tumour spread or complications of skin and neurovascular elements pressure.
Thus we conclude that limb ischaemia achieved with special elastic rings have benefits and may be considered as safe in oncological surgery.
To analyze the treatment results of late instability and dislocation of the hip following total hip arthroplasty.
The study refers to 16 patients from 42 to 71 years old when had primary THA. The mean time of late dislocation was 9,5 years and the revision mean time was 11 years following THA. In most patients extensive polyethylene wear was documented, in 12 patients the cup or the polyethylene insert on a stable metal implant was revised and in 4 patients new polytethylene cemented insert was placed in a stable metal implant. In all cases exchange of the femoral component metal head took place.
During follow up and re-evaluation 2–7 years after the revision there were 13 patients (81.25 %) with a stable THA and good function. Instability remained in three patients, which in 2 was resolved with re-revision of the cup whereas in the third (over aged) a special abduction brace was applied.
Late hip dislocation 5 or more years after THA occurs mainly due to extensive polyethylene wear and in contrast with early dislocation requires more often surgical intervention. The main cause of late hip dislocation was the extensive polyethylene wear, which in three cases was associated with prosthesis mal-orientation at primary implantation and in lots of cases with age-related neuromuscular deficit.
The treatment of late instability with repetitive dislocations requires surgical intervention. The revision might need exchange of cup or polyethylene insert on a stable metal implant or new polytethylene cemented insert on a stable metal implant.
Isolated osteochondral defects (OCD) of the femoral head remain a challenging issue for the surgeons when trying to balance between a less invasive procedure and the maximum benefit for the patient. We present our experience of the Hemicap partial hip resurfacing system in 12 patients. In ten patiens the defects were identified arthroscopically. Seven of them had concurrent early degeneration of cartilage (OA, Grade I). Three patients had OCD surrounded by normal cartilage and two patients had avascular necrosis. The mean patient age was 41 years (30 to 63) and mean follow-up 27 months (range 9 to 48).
Five patients required a hip resurfacing arthroplasty or total hip replacement at a mean interval of 17 months (12 to 24) due to persistent pain. Three patients required further hip arthroscopy at a mean interval of 36 months (range, 24 to 48). Four patients did not require secondary surgery with mean follow-up 32.7 months (range, 9 to 43). In all hips with revision surgery the components were found to be stable and secure.
Partial resurfacing arthroplasty seems to have a tendency towards early failure, especially in OA patients, but more favourable results in AVN patients, and the surgeons should have a cautious approach to this type of arthroplasty.
Failure of a TKA is caused many times from the polyethylene debris or the mechanical forces which lead to loosening mostly to tibial component. The mobile meniscal knee prosthesis could provide solution as it simulates better normal knee function.
The aim of our study is to present the midterm results of TKA using mobile bearing platform Rotaglide.
During the period 2000–2004 we performed 261 TKA with the Rotaglide mobile polyethylene prosthesis (Corin Medical, UK). They are 235 women and 26 men, mean age 76.33 years, and the 93.7% of them (N=245) with primary osteoarthritis. The tibial component was cemented for all them, and for the femur was cementless for 146 cases (hybrid) and cemented for 115. None of them had patella replacement. One hundred five patients (59 hybrid and 46 cemented) were examined clinically and radiologically and the minimum follow-up time was 5 years (mean 6,6 /range 5–8 years). We use the Knee injury and Osteoarthritis Outcome Score (KOOS- range of scale for each subscore 0–100).
There was significant improvement of knee function and the majority of our patients were satisfied from the result. Specifically, the score for general symptoms and joint stiffness was 89.1, for pain was 83.3, for daily activities was 75.6 and for the quality of life was 72.5. One patient had revision TKA for femur component aseptic loosening.
Our results indicate that the Rotaglide total knee arthroplasty is a great choice for primary knee OA with excellent functional result.
The purpose of this study is to present early results, common pitfalls and management in in cases of revision hip arthroplsty in patients with congenital disease of the hip.
From 2001 to 2006, 36 consecutive cemented THAs with a history of congenital hip disease were revised due to aseptic loosening (31 cases), stem fracture (3 cases), septic loosening (2 case). There were thirty patients, all females, with a mean age at revision 61.7 years (range, 40 to 76). The revision was performed after a mean 15.4 years post primary operation (range, 9 to 26). In 7 cases the cup only, in 5 cases the stem only, and in 24 cases both components were revised.
The mean follow-up was 43 months (range, 24 to 84). There were 3 intraoperative femoral fractures managed with long stem and circlage wires. Postoperatively, 5 hips were infected and sustained a 2 stage revision using a cement spacer. 3 hips were revised due to loosening.
28 cups and 28 stems remained intact for an average 45.2 months (range, 24 to 84). The probability of survival at 48 months was 76.3% (±9.7%) for the cups (12 components at risk) and 76.4% (±11.3%) for the stems (9 components at risk).
Revision of a CDH arthroplasty is difficult and non predictable. Lack of acetabular bone stock and anatomical abnormalities of the femur lead to increased intra and postoperative complication rate.
Between 1986 and 1999, 94 patients (96 hips) including 31 male and 63 female (mean age 59.5 years), with massive bone loss had a revision hip arthroplasty using an allograft-prosthesis composite (APC). A previous history of infection was present in 21 of these cases.
At an average follow-up of 11 years (range, 8 to 20 years), 72 patients were alive, 21 patients died, and 1 patient was lost to follow-up. Major complications occurred in 33 cases: femoral stem loosening (12); dislocation (15); periprosthetic fracture (10); and infection (7). Further revision surgery was performed in 21 of the 96 cases including revision of the acetabular component (3), femoral APC (16) or both (2). The 10 year survival of the APCs was 68.8% (95% CI 58.6%–79%, 26 cases remaining at risk). There was no statistically significant difference in survival time between gender, age, indication for APC (including infection), surgical approach and APC technique. Statistically significant factors negatively impacting APC survival included two or more prior revisions, severity of preoperative bone loss (Paprosky type IV) and use of plates and screws (p< 0.05). Statistically significant improvement in APC survival was identified in those reconstructions in which cement was used for proximal fixation of the femoral component within the allograft (p< 0.05).
Reconstruction with an allograft-implant composite is a demanding procedure. However, preservation of bone stock is a major advantage.
In revision of cemented femoral components, removal of cement can be challenging. This study evaluates the use of an ultrasonic device (OSCAR, Orthosonics Ltd UK) for cement removal.
30 consecutive patients that attended our outpatients\’ clinic between May 2008 and September 2008, who underwent revision THR by the senior author or his fellows, were retrospectively reviewed. Minimum follow up was 12 months (average 34.9 months).Indications were aseptic loosening and recurrent dislocation. A posterolateral approach was used routinely. Cement was removed with osteotomes and OSCAR. An uncemented modular femoral component was used. At follow-up, radiographs were evaluated for the evidence of extended trochanteric osteotomy (ETO), fracture, cortical perforation, component loosening, migration, and adequacy of cement removal.
None of the cases required an ETO or cortical windowing. In 5 cases prophylactic cabling of the proximal femur was performed. There was one intraoperative femoral shaft fracture (3.33%). There was incomplete cement removal in 7 cases. There was no cortical perforation and no postoperative fracture. There was no case with loosening or migration of the implant.
In all cases that OSCAR was used ETO and cortical windowing were avoided. At an average 34.9 month follow up there was no evidence of thermal tissue damage. In the cases that cement was retained in the canal, this did not affect the stability of the implant. The fracture and the incomplete cement removal were in cases performed by a fellow illustrating the learning curve of the technique.
Periprosthetic fractures represent a challenging problem in joint arthroplasty the incidence of which seems to be increasing due to the big number of the arthroplasties and the increasing average life expectancy.
The purpose of this study is to present the methods of treatment, the problems that we have to solve intra-operatively and our long term results about the healing procedure and the fuctional restoration.
Between 2000–2008 we operated 15 femoral peri-prosthetic fractures(1 re-fracture). 10 of them were after hip arthroplasties.
The classification which used was Lewis-Rorabeck for the fractures after TKR and Vancouver for them after THA.
Cause of fracture was fall and the time interval from the primary operation was 1–14 years. The majority of the patients were women(14), and the mean age 65 years.
13 of the 15 fractures were treated with ORIF and the remaining two need to be revised. During the follow up 2 of them died due to other pathological problems. The post op follow up ranged from 1–8(3.5)years.
The postoperative evaluation was done according the Harris Hip Score and the Knee Society Clinical Rating System.
The fractures healed after a mean time of 6 months. Two postoperative wound infections were registered to the revised fractures and their treatment were successful with surgical debridement.
All the patients are in good health condition, moving with some kind of support and they are selfreserved.
As a conclusion we believe that this kind of fractures demand the proper surgical planning, prediction of all possible complications and the cooperation of other specialties and physiotherapisties.
We present the results of a single percutaneous injection of platelet-rich-plasma (PRP) to lateral epicondyle in patients with severe chronic lateral elbow epicondylitis(ELE).
Between 2006–2008 eight patients suffered from severe chronic ELE. They had severe persistent pain (mean 85, range 70–100 on a Visual Analogue Pain scale(VAS)) despite conservative methods at least one year. Three patients were men and five were women with age from 38–63 years (mean 44). Right elbow was the involved in six patients, left elbow in one and the last patient had bilateral ELE. All patients underwent a single percutaneous injection of PRP (located to lateral epicondyle using a specific technique). PRP is derived from centrifugation of 27–30 ml autologous blood using the GPS system. After the injection of PRP all patients underwent a 2-week standardized stretching protocol and then a strengthening program for four weeks. The results estimated with a 100-mm VAS (0 no pain, 100 the worst pain) and a modified Mayo Elbow Performance Score (MEPS). The patients examinated four, eight and twenty four weeks after the injection and also at the last follow-up (mean 28, range from 16 to 38 months).
There were no regional or systemic complications. Four weeks after treatment the patients reported improvement in VAS mean score from 85 to 40 and in MEPS from 51 to 75. Eight weeks after injection the VAS mean score improved from 85 to 22 and the MEPS from 51 to 82. At six months the VAS score was 10 (mean) and the MEPS 90. Finally at the last follow-up the mean VAS score was 7 and the MEPS 92.
The percutaneous injection of PRP to lateral epicondyle in patients with severe chronic ELE seems to lead in a significant reduction of their pain and improvement of their elbow function. These good results may sustain over time.
Cartilage calcification induces the synthesis of degrading enzymes, such as matrix metalloproteinases (MMPs) and prostaglandin E2 leading to tissue degeneration. The aim of the study was to investigate the effect of vitamin D on the calcification process in osteoarthritic cartilage.
We evaluated the effect of vitamin D on klotho (KL), Fibroblast Growth Factor 23 (FGF23) and Fibroblast Growth Factor Receptor 1c (FGFR1c) mRNA and protein expression levels by real-time PCR and western blot analysis, respectively. Possible interactions between klotho and FGF23 on the receptor FGFR1c in normal chondrocytes were investigated using immunoprecipitation assay. The direct effect of 1,25 dihydroxyvitamin D3 (1,25D) on KL, FGF23 and FGFR1c promoter was also evaluated.
We found that FGF23 and FGFR1c mRNA expression levels were significantly increased in osteoarthritic chondrocytes compared to normal, while KL mRNA levels were decreased (p=0.001 for all genes). We showed that klotho-FGF23-FGFR1c form complexes in normal chondrocytes and confirmed the participation of klotho in the initiation of FGF23-FGFR1c signalling. Treatment of normal chondrocytes with 1,25D resulted in a significant dose and time dependent increase of FGF23 and FGFR1c mRNA levels and in an increase of KL mRNA levels in osteoarthritic chondrocytes compared to untreated (p=0.001). We revealed, for the fist time, the presence of conserved, canonical VDREs in the proximal promoters of KL, FGF23 and FGFR1c.
We propose a common regulatory scheme of mineral homeostasis and aging in osteoarthritic chondrocytes evidenced by the positive/negative feedback actions by KL, FGF23, FGFR1c and 1,25D, through binding of vitamin D receptor (VDR) on the promoters of the above mentioned genes.
Several observational and experimental studies have investigated the potential anabolic effects of statins on undisturbed bone but only a few recent studies have examined the effect of statins on skeletal repair. The goal of the study is to investigate any potential early anabolic effect of the systemic administration of simvastatin in low doses (based on earlier safety and efficacy studies on undisturbed bone) on fracture healing.
Fifty-four skeletally mature male New Zealand White rabbits were used for the study. The rabbits were assigned to one of three experimental groups: a control group, and two groups that were orally administrated a diet with 10 and 30 mg/kg/day of simvastatin, respectively. A complete biochemical blood count was performed to exclude drug-induced complications. Half of the animals of each group were sacrificed at 15 days and the other half at 30 days after surgery at which time intervals healing quality was assessed. The bones were subjected to biomechanical testing, histomorphometric analysis and peripheral Quantitative Computed Tomography.
In animals received simvastatin of 30 mg/kg/day a significant reduction of BMD, stiffness, and energy absorbed to failure were observed. At 15 days, the amount of cartilaginous callus formation was reduced, and the void space was significantly increased, in the animals of both groups that received simvastatin when compared to the control group (p< .05).
Our results suggest that simvastatin doses of 30mg/ kg/day may have a negative anabolic effect on callus formation in rabbits, whereas doses of 10 mg/kg/day seem not to produce a significant positive or a negative effect, especially at the early stages of fracture remodeling.
Comparison of the safety and efficacy of Bilateral Simultaneous Total Hip Arthroplasty (BSTHA) with that of staged (SgTHA) and unilateral (UTHA) was conducted using DerSimonian–Laird heterogeneity meta-analysis. A review of the English-language literature identified 23 citations eligible for inclusion. A total of 2063 bilateral simultaneous THR patients were identified. Meta-analysis of homogenous data revealed that there were no statistically significant differences between rates of thromboembolic events (p=0.268 and p=0.365) and dislocation (p=0.877) when comparing staged or unilateral with bilateral simultaneous THR procedures. A systematic analysis of heterogenous data demonstrated that mean length of hospital stay was shorter after bilateral simultaneous THR. Blood loss was reduced after bilateral simultaneous THR in all studies except for one, and surgical time was not different between groups. This procedure was also found to be economically and functionally efficacious when performed by experienced surgeons in specialist centres.
Periprosthetic fractures around a cemented femoral stem present a challenge to the treating surgeon. We propose a technique whereby a well fixed cement mantle can be retained in cases with simple fractures that can be reduced anatomically. This technique is well established in femoral stem revision, but not in association with a fracture.
24 Vancouver type B periprosthetic femoral fractures were treated by reducing the fracture and cementing a revision stem into the pre-existing cement mantle, with or without supplementary fixation.
3 patients died in the first 6 months for reasons not related to surgery and one was too frail to attend follow up. The remaining 20 cases were followed up for a mean of 3.0 years. The median time to radiological and clinical union was 3.0 months (2–11). The median Modified Harris Hip Score was 76.9 (35–97) and there was no sign of loosening or subsidence of the revision stems within the old cement mantle in any case at most recent follow up. One patient had further surgery for a delayed union and there were 2 subsequent fractures distal to the original fracture site in patients with poor bone stock.
Our results support the use of the cement-in-cement stem revision technique in anatomically reducible peri-prosthetic fractures with a well preserved pre-existing cement mantle. It is particularly suitable for older patients.
Periosteum is a specialized connective tissue that surrounds bone, containing progenitor cells that develop into osteoblasts. The osteo-progenitor cells along with growth factors, such as BMPs, play critical role in development, reconstruction and bone formation. Aim: to evaluate the expression of BMPs in human periosteum and in different subrgroups, including different donor sites, gender, and smoking habits.
Gene expression of BMPs 2,4,6,7 was performed in 60 periosteal samples using quantitative RT-PCR. Samples were obtained from 32 men/28 women, 22 smokers/38 non-smokers, 29 lower/31 upper extremities.
BMP2 gene expression was significantly higher (median: 12.02, p< 0.05) than the mRNA levels of BMPs 4,6,7 (median: 1.36, 2.55, 0.04) in all samples. BMP2 mRNA levels were higher in large compared to small bones (median: 13.4 vs 9.48), while BMPs 4,6,7 gene expression was similar (1.3 vs 1.4, 2.7 vs 2.1, 0.04 vs 0.03, respectively). In lower extremities, BMPs mRNA levels were higher than in the upper; the same was detected in non-smokers versus smokers group (BMPs2,4,6,7: 13.9 vs 1.5, 3.1 vs 0.048, 8.7 vs 1.06, 1.6 vs 0.026, respectively). mRNA transcripts of BMP2 were higher in men than women (median: 13.1 vs 10.8).
In our study, BMP2 expression is characteristically higher than that of BMP4, BMP6 and BMP7, highlighting the critical role that BMP2 plays in bone homeostasis. Furthermore, the elevated expression of BMP2 in men towards women, and of all BMPs of the lower extremity samples indicate the effect of hormones and mechanical factors in periosteal BMPs gene regulation; while the effect of smoking is reflected in the reduction of BMPs expression in smokers.
The aim of the study was to investigate the expression of genes regulating cholesterol efflux in human chondrocytes and to study the effect of an LXR agonist on cholesterol efflux and lipid accumulation in osteoarthritic chondrocytes.
Human cartilage was obtained from 24 patients with primary osteoarthritis (OA) undergoing total knee replacement surgery. Normal cartilage was obtained from 8 individuals undergoing fracture repair surgery, with no history of joint disease. ATP-binding-cassette transporter A1(ABCA1), apolipoprotein A1 (ApoA1), and liver X receptors(LXRα and LXRβ) mRNA expression levels were evaluated using real-time PCR. The effect of the synthetic LXR agonist TO-901317 was studied after treatment of osteoarthritic chondrocytes and subsequent investigation of ABCA1 and ApoA1 mRNA expression levels. Cholesterol efflux was evaluated in osteoarthritic chondrocytes radiolabeled with [1,2(n)-3H] cholesterol after LXR treatment, while intracellular lipid accumulation was studied after Oil-red-O staining. Apoptosis was evaluated using flow cytometry.
ApoA1, ABCA1, LXRα and LXRβ mRNA expressions were significantly lower in osteoarthritic chondrocytes compared to normal. Treatment of osteoarthritic chondrocytes with the LXR agonist TO-901317 significantly increased ApoA1 and ABCA1 mRNA expression levels as well as cholesterol efflux, while it significantly reduced apoptosis. Additionally, osteoarthritic chondrocytes presented intracellular lipids deposits, while no deposits were found after treatment with TO-901317.
Our findings suggest that impaired expression of genes regulating cholesterol efflux may be a critical player in osteoarthritis, while the ability of the LXR agonist to facilitate cholesterol efflux and decrease apoptosis suggests that it may be a target for therapeutic intervention in osteoarthritis.
Our study aimed to investigate the role of an HMG-CoA reductase inhibitor (atorvastatin) in human osteoarthritic chondrocytes and to test the in vivo effects of intra-articular injections of atorvastatin in a rabbit experimental osteoarthritis model.
Human articular osteoarthritic chondrocytes were cultured in the presence and absence of atorvastatin. mRNA and protein expression of MMP-13, COL2A1 and aggrecan were measured using real-time PCR and Western Blot analysis.
New Zealand rabbits (n=15) underwent bilateral anterior cruciate ligament transection (ACLT) to induce osteoarthritic degeneration and received intra-articular injections of atorvastatin and normal saline in the left and right knees respectively. The first injection was at the time of ACLT and injections were repeated every 3 days for 3 weeks. Data were obtained from macroscopic and histological evaluation as well as from gene expression analysis for COL2A1, aggrecan and MMP-13.
Incubation of the cultures with atorvastatin produced a decreasing effect in MMP-13 expression. Regarding aggrecan and COL2A1 expression a significant increase was observed.
Gross morphologic evaluation showed that the joints which received atorvastatin injections, showed minimal cartilage erosion, compared to the non-treated knees where the cartilage was markedly eroded, especially on the medial knee compartment. These results were supported by histological and gene expression analysis. The mRNA expression of MMP-13 was significantly reduced in the cartilage of the statin-treated knee joints, while the expression of COL2A1 and aggrecan was increased.
The clinical relevance of our results indicates a potential protective effect of atorvastatin on articular cartilage undergoing osteoarthritic degeneration.
Implant materials impregnated with antibiotics have long been used to manage the dead space created by debridement surgery in patients with osteomyelitis.
To present our preliminary results and in vivo response of patients to PerOssal used to treat bone infection in the form of long bone chronic osteomyelitis. PerOssal is a new osteoconductive bone substitution material for bone filling which consists of an entirely synthetically produced, nanocrystalline hydroxyapatite and calcium sulfate. It can be used effectively as a local antibiotic carrier for the reconstruction of infected bone defects.
We have treated 19 patients with long bone osteomyelitis (15 tibial, 4 femoral) with PerOssal impregnated with the appropriate antibiotic which was used following radical debridement surgery. In all cases we did not rely solely on the mechanical stability that it may provide but we supported the bone when necessary. Postoperative observations were focused on primary wound healing and clinical eradication of infection.
We had: 15 eradication of infection, 2 recurrences, in terms of re-infection by different species or amputation, and 2 on-going cases. Declining wound leakage and delayed wound healing was present in 5 cases where PerOssal was used either intramedullarily but not sealed or extraosseously in relatively large amounts.
We have so far good results with respect to infection control. PerOssal seems to perform better when used in contained defects whereas extraosseous use seems to predispose to prolonged leakage and compromised wound healing or breakdown. The mechanical stability that it provides remains under consideration.
Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting. The efficacy of BMP-7 in the treatment of recalcitrant aseptic femoral non-unions was studied.
Since 2003 a multicenter registry (bmpusergroup.co.uk) was created collecting details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.
Seventeen patients, who had undergone a median of 1(1 to 4) prior revision operations, over a median period from the injury of 17 months(9 to 42), were included in this observational study. In 76.4%(13/17) the BMP7 was combined with revision of the fixation. Non-union healing was verified in 14/17 cases(82.3%) in a median period of 6.5 months(3–15). Over 80% of these patients returned to their pre-injury level of activities, the median overall health state score was 82.5(35 to 100). No adverse events or complications were associated with the BMP7 application over the median follow-up of 24 months(12–68).
Purpose of this study is to create an experimental model on rats for EMG evaluation of the supraspinatus muscle after traumatic rupture of its tendon.
The population of this study consisted of 5 male rats of 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The electrode of a stimulator was placed under suprascapular nerve and the supraspinatus tendon was sutured on a transducer for digital record of the produced signal. Initially we found the resting length and the electric intensity for higher muscle contracture. The parameters that were evaluated after single contracture (single twitch) were strength, time to peak, half relaxation time. Furthermore, it was evaluated the strength of tetanic contractures at 10,20,40,80,100 Hz (Stimulation for 350msec each time).Finally it was evaluated the muscle fatigue with stimulation at 40Hz for 250msec and total duration of 3 minutes. Fatigue index was calculated according to the decrease of titanic muscle contracture (Initial value-Final Value/Initial Value x 100)
Our results are presented in mean ± sd. The single twitch was 8.2(5.1),the time to peak 0.034(0.02) msec, the half relaxation time 0.028(0.008)msec. The strength of titanic muscle contractures was 5.7msec at 10Hz and 17.7 at 100Hz. Finally the fatigue index was calculated at 48.4.
We believe that EMG evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair.
The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing.
22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group.
The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay > 5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03).
Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process.
The evaluation of the results obtained after a long term follow up (over 60 months) from patients that were treated arthroscopically for shoulder instability.
In our paper we evaluated 116 patients (108 men and 8 women) with mean age of 24 yo, that were treated surgically by the same surgeon from 1999–2004. Seventy seven (77) of them (66,4%) were into sports activities and during pre op clinical examination 15 patients (12,9%) were diagnosed with joint hypermobility syndrome taking into account the Beighton criteria. Arthroscopic findings showed that 80 of them (68,9%) had some kind of bone loss, either glenoid (7 Large, 23 Medium, 6 Small) or Hill Sachs lesion (28 Large, 30 Medium, 20 Small) and in 8 patients an “inverted pear” glenoid shape was found. Our follow up ranged from 60–117 months (Mean=84) and the recurrence of instability and functional outcome were evaluated post-op using the Rowe Zarins Score.
Recurrent instability presented in 7 patients. Five (5) of them was due to high energy accidents, one was due to non-compliance and one was involuntary. Of these patients 5 presented Hill Sachs lesion, 3 showed glenoid bone loss (2 Large, 1 Small) and in none of them an “inverted pear” glenoid shape was found. All recurrent cases were into some kind of Overhead/Contact sports activity (6 Amateur, 1 Professional). The post op Rowe Zarins Score ranged from 80–100 (Mean=95,53).
The arthroscopic treatment of glenohumeral instability is an excellent method that provides similar or better results when compared to the open surgical treatment and with clear advantages over the latter because of lower morbidity, better cosmetic effect and lower total cost.
We investigated the effect of the location and the number of distal screws in the efficiency of an intramedullary nail implementing the finite element method (FEM).
The left proximal femur of a 93-year old man was scanned and two series of full 3D models were developed. The first series, consisting of five models, concerned the use of a single distal screw inserted in five different distal locations. The second series, consisting of four models, concerned the use of four different pairs of distal screws. Each model was analyzed with the (FEM) twice, first considering that the femur is fractured and then considering that the femur is healed.
For nails with a single distal screw, stresses around the nail hole were reduced with proximal placement of the distal screw but the area around the nail hole where the lag screw is inserted is stressed more. Furthermore, for nails with a pair of distal screws, placing the pair of distal screws at a specific location is most beneficial for the mechanical behavior of the femur/nail assembly.
The distal area of the nail generally gets less stressed when a pair of distal screws is introduced, while the presence of two distal screws far away from each other results in lower proximal femoral head displacements. The stress field at the area of fracture is not influenced significantly by the presence of a single distal screw or a pair of distal screws.
The expansion of arthroscopic treatment to serious and catastrophic injuries to the weightlifters of the Hellenic National Weightlifting Team. The evaluation of the results of this specific arthroscopic treatment.
45 athletes (36 male, 9 female) with shoulder injuries 2000–2009. 15 yrs – 35 yrs, average: 27 yrs. One 3-times Golden Olympic. One Bronze medalist, Two Silver Olympic, Three Olympic winners, Five World championsetc. Clinical examination and musculoskeletal ultrasound. Plain X-rays. E.M.G, M.R.I.-arthrography, 3DC/T when that was required. Strength measurement with Nottingham McMecin Myometer for ipsi-contro lateral shoulder. Full ROM was necessary for the operated shoulder before starting exercise for a competition.
All 48 underwent arthroscopic treatment (3 mini-open). Arthroscopic stabilization using absorbable or non anchors. 45 athletes, 48 shoulders operated,(3 bilat-erally).36 RC tears, 6 bony-bankart, 2 posterior and 28 anterior labrum detachment, 3 avulsion osteochondral fractures, 2 AMBRII, 4 deranged LH of biceps, 4 underwent SSN release.
All patient returned at same sport level except one with AMBRII and cervical spine pathology. Rehabilitation time for basic weightlifting exercise was 3.5 months and for competition level was 4,5 -6 months.
The shoulder demands during the snatch, clean and jerk of the weightlifters provoke often shoulder injuries. The arthroscopic surgery gives thorough and broad knowledge of their shoulder injuries. The minimal detachment, less postoperative joint stiffness and decreased shoulder pain are encouraging factors for the arthroscopic treatment. Additionally, the returning time for training and competition combining with a proper rehabilitation seems to be less than open surgery.
The early diagnosis of the suprascapular nerve (SSN) entrapment in overhead athletes with simultaneous shoulder injuries and its arthroscopic release plays an important role for their appropriate treatment and recovery. SSN release at suprascapular and spinoglenoid notches, seems very helpful for increasing their performance.
21 Elite overhead athletes were treated from Jan 2005–May 2009. From 16 to 34 years old, mean 26 years, 4 Javelin throwers (Olympic and National level thrower), 4 Weightlifters (International level), 8 Volleyball Players, 3 Kick Boxer, 2 Water Polo Players.
Extreme ROM of arm creates large torques about the shoulder cycle of repetitive microtrauma to the SSN, Direct trauma: fracture, dislocation, blunt trauma traction injury, Sling effect with hyper-abduction injury at the SS Notch, Correlation ROM with SSN entrapment in volley ball players, Eccentric contraction of the ISP (spinoglenoid notch), Internal impingement, Rotator cuff tears, Biceps lesions, Instability, SLAP lesion, Bankart lesion, Mainly infraspinatus muscle atrophy. X-rays, Nerve conduction studies, EMG studies, MRI
All of them had complete pain relief, especially at the posterior shoulder, regained full ROM of the operated shoulder, 19 fully recovered at the pre-injury level, 2 at the postoperative phase, Muscle atrophy improved
Advanced SSN entrapment provoke significant muscle wasting, often irreversible. This underscores the importance of a quick and accurate diagnosis to appropriate intervention. The overhead athletes with increased ROM of their shoulder predispose in SSN entrapment and shoulder injuries and vice-versa. An arthroscopic shoulder procedure for repairing the glenohumeral pathology with a simultaneous arthroscopic SSN release seems to be the appropriate treatment regarding to our resu
The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively.
Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy.
Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears.
On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis).
Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients.
Tunnel enlargement after AC reconstruction with a hamstring autograft has been noticed mainly the first 3–6 months postoperatively. Its etiology involves biomechanical and biological factors. The aggressive rehabilitation program is another etiological factor. The aim of this study is to investigate the tunnel enlargement after ACL reconstruction with a Hamstring autograft by the aid of CT-scan.
We investigate the tunnel diameter in a series of 25 consecutive patients who operated with a Hamstring autograft 3 months postoperatively. The mean age of the patients was 23.6 years old (18–35). The same femoral fixation system (XObutton) and the same tibial fixation system (bioabsorbable screw) were used in all the patients. All the follow the same rehabilitation program, partial weight bearing from the 1st postoperative day, brace for 3–5 weeks and return to sports activities in 6 months.
In 2 patients a meniscal suture was performed and in 3 patients a partial meniscectomy was performed. All patients had excellent clinical result which was demonstrated by the physical examination and by the KT-1000 results. Statistical analysis was performed with the SPSS system. We noticed a tunnel enlargement in the majority of the patients, but this was not statistical significant (P< 0.01).
Tunnel enlargement after ACL reconstruction with a hamstring autograft has been noticed the first postoperative months, especially with the use of suspensor fixation systems. However in our study the tunnel enlargement is not correlated with a poor clinical outcome.
Evaluation of transtibial aiming of the femoral tunnel at its anatomical position in arthroscopical ACL reconstruction.
43 ACL reconstructions with hamstrings’ graft were studied. First, the femoral tunnel was drilled through the anteromedial portal at 09.30–10.00 (14.00–14.30 resp.) and then the tibial tunnel (av. anteroposterior angle: 63,5°, sagittal: 64,2°) at the same diameter with simoultaneous radiological documentation. Then, with a femoral aiming device, we tried to put a K-wire at the center of the drilled femoral tunnel. Fotographic documentation took place. In 20 cases the diameter of the tunnels was 7mm, in 11, 7,5mm, in 7, 8mm, in 3, 8,5mm and in 1, 9mm. Evaluation of all radiological and photographic material from 2 observers followed, according to the deviation of the transtibial K-wire from the center of the femoral tunnel.
38 ACL reconstructions were evaluated. It was shown that in 11 cases the transtibial K-wire was in the femoral tunnel (28,9%) (in 7 with a diameter of 7mm., in 2 with 7,5mm. and in 2 with 8mm.). The K-wire was in 23 cases (60,5%) at the perimeter or out of the femoral tunnel (in 11, with a diameter of 7mm., in 8 with 7,5mm., in 4 with 8mm., in 3 with 8,5mm. and in 1 with 9mm.). There was no correlation with the angles of the tibial tunnel or the age of the patients.
Transtibial aiming of the femoral tunnel at its anatomical position is very difficult and there is no correlation of the transtibial deviation with the diameter of the tibial tunnel.
The goal of this prospective study was to evaluate the results of arthroscopic meniscal repair with the FasT-Fix repair system. Type of study: Prospective case series. Methods: 83 meniscal repairs with the FasT-Fix meniscal repair system in 80 patients with a mean age of 29 years were performed between 2004 and 2008. Concurrent anterior cruciate ligament (ACL) reconstruction was performed in 70% of the cases. All tears were longitudinal and located in the red/red or red/white zone. Criteria for clinical success included absence of joint line tenderness, locking, swelling, and a negative McMurray test. Clinical evaluation included also the Lyscholm knee score, and KT-1000 arthrometry. Results: The average follow-up was 38 months (range, 10–61 months). Six of 83 repaired menisci (7.23%) were considered failures according to our criteria. Therefore, the success rate was 92.77%. Time required for meniscal repair averaged 15 minutes. Postoperatively, the majority of the patients had no restrictions in sports activities. 92% had an excellent or good result according to the Lysholm knee score. Four patients had a restriction of knee joint motion postoperatively, and an arthroscopic arthrolysis was performed in one of them. Analysis showed that, age, length of tear, simultaneous ACL reconstruction, chronicity of injury, and location of tear did not affect the clinical outcome. Conclusions: Our results, shows that arthroscopic meniscal repair with the FasT-Fix repair system provides a high rate of meniscus healing and offers reduction of both the risk of serious neurovascular complications and operative time.
Hip arthroscopy has gradually evolved over the past two decades. Recently hip arthroscopy has an increasing role in diagnosis and treatment for specific intra articular and extra articular hip injuries and especially for soft tissue injuries.
February 2002 – May 2009
18 athletes 5 football players 8 basketball players 2 weight lifters 3 gymnasts
Mean age: 32 y.o. (19–39 y.o.)
Undiagnosed hip pain, Osteoarthritis, Labral pathology, Loose bodies, Osteochondral defects, Sepsis, Liga-mentum Teres, Trauma, Synovitis
Symptoms: Deep dull ache pain during hip flexion and external or internal rotation. Decreased R.O.M.
12/18 Cam sign + (positive), 11/18 Pincher sign + (positive), 14/18 Impingement syndrome in adduction and in flexion.
Instrumentation and Equipment: 30°, 70°, 4,5mm arthroscope, High flow rate mechanical pump, 15 gauge 6" cardiac needle, Convex full radius chondroplasty blades, Special electrocautery (Philippon), Distraction apparatus, Mechanical water pump unit, Image intensifier
Surgery: Standard orthopaedic traction table, Supine position, Hip is extended and abducted 25° Portals: Anterior, Anterolateral, Posterolateral Intraoperative Findings – Results
Detachment of the labrum, 2/18 erosion of the articular cartilage of the acetabulum and drilling of the bare area, 12/18 Cam sign excision
The athletes with symptoms of an internal hip pain and impingement signs after a clinical exam of their hip will get a benefit from an arthroscopic procedure for treating any existing cetabulo-femoral pathology, especially for the athletes with femoraloacetabular impingement syndrome (FAI).
To evaluate the clinical outcome of arthroscopic treatment of ACL with an Achilles tendon allograft in patient with acute rupture.
22 patients, between 2003 and 2006, with acute rupture of ACL, were treated with an Achilles tendon allograft. The mean age was 26 years. Patients were evaluated before and after surgery and at the latest follow-up with Noulis-Lahmann test and Pivot shift test. We also used IKDC score, Lysholm score and one leg stance test and functional reach test. Patients were also evaluated with Cybex II + and with plain radiographies.
The mean follow-up time was 3.5 years. 90% of the patients had a negative pivot shift test and 95% of the patients had a score at Noulis-Lahmann test +1. The mean value of IKDC score was 88 (62–100) and the mean time of Lysholm score was 91 (75–100). Until the latest follow-up there were no clinical sighs of inflammation or graft rejection. Radiologic evaluation revealed no sign of tunnel enlargement.
We believe that the use of a fresh-frozen allograft in the treatment of acute ACL ruptures is an effective procedure for the restoration of ligamentous stability of the knee.
The bead EndoPearl is bioabsorbable material which placed in the ACL graft edge, and augment the stabilization in the femoral tunnel when an interference screw is used. Our aim was to recorded the operative characteristics of this technique and the clinical results after using EndoPearl in ACL reconstruction with hamstrings graft.
In 36 of our patients who had ACL reconstruction with hamstrings we used EndoPearl bead. They were 23 men and 13 women mean age 27.8 years (17–46). The graft was fixed in the femur side with interference screw. All patients followed the same p.o. rehabilitation regime. We followed them up the 1st, 2nd, 3rd, 6th and 8th p.o. month. During the last follow-up we checked the anterior drawer test, Noulis-Lachman test and in some cases pivot shift test, and in parallel Lysholm score was recorded pre-operatively and in the last examination.
In this last F.U. check none of them had positive Noulis-Lachman test or pivot shift test. The anterior drawer test was negative to 32 patients and in 4 we found slight laxity in comparison with the health leg. Lysholm score showed significant improvement (mean 90.2 p.o.), and nobody had “giving way”.
The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased in p.o. laxity.
The aim of this retrospective study is to isolate the cases of “overuse syndromes” in young athletes in whom the initial diagnosis proved wrong.
During six-year period 2002 – 2007, 28 young athletes (16 boys and 12 girls) aged 9.6 years (ranged from 6.5 to 14 years), suffering an underlying disease that had initially attributed to “overuse syndromes”, were treated in our Department. In all of the cases the history was misleading and the clinical examination was precarious, while the x-ray examination proved to be unclear. The remaining imaging exams led finally to the correct diagnosis that was confirmed in the operating room or via the biopsy.
In 4 cases a slipped capital femoral epiphysis was ascertained. In other cases we verified an osteochondritis dissecans of femoral condyle or talus (4), an osteoid osteoma (4), Perthes disease (3), osteochondromas (3), calcaneonavicular synchondrosis (3), hemangioma (2), discoid meniscus (1), herpes zoster along the sciatic nerve (1), aneurysmal cyst of fibula (1), accessory navicular (1), and osteosarcoma of fibula (1).
Overuse syndromes in young athletes should be treated with skepticism because another more serious disease may be hidden behind the symptoms and clinical signs. The children and adolescents have a skeleton that grows constantly and develops a special pathogenesis and this fact must be always kept in mind of parents, trainers and therapists. The young subjects who expect to be integrated in the athletic family should be previously examined by Pediatrician and Pediatric Orthopedic Surgeon so that a congenital anomaly or an acquired disease will be diagnosed in time.
To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents.
Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed.
Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases.
Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones.
To evaluate in-vivo the effectiveness of the double bundle technique for Anterior Cruciate ligament (ACL) reconstruction in restoring knee rotational stability under varying dynamic loading conditions.
The study group included 10 patients who underwent double-bundle ACL reconstruction with hamstrings tendon autograft, 12 patients with single-bundle reconstruction, 10 ACL deficient subjects and 12 healthy control individuals. Kinematic and kinetic data were collected using an 8-camera optoelectronic motion analysis system and one force plate. Knee rotational stability was examined during two maneuvers: a combined 60o pivoting turn and immediate stairs ascend and a combined stairs descend and immediate 60o pivoting maneuver. The two factors evaluated were the maximum
There were no significant differences in tibial rotation between the four groups in the examined maneuvers. Tibial rotation in the single- and the double-bundle groups were even lower than the control group. Rotational moments did not differ significantly between the four groups in any of the examined maneuvers. In general, rotational moments in the affected side of the ACL reconstructed and deficient groups were found reduced compared to the unaffected side.
Double-bundle reconstruction does not reduce knee rotation further compared to the single-bundle technique during dynamic stability testing under varying conditions. The injured side of ACL reconstructed or deficient individuals is exposed to substantially lower rotational moment compared to the intact side.
During the period 2004–2009, 35 children were admitted to the emergency department,(24 males:11 females), aged 3–14 years old,(MEAN 8,45 years), with supracondylar humeral fractures (33 extension type and 2 flexion type). All fractures were closed and result of sports injuries or games and were treated with closed reduction under general anesthesia and percutaneous k-w fixation.
The postoperative follow-up lasted from 6 months to 4 years. The Bauman’s angle was evaluated postoperatively on the operated and normal elbow and was 76, 6 ±1° and 74, 7 ±0, 6°. According to Flynn’s criteria the functional outcome was excellent in 29 cases. In 6 cases where the Bauman’s angle was greater than 10–15° there has been observed varus deformity (4 cases), valgus deformity (1 case), and flexion deficit (1 case).
The percutaneous k-w fixation and preservation of Bauman’s angle with carrying angle too, on supracondylar humeral fractures on children is a safe solution to avoid future complications.
The aim of our study is to report on our experience with elbow dislocations in childhood, the spectrum of the associated injuries and the various treatment modalities used.
In a period of 18 years, 52 children (33 male and 12 female) with elbow dislocations were treated in our clinic. 45 patients were followed-up with an average time of 7.2 years. 13(29%) dislocations were pure while associated injuries were present in 32(71%). Three had compound injuries. 23 of the associated injuries involved medial epicondyle fractures, 6 radial head fractures, 2 coronoid fractures, 2 lateral humerus condyle fractures, 1 ulnar diaphysis fracture and 1 radial peripheral metaphysic fracture. 27 patients treated conservatively while 18 patients treated surgically.
At the final re-examination, according to Roberts PH criteria, the clinical results were excellent in 24(56%) patients, good in 11(27%) patients, fair in 4(13%) and poor in 2 (4%) patients. A transit ulnar nerve paresis was perceived in 1 patient. The x-ray findings demonstrated 6 patients with medial epicondyle pseudartrosis and 6 patients with ectopic ossification.
Most elbow dislocations are associated with elbow fractures, therefore examination for an associated fracture is necessary. Closed reduction is the treatment of choice for elbow dislocations. Surgical treatment is indicated in elbow dislocations that are not reduced closely, in open injuries and in the presence of associated injuries that demand surgical treatment. The clinical and x-ray results are usually excellent. The presence of associated fractures, especially fractures of the radial head tent to lead in poor results.
We aimed to evaluate the relationship of forearm rotation with the magnitude of radial bowing and the localization of maximal radial bowing in children. The purpose of the study was to estimate the future forearm rotation limitation related the with the radial bowing.
Forearm fractured 26 children (younger than 15 years, 20 male, 6 female) were evaluated in 2 groups. Operatively treated (n=14) and nonoperatively treated (n=12) groups included diaphysis fracture of both forearm bones. In the early postreductive X-rays, maximal radial bowing (MRB) and the localization of maximal radial bowing (LMRB) were measured. Both groups were re-evaluated after a mean follow up of 25.5 months (range 4–62) clinically by the technique of Price et al. and radiologically by the method of Schemitsch and Richards. The relation of the MRB and LMRB with the forearm rotational movements were evaluated statistically.
No meaningful difference could be observed between the MRB and LMRB values of the injured and normal sides statistically (p> 0.05). Operatively treated patient group had closer degrees of MRB when compared with the normal side but there was not any meaningful statistical analysis. The number of patients having forearm rotation was so low that limits of forearm rotation could not be determined by the statistical methods. In the forearm pronation limited cases, it was observed that, when MRB decreases, the ability of pronation decreses and when LMRB increases, the ability of pro-nation also decreases.
If radial bowing degrees close to the normal side can be obtained, forearm rotation limitations due to differences of radial bowing can be prevented. The mean values of radial bowing and localization of radial bowing must be measured after forearm fractures of both bones.
Study of olecranon fractures in childhood and evaluation of the treatment approach.
During a 20 year period, 64 children with olecranon fractures were treated in our clinic. 51 children (41 males and 10 females) aged from to 2.5 to 14 years were reviewed. The follow up period was 1 to 20 years(average 9 years). Coexisting skeletal injury appeared in 31 patients. 36 children were treated conservatively while we follow operative treatment (open reduction and stabilization with Kirschner wires with or without tension-band or screws) in 15 children.
At the very last examination 2 children complained of mild pain during weather changes. Elbow extension was reduced from 5° to 15° in 6 patients and elbow flexion was reduced up to 5° in 3 patients. Pronation shortage was observed in 3 patients from 5° to 20° and a 10° supination shortage was observed in 1 patient. One case with pronation – supination shortage (40° and 70° respectively) while persisting subluxation of radial head was in 1 patient. The greatest degree of mobility limitation was observed in patients with comminuted fractures and associated injuries. Transient paresis of the radial nerve was observed in 1 patient.
The usual therapeutic approach to olecranon fractures is conservative.
In cases of displaced fractures, especially when the intraarticular displacement is greater than 3mm, surgical approach is indicated. Complications tend to occur more frequently among those cases with associated injuries. Olecranon paramorphosis in varus needs special attention since it usually coexists with radial head dislocation.
The objective and dynamic documentation of the knee kinematics in ambulatory children with spastic cerebral palsy and the examination of possible causes of differences when compared to normals.
17 ambulatory patients with an average age of 10,5 years (6–17 years) with cerebral palsy, spastic diplegia where examined clinically including Duncan-Ely test. They were also examined with 3-D instrumented gait analysis. The Elite system with six cameras was used and the knee kinematics in the sagittal plane was recorded.
Almost all patients (16/17) had a positive Duncan-Ely test during clinical examination. The knee kinematics in the sagittal plane showed that in 20/34 knees the range of motion was decreased compared to normal values. In 30/34 knees there was a delayed maximum knee flexion in swing phase and in 16/34 knees the amplitude of the maximum knee flexion was decreased compared to normals. Patients with severe crouch or mild rectus spasticity had almost normal knee flexion.
Foot clearance in swing phase is one of the basic prerequisites of normal gait. Patients with spastic cerebral palsy who are able to walk have an impaired foot clearance because of the pathological action of the rectus femoris.
In our study the majority of the patients with clinically confirmed rectus spasticity had decreased timing and amplitude of max. knee flexion in swing. In patients with severe co-contraction of the knee flexors and extensors max. knee flexion within normal range. Therefore it should not be considered as the only evaluation parameter in rectus femoris spasticity.
Pes equinovarus is a multi-factorial congenital disease that involves 1/1000 births, is bilateral in half of the cases and affects usually male children.
From 1995 – 2008 we have treated in total 172 children with pes equinovarus, 116 male and 56 female with age from 1 week to 4 years-old. There was bilateral pes equinovarus in 36 children whereas unilateral disease revealed equal rate of incidence. All children were treated initially with corrective casts and sequentially 122 children had surgery consisting of Achilles tendon lengthening and posterior capsulotomy, whereas in the rest of the cases was necessary medial hind foot structures and tendons release.
Final correction with only one operation were achieved in 108 children, there were pes equinovarus recurrence in 18 children that was treated with new soft tissue operation whereas 3 children had to undergo some kind of osteotomy in a later time. The recurrence time varied from 30 months to 13 years. The treatment was successful in 70% of the cases and 30% of them needed more than one operation for achieving a satisfactory functional result.
Pes equinovarus is a severe condition that now-a-days can be early diagnosed even in fetal life, but leads to significant handicap if left without treatment. In our department there were successful rates similar to international reports. The importance of an established long-term follow up of children that were operated for pes equinovarus is the keystone of a successful outcome and the early treatment is mandatory.
The purpose of the present study is to evaluate the early results of the Ponseti method when used for the treatment of idiopathic clubfoot among the population of the island of Crete.
Fourteen consecutive infants (twenty-one feet) with idiopathic clubfoot deformity were managed with the Ponseti method and were retrospectively reviewed at a minimum of six months. The severity of the foot deformity was classified according to the grading system of Pirani et al. The number of casts required to achieve correction was compared with published data for the treatment of idiopathic clubfoot. Recurrent clubfoot deformities or complications during treatment were recorded. Initial correction was achieved with a mean of 5.2 casts. Tenotomy and Dennis-Browne braces followed the cast applications. One foot had a relapse which was then treated by a repeat tenotomy at the age of 8 months. Two children abandoned the protocol because the parents could not comply with bracing. No extensive surgery is needed so far and all feet are flexible and pain free. X-rays when taken showed the talo-calac-neal angle within normal limits.
We support the use of the Ponseti method for the treatment of idiopathic clubfoot, since it can deliver flexible physiological feet, in the outpatient environment, thus avoiding the consequences of extensive open surgery.
Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point.
A sample population of 22 cadaveric femurs was used. Computed-tomography sections every 0.5 mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools.
In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5±1.5 mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R2=0.7310) and the projected femoral neck-shaft angle (R2=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing.
The clinical relevance of the results is that in varus hips (neck-shaft angle • 120o) the correct entry point should be positioned over the trochanter tip and the use stiff nails is advised. In cases of hips with neck-shaft angle between 120o and 130o, the optimal entry point lies just medially to the trochanter tip (at the piriformis fossa) and the use of stiff implants is safe. In hips with neck-shaft angle over 130o the anatomical axis of the canal is medially to the base of the neck, in a “restricted area”. In these cases the entry point should be located at the insertion of the piriformis muscle and the application of more malleable implants that could easily follow the medullary canal should be considered.
The Wnt/b-catenin signaling pathway participates in normal adult bone and cartilage biology and seems to be involved in cartilage degeneration and subsequent OA progression. The aim of this study was to investigate the activation of Wnt/b-catenin pathway in osteoarthritis and the role of LRP5, a coreceptor of Wnt/b-catenin pathway, in human osteoarhritic chondrocytes.
Human cartilage was obtained from 11 patients with primary osteoarthritis (OA) undergoing total knee and hip replacement surgery. Normal cartilage was obtained from 5 healthy individuals. b-catenin and LRP5 mRNA and protein levels were investigated using real time PCR and western blot analysis, respectively. Blocking LRP5 expression was performed using small interfering (siRNA) against LRP5 and subsequent MMP-13 mRNA and protein levels were evaluated by real time RCR and western blot analysis, respectively.
We confirmed the activation of Wnt/b-catenin pathway in osteoarthritis, as we observed significant upregulation of b-catenin mRNA and protein expression in osteoarthritic chondrocytes. We also observed that LRP5 mRNA and protein expression was significantly up-regulated in osteoarthritic cartilage compared to normal. Also, blocking LRP5 expression using siRNA against LRP5 resulted in a significant decrease in MMP-13 mRNA and protein expressions.
Our findings suggest that the upregulation of LRP5 mRNA and protein expression in osteoarthritic chondrocytes results in an increased activation of Wnt/b-catenin pathway in osteoarthritis. The observed reduction of MMP-13 expression after blocking LRP5 expression in osteoarthritic chondrocytes, suggests the involvement of LRP5 in the progression and pathogenesis of osteoarthritis.
The cause of Legg-Calve Perthes disease, 97 years after its original description remains undefined. In the present study we examined factors, which were correlated with a favourable or negative impact on the outcome of surgical treatment.
From a total of 98 children, treated during the period 1994–2006, we studied 20 cases (classified as Catterall III and IV), treated surgically. The average age was 7.4 years (4–13 years). We studied in comparison the most common procedures performed: these were the varus femoral osteotomy (12) and the lateral shelf acetabuloplasty (7). The subtrochanteric osteotomy yielded superior radiological results Stuhlberg I–II (I:6, II:6), than the lateral shelf procedure Stuhlberg II–IV (II:3, III:3, IV:1). The clinical results were similar between the two groups according to the Barrett scale, excellent or good.
Regarding the subtrochanteric osteotomy the most important factor was the precise varisation of the femoral neck and secondly the timing of surgical treatment early during the fragmentation stage of the disease, before the femoral head is significantly distorted. The most important positive factor regarding the lateral shelf procedure appears to be the accuracy of the surgical technique, in order that the graft coverage of the femoral head is accurately placed on the hip capsule. Negative factor for the lateral shelf procedure in one case was early weightbearing, which resulted in collapsing of the femoral head. It appears that with extensive necrosis (Caterall IV) the femoral head isn’t biomechanically enough resistant with this procedure to resist loads that result from early ambulation.
In the treatment of osteosarcoma, many reports in the literature outline that tumor response to chemotherapy directly correlates with disease-free survival and/or mortality. The aim of this study is to evaluate if the percentage of tumor necrosis is a sole prognostic indicator of overall survival in osteosarcoma patients.
We retrospectively studied 33 osteosarcoma cases treated in our institution from 1997 to 2006. All patients were treated preoperatively with HDMTX chemotherapy. The percent necrosis of the excised specimen were compared with survival rates of the patients.
Sixteen patients were good responders (Huvos III, IV- > 90% necrosis), 16 patients were poor responders (Huvos I, II- < 90% necrosis), and one patient died during preop. chemotherapy. With a mean follow-up of 5,48 years (3–12 years) 22 patients are NOD (not evident disease), in 8 patient disease progressed, 8 patients died. Statistical analysis could not establish a significant correlation between percent necrosis and patient survival.
Outcome of osteosarcoma may be dependent on a variety of factors s.a. tumor size, location, metastasis, surgical therapy, pathologic fracture. Tumor necrosis itself may be dependent on the histological subtype of the tumor and P-glycoprotein expression. In this series we could not establish tumor necrosis as a sole prognostic factor of patient survival.
We investigated the effect of Platelet Rich Plasma (PRP) in tendon healing. The aim was to assess the effect of an application of PRP on angiogenesis and immunohistochemical expression of TGF-b1 and IGF-I during tendon healing. We used a patellar tendon defect model after resecting its central portion. 48 skeletally mature New Zealand White rabbits were divided into the respective group and each group they were randomised into controls and PRP treated cases. The rabbits were sacrificed at weekly intevals and histological and immunohistological assessments were performed. The results showed a faster healing rate, increased vascularity, and higher expression of the growth factors in the PRP group. We conclude that the mixture of growth factors present in PRP gel improved the rate and quality of tendon healing.
The aim of the study to analyze the circulating white blood cells including the intensity expression of surface receptors and cytoplasmic molecules in patients underwent total hip replacement, with either aseptic or septic loosening of hip prostheses in order to identify cell-surface and cytoplasmic markers that could be indicative of early loosening. Flow cytometry was performed in whole peripheral blood samples of 20 patients with loosening (10 septic and 10 aseptic). Ten healthy individuals served a control group. The CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated. The mean fluorescence intensity (MFI) of CD 18 was decreased on all leukocytes subsets compared to control group. For patients with aseptic loosening we demonstrated an increase of MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to control group. In patients with septic loosening an increase of MFI for CD 11c was observed in monocytes compared to control group. The comparison between aseptic and septic loosening showed a statistically significant lower CD18 MFI value in granulocytes for aseptic loosening. A trend towards lower MFI values of CD 62L in lymphocytes and granulocytes were observed in aseptic but not in septic loosening patients compared to control group. The present study is the first study in published literature to demonstrate cell surface and cytoplasmic markers in peripheral blood indicative of loosening of THAs by means of flow cytometry.
Aim of this experimental study was to develop an in vitro model that simplifies the study of various factors regulating neuronal regeneration.
An in vitro-system that allows co-culture of slices from rat motorcortex and spinal cord (p4) was established. Two groups of cultures were investigated: In the first group, intact spinal cord slices were cultured adjacent to motorcortex slices, while in the second group the spinal cord slices were sagitally cut into halves, with the sectioned interface placed directly adjacent to the motorcortex, in order to prevent the spinal white matter from interference. Each group was further divided into two subgroups: The NT-3 group, where the culture medium contained 50 ng/ml NT-3 and the control group treated with normal culture medium. Motorcortex pyramidal neurons were anterogradely labelled with MiniRuby, a 10 kD biotinylated dextran amine.
After 4 days the co-cultures were propagated, and axonal sprouting occurred. The group of co-cultures treated with NT-3 showed an improved cortical cytoarchitecture, and sprouting axons were more frequently observed. In NT-3-treated co-cultures where spinal cord gray matter was directly opposed to cortical slices sprouting axons entered the adjacent spinal cord tissue. This phenomenon was not observed if spinal white matter was opposed to the cortical slices, or if NT-3 was absent.
Our data suggest that the absence of repellent factors such as white matter and the presence of neuro-trophic factors promote axonal sprouting. Co-cultures of motorcortex and spinal cord slices combined with anterograde axonal labelling could provide a valuable in vitro model for the simplified screening of factors influencing corticospinal tract regeneration
Simvastatin is a 3-Hydroxy-3-methylglutaryl Co-enzyme inhibitor, widely used to reduce lipid levels. Recent studies have demonstrated pleiotropic beneficial effects the skeleton. We aim to demonstrate the effect of Simvastatin on the osteogenic differentiation and proliferation of murine embryonic stem cells.
Tg2a cells were cultured in maintenance medium until confluence and passaged twice into tissue culture flasks. They were then seeded into 6 well and 24 well plates at a density of 10.000 cells/cm2 and cultured for 3 days in maintenance medium mixed at 1:1 with HepG2 conditioned medium. The culture then continued using osteogenic medium with different concentrations of simvastatin for another 16 days. Measurements included Alizarin Red quantification for calcified matrix, ALP assay, RT-PCR for genes expressed during osteogenic differentiation (osteocalcin, Runx2, osterix, Col1a1).
Simvastatin has dose dependent effect on mineralized matrix formation. Alizarin Red quantification assays demonstrated that simvastatin (all dose groups) induced a statistically significant increase in calcified matrix formation on day 11 (P< 0.05) and 16 (P< 0.01) compared to the control group. ALP activity was significantly higher on day 8 in the groups that had a simvastatin concentration of 1nM, 10nM and 100nM (P< 0.05). RT-PCR has demonstrated that simvastatin caused increased expression of all genes measured on differentiation. Statins can induce bone formation when combined with embryonic stem cells.
During hip revision removal of old cement mantle is a major problem. In cases of satisfactory bond between cement mantle and the underlying bone, cementing the revision stem into the old mantle is regarded as a highly attractive option. The aim was the analysis of the shearing strength of the interface between two layers of poly-methylmethacrylate cement in the presence of fluid.
A laboratory, two-dimensional model of the interface was used. Effect of different viscosity fluids and volumes on its strength was checked. 6 variants (control monoblock, dry surface, surface stained with small or large volume of water or highly viscous fluid) containing 7 repeats were exposed to a single shearing stress to failure.
Large volume of viscous fluid prevented bonding completely in two cases and significantly weakened the other samples showing mean failure stress of 5.53 MPa. This was significantly lower compared with control monoblock (19.8MPa), dry surface variant (16.9MPa) and the stain with small amount high viscosity fluid (16.01MPa). Interestingly, presence of a large volume of low viscosity fluid did not significantly reduce resistance to shear stress (17.05MPa).
In all but large volume of viscous fluid variants, the failure occurred away from the interface between two cement layers. Large amount of viscous fluid weakened significantly this interface. If such a viscous fluid could be eliminated by copious water irrigation it is likely that strength of the cement-cement bond will be maintained. Our observations suggest that cement-in-cement technique seems to be biomechanically acceptable
The aim of this experimental study was to provide an in vitro model suitable for the investigation of the complex interactions of neurons with non-neuronal cells that take place throughout the degenerative and regenerative processes induced by spinal cord injury.
Organotypic spinal cord slice cultures (OSCSC) were prepared from postnatal Wistar rats (p0–12), were sustained in vitro up to 12 days and characterized by immunohistochemistry by well-established markers such as NeuN, Calbindin, GFAP, IB4 and Nestin.
Calbindin+ neurons, distributed across the entire gray matter, were visible also after longer culture periods. NeuN+ neurons were best preserved in the dorsal horn, whereas large NeuN+ and ChAT+ motoneurons in the ventral horn vanished after 3 days in vitro. GFAP+ astro-cytes, initially restricted to the white matter, invaded the gray matter of OSCSC early during the culture period. Microglial cells, stained by Griffonia simplicifolia isolectin B4, were rapidly activated in the dorsal tract and in the gray matter, but declined in number with time. Nestin-immunoreactivity was found in animals of all age groups, either in cells interspersed in the ependymal lining around the central canal, or in cells resembling protoplasmic astrocytes. OSCSC derived from p0 or p3 animals showed a better preservation of the cytoarchitecture than cultures derived from older animals.
In summary, OSCSC contain defined neuronal populations, the cytoarchitecture is partially preserved, and the glial reaction is self-limited. Our model of OSCSC could prove useful in future experiments on the patho-physiology of spinal cord injury
The evaluation of two methods for the placement of the tibial component of total knee arthroplasties in obese patients
Between December 2004 and October 2008 we studied 38 obese patients who underwent cemented total knee arthroplasty (using the rotating platform tibial tray) due to medial compartment osteoarthritis and consequent varus deformity. All patients had a body mass index (BMI)> 40. Functional outcome was assessed using the Knee Society Score (KSS). The study was based on the comparison between extramedullary (group A) and intramedullary (group B) instrumentation systems for the placement of the tibial prosthesis. The main endpoint was the immediate post-operative knee joint alignment.
There were 10 male and 28 female patients. The average follow-up period was 13.8 months (minimum follow-up of 6 months). There were 22 patients in group A whereas 16 patients comprised group B. In 5 of the 22 patients in group A there was an average varus malalignment of 40 and a mean KSS of 71.5 at the time of the latest follow-up visit. In the rest of patients of both groups there was a valgus alignment between 0 and 70 and a mean KSS of 86.4 respectively
Our experience suggests that the intramedullary instrumentation technique for the placement of the tibial component offers a more favourable post-operative alignment as well as better functional outcome in obese patients.
Because ankle inversion trauma can result in persistent isolated subtalar joint instability and can contribute to chronic lateral ankle instability, optimization of subtalar joint ligament injury diagnosis and treatment is essential.
12 fresh-frozen cadaver lower extremities were used. The cradle was a component of a gimbal system that allowed unrestricted inversion/eversion and anterior-posterior and medial-lateral translation of the subtalar joint. The bearing system to which the tibia/fibula were attached allowed unconstrained internal/external rotation and superior-inferior translation. 4N-m inversion/ eversion and internal/external rotational moments and translational forces of 67N were applied. All measurements were performed sequentially in neutral, 10° dorsiflexion and 20° plantarflexion, and were repeated as the cervical, calcaneofibular, and interosseous ligaments were consecutively sectioned in all possible different orders.
In neutral position, inversion increased after sectioning of the cervical (3.7°), interosseous (0.8°), and calcaneofibular (1.9°) ligaments individually. Combined sectioning of all three ligaments showed an increase in inversion of 8.3°, 8.5° and 1.4° in the neutral, plantarflexed, and dorsiflexed positions, respectively, compared to the intact ankle. External rotation also increased in neutral position after sectioning the cervical ligament (2.0°). Combined sectioning of all ligaments showed an increase in external rotation of 3.6° and 5.4° for neutral and dorsiflexion, respectively.
This is the first comprehensive biomechanical cadaver study of the contributions of the cervical, calcaneofibular, and interosseous ligaments to stabilization of the subtalar joint. The surgeon may refer to the findings in both diagnosing and planning treatment of problematic subtalar joint instability
To study the use of TSF system in treating trauma and bone deformities in children. To determine the difficulties of this process and the risk factors that lead to complications.
From January 2004, in 61 children (37 male and 24 female), 67 extremities, with a mean age 8.9 years children a TSF external fixator was applied for the treatment of trauma or bone deformities. 21 children were operated for angular deformity, 19 for bone lengthening, 10 for rotational deformity, 6 for combined angular deformity and lengthening and 11 for pseudoarthrosis. Intra and postoperative difficulties were classified using the Palay method in problems, obstacles and complications.
The rate of difficulties was 22.2 %. Problems were presented in 5.9% (4/67) consisting of 2 non-axial deformities, 1 pin fracture and 1 subluxation of the knee. Obstacles were presented in 10.4% (9/67) including 3 cases with delayed bone healing that needed infusion DBM, 1 peroneal nerve palsy due to hematoma formation treated with decompression of the region, 1 early bone fusion that needed re-operation and 2 cases of percutaneous achilles lengthening. Complications presented in 5.9% of (4/67) the cases including 1 fracture, 1 pseudoarthrosis, 1 peroneal nerve palsy and 1 limitation of range of motion in the knee (0–45 0).
The problems, obstacles and complications that presented during treatment influenced the final therapeutic objective. Initial deformity, preoperative planning and surgeon’s experience are associated with reducing the rate of all difficulties
Most studies on LBP have focused on adults although many investigations have shown that the roots of LBP lie in adolescence. Several mechanical, physical and behavioral factors have associated with non-specific LBP in adolescents. To our knowledge no previous study has investigated using advanced statistics all previously reported parameters together with psychological and psychosocial factors on LBP in adolescents aged 15–19 years.
688 students aged 16± 1 years from 5 randomly selected high schools participated in this multifactorial study and completed a questionnaire containing questions on daily activity, backpacks carrying, psychological and psychosocial behavior. Anthropometric data as well biplane spinal curvatures together with questionnaire results were included in the analysis using advanced statistics.
LBP reported 41% of the participants. Generally, statistically significant correlations were found between LBP(0.002), physical activity(P< 0.001), physician consultation(P=0.024) and depression (P< 0.001) Gender-related differences were shown regarding LBP intensity(P=0.005) and frequency(P=0.013), stress(P< 0.03), depression (P=0.005) and nervous mood(P=0.036) in favor of male students. Male adolescents had continuously energy (P=0.0258) and were calm (P=0.029) in contrast to female counterparts.
LBP was gender-related and was less common in adolescents with frequent activity. Adolescent girls with stress, depressive mood and low energy have more LBP than boys that makes physician consultation for LBP more common in female adolescents.
Systematic physical activity and control of psychological profile should decrease LBP frequency and intensity
We evaluated the contribution of specific gene polymorphisms of IL-1a/IL-1R/IL-1RA/IL-4Ra/IL-1b/IL-12/γIFN/TGF-b/TNF-a/IL-2/IL-4/IL-6/IL-10 cytokines in patients with AVN.
DNA was extracted from 112 patients and 238 healthy Greek individuals. DNA analysis was performed by the PCR-SSP method and the use of the Protrans kit. Statistical analysis was performed by χ2 test.
In the patients, the TC frequency of the IL-1a (nt-889) was 52% while in normal was 40%. The C/G allele frequency of TGF-b codon 25 in patients was 9% C and 91% G vs 13% C and 87% G in normal. At position −238 of TNFa, 11% of the patients had the GA genotype in contrast to 1% of the controls. The GG/GG haplotype of TNFa gene promoter (nt. −308 and −238) was more frequent in both groups, while the GG/GA haplotype detected in 9% and 1% of the patients and controls, respectively. At the −1082 position of the IL-10 gene, the GG genotype was detected in 15% of the controls and 7% of the patients. Also, the GCC/GCC haplotype in IL-10 (positions -1082/-819/-592) was higher in the controls (15%) than the patients (7%).
The genotypes TC (nt-889) of IL-1a, GC (codon 25) of TGF-b, GC (nt-1082) of IL-10 and GA (nt −238) of TNFa, are more prevalent in the patients than the healthy individuals (p< 0.05). Based on our results, the presence of one of the above mentioned polymorphisms or the simultaneous carriage of more than one may contribute to the risk for osteonecrosis
Avascular necrosis (AVN) is a disorder leading to femoral head (FH) destruction, while BMPs are known for their osteogenic ability. In this study we analyzed BMP-2, BMP-4, BMP-6 and BMP-7 expression at the RNA and protein level in the normal and necrotic sites of the FHs.
Quantitative RT-PCR for BMP-2,-4,-6,-7 genes was performed in samples from the normal and necrotic sites of 52 FHs with AVN. Protein levels of BMP-2,-4,-6 were estimated by Western Blot analysis. Statistical analysis was performed using the t-test (p< 0.05).
BMP-2 and BMP-6 mRNA levels were higher in the normal than the necrotic site (BMP-2 and BMP-6, normal vs necrotic: 16.8 vs 7.5 and 2 vs 1.66, respectively). On the contrary, BMP-4 mRNA levels were higher in the necrotic (1.2) than the normal site (0.97), while BMP-7 mRNA levels were low in both sites. At the protein level, BMP-2 expressed higher in the normal (0.63) than the necrotic region (0.58), while BMP-4 and BMP-6 detected at higher levels in the necrotic site (BMP-4 and BMP-6, normal vs necrotic: 0.51 vs 0.61 and 0.52 vs 0.57, respectively).
Different mRNA levels between the normal and necrotic site, as well as discrepancies between the gene and protein BMPs expression levels suggest a different regulation mechanism between the two regions. Better understanding of the expression pattern of BMPs could lead to a more successful use of these molecules in the prevention and treatment of AVN
To evaluate the effectiveness of Pulsed-Lavage and of Versajet-hydrosurgery in removing two Staphylococcus aureus strains from porcine tissue and graphite powder from simulated fractures.
Overnight broth cultures (NCTC-6571) and S.aureus strains were diluted to yield inocula containing 1x103c. f.u. ml-1. Initially 8 porcine legs were used; porcine tissues were inoculated with 10ml of either of the two S.aureus strains. Control tissues were inoculated with PBS. All inoculated samples were irrigated with 300ml of saline using the pulsed-lavage system or using the Versajet. 10ml of each of the following were plated out in triplicate:
inoculum pre-incubation inoculum post-incubation, each left over inoculum following removal of tissue and dilutions of 10-1 and 10-2 and Wash from all samples.
Eight additional porcine legs were used where 2 incisions were made down to bone in a cross-hatch pattern. 1g of graphite powder was infiltrated into each fracture site to simulate a contaminated open fracture. Each fracture site was irrigated with 500ml saline through pulsed-lavage or Versajet.
The average microbiological reduction using Pulsed-Lavage or Versajet was 2% and 15% respectively. The clinical S.aureus strain was more adherent than the laboratory strain. The Versajet maintained a 12–16% reduction of S.aureus, whereas pulsed-lavage did not reduce contamination. The number of graphite particles was significantly reduced with the use of the Versajet system compared with the pulsed-lavage.
Versajet system was more effective in removal of foreign particles and more effectively reduced the micro-biological load of both examined S.aureus strains in a porcine model. Further studies are indicated to evaluate the efficacy of this system in clinical practice
Our aim was to assess the value of external fixation in pathological fractures in selected patients.
During 2003–2008 we treated 35 patients with multiple myeloma or disseminated cancer, visceral metastases and pathological fractures with external fixation under sedation and local anaesthetic, because they were not fit for general anaesthesia. We used external fixation on 1 hip fracture, 1 fracture of the second metatarsal, 2 wrist fractures, 4 radial, 5 intertrochanteric, 1 subtro-chanteric, 12 fractures of the humerus, 1 ulna fracture, 4 femoral fractures, 3 tibial fractures and 1 femoral osteolysis. Operating times were 15–35 min, all patients were comfortable, cooperated well and they did not experience any pain during the procedure. In all cases XRT was applied either pre- or post-operatively.
On follow up (2–48 months) 4 of the patients were deceased. Fracture stabilization was adequate and X-rays confirmed porosis in 4 fractures; however, two lesions expanded further, despite proper adjuvant bio-pharmaceutical therapy. 5 patients impoved so we could operate them later to treat the fractures definitively. All individuals experienced pain relief, they were adequately mobilized and most function was restored, while there was no major problem with pin tract infections.
We suggest external fixation as a palliative treatment in patients with pathological fractures and multiple metastases, who don’t qualify for major surgery because of their critical illness. The later puts under local offer an excelent chance to fix fractures quikly, manage the pain and restore function without the risks of general anaesthesia
Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis.
Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest.
All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site.
CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area.
In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects
To evaluate the functional outcome after complete median nerve transaction and repair, and sensory reeducation.
We studied 40 patients, aged 20 to 32 years, with median nerve neurotmesis at the wrist. Primary epineural microsurgical repair using 8-0 single strand sutures was done in all patients, and a hand and wrist cast was applied for 4 weeks. After cast removal all patients went through physical therapy for 1 month to restore motion and reduce stiffness of the injured hand. After reinnervation was completed, the patients were randomly allocated into 2 equal groups: Group A patients were instructed to a sensory re-education program; Group B patients had no further treatment. Clinical evaluation was done at 18 months postoperatively including the localization test (locognosia), the static and the moving 2 point discrimination tests, the Moberg’s pick-up test (stereognosia), and the hand grip and the opposition strength tests.
All patients were included in the postoperative evaluation. Hand grip and opposition strength, static and moving two point discrimination were not statistically significant between the two groups (p= 0.622, p= 0.112 and p= 0.340, respectively). The localization test was statistically significant in group A (p= 0.007), and a trend to statistical significance was observed regarding the Moberg’s pick up test in group A (90% statistical significance, p= 0.063).
Sensory reeducation is essential for patients with median nerve neurotmesis and repair, as it significantly re-educates localization and stereognosia in the shortest time following peripheral nerve injury and repair
In the peripheral nervous system of rats, a wide-variety of toxins has been studied to selectively target neurons projecting through a particular nerve. We employed 54 adult male rats to create a neuroma-in-continuity and to evaluate the effect of the immunotoxin OX7-saporin to inhibit neuroma-in-continuity formation. Materials and Methods: The left common peroneal, tibial or sciatic nerves were crushed by one 10-second application of a microforceps. At 3 and 6 weeks after nerve crush, the respective nerve was cut distal to the site of nerve crush, and microinjection of 2 μl of natural saline or 2 μl of the OX7-saporin was done.
In all nerve specimens of the control group and the saline-injection experimental subgroups, gross observation showed a thickened area at the site of nerve crush. Histology showed features consistent with a neuroma-in-continuity. In 11 of the 14 nerve specimens of the OX7-saporin injection experimental subgroups, gross observation showed a narrowed area at the site of nerve crush. Histology showed prevention of neuroma-in-continuity formation as seen by wiping out of almost all nerve fibers, leaving an empty tube encasing by connective tissue.
This study supports the hypothesis that intraneural injection of the OX7-saporin may inhibit neuroma-in-continuity formation
We assessed 224 patients treated with Autologous Chondrocyte Implantation performed 10–20 years ago (average 12.8 years). Average age at the time of the implantation was 33.3 years. Average size of lesion was 5.3 cm2 (range 0.6–16), while 55 patients sustained multiple lesions. The participants filled out five questionnaires. Lysholm score, Tegner-Walgren, modified Cincinnati (Noyes), Brittberg score, and KOOS were assessed. In addition, the patients were asked to grade their current situation compared to their previous follow up as better, worse of unchanged. Finally, they were asked if they would do the operation again, answering with yes or no.
The patients were divided into groups according to the location and characteristics of the cartilage lesions, or concomitant surgeries during the ACI. Assessment of the outcomes reveals a significant improvement in all groups, compared with the preoperative values.
There is no other study assessing a cartilage treatment with such a long follow up. According to the results of that study, autologous chondrocyte implantation seems to be an effective and durable solution for the treatment of large full thickness cartilage and osteochondral lesions of the knee joint
Locking strategies of the sliding screw in gamma nailing (G3) were tested in an experimental biomechanical study.
Twelve Composite Femoral Bone models were used. An intertrochanteric osteotomy was performed and a gamma nail was implanted in each specimen. The specimens were divided in 3 groups:
compressed and locked, locked at distance and unlocked. Each specimen was subjected to 4 cycles of static vertical loading of up to 1100 Newtons (N) at a rate of 10 mm/minute.
Subsequently, the specimens were investigated for cut-out patterns using digital photography and management.
All failures occurred under supraphysiological loads. During their first loading cycles, no statistical differences for stiffness and yield load were noted. Nevertheless, there was a non–significant tendency for higher failure loads for the unlocked group. Under maximum load (1100 N) and already established deformations, all Gamma Nails behaved similarly in terms of neck-screw displacement, with no statistical differences.
Unlocked screws exhibited the most moderate failure modes followed by the compressed and locked group. The third group showed the most severe failures.
In conclusion, there is evidence that sliding is biomechanically superior in gamma nailing. Despite adverse mechanical circumstances all specimens behaved satisfactorily under physiological loading
The frequent choice of treatment for tibial shaft fractures is intramedullary nailing. However there are cases where this treatment is problematic and alternative treatments are chosen with satisfied results.
Twenty-nine patients with complex, unstable tibial shaft fractures (13 males and 16 females) aged 18 to 76 years (mean age 49 years) were treated using Ilizarov external fixation, the last decade in our Department by the same surgeon. The indications were open Gustillo III fractures, comminuted fractures of the proximal or distal third tibia near metaphysis, concomitant plateau or pillon fractures and fractures after total knee arthroplasty (TKA). All frames were applied the first day of injury. Patients without concomitant intraarticular fracture or bone deficit allowed to full weight bearing within2 weeks after surgery.
Union and good to excellent alignment with full range of motion in the knee and ankle joints was obtained in all patients. Three patients needed bone lengthening using the initial applied frame after corticotomy in second operation. There were 7 delayed unions in fractures without bone deficit, 10 superficial pin tract infection treated with antibiotics and local care and 1 deep infection which needed surgical intervention.
Ilizarov external fixation gives the solution in difficult and problematic tibial shaft fractures and allows early weight bearing
Treatment of tibial plateau fractures Schatzker type V and VI or with soft tissues injuries is still remains under discussion. The purpose of this study is to evaluate the results of treatment with circular frame and closed reduction in 25 patients (15 males and 10 females) with tibial plateau fractures, with a mean age of 42 years old (20 – 76 years).
Five fractures were classified as Schatzker type II and III and 20 as type V and VI. Reduction was obtained in 22 cases under foot traction and in 3 arthroscopically. Bone grafts inserted through a hole (• 1 cm) in the inner cortex of the tibia metaphysis under fluoroscopy. Eight unstable knees needed bridging the joint for 4 weeks. In 2 cases a cannulated interfragmentary screw was used. Full weight bearing was allowed 3 months after injury when the device was removed.
Follow up ranged from 1 to 10 years (mean 5 years). All fractures were united and there was no infection. Full range of the knee motion was achieved in 23 patients while 2 needed an open arthrolysis. There were 2 malunions which were treated with one valgus osteotomy and one TKR. Asymptomatic arthritis appeared in 6 patients. According to Knee Society Score (KSS) the results were classified as excellent in 12, good in 8, fair in 3 and poor in 2 patients.
Circular frames are a satisfactory alternative method for the treatment of tibial plateau fractures either in severe soft tissues injuries or in very complex cases
The treatment of high energy fractures of distal tibia by internal fixation is followed by a high rate of soft tissue complications.
The result estimation of these fractures in a two stage treatment, bridging the ankle by Ex-Fix with/without internal fixation of the fibula and internal fixation of the tibia after soft tissue recovery
In a 4 year period (2005–8), 15 patients, average of 42 years were treated. The AO fracture classification was followed. The soft tissue damage estimation (Osternn-Tscherne and Gustillo classification), the fracture pattern of the fibula and the injury mechanism consisted of the choice method criteria. The majority of the injuries was classified Tscherne II & III, and 3 open fractures Gustillo II. Fracture reduction was performed by bridging Ex-Fix of the ankle with/without plating the fibula with a 1/3 or DCP 3.5 mm plate. Definite internal fixation of the tibia by locking plate was performed from 8th –14th postoperative day after soft tissue recovery. Preoperatively CT scan was performed with grate significance, defining the soft tissue condition, the surgical approach and the osteosynthesis type.
Follow up average 14 months. None of the patients developed infection. All wounds were healed in one stage. Superficial skin necrosis was conservatively treated in two patients.
Soft tissue complications, after internal fixation of high energy fractures of the distal tibial, usually appear. Two stages treatment allows better preoperative planning, immediate patient mobilization and reduce complication rate
Although intramedullary nail fixation maybe highly indicated for comminuted and segmental humeral fractures that require operative treatment, the literature lacks reviews of this content.
The aim of the present study is to prospectively evaluate the clinical and radiographic outcomes in patients with combined head and shaft fractures of the humerus who were treated by antegrade locking intramedullary nailing.
During a period of four years 21 patients (9 men & 12 women) between 36 and 82 years old, with combined fractures of the humeral head and shaft, were operated by one surgeon. Three types of nail implants were used (Polarus long, Garnavos nail, True flex nail) and ante-grade technique was performed in all cases.
The mean operating time was 105 min (50′–140′). The period of follow-up averaged 14.25 months (range, 9 to 18 months). Two patients were lost to follow up and one died before the callus formation procedure was accomplished. The functional assessment included determination of the Constant score and documentation of shoulder function as compared with the non injured extremity. Radiographic control was obtained during the follow-up intervals and at the final follow up. No neurovascular complications, deep wound infections or non-unions were recorded and all fractures were fully healed between 4 to 8 months post-operatively. In one case the nail was extracted before callus formation was achieved, because of acromion impingement.
The results are judged as very satisfying, taking into account the comminution of the fractures. Further evaluation of the results, with comparable methods of internal fixation of such fracture patterns, is needed.
During the last few years, the arthroscopically assisted technique for reduction and internal fixation of tibial plateau fractures is of increasing popularity. The accumulated surgical experience allowed the possibility of treating type I, II, III according to Schatzker classification.
During the last two years 17 patients who had suffered a tibial plateau fracture were treated this way. The mean age was 44 years, while the mean FU was 16 months. According to Schatzker classification 8 fractures were type I, 6 fractures type II and 3 fractures type III. The bone reduction was achieved under arthroscopic view and flouroscopy. In all cases the fracture was fixed by the with cannulated Herbert type screws. Meniscal lesions were fixed in 9 patients, while in 5 patients ruptures of the ACL were detected, which were reconstructed at a later stage.
Full range of motion of the knee was restored in 11 patients, while lack of full knee flexion (mean 100) was found in 6 patients. All patients were assessed with a modified Lyslom Knee Scale. The Knee score was 85 points to 96 points (mean 92 points), while the anterior knee pain was the common problem especially following increased activities.
The proposed arthroscopically assisted technique for reduction and fixation of certain types of tibial plateau fractures consists a alternative minimal invasive approach. Visualization of the whole joint is possible and concomitant lesions can be detected and possibly fixed at the same time
The use of external fixation in open tibia fractures with severe soft tissue injury is the most preferred and safe treatment. The primary allograft application is doubtful due to high infection risk.
The evaluation of the results of open tibia fractures type II and III according Gustillo-Anderson that were treated with simultaneous external fixation and allograft application.
From 2005–2007, twenty nine open tibia shaft fractures in 27 patients (2 bilateral) with mean age of 35 years-old were treated.
According Gustillo-Anderson classification, there were 20 GII, 6GIIIa and 3GIIIb open tibia shaft fractures without severe bone loss. All patients were treated with thorough and extensive surgical debridment, external fixation and simultaneous application of allograft and double antibiotic scheme. The patients were followed up initially weekly till stitches removal and every second week till the external fixation removal without developing any signs of infection.
Overall, there were uncomplicated union in 23 cases (18 GII, 3GIIIa and 2GIIIb) whereas in 5 cases we had to change method of treatment (3 GII and 2GIIIa) due to union delay or non acceptable fracture angulations. There were also a case that developed deep infection and septic pseudarthrosis.
The simultaneous external fixation and allograft application seems to provide a small advantage in open fracture consolidation despite the established wisdom for allograft use on a later stage. The proper initial open fracture estimation, the right surgical treatment, the surgeon’s experience and a strict patient’s follow up schedule are fundamental for a good final outcome
Early and safe mobilization remains the mainstay of treatment for the intertrochanteric fractures. Many implants have been used but the intramedullary implants seem to provide maximum stability in unstable fractures. The aim of this study was to compare two intramedullary devices which have different philosophy and modes of action.
Between 01.07.2005 to 30.06.2007, 110 patients with trochanteric fractures treated with the intramedullary hip screw (IMHS, Smith & Nephew) nail and 105 with the ENDOVIS (Citieffe) nail. The data recorded were the fracture’s type, preoperative hemoglobin level, pre-fracture walking ability. Postoperatively were recorded the operative time, the level of hemoglobin on the first day, mobility status, complications and 12 months mortality rate. The results were comparable regarding blood loss, operative time, and mortality rate. However, the rehabilitation and functional outcome were superior in the IMHS group. This probably was attributed to the higher number of complications of the ENDOVIS nail.
IMHS is a valuable tool for the treatment of stable intertrochanteric fractures, offering also excellent results in the management of reverse obliquity, comminuted fractures and those with a subtrochanteric extension. Further investigations are necessary to prove which the ideal intramedullary implant is. However, it seems that devices combining the principles of the sliding hip screw with those of an intramedullary nail present safe and accurate fixation, fewer mechanical failures and exceptional functional outcomes
Our objective was to investigate the adequacy of the antegrade intramedullary nailing for the treatment of proximal and distal humeral fractures.
From January 2004 to April 2008, 28 proximal humerus fractures and 9 distal humerus fractures were treated with intramedullary nailing. Mean age of the patients was 69-year-old (39–82). 26 patients were males. All fractures of the first group were treated with closed static intramedullary nailing whereas in the second group closed static intramedullary nailing was achieved in 7 fractures. The clinical and radiological outcomes were evaluated.
All the proximal humerus fracture – but one – obtained bone-union at an average of 3 months (from 2 to 4 months). The mean follow up was 22 months (6–40). Functional outcome measured by Constant score showed 22 patients with an excellent and good result and 6 with a poor result. One case with osteonecrosis of the humeral head was recorded. Malunion of the greater tuberosity was recorded in 7 fractures. Only 5 distal humerus fractures united at an average of 5 months (from 4 to 7 months). Functional outcome measured by Burri – Lob score showed 3 patients with an excellent and good result and 6 with a poor result. Failure of the distal locking was noticed in 5 patients and 3 fractures united in valgus position
The antegrade closed intramedullary nailing is an effective treatment method for the proximal humerus fractures. However the role of the nailing for the distal humerus fractures is humeral nail is effective for the treatment of proximal humeral fractures remains
Percutaneous fixation with iliosacral screws has been shown to be a safe and reproducible method for the management of certain posterior pelvic injuries. However, the method is contraindicated in patients with sacral anatomical variations and dysmorphism. The incidence and the pattern of S1 anatomical variations were evaluated in 61 volunteers (35 women and 26 men) using MRI scans of the sacrum. S1 dimensions (12 parameters) in both the transverse and coronal planes were recorded and evaluated. Individuals were divided in four groups based on the S1 body size and the asymmetry of dimensions on the transverse and coronal planes. In 48 (78.6%) patients, dimensions in both planes were symmetrical despite the varying size of the S1 body. In 9 (14.8%) patients, coronal plane dimensions were disproportionally smaller compared to those of the transverse plane with a varying size of S1 body making effective iliosacral screw insertion a difficult task. In 2 (3.3%) patients there was a combination of large transverse plane and small coronal plane dimensions, with large S1 body size. A preoperative imaging study of S1 body size and coronal plane dimensions and an intraoperative fluoroscopic control of S1 dimensions on the coronal plane are suggested for safe iliosacral screw fixation
Purpose of this study is to compare the reduction of discogenic pain associated with disk herniation in two groups. Group A (31 patients) with lumbago, with/ without sciatica, with no neurologic deficit followed consernative treatment (antiflammatory drugs, physiotherapies) and the group B (31 patients) with the same symptoms submitted in percutaneous disc decompression after six weeks consernative treatment with poor results. Follow up had a period of six months, one year and two years in two groups. All patients in both groups evaluated clinically and the symptoms registrated in special protocol that included pain distribution, sensation, muscle strength and reflections (ahilleus and patellar). All of them submitted in X-ray and MRI so that the two groups have the presuppositions for percutaneous decompression of disc (absense of a free, non-contained or sequestered fragment, remained disc height > 50%, no neurologic deficit, no arthritis in facets). An AVS scale on a questionnaire adapted to Greek population helped assessing pain relief degree, life quality and mobility improvement. The method that we used is t-test for small independent patterns.
We found a statisticasignificant decrease on terms of pain relief, mobility and life improvement during the one and two years follow-up in group B which submitted in percutaneus decompression of intervertebral disks comparetively with A
To estimate the outcomes after posterior dynamic stabilization in situ with Dynesys (Zimmer Spine, Minneapolis, MN) for treatment of symptomatic spinal stenosis and degenerative spondylolisthesis in long-term follow-up.
28 patients(mean age 73 years old) with symptomatic spinal stenosis and spondylolisthesis underwent inter-laminar decompression and stabilization with Dynesys. Patients were evaluated clinically and radiologically after a follow-up from 6 months to 4 years.
Pain on VAS and walking distance improved significantly at less than 2 years and remained unchanged at 4 years follow-up. Radiographically, spondylolisthesis did not progress and the motion segments remained stable. 2 patients showed screw-loosening at 1 year follow-up and underwent revision. Overall, patient satisfaction remained high as 93% and would undergo the same procedure again.
In elderly patients with spinal stenosis and degenerative spondylolisthesis, decompression and dynamic stabilization lead to excellent clinical and radiologic results. It maintains enough stability to prevent progression of spondylolisthesis. Because no bone grafting is necessary, donor site morbidity, which is one of the main drawbacks of fusion is eliminated
Periprosthetic femoral fractures around total knee arthroplasty present a challenge in octogenarians with advanced osteoporosis. We describe a salvage technique combining retrograde intramedullary nailing augmented with polymethylmethacrylate (PMMA) cement in five patients followed up for a median time of 12 months. The nail/cement construct bridges the femoral canal tightly and behaves like a stemmed cemented revision component. All patients had an uncomplicated recovery and returned to their pre-injury functional status within four months. This procedure does not disrupt the soft tissue envelope facilitating periosteal callus formation, is easy to perform and permits immediate full range of movement. When standard retrograde nailing or plating alone is inadequate in maintaining severely osteoporotic fracture reduction in octogenarians unfit for lengthy procedures, nailed cementoplasty is proposed as a salvage procedure.
The aim of the present study was to record the MRI characteristics of the thoracic spine in asymptomatic adult males and their correlation with age and thoracic level.
A cross sectional retrospective study was designed in order to record MRI thoracic spine findings in asymptomatic adult males, 35 to 65 years of age. All study participants were evaluated by MRI. The qualitative and quantitative assessed MRI parameters were as follows: disc degeneration (disk signal intensity), bulging, herniation, disc height, Modic changes, endplate irregularities, osteophytes.
Intervertebral disc signal was decreased more in the lower thoracic spine (T6-T12 level). In addition there was a strong correlation between disc degeneration (disc signal loss) and the age of the study participants. Disc bulging was most frequently observed anteriorly than posteriorly with the prevalence increased caudally. Modic changes were not so frequent and there were most commonly seen in the lower thoracic spine (T11-T12 level). In addition osteophytes were larger anteriorly than posteriorly and their prevalence increased caudally. Endplate irregularities (Schmorl nodes) were more common in the upper endplates and in the lower thoracic spine (T6-T12 level). Finally strong positive correlation was noted between osteophytes, anterior and posterior and disc bulging.
This study documents the mild to moderate grade of degenerative changes especially in the lower thoracic spine (T6-T12 level) of asymptomatic adult males, 35 to 65 years of age
The evaluation of early results of combined percutaneous pedicle screw fixation and kyphoplasty for the management of thoraco-lumbar burst fractures
Between October 2008 and April 2009, 9 patients with thoracolumbar burst fractures underwent percutaneous short-segment pedicle screw fixation and augmentation kyphoplasty with calcium phosphate cement. All patients were selected according to the type of fracture (unstable type A3 fractures based on the Magerl classification) the absence of neurological signs and an intact posterior longitudinal ligament on the pre-operative MRI scan. Patient demographics, co-morbidities and complications were recorded. The main endpoints included Cobb angle correction, vertebral body height restoration and the length of hospital stay.
There were 3 male and 6 female patients with an average age of 43.6 years. The average follow-up was 2.4 months. The mean kyphotic angulation improved from 18.40 pre-operatively to 6, 80 post-operatively. The loss of vertebral body height improved from a mean of 38.7 % pre-operatively to 12.1 % post-operatively. The average duration of surgery was 40 minutes with insignificant blood loss. There were no post-operative complications. The average length of hospital stay was 3.2 days.
The combination of percutaneous short-segment pedicle screw fixation supplemented by balloon kypho-plasty for the management of thoracolumbar burst fractures with no neurological deficit offers correction of the normal thoracolumbar anatomy as well as augmentation of the anterior load-bearing column, using a minimally invasive technique. The early results are promising
Although previous lnks have been made between congenital heart disease (CHD) and scoliosis, the molecular mechanisms involved in this association are poorly understood. During development, it appears that embryos exhibiting spine deformations resulting in scoliosis also suffer from an array of cardiac defects. Additionally, idiopathic scoliosis in patients with CHD is thought to be a response to a physiological phenomenon such as an enlarged size or abnormal thrust of the heart. Despite the fact that molecular omics data have been accumulated that are relevant to these two independent phenotypes, there appears to be a gap in the literature of over two decades on this matter and no clear correlations of the omics data have been provided. To identify genes involved in CHD and scoliosis, we have performed an analysis of genomic annotations, functional genomics data and text mining, and derived an inferred network of 123 human genes and 175 known gene interactions. Of these, 20 genes are unique to CHD, 11 to scoliosis and 5 genes are common to both abnormalities. These genes are known to be involved in molecular signaling cascades that affect the development of the musculo-skeletal system in humans and have been associated with disorders such as the Marfan or CHARGE syndromes. Our analysis sets the basis upon which investigations of this association can be performed at the molecular level, in order to both further understand the pathology and, in the future, develop suitable therapies for CHD/idiopathic scoliosis patients
To study the preliminary clinical results of patients submitted to kyphoplasty with an expandable titanium cage (OsseoFix).
Between 09-2008 and 02-2009 16 patients (6 men, 10 women, total 36 vertebrae) with a mean age of 67 (23 to 81) were submitted to kyphoplasty using a system involving the implantation of an expandable titanium cage (OsseoFix) for the treatment of fractures in the lower thoracic and lumbar spine. Five patients were submitted to kyphoplasty at one level, 4 at two levels, 5 at three levels, and 2 at four levels. Two patients additionally needed a posterior spinal fusion. The underlying causes for the spinal fractures were: secondary osteoporosis (7), recent acute trauma (5), and malignancy (4: 1 Hodgkin lymphoma, 1 Non-Hodgkin lymhoma, 1 metastatic breast cancer, 1 metastatic prostate cancer). In 8 patients biopsy specimens were harvested at the same procedure.
Mean follow-up time was 4 months (2 to 6). No intra-operative complication occurred. No bone cement leakage or pulmonary embolism was observed. The mean pain improvement, as measured with the VAS scale, was 5,12 (7,81 preop – 2,69 postop). The mean vertebral body height restoration was 19,5%, and the kyphotic angle was corrected by a mean of 2,24°.
The main advantage of using an expandable metal cage in kyphoplasty is the improved reduction of the vertebral body compression and the minimal risk of bone cement leakage. Especially in young patients, the maintenance of the reduction could potentially be achieved even without cementation, by the mere support provided by the cage. A longer follow-up time is needed for the safe validation of these preliminary encouraging results
The evaluation of results following posterior decompression and fusion for the management of cervical spondylotic myelopathy
Between July 2006 and May 2008, 68 patients with cervical myelopathy underwent posterior decompression with laminectomies and pedicle screw fixation of the cervical spine. All patients were selected based on the presence of multi-level degenerative disease and the correction of cervical lordosis on the pre-operative dynamic radiographs. Patient demographics, co-morbidities and post-operative complications were recorded and analysed. Functional outcome was assessed by using the Japanese Orthopaedic Association (JOA) score.
There were 37 male and 31 female patients with an average age 67.4 years. The average follow up period was 18 months. The mean pre-operative JOA score was 8.7, whereas the mean post-operative score was 12.1 on the latest follow-up visit. 9 patients had unsatisfactory clinical results and consequently underwent anterior procedures with significant improvement. Complications included 1 epidural haematoma, 2 superficial infections and 4 cases of myofascial pain. In three cases there was mild dysfunction of the C5 nerve root which resolved spontaneously with conservative measures.
In the present series of patients posterior decompression with laminectomies is an effective method for the management of cervical spondylotic myelopathy.
The radiological and biomechanical assessment using cement augmented cannulated pedicle screw (Biomet®, Omega 21®) and the correlation of the cement volume to the pullout strength needed for each screw
Cadaveric vertebrae of different lumbar levels were used. Through cannulated pedicle screw a definite volume of cement was applicated. The bone volume occupied by cement was assessed by means of segmentation after Computer Tomography. Biomechanical Pullout tests and statistical correlation analysis were then performed
The maximum pullout strength was 1361 N and the minimum pullout strength was 172 N (SD 331 N). The maximum cement volume was 5,29 cm3 and the minimum 1,02 cm3 (SD 1,159). The maximum cement diameter was 26,6 cm and the minimum cement diameter was 20,7 cm (SD 1,744). There is statistically significant correlation between the pullout strength and the injected cement volume (p< 0,05).
The cannulated pedicle screw was used for a better fixation in the vertebral body. The cement augmentation with this technique is easier and seems to be safer than cement augmentation of non cannulated screws. Pullout strength of the cannulated screws correlates positively with the cement volume. It is though not influenced either by the total vertebral volume or by the ratio cement volume to vertebral volume or by the maximum diameter of the cement drough
The influence of the intravertebral length of vertebral screws on their pull out strength.
64 Cadaveric vertebrae of different lumbar levels were used. By means of Computer Tomography the length of the screw in the bone was assessed. The ratio screw length in bone to the longest possible screw in bone was built. Biomechanical Pullout tests and statistical correlation analysis were then performed
The maximum pullout strength was 1602 N and the minimum pullout strength was 96,4 N (SD 356,9 N). The maximum ratio of the inserted screw was 95,9% and the minimum was 58,8% (SD 0,7%). There is no statistically significant correlation between the ratio of the inserted screw and the pullout strength needed. Moreover, there is a statistically significant correlation between bone mass density and pullout strength (p< 0,05).
The fixation of pedicle screws is better in a non osteoporotic vertebral body. Pullout strength and bone mass density correlate significantly whereas there is no correlation between the insertion length of the screw and the pullout strength under the condition that the insertion ratio is greater than 58,8 %. Factors such as insertion angle of the screw need to be evaluated, and new techniques for pedicle screw fixation in osteoporotic vertebrae need to be developed
To evaluate our results of treatment of kyphosis following osteoporotic fractures of the last 3 years.
28 women with a mean age of 63,2 years were treated for a painful kyphotic deformity of a mean Cobb angle 76,1°. They all had posterior fusion with pedicular screws and rods enhanced with autologous bone graft as well as allografts. Cement augmentation was used in a number of screws. A cell saver for auto transfusion and continuous neurophysiological monitoring was used intraoperatively in all cases. All patients fitted with a thoracolumbar brace for 3 months.
The postoperative mean Cobb angle was 45,2° (40,6% improvement). Pain questionnaires at a mean postoperative follow up of 16 months showed excellent results in 10 patients (35,71%), good in 8 patients (28,57%), satisfactory in 6 patients (21,42%) and poor results in 4 patients (14,28%). All patients were satisfied with the cosmetic result. 2 patients presented a postoperative infection that was treated with debridement and antibiotics.
Kyphotic deformity following osteoporotic fractures may treated satisfactory with rods and pedicular screws with cement augmentation
We estimated the long term results of the different methods in chirurgical treatment of lumbar disk herniation in consideration with the presence or absence of degenerative changes and the grade in witch these factors influence the result of this kind of treatment.
Seventy eight patents with lumbar disk herniation have been submitted in partial discectomy. The men were 42 and 36 women. The patients were separated in tow groups. In the first group [48 patients, 31 of them (A1) without degenerative changes, while the 17 (A2) with degenerative changes], was applied macrodiscectomi. In the second group [30 patients, 18 of them (B1) without degenerative changes and the 12 (B2) with changes], was applied microdiscectomi with use of magnifying lenses. The mean age during operation was 44 years (18–67) and 38 years (24–62) respectively for the tow groups, and the mean time of follow-up was 7 years and 8 months (18 months-13 years). For all patients, the operation was executed from the same surgeon. The elements that were evaluated were the Visual analog scale (VAS, O-10), the Oswestry Disability Index (ODI), as well as the complications during and after the operation and the cases that required a reoperation.
In the first group VAS score was improved from 9.1 to 3.1 and the ODI score was improved from 86% to 24.2%. In the second group VAS score was improved from 9 to 2.6 and the ODI score was improved from 84.2% to 19.2%. From all patients, subgroup B1 without degenerative changes, which was submitted in microdiscectomy presented the biggest improvement. We have had to reoperate 6 patients (7.8%).
In cases of lumbar disk hernia both methods are appropriate and lead to a considerable improvement of the symptoms. Degenerative changes of the lumbar spine is a factor that leads in less satisfactory results
It was previously postulated that the IV disc wedging is a significant progressive factor for mild IS curves. The present report introduces an innovative comprehensive model of IS curves progression based on intervertebral disc (IV) diurnal variation and the subsequent patho-biomechanics of the deforming “three joint complex”, where vertebral growth occurs.
Throughout day and night, due to sustained loading and unloading, the scoliotic wedged IV disc expels fluid and imbibes it more convex-wise. The convex side of the IV sustains a greater amount of cyclic expansion than the concave side. Consequently the imposed, convex-wise, asymmetrical concentrated cyclical loads to the adjacent immature vertebral end plates and posterior elements of the spine lead to asymmetrical vertebral growth. More specifically the loading on the two facet-joins asymmetrically increases during the day, as the wedged IV space narrows due to expelled water and it asymmetrically decreases during the night, as the IV space swells due to imbibed water.
This 24 hour period cyclic asymmetric loading leads both to asymmetric growth of the end plates and wedging of the vertebral bodies, and to similarly asymmetric growth of the pedicles and arches posteriorly as an effect of Hüeter-Volkmann law. This model explains the well described anatomical findings of the more elongated pedicles and the larger facet joints in the convex side than in the concave in scoliotic spines
Degenerative lumbar spinal stenosis is one of the most frequent surgical indications of spinal surgery in the elderly patient group. Because of the progression of the disease and neurologic deficiencies, patients’ quality of life is affected. We aimed to evaluate the postoperative quality of life of the surgically treated spinal stenotic patients.
Between 1998 and 2009, 38 patients, who were surgically decompressed and enstrumentated in our clinic were included to the study. The patients were preoperatively and postoperatively evaluated with Visual Analogue (Scale (VAS) and Japanese Orthopaedics Association (JOA) criterias. The same patient group were re-evaluated on the postoperative 6th month with Hamilton anxiety and depression scale, on the 12th month with short form-36 and Oswestry pain scoring scales to measure the quality of life.
Mean age of 38 patients (31 female, 7 male) was 59.6 (range 44 to 82). Mean preoperative VAS was 7.97 and postoperative VAS was 2.28. The pain decreased 56.9%. According to JOA criterias, in 3 patients (7.89%) no recovery, in 13 patients (34.2%) less than 50% recovery and in 22 patients (57.8%) more than 50% recovery was obtained. On the 6th month, according to Hamilton anxiety and depression scale, in 12 patients anxiety and in 3 of these patients depression which needs treatment was observed. The pain of all the patients with anxiety recovered meaningfully (42.3%) but according to JOA, less than 50% recovery could be obtained.
Surgically treated spinal stenosis patients improved clinically and radiologically and this affected the patients’ quality of life positively
Melatonin’s concentration is high in early childhood and declines gradually thereafter. In the elderly serum melatonin levels are very low. Melatonin, the “light of night”, among other functions is involved in human sexual maturation and in osteogenesis.
Hormesis is the response of cells or organisms to an exogenous (eg drug or toxin) or intrinsic factors (eg hormone), where the factor induces stimulatory or beneficial effects at low doses and inhibitory or adverse effects at high doses [bimodal dose-response] or vice versa.
At the age around 10 years, when idiopathic scoliosis may appear, the circulating melatonin level is about 120 pg/ml – positive hormesis for menses – and menarche appears. Melatonin deficiency may result in a delay of the age at menarche and consequently the girl is susceptible to scoliosis. In these terms melatonin could be certainly involved in the scoliosis pathogenesis. Around the age of 45 years when the circulating melatonin levels are about 20 pg/ml – negative hormesis for menses, menopause starts and the woman has an increased risk for osteoporosis and fractures.
It is documented the bone-protecting effect of melatonin in ovariectomized rats which can depend in part on the free radical scavenging properties of melatonin. Additionally, melatonin may impair development of osteopenia associated with senescence by improving non-rapid eye movement sleep and restoring GH secretion. Whether modulation of melatonin blood levels can be used as a novel mode of therapy for scoliosis and augmenting bone mass in diseases deserves to be studied
Although pedicle screw instrumentation for the treatment of idiopathic scoliosis is very popular, hybrid constructs remain a safe and effective method of scoliotic curve correction. This retrospective study was undertaken to assess the outcomes of hybrid instrumentation in the treatment of idiopathic scoliosis.
Forty three children underwent surgical correction for idiopathic scoliosis. Patients were evaluated at a minimum 2-year follow-up (range 2–9 years). Clinical and radiographic assessment was performed for all patients preoperatively, immediately postoperatively, one year after surgery and at the final follow up. Radiographic parameters assessed included Cobb’s angle, coronal balance, translation of the apex vertebra, kyphosis, lordosis, angle in the T10 – L2 region and sagittal balance. Idiopathic scoliosis was classified according to the King classification system. All patients underwent posterior spinal fusion using hybrid instrumentation while 6 received, prior to the posterior fusion, anterior thoracic discectomies.
Postoperatively overall Cobb’s angle correction was 59.5%. At the final follow-up an average loss of the correction of 9.5% was recorded. Nevertheless, there was an overall correction of the translation of the apex vertebra and a satisfactory coronal balance improvement at the final follow up compared to the immediate postoperative follow-up. Although a trend toward improved sagittal balance was noted, it was not statistically significant. The surgical complications included 2 cases of deep wound infection. In addition one patient required revision and a longer fusion distally.
Operative treatment of adolescent idiopathic scoliosis with hybrid instrumentation yields satisfactory clinical and radiological results. Therefore, it can be considered as a safe and effective method of treatment of adolescent spinal deformity
The documentation of the results of combined anterior -posterior approach in the treatment of spinal tumors in our department.
A total of 28 patients (16 men – 12 women) aged 15 to 75 year old (mean age = 54 years) were treated. Of those 7 presented with a benign primary tumor and 21 with malignancies of which 15 were metastatic. 16 patients had a neurologic deficit but met the international criteria for surgical intervention. The staging of the tumors and their postoperative care was undertaken by a tumor centre. All patients underwent posterior decompression with laminectomy, resection of all posterior elements including part of the pedicle, excision of the tumor and posterior stabilization. This was followed at the same operative session by an anterior approach (transthoracic, transperitoneal or anterior cervical) corpectomy of the affected vertebrae and implantation of interbody cages secured with an anterior plate and screws in the healthy vertebrae.
7 patients improved neurologically following the operation while 9 had no change of their clinical condition. Perioperative complications were recorded in 5 patients. In 3 cases a dural tear was dealt with direct closure and 3 infections had to have surgical debridement at another stage and antimicrobial therapy.
The treatment of spinal tumors with combined anterior-posterior approach in one session for a radical excision of the tumor is a demanding procedure
The aim of school screening is to identify most or all the individuals with unrecognized idiopathic scoliosis (IS) at an early stage when a less invasive treatment is more effective. The present study summarises the contribution of school screening in research of IS epidemiology, natural history and aetiology. In addition, school screening is a unique tool for research of IS in humans, as in most published articles, all aetiopathogenetic factors are studied in animals and not in humans.
Such contribution is beyond the original aim of school screening but is very important to expand our knowledge and adequately understand the pathogenesis of IS. The role of biological factors such as the menarche, the lateralization of the brain, the handedness, the thoracic cage, the intervertebral disc, the melatonin secretion, as well as the role of environmental factors such as the light and the impact of the geographical latitude in IS prevalence were studied in children referred from school screening. The present study provides evidence to support that school screening programs should be continued not only for early detection of IS but also as a basis for epidemiological surveys until we learn much more about the aetiology of IS
Aim of our study was the investigation and the cross-correlation of various neurologic scales to estimate, comparatively with the functional results of patients after damage of spinal cord injuries.
Between 1989 – 2005, 115 patients were submitted in stabilization of Lower Cervical Spine that was judged unstable.
The neurologic situation was certified with the scales: Frankel, ASIA motor score, NASCIS motor score, FIM scale, and MBI scale.
In the protocol took part the 94 patients for that existed in neurologic details and long follow-up for at least two years.
From the study of course of scores of all scales was not found statistically important difference between ASIA, NASCIS and other motor scales. However 12 patients with important improvement of mobility at ASIA motor score and NASCIS motor score they have not difference in Frankel scale, despite the make that the MRP (Motor Percentage Recovery) was improved: 21.5%
Also 8 patients with relatively big improvement in their total scores did not have corresponding functional improvement (FIM scale, and [MBI] scale)
A lot of neurologic methods – scales were used and are used today. However for the essential and modern follow-up of patients with spinal cord injuries, it needs certification with a scale of classic team of (measurement of mobility) and a scale of functional faculties of the patient
This paper evaluates severe normal trunk asymmetry (TA) by higher and lower body mass index (BMI) values in 5953 adolescents age 11–17 years (boys 2939, girls 3014) whilst standing forward bending (FB) and sitting FB during screening for scoliosis. TA was measured as angle of trunk inclinations (ATIs) across the back (thoracic, thoracolumbar and lumbar) with abnormality defined as 2 standard deviations or more. The findings for sitting FB position are reported because the readings express TA free from any leg-length inequality. Relatively lower BMIs are associated statistically with
excess of abnormal TAs, and later menarche.
BMI is known to be linked to puberty timing and energy balance but not to TAs in healthy students. Similar to girls with adolescent idiopathic scoliosis, we suggest that severe TA is caused by a genetically-determined selectively increased hypothalamic sensitivity to leptin with asymmetry as an adverse hormetic response, exacerbated by presumed lower circulating leptin levels associated with relatively lower BMIs. The asymmetry is expressed bilaterally via the sympathetic nervous system to produce left-right asymmetry in ribs and/or vertebrae leading to severe TA when beyond the capacity of postural mechanisms of the somatic nervous system to control the shape distortion of the trunk
Since the commencement of the Neuromuscular-Unit in the Children’s-Hospital “Agia Sofia”, from December 2002 until December 2008, 306 patients were examined suffering from different neuromuscular diseases (ND). In the present study we examined
the frequency of spine deformities, the management in correlation with the poor general health of these patients, analyzing the most frequent presenting disease, that is Duchenne’s-muscular-dystrophy, cases of surgical management of our Unit are presented.
From the analysis of our material we found that 152 patients were suffering from Duchenne’s-Becker muscular-dystrophy, 59 patients from spinal-muscular-atrophy I-III, 13 patients from fascioscapulohumeral muscular-dystrophy, 15 patients from hereditary motorsensory-neuropathies, 5 patients from Friedreich’s Ataxia and 62 patients from different types of dystrophinopathies–myopathies. The ages of the patients varied between 8 months and 37 years.
From the total, 89% of the patients above 10 years presented with spine deformities. Most of them were managed with wheelchairseating modifications and 33 patients were fitted with braces in an attempt to slow curve progression. Surgically were managed 24 patients with spine arthrodesis, 5 of them abroad (USA-Eng-land-France). The older patients (> 17 years wheelchair-bound) were frequently, because of impaired general health, not suitable candidates for surgery.
Pulmonary function was examined in 84 patients suffering from Duchenne’s muscular dystrophy. The crucial age, were pulmonary function has fallen dramatically (FVC< 40%), was between ages 12–15 years.
In conclusion spine deformities are very common in patients suffering from neuromuscular diseases. Because of the rapid deterioration of the general health of these patients spine arthrodesis should be performed early, in the patients severely affected, between ages 12–15 years
Whiplash vertigo syndrome is often seen in victims of rear-end vehicle collisions. These patients commonly complain of headache, vertigo, tinnitus, poor concentration, irritability, and sensitivity to noise and light.
Sixteen patients (medium age, 39,5 years) that they refered in orthopaedic examination because of long-lasting subjective complaints after cervical spine injury underwent clinical, laboratorial and psychometric examinations. The mean posttraumatic interval was 43 months. Ten patients were injured in road accidents, 5 during sports and one at work, all with mechanism trial of whip. Each patient was evaluated with otorhinolaryngologic examination, audiometry tests, CT: petrus – internal auditory meatus and cerebellopontine corner. Also each patient was evaluated with neurologic examination, psychological well-being scale (sf-36), and personality profile scale.
None of the patients had neurologic symptoms, and no lesions of the cervical spine were identified. All the patients had negative clinical, radiological and standard laboratorial control, but may be is a critical point that the eleven of these patients had pathologic OGTT (Oral Glucose Tolerance Test). Also did not exist differentiations from the mean values in psychological well-being scale (SF-36), and personality profile scale of healthy population. Test results were unrelated to the length of the post-traumatic interval. However, 2 distinct syndromes were identified. Ten patients had cervicoencephalic whiplash type syndrome (CES), characterized by headache, vertigo, tinnitus poor concentration, and disturbed adaptation to light intensity. Six patients had the lower cervical spine whiplash type syndrome (LCSS), characterized by vertigo, tinnitus cervical and cervicobrachial pain.
The verification of Whiplash Vertigo syndrome require more objective clinical means. This article proposes that exists an organic base for the syndrome, but does not promote that whiplash injury certainly cause it
Acute fractures of the humeral shaft are usually managed conservatively. The rate of union is high, whereas that of nonunion ranges from 1 – 6%. Various risk factors for nonunion have been identified, including the following: open fracture, mid shaft fracture, transverse or short-oblique fracture, comminuted fracture, unstable fixation, fracture gap.
This paper evaluates the results of treatment of humeral shaft fracture by open reduction and internal fixation with DCP, supplemented with cancelous bone graft but not in all cases.
One hundred and five cases of nonunion of a humeral shaft fracture between 1988 and 2006 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average of 46.2 years (range, 17 – 81 years). Sixty seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixaztion with DCP and cancelous bone graft. The mean follow up period was 20 months (range, 14 – 28 months).
All nonunion fractures united within an average of 16 weeks (range 10–26 weeks).
Complications included 4 patients with temporary radial nerve palsies, and 3 patients with wound infections. At the final follow-up shoulder and elbow functions of the operated limbs were all satisfactory.
Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture
The presentation of results of this comparative study on the various methods of treatment for Transtrochanteric fractures.
From 2006 to 2008 we treated 272 Transtrochanteric fractures, in 75 with DHS, 116 with G3-nail (STRIKER) and 91 with F-nail (ARITI) where antjrotation screw was applied in the 37 (type F) while in the remained 54 was not applied (type G). We compared the duration of surgery, the need for transfusion, the post surgical difference of Hb, the starting day for weight bearing on the fractured limp, the days of hospitalisation and the complications between the different methods.
The patients were separated in 4 groups regarding the method of treatment (A: DHS, B: G3-nail, C: F-nail type F and D: F-nail type G). They did not differ statistically significant regarding age, sex as well as the time of the surgery from the admission. There were no difference in the duration of surgery, the need for transfusion and changes in Hb and the days of hospitalisation. Difference not statistically significant existed in the starting day for weight bearing on the fractured limp (A:3.1, B:2.5, C:2.9, D:3.0). Regarding complications D group had an incident of broken peripheral screw and C group one of broken nail after fall of the patient.
No method of treatment seams to be superior regarding incidents during hospitalisation. More data are expected to compare these methods on the issues of rehabilitation, complications and mortality
Is to analyze the preliminary results of surgical treatment of hip fractures in regard to the time of the intervention from the admission.
In our department we treated 383 hip fractures, 272 Transtrochanteric and 111 IC-NOF fractures, from August 2006 to August 2008. The patients were split in 2 groups regarding the day of the surgery from the admission. In the group A were included patients with immediate surgical treatment (in the 1st 24 hours) and in group B patients who had there surgery after the 1st 24-hours. We evaluated the difference in Hb between the admission and the 1st post surgical day, the need for transfusion, the duration of hospitalisation and the complications.
The two groups did not differ statistically considering demographic details. Also there were no differences in regard of the change of Hb and the need for blood transfusion. There was statistically significant difference in the duration of hospitalization (A: 6.5-B: 10.3) as well as and in complications. Post surgical OPS 15 in group A and 56 in group B, urine infection 1 in A and 16 in B, respiratory infection 1 in A and 11 in B. The A group had 1 case with cardiac arrest and 1 AMI. Finally the B group had 5 cases with arrhythmia, 1 with PE and 3 with CA. Conclusions: It appears that the immediate surgical intervention of patients with hip fracture has positive effect in the duration of hospitalization, morbidity and mortality
The SRS-22 is a valid instrument for the assessment of the health related quality of life of patients with Idiopathic scoliosis. The purpose of this study is to evaluate the reliability and validity of the adapted Greek version of the refined Scoliosis Research Society-22 Questionnaire.
Following the steps of cross – cultural the adapted Greek version of the SRS-22 questionnaire and a validated Greek version of the SF-36 questionnaire were mailed to 68 patients treated surgically for Idiopathic Scoliosis with a mean age at the time of operation 16.2 years and a mean age at the time of evaluation 21.2 years respectively. A 2nd set of questionnaires was mailed in 30 patients within 30 days from the 1st set. Reliability assessment was determined by estimating Cronbach’s a and intraclass correlation coefficient (ICC) respectively. Concurrent validity was evaluated by comparing SRS-22 domains with relevant domains in the SF-36 questionnaire using Pearson’s Correlation Coefficient (r).
The calculated Cronbach’s a of internal consistency for three of the corresponding domains (pain 0.85; mental health 0.87; self image 0.83) were very satisfactory and for two domains (function/activity 0.72 and satisfaction 0.67) were good. The ICC of all domains of SRS-22 questionnaire was high (ICC> 0.70). Considering concurrent validity all correlations demonstrated high correlation coefficient.
The adapted Greek version of the SRS-22 questionnaire is valid and reliable and can be used for the assessment of the outcome of the treatment of the Greek speaking patients with idiopathic scoliosis
We present the results of the use of a functional brace (Sarmiento) for the treatment of diaphyseal humeral fractures.
576 patients with humeral fractures (AO classification A1, 2, 3 and B1, 2) were treated in the period from 1984 to 2009. None of them had neurovascular damage.
Initially the patients were treated with a U-shape slab or a “Velpeau” bandage. After three weeks The Sarmiento brace was applied, provided that the reduction was acceptable (anterior angulation < 20°, varus deformity < 30°, shortening < 3cm)
RESULTS97.5% of the fractures examined united (562/576)
Duration of bone healing 8–11 weeks Successfully used for treatment of compound fractures (Gustilo I) The Sarmiento Brace is to be used only in patients who thin, ambulatory and with full range of movement of the shoulder joint. The majority of the diaphyseal humeral fractures is successfully treated conservatively
To present the results of femoral fracture treatment with long cephalomedullary nails.
We used long cephalomedullary nails for the treatment of certain femoral fractures. There were 30 fractures in 30 patients (12 male – 18 female), age from 32 to 87 years old, operated in our department in a 9 year period (1998 to 2007). The fractures were classified as follows: combined fractures 10 (Ia: 4, IIa:3, IIb: 3 according to Lampiris’ classification), subtrochanteric fractures 18 (IIa:2, IIb:1, IIIa:3, IIIb:7, IV:3, V:2 according to Seinsheimer’s classification), periprothetic fractures 2 (previous nailing with short g-nail). One fracture was open grade II according to Gustilo’s classification and a pathologic fracture (metastatic Ca).
We used 13 long trochanteric g-nails, 14 long gamma-3 nails and 3 long Super nails.
All nails were statically locked.
The patients were allowed partial weight bearing since 2nd post-op day. Average hospital stay: 8 days. Patient X-rays were reviewed monthly until fracture healing. In one case, the nail was dynamised in the 2nd post op month.
All fractures healed in 3–5 months (average: 17 weeks). There was no functional deficit.
The treatment of combined and subtrochanteric femoral fractures with long cephalomedullary nails is a safe and reliable choice.
It ensures early mobilization and excellent functional outcome
We reviewed in retrospect the preliminary results of ilizarov type fixator for the treatment of severely comminuted calcaneal fractures.
Between February 2006 and December 2008 we dealt with six severely comminuted calcaneal fractures in six patients. Two of which were open type Gustillo IIIa. Mean age was 43 years old(28–56 years old) two of which were female and four male. Preoperatively all fractures were checked by x-ray and computed tomography and were all rated as Sanders type IV. The open fractures were treated within 6 hours and the closed ones the following day. After the positioning of the ilizarov tibial and foot frame, an indirect reduction was achieved using the Ilizarov olive wires.
Mean follow up was 20 months (9 to 36 months). Results were rated as very good in two patients (33%), good in three patients (50%) and fair in one (17%).
So far no re-operation has been required and four of the patients are back to work.
We conclude that the ilizarov system, even with indirect reduction can give very promising results in severely comminuted and complex calcaneal fractures whereas internal fixation has questionable success and many complications
The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction.
Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the EuroQol-5D questionnaire were documented over a median period of follow-up of 40 months (12–206).
Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5 years (16–80). Half of them were posterior-wall fractures, 21.6% bicolumn, 14.7 %posterior-wall and column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases.
Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome
Anterior wall and/or column acetabular fractures (AW/ C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre.
Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64).
15 patients (10 males) met the inclusion criteria (mean age 55.5 years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14 days(10–21 days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7 days), and 21 days(14–37 days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis.
Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favourable outcome resulting in early mobilization with limited patient morbidity
The study of effectiveness of PHILOS plate in the internal osteosynthesis of humeral head fractures.
Since 2006 23 patients with 24 humeral head fractures ere treated in our clinic. 10 of them were men (43,48%) and 13 women (56,52%). The average age was 50,4 years (range 16–89 years). Fractures of the surgical neck of humerus were 8 of these (33,33%), 12 were 3 parts fractures according to Neer classification (50%) and finally in 3 cases there was a 4 part fracture (16,66%). Shoulder of dominant upper limb was injured in most of the cases (68%).
19 patients (82,6%) were examined periodically in an average follow-up period of 19 months (range 13–26 months). All the fractures were healed. In 4 cases (16,66%) insufficient reduction was detected postoperatively. Constant score was calculated 12 months post-operatively up to 82,05 by mean (range 62–100). Differentiation was observed between the patients of age less than 60 years (12 patients with average constant score 91,25 with range from 78 until 100) and these of age of 60 years or more (7 patients with average constant score 71,43 with range from 62 until 81).
Internal osteosynthesis humeral head fractures with PHILOS plate is a reliable method of treatment not only for simple head fractures but also for them of 3 or even 4 parts, without complications and with very good functional results
Pelvic x-ray is a routine part of the primary survey of Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard in the diagnosis of pelvic fractures. This study aims to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis, in favour of later pelvic CT scan.
A retrospective analysis of polytraumatized patients in our emergency room was conducted between 2005 and 2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and clinically stable pelvis. We excluded patients requiring immediate intervention.
We reviewed the records of 452 patients. 91 fulfilled inclusion criteria (56% male, mean age 45 years). 43% were road traffic accidents and 47% falls. In 68/91 (75%) patients, both pelvic x-ray and CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None false positive pelvic x-ray was detected. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).
In hemodynamically stable patients with clinically stable pelvis, x-ray sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination. The results support the safety and utility of our modified ATLS algorithm
Tibial plateau fractures are common fractures which most of the times require surgery. Recovery can take several months. The aim of our study was to estimate the effect of tibial plateau fractures in quality of life of patients one year after the surgery.
During the time period 2004–2007 we treated 86 patients, with a mean age of 44 years (23–68). Fracture classification was according to Schatzker, hence, there were 9 patients with type I, 14 with type II, 20 with type III, 22 with type IV, 13 with type V and 8 with type VI. In 45 (52.3%) patients the articular surface was reduced with limited use of internal fixation and bone grafts, whereas the remaining patients had syndesmotaxis performed. In all patients stabilization was achieved with hybrid external fixators. Sixty four patients returned in one year postoperative for the study, at which time they completed the Short Form-36 (SF-36) general health surveys.
Compared to the standardized SF-36 categorical and aggregate scores there was no statistically significant difference between the healthy age-matched population and young patients with Schatzker I, II, III and IV fractures. But in 16 patients over 40 years old with Schatzker V and VI fracture, SF-36 score was lower in all categories, despite that 13 of them had full or partial return to pre-injury levels of functioning
We conclude that the age of patients and the complexity of tibial plateau fractures influence the quality of their life one year post-operative
We treated 60 patients with type III Pilon fractures (Ruedi and Allgower Classification) between 1996 and 2005. The fractures were distracted and then fixed with an Ilizarov circular ring fixator, without the use of open surgery. No internal fixation was used for the tibia or fibula. No bone grafting was performed.
The average time from injury to frame application was four days. The patient stayed ib frame for a mean time of 15 weeks. No second operative procedure was needed. All cases united in good alignment.
The patients were reviewed from ten years to nine months after frame removal. Four separate evaluations were performed (functional, objective, radiological and an SF-36). The function and the range of movement were better than the radiological assessment suggested.
This method of treatment gives better results with fewer complications than open surgery with internal fixation
We report our experience in treating victims of the recent Earthquake Disaster in Pakistan. Our experience was based on 2 humanitarian missions to Islamabad. First in October 2005, 16 days after the earthquake and the second in January 2006, three months later. The mission consisted of a team of orthopaedic and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov External Fixators (IEF). We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad.
During the first visit we treated 12 injured limbs in 11 patients. 7 of these were children (ages 6 – 14). All the cases were complex and severe multifragmentary fractures associated with crush injuries. All of the fractures involved the tibia, which were treated with IEF.
Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening of the limb segment. After stabilization, the plastic surgeons provided soft tissue cover.
During the second, we reviewed all patients treated during our first mission. In addition we treated 13 new patients [Table 3] with complex non – unions. Eight out of 13 non-unions were deemed to be infected. All patients had previous treatment with monolateral fixators (AO type) as well as soft tissue coverage procedures, except one patient who had had a circular fixator (Ilizarov) applied by another team. All these patients had revision surgery with circular frames
To evaluate the operative treatment of Blount disease using the TSF external fixator and to evaluate the system.
During January 2004 and August 2008, 8 males and 2 females with Blount disease (16 limbs) were treated using TSF system. For the radiological assessment we obtained standard long-leg standing radiographs and we measured the anatomic medial proximal tibial angle (aMPTA), the diaphyseal-metaphyseal tibial angle (Drennan), and the femoro-tibial angle.
The mean follow-up was 29 months (15 to 45). No patient had pain around the knee, medial or lateral instability. The range motion of the knee immediately after frame removal was 10° to 90° of flexion in two patients while in the other it was from 0° to 110°. The mean leg-length discrepancy was reduced postoperatively from mean 1,9 cm (1,7–3,2) to 0,9 cm (0− +1,5). The aMPTA angle increased from mean 73° (59°– 83°) to 94° (107°–90°), Drennan angle from 17° (14°–22°) to 3° (0°–7°), and femoro-tibial angle from 17° (10°–30°) varus to 7° (2°–10°) valgus. The frame was removed at mean 9 weeks (7–14). Two patients had delayed union, two presented with loss of correction (due to dissociation of struts and secondary to medial physeal bar), two patients had pin track infection. No neurologic complications were referred.
Accurate corrections of multiplanar deformities as varus, internal rotation and shortening of the limb that coexist in Blount disease may be accomplished using TSF system
The definite treatment of closed or compound fractures of the long bones in polytrauma patients, who had been treated by bridging external fixation during the damage control phase is challenging, especially if it is performed delayed when the risk of infection is increased. In such cases the use of ring type external fixators seems to be a good choice.
During the last two years (mean FU 16 months), 22 Polytrauma patients with fractures of the long bones were treated with the use of ring type external fixators as the definite method. Multiplanar reduction at the fracture site could be achieved with this method. 14 patients had a high ISS score in the emergency department. 14 had sustained fracture of the femur while the remaining 8 patients had suffered a tibial fracture.
In all but one patient the bone union was achieved in a mean time of 19 months. In a patient with a tibial fracture where a bone defect the bone union was accomplished with bone grafting and the use of growth factors. No complications or loss of reduction were seen, while local signs of infection at the site of half pins insertion in three patients were subsided with administration of local antibiotics.
The definite treatment with ring type external fixators of long bone fractures in polytrauma patients seems to be a very good choice. Bone consolidation with no evidence of bone infection was achieved in all patients. while low rate of complications were seen
Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intraarticular calcaneal fractures.
In a period of 3 years, 16 patients with 18 intraarticular fractures of calcaneus (eleven type III and seven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twelve patients were male and four female. The average age was 42 years (range 25 – 63 years). Three fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamento-taxis, and closed reduction of the subtalar joint were performed in 14 cases. In 4 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients.
The mean follow-up period was 1,5 years (range 1 – 3 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 79,8 (range 72 – 90). Six patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. One of the patients complained of heel pad pain. Nine (6.25%) grade II pin tract infections were detected from a total of 144 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done.
Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intraarticular calcaneal fractures
The purpose of this study is to classify the pitfalls, obstacles and complications that occur during distraction histogenesis and also to evaluate the risk factors likely to lead to these problems.
In this study we have retrospectively and prospectively studied the difficulties occurring during distraction histogenesis since 2003. We studied 74 patients (mean age 19,2 years, age range 11–60 yrs) whose 97 limbs segments were lengthened. 21 patients underwent angular correction, 42 patients limb lengthening, 17 patients both angular correction and limb lengthening and 14 non-union correction. In 46 cases, we used the Ilizarov fixator, in 38 the Taylor Spatial Frame and in 10 cases the monolateral external fix-ator Orthofix LRS. Difficulties that occured during limb lengthening were subclassified into pitfalls, obstacles, and complications. For all cases we have recorded the time of appearance of all these difficulties and have associated them with the severity of the initial deformity.
The total number of difficulties in distraction histogenesis was 20%. The number of presenting problems was estimated 5.4% and involved knee subluxation, pin breakage and malalignments. Obstacles presented in 9.5% and included cases with poor bone regeneration, peroneal nerve palsy, premature consolidation and heel cord lengthening. Finally complications were noted in 5.4% of the cases. These consisted of infection, fracture, non-union and loss of range of knee motion.
The problems, obstacles and complications that occur during distraction histogenesis can all impact on the optimal therapeutic target. Extensive surgical experience, and optimal pre-operative planning in conjunction with the type of the original deformity may all contribute in minimising these difficulties
In this study we aimed to identify infection rates in arhroplasty patients which were operated bilaterally with single anesthesia and to discuss the reasons of infections in these patients.
We evaluated 163 knees of 82 patients (Follow up: 12 to 60 months). Mean age was 66.8. Right knees were operated first followed by left knees. 16 of the patients had diabetes mellitus, 4 of them had rheumatoid arthritis, and 1 of them had systemic lupus erithmatosus. All patients were evaluated according to operation time, wound healing, laboratory findings, clinical presentation and X rays. We had 7 infections (6 deep, 1 superficial infection). When we evaluate operation times, no statistically significant difference was obtained between the infected knees and non infected knees (p=0,275). Two of the infected knees had urinary track infection and dental abscess after the opertaion. Five of seven infected knees were left sided. Six of the infected knees were treated with debridement irrigation and antibiotics successfully. But one had two staged revision.
Bilaterally operated knee arthroplasty increases operation time significantly. This increase of operation time decreases the sterility of surgical field, and may increase infection rates. The increased infection rates in left sided knees may explain this. Postoperative dental and urinary tract infections may also increase infection rates. There is no correlation between infection and other systemic diseases like diabetes mellitus, systemic lupus erithematosus or rheumatoid arthritis
To determine the effectiveness of Ilizarov external fixator in the treatment of complex fractures of the tibial plateau.
From July 2006 to April 2009, we treated 10 patients with the Ilizarov fixator. Six men and four women ranging in age from 31 to 70 (mean age 56.3 years) were evaluated. All patients were preoperatively evaluated with Computed Tomography scans for better preoperative planning. Eight cases had fractures type VI according to Schatzker Classification and 2 cases type V.
In all patients fixation included pushing olive wires or simple wires and 2 to 4 frames. In 4 patients minimal invasive open reduction was performed with use of bone allograft. In 2 fractures, we combined the treatment with minimal internal fixation
There was no major complication trans- or postoperatively. The mean follow-up was 16 months (4–30). The mean hospitalization was 8 days and there were no cases of blood transfusion. Mobilization with no weight-bearing was immediately allowed, with partial weight bearing after 2 months and full weight bearing after 3 months. Three patients had minor pin tract complications. The average duration of external fixation was 120 days. All the fractures united and patients achieved full extension with more than 110 degrees of flexion.
Ilizarov circular fixation is an alternative method of treatment for these fractures when internal fixation is contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution
Advance medial pivot total knee replacement has been designed to reflect contemporary data regarding knee kinematics. We report the clinical outcome of 284 replacements in 225 consecutive patients. All patients were prospectively followed for a mean of 7.6 years (5 to 9) using validated rating systems, both objective and subjective.
All patients showed a statistically significant improvement (p~0.01) on the Knee Society clinical rating system, WOMAC questionnaire, SF-12 questionnaire, and Oxford knee score. The majority of patients (92%) were able to perform age appropriate activities with a mean knee flexion of 117° (85 to 135). Survival analysis showed a cumulative success rate of 99.1% (95% CI, 86.6 to 100) at five years and 97.5% (95% CI, 65.6 to 100) at seven years. Two (0.7%) replacements were revised due to aseptic loosening, one (0.35%) due to infection and one (0.35%) due to a traumatic dislocation. In only two (0.7%) replacements, progressive radiological lucent lines (combined with beta angle of 85°) were observed
Aggrecan is a major constituent of joint cartilage. A prominent feature in joint disease is loss of Aggrecan. The aim of this study was to assess the relation between the concentration of Aggrecan in the synovial fluid of knee joint and this of the peripheral blood in patients suffering from end stage knee osteoarthritis
37 postmenopausal women suffering from end-stage idiopathic knee osteoarthritis, scheduled to undergo Total Knee Arthroplasty (TKA), were enrolled in this study. Their mean age was 69.8 years (range: 49–81 years). The serum levels of Aggrecan were evaluated one day pre-operatively whether synovial fluid levels from fluid taken during the operation day.
Patients suffering from any endocrine disorder, rheumatoid or other secondary arthritis or any other disease that could interfere with the cartilage homeostasis were excluded from the study. Concentrations of aggrecan turnover were measured with appropriate assays.
Moderate correlation between serum and synovial fluid concentrations of aggrecan was revealed (r= 0, 337, p=0,197)
Serum levels of aggrecan may be related to the synovial concentration of Aggrecan in patients suffering from end stage knee osteoarthritis. The possible significant relationship between these markers may be of value in assessing cartilage degradation in patients with involvement of a single joint with a blood sample. However this correlation needs to be further investigated
The osteonecrosis of the medial femoral condyle, depending on the area occupied, causes pain and may progress into osteoarthritis. For the management of osteonecrosis numerous treatment methods have been described, as conservative, drilling, osteotomy and others.
The aim of our study is to evaluate the results of management of knee osteonecrosis with unicompartmental arthroplasty.
We studied 16 knees in 15 patients (all women) with osteonecrosis of the medial femoral condyle. The size of osteonecrosis was greater than 3.5 cm, as revealed by MRI. The mean age of patients was 72 years (range 64–80 years). The time elapsed from the onset of symptoms to surgical treatment ranged from 3 to 10 months.
All patients were followed clinically and by X-ray 1 to 6 years post-operatively and scored with Knee Society Score. The result in 14 patients was excellent and in 1 was good.
In conclusion, unicompartmental knee arthroplasty is a satisfactory method of treatment of osteonecrosis, which provides immediate relief from pain, long-term satisfactory outcome and avoids multiple operations
The aim of the study was to assess the knee function after MPFL reconstruction with single hamstring autograft.
In this case series 86 patients (87 knees) were treated in total, from July 2002 till December 2008. Clinical and radiological evidence of patellar instability and MPFL rupture or deficiency were documented prior to surgery. The MPFL was reconstructed with semitendinosus autograft. The tibial insertion of the graft was retained whereas its free end was rerouted through the most distal part of the medial intermuscular septum, to the supero-medial border of the patella, where it was fixed. Knee function was assessed preoperatively and postoperatively with the use of Kujala, Tegner, Lysholm and International Knee Documentation Committee (IKDC) scores.
There were 60 male and 26 female patients with an average age of 29.73 years (median age 28) and range 16–54 years. The mean follow-up was 22.4 months (range 6–78 months). All knee functional scores significantly improved postoperatively. Kujala score improved from 61.3 to 84.8, Tegner score improved from 3 to 5.3, IKDC score improved from 52.4 to 73.8 and Lysholm score improved from 58 to 76.5. The comparison was made between the preoperative and the postoperative values at two years after surgery or at the last follow up, if it was shorter than two years. All scores showed significant improvement after the third postoperative month. One of the patients required revision of the MPFL reconstruction following traumatic redislocation of the patella.
Rerouting of the semitendinosus tendon for the reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability. Significant functional improvement is achieved between the third and sixth postoperative months
Controversy still remains as to whether patella resurfacing in total knee arthroplasty (TKA) should be conducted as a matter of routine. Some authors recommend routine resurfacing of the patella and advocate this due to the reduction in post-operative anterior knee pain and the reduction in requirement for revision surgery.
A database search was conducted to identify prospective randomized controlled studies only. Eighteen prospective randomized trials were identified and found eligible for inclusion. A cumulative sample of 8006 knees were involved, 3418 undergoing resurfacing and 4588 undergoing no resurfacing. Primary outcome data extracted was incidence of secondary operations, incidence of anterior knee pain and functional outcome scores including subgroup analysis of the type of prosthesis used in each study. Der Simonian Laird metanalysis was conducted if studies were found to be homogenous where statistical significance was defined as an overall alpha error of < 0.05.
No statistically significant differences were found to exist between patients undergoing patella resurfacing as a primary total knee replacement and those who preserved the native patella. No differences could be found between specific prosthetic design when subgroup analysis was conducted.
The study does not offer evidence to suggest any advantage of resurfacing versus non-resurfacing. Furthermore, no significant discrepancy existed when comparing different types of total knee prosthesis. This may be due that all the knees analysed are designed to be patella friendly and allow conformity of articulation of both a native and patella button equally
To present our experince in the use of different autologous cartilage transplantation techniques with concomitant procedures.
The last 30 months we treated 42 patients with chondral defect at the knee. Their mean age was 34 y.o. and the men to women ratio was 28/14. The defect concerned the medial femoral condyle(20), the lateral femoral condyle (14), the medial facet of the patella (4) while 4 patients demonstrated chodral defects in both femoral condyles. The mean area of the defect was 6.5 cm2 while defects measuring below 2.5 cm2(10) were treated arthroscopically using microfracturing trechnique. 20 cases were treated for chondral defect alone using either MACI or ACT-3D technique for chondrocyte transplantation and in 12 cases there was a combination of cartilage transplantation with alignment correction procedures. Finally a modified rehabilitation protocol was used.
All the cases were performed uneventfully. We assesed the patients 12 months post-operatively using the LYSHOLM & GILLQUIST score, FAFA kai Visual Analogue Pain Score. The clinical outcome was excellent, the follow-up using ‘MRI showed adequate filling of the defect without significant bone swelling.
Our early results using the method are more than encouraging. The method continues to evolve and is very challenging. As far as we know this the first publication concerning 3rd generation autologous chondrocyte transplantation in both femoral condyles silmutaneously
Measurement of precision in positioning multiple autologous osteochondral transplantation in comparison to the conventional free hand technique.
The articular surfaces of 6 cadaveric condyles (medial – lateral) were used. The knee was referenced by a navigation system (Praxim). The pins carrying the navigation detectors were positioned to the femur and to the tibia. The grafts were taken from the donor side (measurement I) with the special instrument which carried the navigation detectors. The recipient site was prepared and the donor osteochondral grafts were forwarded to the articular surface (II). The same procedure took place without navigation. The articular surface congruity was measured with the probe (measurement III)
The angle of the recipient plug removal (measurement I) with the navigation technique was 3,27° (SD 2,05°; 0°–9°). The conventional technique showed 10,73° (SD 4,96°; 2°–17°). For the recipient plug placement (measurement II) under navigated control a mean angle of 3,6° (SD 1,96°; 1°–9°) was shown, the conventional technique showed results with a mean angle of 10,6° (SD 4,41°; 3°–17°). The mean depth (measurements III) under navigated control was 0,25mm (SD 0,19mm; 0mm–0,6mm). With conventional technique the mean depth was 0,55mm (SD 0,28mm; 0,2mm –1,1mm).
The application of navigation showed that complications like diverging of the grafts leading to breakage or loosening as well as depth mismatch which can lead to grafts sitting over or under the articular surface can be avoided providing better results in comparison to the free hand procedure
If and how closed valgus osteotomy of tibia is possible to influence intra and post operative results of total knee arthroplasty.
Since 1985 to 2002 196 high tibial osteotomies were performed. 57 of them were treated by T.K.A. In 21 of 196 cases diagnostic arthoscopy performed for evaluation of the lesion. All osteotomies were closed wedge. Stabilization of the knee was done with plaster clast and in 50% of cases staples used. The time interval from osteotomy to T.K.A was 2–17 years mean 8 years. Follow-up of T.K.A. was 3–20 years.
Scars, patella Baja, shortens of patellar tendon increased operative time and degree of difficulty. Postoperative results of T.K.A, were evaluated according the WOMAC (pain, stiffness, function) KSS (function) KSRIS (x-ray findings) were the same with those of primary T.K.A.
Postoperative complications:
11 cases decrease in range of knee movment 3 fractures of external tibial condyle 2 mechanical loosening of T.K.A skin necrosis rupture of extension complex.
Intaoperative difficulties in high valgus tibial osteotomy and afterrwords in T.K.A. were increased although postoperative results were the same. This is the reason that surgical experience is the target point of the result
The evaluation of the outcome of CCK prostheses in primary TKA
Between 2002 and 2008 we implanted 34 CCK knees in 31 patients. Mean age was 69 (58–79) 10 patients were operated because of valgus knee and lateral compartment arthritis, 8 because of post-traumatic ligamentous laxity and/or bone loss and the remaining patients presented with advanced OA and varus deformity exceeding 30 degrees. All patients were followed regularly with radiographs annually and there were assessed clinically with KSS and Womac score. The findings were compared with a group of patients with similar characteristics and a CR prosthesis.
Mean follow-up was 3 years (6–1) There was no revision in this group neither was any radiological abnormality. Clinical outcome in terms of KSS and WOMAC score was excellent and comparable to the CR group.
The main indication for a CCK prosthesis is the ligamentous insufficiency. There is enough evidence to support its superiority as a treatment option in valgus knees but long term performance is yet unclear.
CCK prostheses are a reliable solution for unstable or imbalanced knees their long term behaviour though, is yet unclear
The timing of performing knee arthroplasties in bilateral osteoarthritic knees remains controversial. Our aim was to compare one-stage with two-stage bilateral knee arthroplasties (TKA).
Between November 2004 and April 2008, 128 patients (72 female and 56 male) underwent one-stage bilateral TKAs. Another group of 115 patients that underwent two-stage procedures during the same period formed the control group. All patients received the same type of anaesthesia. Study parameters included age, weight, medical co-morbidities, length of hospital stay, blood loss, post-operative complications and functional outcome.
There were no significant differences between the two groups. Co-morbidities and functional outcome based on the Knee Society Score were similar in both groups. In the one-stage group the length of hospital stay and blood losses were higher than the two-stage group; however less than double compared to the two-stage group. The early post-operative complications were higher but not statistically significant in the one-stage group.
Despite the fact that the early post-operative complications are slightly higher in the one-stage group, this particular method is an effective way of dealing with bilaterally osteoarthritic knees. It offers excellent functional outcome at a reduced cost
Data from the Australian Joint Register suggests that the revision rate for cruciate retaining [CR] prosthesis is less than for cruciate sacrificing prosthesis[PS]. We have analysed data from the NZOA joint register to see if this is the case in NZ.
Data for all PS and CR knee replacements in NZ between 1999 and 2004, and any subsequent revisions were analysed and the results compared with the AOA registry data [2008]. There were 3808 PS knees and 7152 CR knees on the AOA register, with a seven year revision rate of 3.3% and 2.1% respectively p=.002. On the NZOA register there were 1869 PS knees and 5749 CR knees, with a five year revision rate of 1.55% and 1.39% respectively p=.608
This aspect of prosthesis design did not influence the revision rate at five years.
Total Knee Joint Replacement is mostly commonly performed using a measured resection technique. When the PCL is retained 9mm of bone is resected off the distal femur. If the PCL is excised 11m of bone is resected. Computer assisted total knee joint replacement will guide the surgeon to perform the optimal distal femoral resection to gain neutral alignment and full post operative extension.
Three hundred TKJR’s were performed by one surgeon using the De Puy Ci navigation system. A ligament balancing technique is used whereby a neutral tibial resection is performed. A ligament tensor is inserted in extension and flexion. The navigation system then performs an optimization process whereby the distal femoral cut is calculated to give a neutral mechanical axis and 0° of knee extension. Data was collected measuring the distal femoral resection in the PCL retained and resected knees.
The distal femoral cut required to achieve full extension for the PCL retaining TKJR ranged from 5 – 15mm. The mean was 11.2mm. The distal femoral cut required to achieve full extension for the PCL sacrificing TKJR ranged from 5 – 15mm. The mean was 10.8mm. There was no difference between the two groups (p=0.07). Both the PCL retaining and sacrificing TKJR distal resections correlated with the preoperative flexion deformity, i.e. patients with a greater fixed flexion deformity required a greater distal femoral resection to achieve full extension
There is a wide variation in the distal femoral cut to achieve full extension in TKJR. It is accepted that a smaller distal resection is required for a PCL retaining than a PCL sacrificing TKJR. Our study refutes this premise. A greater femoral resection is required if there is a greater fixed flexion deformity. A measured resection technique will result in a large percentage of patients with a fixed flexion deformity following TKJR
The purpose of this study was to investigate the surgical options for unicompartmental osteoarthritis (OA) in younger patients by comparing the survivorship and functional results of Total Knee Replacement (TKR) following osteotomy with the results for both primary TKR and revision of Unicompartmental Knee Replacement (UKR) to a TKR, and thereby recommend the most appropriate index procedure for this group of patients.
We reviewed the revision rate and functional outcome of all patients who had a total knee replacement (TKR) following an osteotomy or Unicompartmental Knee Replacement (UKR) on the New Zealand Joint Registry. We used this data to compare the results to primary TKR scores, including comparison of age-matched subgroups.
There were 711 patients who had undergone TKR as salvage for a failed osteotomy with a revision rate of 1.33 revisions per 100 component years and a mean Oxford knee score (OKS) of 36.9. 205 patients had failed UKR converted to TKR with a revision rate of 1.97 revisions per 100 component years and a mean OKS of 29.1. The revision scores of TKR for both failed osteotomy and failed UKR were significantly poorer than following primary TKR (p← 0.05). The mean OKS following revision of a UKR was significantly poorer than both primary TKR (p←0.001) and TKR for a failed osteotomy (p←0.001). There was no significant difference in mean OKS between primary TKR and TKR for a failed osteotomy, even amongst patients younger than 65 years (p=0.8).
This study has shown that if a surgeon is choosing between an osteotomy and a UKR in the younger patient than the better for any subsequent revision procedure will be achieved with an osteotomy. Revision of a failed osteotomy to a TKR has improved functional results compared to revision of a failed UKR. However, both yield poor survivorship rate compared to primary TKR.
MACI Cartilage Transplantation has been performed in New Zealand for the last five years for patients with isolated articular cartilage defects who have failed a microfracture technique.
Thirteen patients have undergone this procedure. Patients were evaluated by an independent research assistant preoperatively and at 6 months, 1, 2, 3 and 5 years Visual analogue pain score, ICRS score, WOMAC score, KOOS score, IKDC score and SF 36 were collected at all time points. An MRI scan was performed in all patients at all time periods. Biopsies are taken at three years.
There is an improvement in visual analogue pain score, ICRS score, WOMAC score, KOOS score, IKDC score and SF 36 at all time points. Results improve with time. No procedures have failed. All MRI scans showed restoration of articular cartilage. Histology shows hyaline like cartilage
Medium term results are encouraging. The rehabilitation is long thus 12 month data does not give an accurate outcome measure. Ongoing evaluation is occurring.
Osteomyelitis continues to be a common problem amongst the paediatric population. Osteomyelitis of the calcaneus is an uncommon problem that still poses a problem to the treating physician. The purpose of this paper is to retrospectively review a large series of paediatric patients with calcaneal osteomyelitis. We compare our experience with that in the literature to determine any factors that may aid earlier diagnosis and or improve treatment outcomes.
A 10-year retrospective review was performed of clinical records of all cases of Paediatric calcaneal osteomyelitis managed at the two children’s orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007, at Starship Children’s Hospital, and 1998 and 2008 at Middlemore’s Kids First Hospital.
Sixty patients fulfilled the inclusion criteria. The average duration of symptoms was 6.8 days. 40% of patients had a recent episode of trauma. 82% of patients could not weight bear on admission. Only 22% of patients had a temperature above 38 C. 27% of patients had positive blood cultures with Staph aureus being the most commonly cultured organism. X Rays, bone scans and MRI were all used to aid the diagnosis. ESR was elevated in 81% and the CRP was elevated in 77% of patients. 20% of patients had surgery with an average of 1.3 surgeries for those who progressed to surgery. Treatment length was an average of 2 weeks 6 days of oral antibiotics and 3 weeks 2 days of oral treatment. There was no post surgical complications and 10 readmissions, 3 for relapse, 3 for PICC line problems and 4 for antibiotic associated complications.
Although a sometimes more difficult diagnosis to make, calcaneal osteomyelitis can be diagnosed with an appropriate history, clinical examination and investigations. Treatment with intravenous and oral antibiotics and surgical debridement if indicated can lead to a good clinical outcome with minimal complications
Child abuse is often called a New Zealand Epidemic in the popular media. It encompasses sexual, physical, emotional, and neglect. As Orthopaedic surgeons, our primary involvement is with the physical side. The diagnosis of a femoral fracture in very young children has been reported as highly suggestive of NAI, with rates ranging from 11% to 60%. The purpose of this study was to determine the characteristics of children presenting to the Starship Hospital who had sustained a femoral fracture as a result of Non-Accidental Injury (NAI).
All confirmed cases with concurrent diagnoses of NAI and femoral fracture presenting to the Starship over a ten year period from Jan 1999 to 2009 were reviewed. These patients were then compared with all patients with femoral fracture who were referred to the child protection team and with all patients presenting with traumatic femoral fracture during this period. Cases were examined with regards to demographics, circumstances of injury, comorbidities and fracture characteristics.
Compared to all femoral fractures, those as a result of NAI were significantly younger. All were aged 3 years or less, with the majority aged 12 months or less. In this age group, approximately a third of those with femoral fracture had a confirmed diagnosis of NAI. In the NAI group, multiple fractures including bilateral femoral fractures were more common. Prematurity was a common co-morbidity. Approximately half of the patients had been seen in hospital for any reason prior to the index admission.
More than half of the cases of confirmed NAI presented primarily to the Orthopaedic service. It is important for Orthopaedic surgeons to be able to identify those children with fractures who may be at risk of NAI. In particular, this includes children under the age of 1 who present with femoral fractures.
Knee flexion is often decreased in severe arthritis causing pain, and functional limitations in lifestyles and occupations. Newer knee replacement designs offer the possibility of greater knee motion. The objective of our study was to compare the clinical outcomes, in particular the range of motion, in patients treated with a total knee arthroplasty using either a standard posterior stabilized knee prosthesis or a high flexion posterior stabilized knee prosthesis, with regard to return to function within 1 year of surgery.
This was a prospective randomized single blinded study. Forty patients were randomly assigned to receive either a standard fixed bearing posterior stabilized or a modified high flexion fixed bearing posterior stabilized Smith & Nephew Genesis II total knee joint replacement. Clinical outcomes were determined from data collected on all patients who were evaluated pre-operatively, at twelve weeks post-operatively, and at one year post-operatively. Data collected included SF-12, WOMAC, and Oxford knee scores, and knee range of motion measurements.
37 of 40 patients enrolled completed the study. 22 patients were randomized to receive a standard posterior stabilized fixed bearing Genesis II knee replacement and 22 were randomized to receive a Hi-Flex posterior stabilized fixed bearing knee replacement. ROM, quality of life, and clinical scores at 12 months will be presented.
Acute haematogenous osteomyelitis in children is relatively uncommon but delay in diagnosis and inadequate treatment can result in significant morbidity. Most recently evidence has suggested conservative treatment with adequate antibiotic therapy should be the mainstay, with provision for surgical intervention in those who fail to respond to conservative management. The outcome of primary management has been evaluated in this review.
Retrospective analysis of an osteomyelitis database was conducted on individuals presenting to Auckland’s Starship and Middlemore Hospital with an ICD-10 diagnosis of Osteomyelitis between January the 1st 1999 and December the 31st 2008.
813 children fulfilled the criteria for inclusion into this review. The annual incidence of acute haematogenous osteomyelitis in the paediatric population in Auckland over this period was approximately 1:4,000. 64% were male and 36% were female. The majority were New Zealand European (35%), with the other significant ethnic groups represented being New Zealand Maori (22%), and Pacific Island (30%). 23% of patients were aged less than three. 51% of patients were between three and ten, and 26% older than ten. Only 32% had an elevated white cell count on admission. A responsible pathogen was isolated in 50% with the most common being Staphylococcus aureus, which was isolated in 77% of this group. Diagnosis was made radiologically in 66%, clinically in 27%, and surgically after exploration in 7%. The most common site of osteomyelitis was the femur in 254 individuals, followed by the tibia in 198 individuals. 49 had multi-focal involvement. Flucloxacillin was the most common antibiotic used, with 510 individuals being administered flucloxacillin at one point in time during their management. The average length of treatment was 43.7 days, which included intravenous therapy of 22.3 days, and oral therapy of 21.4 days. 60% had a range of duration of therapy from greater than three weeks through to six weeks. 44% required surgical intervention. The relapse rate was 6.8%. The average duration till relapse was 5.8 months. Only 1.7% of the total population went on to develop chronic osteomyelitis.
The incidence of paediatric acute haematogenous osteomyelitis in this population appears to be relatively high. The average length of treatment was longer than that now reported to be successful for eradication. This could possibly be a factor in the relatively low rate of relapse and low subsequent rate of chronic osteomyelitis.
This study reviewed the revision rate of fully cemented, hybrid and cementless primary total knee replacements (TKR) registered in the New Zealand Joint Registry from 1999 to May 2008 to determine whether there was any significant difference in the survival and reason for revision with these different types of fixation.
The percentage rate of revision was calculated per 100 person years (HPY) and compared to the reason for revision, type of fixation and the patient’s age.
Of the 28707 primary TKR registered, 522 underwent revision procedures requiring change of at least one component with a survival rate of 0.44 HPY (1.8%). The majority of revisions were for pain (153) followed by deep infection (133) followed by loosening of the tibial component (98). Overall the rate of tibial loosening was 0.07 HPY (0.3 %) in the cemented group vs 0.25 HPY (1%) in the cementless group (p < 0.001). There was no significant difference in the type of fixation used for the femoral component, but there was a significant difference in the different types of fixation when revised for pain, with the uncemented tibia performing the poorest. There was no significantly difference in the younger patient (< 55 years) with respect to tibial loosening (p=0.92).
Failure of the uncemented total knee replacement was due to pain and tibial loosening although the results in patients under 55 years were similar in all fixation groups. There was no difference in the fixation method of the femoral component.
The ideal treatment of the unstable slipped upper femoral epiphysis (SUFE) is not clearly defined in the literature. Unstable SUFE occurs with less frequency than the stable SUFE. The incidence of unstable SUFE is between 14–25% of all SUFE’s. The literature reports a variety of accepted methods of treatment of the unstable SUFE, consequently, in Auckland there are various methods of treatment.
The unstable SUFE is at risk of development of avascular necrosis (AVN) of the femoral head. The reported incidence of AVN in unstable SUFE is between 15–50%. We expect that different treatment will influence the rate of AVN.
Our aim was to determine current practice and outcomes in Auckland. We reviewed the records and radiographs of all SUFE’s treated in Auckland from 2000–2007. In this time period there were 463 patients across the Auckland region, 109 of which had bilateral SUFE’s which allowed 572 treated hips to be followed. Over this time period there were 34 unstable SUFE representing 6% of treated hips. There was a difference in average weight, with unstable SUFE on average 10kgs lighter (60.5 vs 70.3kgs). Average time to surgery was 43 hours (range: 4–360hrs). Cases operated within 24 hours have a reduced rate of AVN (20%) compared to those operated after 24 hours (AVN 50%). Of the 34 cases, 13 cases had radiological evidence of AVN (35%). Of these there were 11 cases of pin penetration requiring further surgery. There was no difference in rate of AVN when comparing single screw to double screw fixation (SS 44% v DS 38%). There were 11 cases of pin penetration, 8 with single screw and 3 with double screw fixation.
Our review of unstable SUFE in Auckland has shown a difference in the weight of patients when compared to stable SUFE’s presenting from the same population. We have also found that cases operated on within 24 hours have a lower rate of AVN. Single screw fixation is more common than double screw fixation. There was no statistical difference in the rate of AVN but there was a higher rate of screw penetration when using a single screw fixation.
A cementless version of the Phase 3 Oxford UKR has been used in our unit since mid 2005. We report on our early experience with this implant, reviewing the National Joint Register (NJR) data on UKR in general and Oxford specifically, with respect to six month Oxford Knee Scores (OKS) and revision rates.
A single surgeon review of 170 cementless and 132 cemented cases revealed a mean 6 month OKS of 41.5 and revision rate per 100 component years of 0 for the cementless group, and mean 6 month OKS of 40.0 and revision rate of 1.05 for the cemented group. The equivalent results from the NJR for UKR are 38.75 and 1.44. Radiological review of the 170 cementless cases showed no concerns regarding subsidence and encouraging features with respect to ingrowth. There were no radiolucent lines at one year. The cementless components appear to be strongly osteophilic. The NZ experience with the Cementless Oxford is single centre, comprising a small number of high volume surgeons, and the OKS and revision rates are presented. To date, there have been 346 cases with a revision rate per 100 component years of 0.30.
In summary, single surgeon and national early experience of the Cementless Oxford UKR from clinical and radiological evidence is encouraging.
Correct sizing of knee arthroplasty implants avoids problems such as stiffness from too large an implant, or periprosthetic fractures from undersizing. Currently most implants are based on a generic unisex population. Femoral component sizing is therefore based solely on the AP measurement after the distal femoral cut. In order to investigate the differences between the New Zealand population and other populations with reported anthropometrics we studied the anthropometrics of the male and female distal femur.
The distal femur of 26 cadaveric knees was resected using standard cutting guides. Using a sizing guide the AP dimension was measured from the posterior condyle to the anterior cortex just proximal to the trochlea (posterior referencing). The ML dimension was measured at the cut surface in the coronal plane of the epicondylar axis.
Overall AP measurement had a mean(standard deviation) of 62(±6.7) mm, the ML measurements had a mean (sd.) of 72(±6.6)mm yielding an ML/AP(100) ratio of 117(±11). The male AP mean was 67(±4.5) mm and female AP 57 (±4.4)mm. The male ML was 77 (±4.7)mm and female ML 68 (±4.5)mm. The ML/AP ratio for male was 111(±12) and female was 120 (±10).
This pilot study has shown differences between genders in the NZ population even with this small sample size. As this data is important for designers of total knee implants, planning is currently underway to perform measurements intraoperatively from approximately 400 patients undergoing total knee replacement.
The non-operative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. Non-compliance with abduction bracing has been proven to be a major risk factor for recurrence of clubfoot. The purpose of this retrospective study was to identify those patients who were non-compliant with the abduction bracing post casting and to then assess the rate and severity of recurrence.
One-hundred and fifty children (184 feet) with unilateral or bilateral clubfoot who were treated with the Ponseti method by the senior author from 1999 to 2008 were reviewed. We identified those patients who were non-compliant with the abduction bracing. Compliance was defined as three months full time wear followed by twelve months night-time/nap-time wear. Recurrence was classified as minor, defined as those requiring an extra-articular surgical procedure and major, requiring an intra-articular procedure.
We identified fifty children with seventy clubfeet who were followed up for a minimum of 12 months. None of these patients were compliant with brace wearing. Of the 70 feet, 40 (57%) required surgical intervention. There were 30 (43%) feet with no clinical recurrence. In 5 of the bilateral cases only one of the feet had required corrective surgery. In the 29 patients who required surgical intervention we identified 52 procedures (37 extra-articular and 15 intra-articular).
Compliance with the post correction abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. Despite non-compliance however there is a significant proportion of patients who do not require any surgical intervention. We recommend initiating the Ponseti technique on all patients with clubfeet rather than being selective due to anticipated compliance issues with the family.
We prospectively reviewed patients who had undergone a Revision Total Knee Replacement (TKR) to a mobile-bearing arthroplasty. We wanted to assess functional outcome and survival, and to determine whether the perceived advantages of a mobile-bearing arthroplasty could be expanded to the revision situation.
We divided the patients into two groups. Group 1 consisted of 40 patients who were revised to a rotating platform, with or without stems and augments, and group 2 consisted of 41 patients revised to a varus-valgus constrained mobile-bearing device that still allowed rotation of the bearing. All were assessed with Knee Society Knee Scores, WOMAC, and New Jersey Knee Scores and standard radiographs by an independent examiner.
Group 1 had an average age of 71 years at revision and a follow-up of 5–9 years. Seventy-six percent had excellent or good results with 89% survival at 9 years. Group 2 had an average age of 71 years at revision and a follow-up of 2–5 years. The patient satisfaction score was 8/10 and the normality score was 6.8/10. There was only one case of instability in both groups in a patient with a patellar fracture.
A mobile-bearing TKR can be used in the revision situation with acceptable clinical results and patient outcome without compromising the stability or survivorship in the short-term. It has proved to be a “patellar-friendly” procedure with reduced re-operation for patellar complications; however longer-term studies are required to determine whether the rates of polyethylene wear are reduced by the use of a more congruent articulation.
The aim of this study was to evaluate the results of a consecutive series of distal tibial fractures treated by percutaneous plating.
85 patients with distal tibial fractures were treated using minimally invasive medial plate fixation. 18 patients had open fractures. Eight had displaced intra-articular fractures (AO type 43C). The majority had extra-articular fractures (AO type 42 or 43A). Patients ranged in age from 16–89 years. All were followed to union with a minimum follow-up period of 6 months (average 47 months). Outcome measures assessed retrospectively were alignment, time to full weight bearing and complications including infection, delayed or non-union and secondary surgery.
The mean time to surgery after injury was 5 days (range 0–22). 51 patients had unlocked pre-contoured plates and the remaining 34 had locking plates. The fibula was plated in 41 cases. Post-operative mal-alignment greater than 5 degrees varus or valgus occurred in 3 cases (3.5%). The average time to full weight bearing was 11 weeks. Superficial infection occurred in 6 patients (7%) and deep infections in 4 cases (4.7%). There was one case of plate fracture. 4 patients, including this case, required further surgery to achieve union. There was a high rate of metalware symptoms that prompted plate removal.
Percutaneous plate fixation of distal tibial fractures is a reliable method of treatment with complication rates lower than reported for open techniques.
Unrecognized pin penetrance in the treatment of SCFE by percutaneous pinning has been shown to be under-reported with serious long-term sequelae. The purpose of this study was to use post-operative CT to determine the true position of the screw tip when compared to intra-operative x-rays.
Twenty-four patients were offered post operative CT scans in the acute and clinic setting. Intra-operative plain films (AP and lateral) were compared to post operative CT scans (coronal and axial) to determine
the distance of the screw tip from the particular surface of the hip joint, the number of screw threads across the physis and the three dimensional placement of the screw tip in the femoral head relative to the physis.
The positions of a total of 38 screws were measured. Plain x-rays where shown to consistently underestimate the distance to the articular surface. There were significant differences in the distance to the articular surface in the AP (5.5 mm) vs. coronal (3.4 mm) and lateral (4.7 mm) and vs. axial CT (4.1 mm) planes (p < 0.01). The average number of screw threads across the articular surface on the lateral x-ray was 6.7 vs. 8.1 in the coronal CT (p< 0.05). Four of the screws were shown to penetrate the joint surface in CT not shown on plain film.
This study has found that CT scans show screws are closer to the joint surface in the axial and coronal plane on CT when compared to plain x-ray in the AP and lateral plane. CT scans also show that there are more screw threads across the epiphysis than shown on plain x-ray. Placement of the screw within specific quadrants of the femoral head was found to be similar on CT and x-ray. CT scans identified pin penetrance not seen on intra-operative images.
Most researchers have employed conventional histological and related methods to investigate the complex architecture of the IVD. Recognizing the inherent limitations of these methods we have pioneered new microstructural and micromechanical techniques that have greatly enhanced our understanding of the 3-D architecture of the IVD. Using sectioning planes that take full account of the oblique fibre angles in the annular wall, combined with specialized optical imaging techniques that provide high resolution structural images of fully hydrated thick sections we have described new levels of structural complexity that are clearly implicated in the biomechanical function of this highly complex connective tissue organ.
The primary regions of structural interest are the annulus, the annular-endplate junction and the nucleus-end-plate junction. Within the complex multilayered annular wall we have identified a system of collagen-rich bridging structures that both integrate proximate oblique and counter-oblique layers as well as providing long-range radial continuity across many layers. We argue that this system has an important biomechanical role of lashing alternate ‘like’ layers together whilst providing for some freedom of fibre angle change between immediately adjacent layers coursing in counter oblique directions. Thus, under the deformations generated by direct compressive, bulging, flexion and minor rotational forces, the structural integrity of the annulus is maintained.
We have also clarified important features of both annular/endplate and nucleus/endplate structural integration. Our very recent structural studies of the lumbar motion segment suggest that the current models of disc/endplate integration require substantial revision. This presentation will describe new experimental evidence in support of a more appropriate model of structural integration.
The Lumbar Spinous Processes (LSP) have an important anatomical and biomechanical function protecting the neural structures in the spinal canal, and as an anchor for the inter and supraspinous ligaments, and the inter-segmental paraspinal muscles. They also influence access to the spinal canal for neural decompressive surgical procedures. More recently the LSPs have attracted increased interest as a site for surgical device attachment in an attempt to both decrease the symptoms of spinal stenosis, and as a site for intersegmental stabilization without formal fusion. There is evidence that various anatomical structures have altered morphology with ageing, and there is anecdotal evidence of changing LSP morphology with age. This study aims to clarify the influence of age on LSP morphology, and on lumbar spine alignment.
200 CT scans of the abdomen were reformatted with bone windows in sagittal and coronal planes allowing precise measurement of LSP dimensions, and Lumbar Lordosis. Observers were blinded to patient demographics. Inter-observer reliability was examined. Data was analysed by an independent statistician.
The smallest LSP is at L5. The male LSP is on average 2–3mm higher and 1mm wider than the female LSP. LSP height increases significantly with age at every level in the lumbar spine (p< 10-5 at L2). The LSPs increase in height by 2–5mm between 20–85 years of age (p< 10-6), which was as much as 31% at L5 (p< 10-8). Width increases proportionally more, by 3–4mm or greater than 50% at each lumbar level (p< 10–11). Lumbar lordosis decreases in relation to increasing LSP height (p< 10-4) but is independent of increasing LSP width (p=0.2).
This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology.
The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disc space narrowing, but also as a consequence of increased LSP dimensions.
Spinal infections can result in devastating consequences for the patient. Surgery is indicated in certain circumstances. Our institution’s surgical intervention for the treatment of spinal infection was studied. The aim was to identify characteristics helpful for future management. Areas of particular interest were the causative agent, organism identification methods, indications for surgery, materials used for anterior column reconstruction and the ultimate outcome.
A retrospective investigation of all patients receiving surgery for spinal infections between the years of 2004 to 2009 was conducted. All surgical postoperative infections were excluded. Twenty patients were identified in the nominated study period. Twelve males and eight females aged in between 15 to 83 with an average age of 59.4 years. The offending organism was a gram positive in half (50%) of the study group. Staphylococcus aureus was overwhelmingly the representative bacterium (90%). Five cases (25%) were attributed to gram negative organisms while tuberculosis was present in four (20%). No organism was identified in one. Blood cultures identified the causative agent in just over half (55%) of the cases while seven (35%) relied on surgically obtained tissue. Computer tomography guided biopsy was positive in only one case. The most common reason for surgical intervention was a combination of neurological deficit and failing medical management. The second most common reason was in cases with an unidentified organism along with neurological issues. Anterior column reconstruction using cortical strut allograft was performed in four patients while another four received a synthetic spacer device. Two patients had both allograft bone and a spacer device. Only single case of autograft anterior column reconstruction was identified. Two deaths occurred following surgery while all surviving patients with preoperative neurological deficits improved. All surviving patients are currently infection free.
The surgical management of spinal infections can result in advantageous outcomes for the patient, especially in the setting of neurological deterioration or failing medical management. The use of allograft bone and synthetic spacer devices in the midst of infection does not appear to prevent successful organism eradication. The possibility of tuberculosis being the offending bacterium cannot be overlooked.
The aim of this study was to examine the results of medial opening wedge high tibial osteotomies in which TRISOITE (hydroxyapatite tricalcium phosphate composite) wedges have been used as bone graft substitute and to compare the histological results with the clinical outcome.
There were 36 medial opening wedge high tibial osteotomy performed in 33 patients with a mean age of 45 years. Medial compartment osteoarthritis with varus alignment was the indication in 32 patients. All were followed to union with a minimum follow up of 6 months (average 50 months).
The surgical technique involved creating an oblique upper tibial osteotomy at an angle of 60 degrees from distal-medial to proximal lateral, passing distal to the insertion of the patellar ligament and preserving the lateral cortex. The osteotomy was opened to the desired angle of correction and preformed Triosite wedges were inserted. Stabilisation was obtained with a contoured titanium T-plate (ENZTEC). Re-operation was required for metal removal or conversion to total knee replacement in 10 cases. All of these patients had a biopsy of the osteotomy site.
The clinical notes and x-rays were retrospectively reviewed. One patient developed a superficial infection post-operatively which was successfully treated with intravenous antibiotics. Bone grafting was required to achieve union in 1 case (2.8%). There were no cases of varus deformity recurrence as a result of graft collapse. Biopsies provided microscopic evidence of bony incorporation around the tricalcium phosphate with bone healing. Three patients were converted to total knee replacement with no problems at the osteotomy site.
Triosite wedges appear to be a reliable synthetic bone graft substitute to act as a scaffold for bone healing in opening wedge osteotomies. They reduce the morbidity associated with iliac crest bone graft.
Intervertebral disc herniation and internal disc disruption are both thought to be primarily mechanically based pathologies. Although several studies have previously disrupted discs in vitro, none have examined the resulting disruptions microscopically.
The technique of nuclear pressurization was used to mechanically disrupt ovine lumbar motion segments. A hollow injection screw was inserted longitudinally through the inferior vertebra of each motion segment, so that the injection screw’s tip was located in the centre of the nucleus. Through this screw, a radio-opaque gel was gradually injected into each segment’s nucleus until failure occurred, marked by a large drop in nuclear pressure, or focal change to the disc’s periphery. Following mechanical testing, the internal failure characteristics of each motion segment were assessed using micro-CT and microscopy. During nuclear pressurization, motion segments were held in one of four postures:
0° flexion, 7° flexion, 10° flexion, or 7° flexion plus 2° axial rotation.
Group I (0° flexion; n=12): Discs failed at a mean nuclear pressure of 13.2±2.1MPa. In most cases failure occurred in a diffuse manner via sequential circumferential tears within the posterior annulus. Group II (7° flexion; n=17): Discs failed at a mean nuclear pressure of 11.2±2.5MPa. Compared to the Group I discs, 7° flexion led to the creation of radial tears extending through the central posterior disc wall. Two types of radial tear occurred: mid-axial and annular-endplate. Mid-axial radial tears were confined to the annulus. Annular-endplate radial tears incorporated both annular and endplate failure; endplate failure in these tears always occurred adjacent to the mid-annulus at the cartilaginous/vertebral endplate junction. Group III (10° flexion; n=17): Discs failed at a mean nuclear pressure of 9.8±2.6MPa. Compared to the Group II discs, 3° of additional flexion increased the proportion of annular-endplate radial tears. Group IV (7° flexion + 2° axial rotation; n=25): Discs failed at a mean nuclear pressure of 7.9±2.4MPa. Compared to the Group II discs, the addition of 2° axial rotation significantly decreased the nuclear pressure at which discs failed, and reduced the occurrence of mid-axial radial tears.
Postures that reduced the disc wall’s ability to withstand high nuclear pressures were associated with an increase in the proportion of disc failures that incorporated tears of the cartilaginous endplates, specifically at the cartilaginous/vertebral endplate junction adjacent to the mid-annulus. The robustness of this junction appears to be intimately linked to the robustness of the disc wall.
Prospective match cohort study of disc degeneration progression over ten years with and without baseline discography
To compare progression of common degenerative findings between lumbar discs injected ten years earlier with those same disc levels in matched subjects not exposed to discography
Seventy-five subjects without serious low back pain illness underwent a protocol MRI and a L3/4, L4/5 and L5 S1 discography in 1997. A match group was enrolled at the same time and underwent the same protocol MRI examination. Subjects were followed for ten years. At 7 to 10 years after baseline assessment, eligible discography in controlled subjects underwent another protocol MRI. MRI graders, blind to group designation, scored both groups for qualitative findings.
Well matched cohorts, including 50 discography subjects and 52 control subjects met eligibility criteria for follow up evaluation. In all graded or measured parameters, discs that had been exposed to puncture and injection had greater progression of degenerative findings compared to control (non-injected) discs: progression of disc degeneration, 54 discs (35%) in the discography group compared to 21 (14%) in the control group (p=0.03); 55 new disc herniations in the discography group compared to 22 in the control group (p=0.0003). New disc herniations were disproportionately found on the side of the annular puncture (p=0.0006). The quantitative measures of disc height and disc signal also showed significantly greater loss of disc height (p=0.05) and signal intensity (p=0.001) in the discography disc compared to the control disc.
This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height occur with age. More impressive increases in LSP width occur with advancing age. This study suggests that loss of lumbar lordosis is correlated with changing LSP morphology. The increased width of the LSP with age influences access to the spinal canal, particularly if midline-preserving approaches are attempted in the ageing population. There is increased bone volume for bone grafting procedures with increasing age. The reduced distance between LSPs with age may influence design of implants that stabilize this region of the spine, and occur not only as a result of disk space narrowing, but also as a consequence of increased LSP dimensions.
Modern microsurgery has allowed severed digits to be salvaged by replantation. A retrospective case review was undertaken of all patients undergoing digital replantation at Middlemore Hospital between February 2004 and February 2009. 48 digits from 28 patients underwent digital replantation during this period. The aim of the analysis was to determine what factors were predictive for survival of the replants. Secondary outcomes of interest included subjective functional recovery, pain and further procedures.
Digital replantation over the review period was subject to a 75% survival rate. Smoking and male gender were identified as significant negative prognostic factors (p=0.02). 69% of patients reported post operative stiffness, chronic pain or cold intolerance. The majority of replanted digits underwent secondary procedures.
Patients should be counseled prior to digital replantation that while the procedure is subject to a high rate of digit survival, they should expect stiffness and discomfort and are likely to undergo secondary procedures.
Cuff tear arthropathy represents a challenge to the shoulder arthoplasty surgeon. The poor results of conventional total shoulder arthroplasty in cuff deficient shoulders secondary to glenoid component loosening have meant hemiarthroplasty has traditionally been the preferred surgical option. Recently reverse total shoulder arthroplasty (RSA) has gained increasing popularity due to a clinical perception of an improved functional outcome, despite the absence of comparative data. The aim of this study was to compare the early functional results of Hemiarthroplasty versus RSA in the management of cuff-tear arthropathy.
102 primary hemiarthroplasties performed for cuff tear arthropathy were compared against 102 RSAs performed for the same diagnosis. Patients were identified from the New Zealand National Joint Registry and matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford shoulder scores (OSS) were collected at 6 months and 5 years post operatively and were compared between the two groups, together with mortality and re-revision rates.
There were 51 males and 51 females in each group, with a mean age of 71.6 in the Hemiarthroplasty group and 72.6 in the RSA group. The mean ASA score was 2.2 in both groups. The mean OSS was 31.1 in the hemiar-throplasty group and 38.1 in the RSA group. At follow up, there were 7 revisions in the hemiarthroplasty group and 5 in the RSA group. No difference in mortality was seen between the two groups.
This study provides the first direct evidence of a improved functional outcome of RSA compared to Hemiarthroplasty in the treatment of patients with cuff tear arthropathy. Longer term follow up is needed to confirm that the improved function is maintained, and that late complications such as component loosening remain comparable between the two groups.
Posterior lumbar fusion is a frequently performed procedure in spinal surgery. High percentages of good and excellent results are indicated by physicians. On the other hand patient-based outcomes are reported. Little is known about the correlations of these two assessment types. We aimed at their comparison.
The analysis included 1013 patients with degenerative spinal disease or spondylolisthesis from an international spine registry, treated with posterior lumbar fusion. All patients were pre/postop assessed by physician-based McNab criteria (‘excellent’, ‘good’, ‘fair’, ‘poor’). Of these patients, 210 (mean age 61 years; 57% females) were in addition assessed by patient-based Oswestry Disability Index (ODI). The remaining 803 patients (mean age 59 years; 56% females) were assessed by patient-based Core Outcome Measure Index (COMI), including
Visual Analogue Scale (VAS) for back and leg pain as well as verbal self-rating (‘helped a lot’, ‘helped’, ‘helped only little’, ‘didn’t help’, ‘made things worse’). McNab criteria were compared to the Minimal Clinically Important Difference (MCID) in ODI (12.8), in VAS back (1.2) and leg pain (1.6). We investigated the correlations between McNab criteria and these patient-based outcomes.
In the ‘excellent’ group as rated by physicians, the proposed MCID was reached in 83% of patients for ODI, in 69% for VAS back and in 83% for VAS leg pain. All patients said the treatment had ‘helped’ or ‘helped a lot’. In the ‘good’ group 56% (ODI), 66% (back pain) and 86% (leg pain) reached the MCID. 96% of patients perceived the treatment as positive. In the ‘fair’ group 37% (ODI), 55% (back pain) and 63% (leg pain) reached the MCID. 49% had positive treatment considerations. The ‘poor’ group revealed 30% (ODI), 35% (back pain) and 44% (leg pain) of patients with reached MCID. Only 15% rated the treatment as positive.
The Spearman correlation coefficients between McNab criteria on the one hand and ODI, back and leg pain as well as patients’ verbal self-rating on the other hand were 0.57, 0.37, 0.36 and 0.46 respectively.
The comparison of physician and patient-based outcomes showed the highest correlations between McNab criteria and ODI, somewhat weaker correlations with patients’ self-rating and the weakest correlations with back and leg pain. Based on these findings, physicians’ evaluation of patient outcomes can be considered a valuable part of patient assessment, corresponding very well with patients’ perceptions of success or failure of spinal surgery.
There is controversy whether or not the midline structures (spinous processes, inter and supraspinous ligaments) should be preserved or sacrificed (MLP vs MLS) during decompression in the treatment of lumbar spinal stenosis(LSS). MLP operations are popular as they preserve the posterior tension resisting structures. Equally it is increasingly recognized that the facet joints(FJ), partially resected during decompressive procedures for LSS, have importance resisting postoperative spondylolisthesis and instability. This study was performed to examine the effects of MLP or MLS upon FJ morphology.
MRI scans from 7 patients with LSS (L2/3 to L5/ S1), and 4 patients without LSS (L3/4 to L5/S1) were examined and subjected to theoretical decompression with operative plans that performed decompression via a 10mm corridor that either preserved the midline structures via a parasagittal/laminomy (MLP), or sacrificed the midline structures providing an angled corridor for decompression from the opposite side of the table (MLS). The lateral margin of the decompression was the medial border of the pedicle. Cross sectional area (CSA) was determined for the FJ before and after decompression with both MLP and MLS using Image J cross sectional area analysis.
The cross sectional area of the facet joints prior to surgery was 287 mm2 at L3/4, 275 at L4/5, and 284 at L5/S1 in non-LSS pts. In LSS patients the values were 257, 267, 328, and 319mm2 at the levels L2/3 to L5/S1 respectively. MLS reduced the FJ CSA by 6, 4, and 0 % respectively in the non LSS pts (L3/4 to L5/S1), and 14, 9, 11, and 6% in the LSS pts (L2/3 to L5/S1). MLP reduced the FJ CSA by 34, 25 and 17% in non LSS pts (L3/4 to L5/S1), and 57, 43, 39 and 29% in the LSS pts (L2/3 to L5/S1). The differences between the MLP and MLS reductions of FJ CSA were highly significant. Greater relative reductions were seen with MLP when the CSA of the inferior articular process was examined.
This study demonstrates that preservation of the midline significantly reduces the CSA of the facet joint and in particular the IAP. Biomechanical and clinical evidence suggests that the FJs have a greater role in stability of the motion segment in the lumbar spine, and this study suggests that well-intentioned determination to preserve the midline structures may have a deleterious effect upon the anatomical structures responsible for stability of the lumbar spine.
Functional deficient of the little finger flexor digitorum superficialis (FDS-V) is known to be present in our population. The aim of this study is to evaluate the prevalence of the absence of FDS-V function in the Hong Kong Chinese population. The association between FDS-V absence and various variables (age, gender, hand dominance, occupation, smoking status, plamaris longus absence) were evaluated. The effects on the grip power due to FDS-V absence were analyzed. The anatomical variations were studied by cadaveric study. The clinical and anatomical variations were correlated by MRI study.
152 adult Chinese men and women from age 18 to 65 were recruited randomly. Subjects with congenital abnormalities, history of hand injury, history of upper limb surgery or underlying neuromuscular diseases were excluded. This study has 3 different parts. The first part is a clinical survey to determine the prevalence of the absence of FDS-V function by both the standard test and the modified test. The second part is a cadaveric study to determine the anatomical variations of FDS-V tendon by cadaveric dissection. The third part of this study is to correlate the clinical findings with MRI study.
Total 152 subjects were recruited with 51 male and 101 female, average age 37.6. The prevalence of the absence of FDS-V function by the standard test was 40.1% for right hand and 37.5% for left hand (38.8%). The prevalence of the absence of FDS-V function by the modified test was 9.2% on the right hand and 9.9% on the left hand (9.54%). The absence of FDS-V function was found more common to be bilateral than unilateral. This was found that 68.6% were bilateral by the standard test and 61% were bilateral by the modified test. The associations of functional FDS-V absence with various variables were insignificant. The effects of various variables on the grip power were analyzed using the multiple linear regression. Gender was1he only variable that had significant effects on the grip power for both the right and left hand. On either hand, the absence of Palmaris longus tendon and the absence of the FDS-V function had no significant effects on the grip power. Cadaveric study showed that the little finger FDS tendon was present in all 10 cadaveric hands. Abnormal muscle or tendon interconnection was not found. MRI study showed that there was hypoplastic tendon in subjects with absent FDS-V function.
The prevalence of the absence of FDS-V function in the Hong Kong Chinese population was 38.8% by the standard test and 9.54% by the modified test. The absence of little finger FDS function has no significant effects on the functional status as quantified by the grip power. We can postulate that patients with little finger FDS tendon injury can have normal range of motion and hand function if the FDP tendon is intact.
The New Zealand Nationwide Rotator Cuff Registry is a first worldwide. An initiative of The NZ Shoulder and Elbow Society, work commenced on the project in July, 2005, and the Pilot Study involving four surgeons and 200 patients commenced in September 2007 and finished in February, 2009. The Nationwide Registry commenced in March, 2009, and by 30th June 520 patients had been recruited. This presentation will focus on the data for the first six months of the study.
Analysis of data for the first four months showed that 71% of patients were male and 29% female. 62% involved the right shoulder. 88% of patients considered their shoulder problem accident-related. The rotator cuff repair was undertaken all-arthroscopic in 71 (13.8%), mini-open in 256 (49.6%), and open in 189 (36.6%). 95% were primary operations and acromioplasty was undertaken in 90%.
Using Cofield’s classification, tear size was small (< 1cm in AP length) in 10%, 1–3cm in 62% and large in 28%. Average pain score did not correlate with AP tear size but the Flex-SF activity score deteriorated with tear size. The supraspinatus was normal in 6% and had a full thickness tear of all of the tendon in 39%, part of the tendon in 38% and had a partial thickness tear in 17%. The subscapularis was involved in 33% and infraspinatus in 28%. A labral tear was present in 8.4% and was repaired in 2.1%. Distal clavicle excision was undertaken in 9% of which 62% were open and 38% arthroscopic. The long head of biceps was normally located in 82%, subluxed in 11% and dislocated in 7%. In 47% of cases it was normal, in 42% damaged and in 11% ruptured. Tenodesis was undertaken in 24%, tenotomy in 19% and in 57% the tendon was left in situ. Double row repair was utilised in 60% and single row in 40%. Suture anchors were used in 78% of repairs, bone tunnels in 7% and a combination in 15%. The tendon quality was rated very well in 26%, good in 54% thin in 13% and poor in 7%.
Postoperatively 42% were immobilised for 6 weeks, 24% for 4 weeks and 11% were not immobilised. A polysling was used in 56% and abduction pillow in 21%, and an ultrasling in 10%. Smoking and NSAID use will be compared in patient-derived outcome data at 6 months, one year and two years from surgery.
The objectives of this study were to elucidate the function of Brachioradialis during forearm rotation to determine whether it is a neutralizing muscle and a protector of hyper-rotation by eccentric contraction.
The distance from the brachioradialis (BRAR) origin to insertion was measured on 10 left fresh frozen cadaveric arms using an electromagnetic tracking system. This was done in 10¢aincrements over the full range of forearm rotation. In addition, fine-wire electrodes were placed in the BRAR of twelve living subjects. EMG data was collected as the subject rotated the forearm in both a pronating and a supinating direction.
The muscle length data shows that length is shortest at neutral and greatest closer to full rotation in either direction. When rotating from full pronation to neutral the EMG data show a steady increase while the muscle length decreases indicating a concentric contraction. When rotating from neutral to full pronation the muscle length increased and with load the EMG level increased indicating an eccentric contraction. During rotation from full supination to neutral, the EMG activity increased slightly with the muscle length, indicating a concentric contraction. When rotating from neutral to full supination, the EMG level remained variable while the muscle length increased indicating an eccentric contraction or a passive stretch.
EMG activity can occur during isometric, eccentric, or concentric contractions, the accompanying muscle length data is useful for establishing the direction of the activity. We conclude BRAR is a neutralizing muscle as it has a linear relationship with EMG activity when returning the forearm to neutral. It also acts eccentrically slowing extreme pronation and thus it has a dynamic effect on DRUJ stability.
This knowledge will assist surgeons in Tendon Transfer surgery and injury to the Brachioradialis muscle.
Change in forearm muscle length can be used to predict muscle function during pronosupination. In ten fresh cadaveric specimens, markers were placed at fifteen muscle origins and insertions. The forearm was positioned at 10° increments from 80° of pronation to 90° of supination with the elbow flexed at 90°. An electromagnetic tracking system was used to digitally collect 3D origin and insertion coordinates. These coordinates were used to create a vector representing muscle length as a straight line from the muscle origin to the muscle insertion. To normalize the data, all lengths were normalized as a percentage of the maximum muscle length for each specimen. Differences in the data were determined through paired t-test analysis.
The muscles which exhibited a significant decrease in length from pronation to supination throughout the entire range were the biceps brachii and the palmaris longus. Muscles exhibiting a significant increase over the range were the pronator teres at both the humeral and ulnar origins as well as the pronator quadratus. The brachialis also exhibited an increase, though not as pronounced. The supinator, extensor indicis and the extensor carpi ulnaris all exhibited maximum length at the neutral position while length decreased in both pronation and supination directions. The only muscle to exhibit minimal length at neutral with increasing length in each direction was the brachioradialis. The extensor carpi radialis longus kept a consistent length during pronation and increased during supination. Muscles that remained consistent during pronation but decreased their length during supination included the extensor policis longus, the flexor carpi ulnaris, and the radial and ulnar origins of the abductor policis longus. The extensor carpi radialis brevis and the flexor carpi radialis exhibited no significant change in muscle length during forearm rotation.
Forearm Rotation involves a complex interaction between the Radius and Ulna. Multiple muscles traverse the forearm en route to the hand. Many muscles change significantly in length during pronosupination. These muscles
Must adapt to this change in length to allow coordinated Upper Extremity function. Produce a force vector stressing the Distal and Proximal Radioulnar joints. Assist with Forearm Motion.
Clinical Relevance- Rehabilitation following Injury needs to take into account the effect of forearm rotation, Splint position may vary depending on which Muscle or Tendon is injured, Surgical Procedures and Implants need to be designed to take into account transverse and longitudinal forces on the forearm.
Total elbow arthroplasty is usually performed through a posterior approach. The management of the triceps tendon insertion include; Triceps division (V-Y Triceps turn down), Detachment of the Triceps insertion either by triceps splitting (Gschwind approach) or triceps reflecting (Bryan-Morrey approach), or by leaving the Triceps insertion intact (Triceps On approach). The ideal approach needs to meet three broad criteria; firstly it should be quick and easy, secondly it should offer excellent exposure and thirdly it should have low morbidity to the Triceps tendon. An approach that is also versatile provides an additional advantage.
The purpose of this study was to present and discuss the surgical technique of a “new” posterior approach to the elbow. To biomechanically evaluate and compare the strength of the Triceps tendon repair with the Bryan-Morrey approach (recently demonstrated in a cadaveric study to be the strongest of three methods of management of the Triceps tendon).
The Bryan-Morrey and Oxford approach were each performed on fourteen pairs of cadaveric elbows with the two Triceps tendon repairs carried out. The contra-lateral elbow served as the control. The specimens were then mounted on a material testing system and a constant velocity elongation was applied.
This new approach demonstrated a significant reduction in operative time as well as providing excellent exposure suitable for multiple indications. Final analysis of the data using % ultimate strength loss (%USL) compared to the control specimens as the ultimate end point showed this new approach is as strong as the Bryan-Morrey approach with %USL of −40% for both approaches.
Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland.
A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored.
33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy.
Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate.
Acoustic emission is an uncommon but well-recognised phenomenon following total-hip arthroplasty using hard-on-hard bearing surfaces. The incidence of squeak has been reported between 1% – 10%. The squeak can be problematic enough to warrant revision surgery. Several theories have been proposed, but the cause of squeak remains unknown. Acoustic analysis shows squeak results from forced vibrations that may come from movement between the liner and shell. A potential cause for this movement is deformation of the shell during insertion.
6 cadaver hemipelvises were prepared to accept ace-tabular components. A shell was selected and pre-insertion the inner shape was measured using a profilometer. The shell was implanted and re-measured. 2x screws were then placed and the shells re-measured. The results were assessed for deformation.
Deformation of the shells occurred in 5 of the 6 hemi-pelvises following insertion. The hemipelvis of the non-deformed shell fractured during insertion. Following screw insertion no further shell deformation occurred.
The deformation was beyond the acceptable standards of a morse taper which may allow movement between components, and this may produce an acoustic emission. Further in-vitro testing is being conducted to see whether shell deformation allows movement producing an acoustic emission.
Digital radiographs have taken over from conventional radiographs in most of the hospitals in New Zealand. This has created a challenge with respect to templating and pre-operative planning of total hip replacement surgeries. Digital templating has not, until recently, been available in our hospitals. Recently, a digital templating system (Cedara) has become available and has been installed and used at Middlemore Hospital and at Manukau Surgical Centre. This system allows computerised templating of digital radiographs. The aim of this study was to assess the accuracy of digital templating and to compare this method to the “compromised” conventional templating that has been performed at Middlemore hospital for the last 10 years.
In order to correct for magnification a fiducial stand has been created. This is a plastic stand and a pole with a movable 36mm metal ball. The ball is placed at the level of the greater trochanter and the stand is then placed between the patients legs. A standard templating “AP pelvis for hips” radiograph is then taken with the limbs internally rotated, such that the patellae are facing anteriorly. A traditional hard film was then created from this image for traditional acetate templating. Digital templating, with the Cedara system, was performed on the digital images after calibrating the image size using the fiducial image of known size. The results of the two methods were tabulated. The operation record was read and the component size and type was tabulated. The postoperative radiographs were assessed and the component positioning was evaluated and compared with the conventional and digital templates. A critical assessment of component size, with respect to under sizing and over sizing, was also performed on the postoperative radiographs and this was correlated with the digital and conventional templates.
This templating, and the evaluation of the postoperative radiographs, was performed by the authors of this paper (a consultant surgeon and a registrar). The accuracy of the two templating methods was assessed by comparison with the post operative radiographs and also with the aid of the knowledge of the actual components which were used at the time of surgery.
The templating images and radiographs of 100 patients were evaluated in the above stated manner and the results were analysed. The results from this analysis will be presented.
Revision arthroplasty for infected hip arthroplasty creates a challenging scenario to surgeons. Either a single stage or more traditionally a two-stage revision is performed. Most surgeons utilise an antibiotic loaded cement spacer, but the implant is often rotationally unstable predisposing to dislocation, acetabular bone loss and fracture of the spacer. Pain and discomfort on mobilisation also often occur. We would like to introduce an alternative approach to this challenging scenario with the use of a two-stage revision with an extended trochanteric osteotomy and loosely cemented hip arthroplasty as the first stage spacer.
Surgical Technique: The first stage involves removal of metal ware with all infected tissue and cement performed through an extended trochanteric osteotomy. Circlage wires reduce the osteotomy and a long stem femoral component is inserted with antibiotic infused cement limited to the calcar region. The acetabulum is similarly removed and replaced with a loosely cemented polyethylene liner. The second stage is delayed until the infection is settled and the osteotomy is healed. Removal of the metalware is performed with relative ease, without need for an osteotomy. Reinsertion of an uncemented femoral and acetabular component is then performed. However a second stage is not always required in some patients.
We report a single surgeon series comprising 10 patients from December 2003 to June 2007. The most common organism isolated was Staphylococci species. All operations were performed via a posterior approach. 9 patients were clinically assessed and the Harris hip score calculated. All patients were radiologically assessed. Osteotomies healed in all patients. Only 6 patients underwent a second stage and radiographs show good osseous integration of both components. Two patients are awaiting a second stage revision, while the other two are asymptomatic and not interested in undertaking the second stage.
No dislocations, bony erosions or reinfection was noted in our series.
We recommend this alternative approach to the conventional one or two staged revision arthroplasty. The extended trochanteric ostoetomy ensures rapid and complete removal of all foreign and infected material. The loosely cemented spacer effectively delivers local antibiotic and provides a stable, asymptomatic hip whilst awaiting the second stage, which may not be required.
Moderate to severe acetabular bone loss in revision hip arthroplasty is challenging. Various treatment options are available but the medium to long term results have not been encouraging. The porus tantalum uncemented cup may be used successfully to address moderate to severe bone loss in acetabulum revision surgery.
We report a single surgeon series. Between December 2003 and June 2007, 39 patients (43 hips) underwent hip revision surgery. There were 17 men and 23 women with a mean age at surgery of 71.9 years (range 36–96). The mean follow up was 40 months (range 24–66). A porus tantulum modular multi hole uncemented cup was used in all cases. At time of assessment 6 patients had died, 2 patients developed dementia and another 2 patients were not contactable. All 10 patients had no significant clinical or radiological concerns at their last orthopaedic review. The remaining 29 alive patients (33 hips) were available for clinical evaluation. Harris hip score of these 33 hips showed, 24 excellent or good, 7 fair and 2 poor. Radiological results: All 39 patient’s (43 hips) radiographs were reviewed. The acetabular defect was quantified according to Paprosky.
Classification taking into account the intra operative findings and pre operative imaging. The horizontal (x-axis), vertical (y-axis) distance from the ipsilateral tear drop and abduction angle were measured in both the pre-operative and post-operative radiographs. According to Paprosky’s classification there were two 2A, ten 2B, six 2C, fourteen 3A and eleven 3B defects. All 43 hips showed good osseous integration. No loosening was noticed in our series. No significant improvement was noticed in the abduction angle and x-axis but significant improvement was noticed in the y-axis indicating more anatomical positioning of the cup within the acetabulum.
One deep infection. 2 of the 5 dislocations were recurrent and successfully managed with a constrained liner. We recommend the Porus tantulum uncemented cup as a very useful implant in often very difficult situation. The mechanical properties of the trabecular metal certainly helps to positively encourages osseous integration providing a sound biological fixation and the high co-efficient of friction helps to implant these cup with as little as 30% host bone contact.
The aim was to assess the wear rate of highly Cross Linked (X3) polyethylene with the use of 36mm femoral heads in total hip arthroplasty (THA). We have previously reported our early results and raised some concern regarding the potential excessive femoral head penetration rates. These results give the 2 year wear rates following this initial bedding-in phase.
There were 100 consecutive patients who had a THA with the same femoral and acetabular components using a 36mm femoral head and X3 polyethylene that were assessed prospectively. Validated computer software (Polyware) was used to assess linear and 3 dimensional wear using standardised x-rays. Examinations were performed at 2,12,18 and 24 months.
There were 40 hips that had completed the 2 year x-ray examination (average 2.4 years). The mean 2-dimensional linear wear rate was 0.17 mm/yr and the mean volumetric wear rate was 113.73 mm3/yr. Steady state wear was achieved after the 2 month and before the 1 year examination. The steady state wear rate was 0.001mm/yr. There was no difference in wear rate with the different sized cups used and wear rate was independent of liner thickness.
The early high wear rates reported have now settled into a more expected pattern of steady state wear similar to other results presented in literature with the use of smaller femoral heads. Using a 36 mm femoral head has not adversely increased the wear rates compared to smaller head sizes when used in conjunction with X3 polyethylene in the short term for THA. These results suggest that the wear rate of X3 is not compromised even with thinner liners and raise the possibility of safely using even larger head sizes with this polyethylene.
Correct positioning of the femoral component in resurfacing hip arthroplasty (RHA) is an important factor in successful long-term patient outcomes. Computer-assisted navigation (CAS) shows potential to improve implant positioning and possibly prolong survivorship in total hip and knee arthroplasty. The purposes of CAS systems in resurfacing the femoral head are to insert the femoral head and neck guide wire with greater accuracy and to help in sizing the femoral component, thus reducing the risk of notching of the head and neck junction. Several recent studies reported satisfactory precision and accuracy of CAS in RHA. However, there is little evidence that computer navigation is useful in the presence of anatomical deformities of the proximal femur, which is frequently observed in young patients with secondary degenerative joint disease.
The purpose of this in-vitro study was to determine the accuracy of an image-free resurfacing hip arthroplasty navigation system in the presence of two femoral deformities: pistol grip deformity of the head and femoral neck junction and slipped upper femoral epiphysis deformity. An artificial phantom leg with a simulated hip and knee joint was constructed from machined aluminum. Implant-shaft angles for the guide wire of the femoral component reamer were calculated, in frontal and lateral planes, with both a computer navigation system and an electronic caliper combined with micro-CT.
With normal anatomy we found close agreement between the CAS system and our measurement system. However, there was a consistent disagreement in both the frontal and lateral planes for the pistol grip deformity. Close agreement was found only on the frontal plane angle calculation in the presence of the slipped upper femoral epiphysis deformity, but calculation of the femoral head size was inaccurate.
This is the first study designed to assess the accuracy of a femoral navigation system for resurfacing hip arthroplasty in the presence of severe anatomical deformity of the proximal femur. Our data suggests CAS technology should not be used to expand the range of utilisation of resurfacing surgery, but rather to improve the surgical outcome in those with suitable anatomy.
In this microanatomical and biomechanical study we investigated OA lesion sites and the adjacent intact tissue in an attempt to uncover clues of a pre-OA tissue state and its progression to OA.
Bovine patellae (n=30) showing various degrees of degeneration, where lesions were located in the distal-lateral quarter, were used for the microanatomical study. Cartilage-on-bone samples were cut to include one with the lesion site and the other with the adjacent intact site. These blocks were formalin fixed. For the mechanical testing tissue samples (n=20) ranging from intact to mildly through to severely degenerate were statically compressed (7MPa) to near-equilibrium using a cylindrical indenter, and then formalin-fixed to capture this deformed state. Following mild decalcification of both sets of tissues, full-depth cartilage-bone cryo-sections incorporating the intact-lesion transition and the deformation profile were obtained and studied in their fully hydrated state using differential interference contrast optical microscopy (DIC).
There were three mechanically-significant microstructural features of the cartilage-bone system that varied with tissue degeneration:
the integrity of the strain limiting surface layer, the degree of transverse interfibrillar connectivity, and the degree of calcification at the osteochondral junction (zone of calcified cartilage).
Importantly, our mechanical analysis showed how disruption of the cartilage continuum by surface disruption and matrix fibrillar de-structuring, had wider mechanical consequences at the biologically-active osteochondral junction of the adjacent healthy cartilage. The structural changes in the osteochondral junction beneath the still-intact articular cartilage adjacent to the lesion site included the ‘sprouting’ of bone spicules or cones that were morphologically similar to those associated with primary bone formation.
The microanatomical and micromechanical data suggests that there is a mechanobiological link between the altered microstructural response of degenerate cartilage to load and the way in which structural changes develop in the normal adjacent tissue. We propose that while the progression of OA involves first the processes of new bone formation in tissue adjacent to lesion sites, its initiation is due to a disrupted cartilage matrix that alters a regional mechanical environment that includes adjacent healthy tissue.
Developmental Hip Dysplasia (DDH) presents considerable technical challenges to the primary arthroplasty surgeon. Autogenous bulk grafting using the femoral head has been utilised to achieve anatomic cup placement and superolateral bone coverage in these patients, but reported outcomes on this technique have been mixed with lack of graft integration and subsequent collapse seen as an early cause of failures. Achieving union and incorporation of the autogenous graft have been identified as key determinants of a successful outcome with this technique. The main factors affecting incorporation are stability of the construct and host-graft bone contact. We describe a novel technique combining the use of bulk autograft with an iliac osteotomy, which provides primary stability and optimises direct cancellous-cancellous bone contact.
21 hips in 21 patients with DDH underwent this technique and were followed for a mean 8.1 years. The pre-operative radiographic classification was Crowe type I in 12 hips (57%), type II in 4 hips, and type III in 5 hips, and the mean Sharp angle was 49.6° (range 42–60°). All grafts united by year. At time of follow up, there was no radiographic evidence of graft collapse or loosening. There were no reoperations.
Our study has shown that this technique variation combining an iliac osteotomy with bulk autograft in cases of developmental hip dysplasia provides early stability and reliable graft incorporation, together with satisfactory clinical and radiological outcomes in the medium term. Longer term study is necessary to confirm the clinical success of this procedure.
Aseptic loosening is the leading cause for revision in total hip arthroplasty. Retro-acetabular lysis is often a silent process until severe bone loss causes catastrophic failure. This presents a technically difficult problem for the surgeon and a poorer result for the patient compared to primary arthroplasty. While the major cause of osteolysis is reaction to polyethylene particles, there is little data on the initiation and progression of such lesions. Further, alterations in the mechanical environment caused by such pathology is unclear. We present our use of 3D, finite element (FE) models of retro-acetabular pathology to investigate the biomechanical effects of osteolysis in total hip arthroplasty. Axial CT scan slices from a patient with cystic osteolysis were selected. Areas of cortical bone, cancellous bone, the cup and the cyst are accurately identified. The axial images are matched to a predetermined grid and used to build a complex finte element model. In this way complex anatomy can be built into the FE model and used to map cystic lesions. Force is then applied to the acetabulum.
Initial analysis shows similar stress transmission in cystic disease compared to the post operative pelvis. Pelvic bone still behaves as a sandwich construct with transmission from the acetabulum to the SI joints, pubic symphysis and medial wall. In the setting of pelvic medial wall deficiency, stress transmission is altered with areas of low stress around the defect.
The FE models containing pathology can be compared to models with generic bone density values immediately after total hip arthroplasty. The presence of a cyst in cancellous bone with intact cortical bone, demonstrates strain patterns similar to the post operative pelvis. Once cortical bone loss occurs strain patterns begin to change. This may mark a critical point in osteolytic progression. We present a developing new tool to be used in the assessment of a patient population with retroacetabular cystic disease.
Statistics New Zealand states “Over the next five decades the 65+ dependency ratio is projected to more than double, from 18 (people aged 65+ years) per 100 (people aged 15 – 64 years) in 2006 to 45 per 100 in 2061. This means that for every person aged 65+ years, there will be 2.2 people in the working-age group in 2061, compared with 5.4 people in 2006 “. This will have a profound impact on health care, specifically in those fractures sustained by the elderly e.g. fractured neck of femur (#NOF).
Also at present little is proven regarding outcome following #NOF in the New Zealand population. These two factors (population change and patient outcome) led to disagreement and healthy debate at the 2008 NZOA ASM. After a pilot study in Dunedin we have examined national electronic records of 52,456 patients presenting with a first admission due to #NOF over the last 20 years.
The mean age at which a patient sustained their first #NOF was around 80 and 71% of these patients have since died. Approximately 10% of patients had a subsequent readmission for #NOF. There was a trend for increasing age over the last twenty years proportional to the increased average age of the general population. One year survival was 75% and mean survival was 3½ years with a third of patients living longer than six years. We found differences in outcome for gender and fracture type (intracapsular vs. extracapsular). Our patients also showed a trend to higher survival risk ratios (i.e. they are clinically “sicker” than they used to be). The incidence of #NOF has increased over the last 20 years with a projected doubling in the number of cases (to 5600 per year) at around 25yrs from now based on the most conservative estimates.
Drug Free Sport New Zealand (DFSNZ) aims to maintain New Zealand Sport as a drug free environment and thereby enhance our proud and successful sporting culture. New Zealand is bound into the World Anti-Doping Code and must therefore adhere to World Anti-Doping rules.
Detection of doping violations is one of the functions of DFSNZ. An aim of DFSNZ is to eliminate the risk of athletes failing a sports anti-doping test as a result of using legitimately prescribed medication as treatment without a Therapeutic Use Exemption (TUE). This can create major problems for the athlete who may then have to appear before the Sports Tribunal.
Some substances on the prohibited list are used by Orthopaedic Surgeons as part of regular management. “National level” athletes require a TUE to be completed prior to use of these medications or immediately following use in emergency situations. Examples are:
Narcotics and Intravenous Corticosteroids perioperatively. Probenecid to enhance antibiotic concentrations in treating infections
Other athletes who are not in this category but may be tested do not require a TUE immediately but still have to be able to provide evidence that the medication was used for therapeutic use if they were subsequently to fail a test. It is the athlete’s responsibility to notify the surgeon and obtain the appropriate documentation. Athletes in the Testing Pools will carry a card with reference to MIMS Resources, the DFSNZ website and Hot-line. From time to time athletes stressed by the situation of their injury may forget to notify the surgeon, prior to surgery, of anti-doping requirements. Surgeon (and anaesthetist) awareness and support for the programme will enhance the overall care of the patient and limit subsequent demands on both the patient and medical staff. The aim of this presentation is to enlighten NZOA members regarding the correct procedures to follow should a prohibited substance be required when treating an athlete who is subject to drug testing in sport.
Replacement of damaged or diseased tissues with permanent metal implants based on stainless steel, cobalt chrome and titanium alloys has been at the forefront of classical biomaterials research and the orthopaedic medical device industry for decades. Biodegradable polymers have also reached the market but often have limited capacity in load bearing orthopaedic applications due to their low stiffness and poor mechanical properties. The development of biodegradable metals based on magnesium (Mg) could be heralded as a major breakthrough in the field of orthopaedic surgery. Degradable implants eliminate the time and cost associated with a secondary surgery to remove hardware, and reduces the period the implant is exposed to instability, fibrous encapsulation, stress shielding and inflammation. The metabolism of Mg and its excretion via the kidneys is a natural physiological process that is well understood, however, controlling the rapid degradation of Mg biomaterials in vivo is a major challenge yet to be resolved for the safe and effective use of Mg in orthopaedic implants.
In this study, we describe a novel manufacturing method for fabricating Mg/Mg alloy implants, as well as the development of an in vitro method for screening Mg/Mg alloy degradation rate by considering both their electrochemical corrosion behaviour and biological characteristics.
A range of Mg alloys with varying amounts of calcium (0.8–28%) and zinc (3–10%) were cast and then machined into Ø4mm and 15mm discs for biocompatibility (HETCAM) and parallel in vitro testing. Alloys were placed in various simulated body fluid (SBF) solutions in vitro (7–28 days) to determine effect of alloy composition on degradation rate. These potentiostatic and potentiodynamic tests were designed to simulate, to varying degrees, the in vivo environment, with the crucial factors (e.g. temperature, pH, serum proteins, CO2 level) controlled to ensure consistency across the test methods. The mechanisms of corrosion on the Mg/Mg alloy microstructure and the effect of protein adsorption all played key roles in dictating the corrosion of alloys in vitro. Specifically the inclusion of physiological levels of serum proteins decreased the corrosion rate up to 600% over more standard SBF solutions described in literature.
This work provides an improved understanding of the effects of corrosion variables on Mg alloys, while making major steps towards deciding the most appropriate screening tests for new alloys for their use as a biomedical material prior to moving to in vivo animal studies.
We reviewed the charts of all patients (126) with a soft tissue tumour referred to the senior authors in 2006 and 2007. The information was stored in a prospective Tumour Registry Database. Where information was not available in records kept at our institution, the referring institution was contacted.
There were 92 tertiary referrals and 34 GP referrals. The majority of the tertiary referrals came from orthopaedic surgeons (55), and general surgeons (28). The mean duration between referral and review was 16 days (0–215 days). There was a of 13 days wait for tertiary referral review. Tissue samples and histology reports accompanied 33 patients which had resulted from 35 invasive Pre Referral Procedures (PRP). This group suffered 21 complications affecting 18 patients. The remainder (91) were Pre Biopsy Referrals (PBR). Biospy was deemed necessary in 47 cases. The PBR group suffered 4 complications. Only one complication occurred to a patient with benign histology in each group. There was an extremely significant relationship between Pre Referral Procedures and suffering a complication (P< 0.0001). The relative risk of complication was 6.2 (C.I. 2.0–18.4) if an invasive procedure was performed prior to referral. There were 3 amputations (plus one recommended but refused by patient) in the PRP group and 1 amputation in the PBR group. This was not statistically significant. The median interval between referral and senior author review was 8 days for the PRP group and 10 days for the PBR group (P=0.2574). Sixty six percent of tertiary referrals were PBR (74% when including GP referrals).
Biopsy of suspected appendicular Soft Tissue Sarcoma should be done by a tumour specialist or in prior consultation with one. There is virtually no delay to see an orthopaedic tumour specialist in New Zealand and achieving a tissue diagnosis does not expedite this.
Osteoporosis affects over 350,000 New Zealanders including 30% of women aged over 60 years and more than half aged over 80. Osteoporotic fractures are a significant cause of morbidity and mortality. From July 1999 to 30 June 2000, 3131 people aged over 65 sustained a fractured neck of femur. 27% died in the subsequent 12 months, equating to 17% of all cause mortality. Fractures are also a significant economic burden. In the period, July 2005 to June 2006, over $18 million was spent on hip fractures in those aged over 65 years. Bisphosphonates improve Bone Mineral Density and consequently reduce the incidence of fracture; however oral bisphosphonates are contraindicated in some patients. Zoledronate is an intravenous bisphosphonate that has recently been licensed for osteoporosis treatment.
We undertook a retrospective chart review and General Practitioner consultation of CMDHB patients who received zoledronate from June 2006 to June 2008. Assessment of clinician compliance with current safety protocols, patient outcomes and side effects were assessed. 78 patients received 101 doses of zoledronate, approximately double the preceding 2 year period (37 patients and 60 administrations). The most commonly indication was osteoporosis. 19% (19/101) administrations were organised through the geriatric clinic and 81% (82/101) were inpatients
Bone Mineral Densities within 2 years were available for 59% (48/82) of administrations. 80% (51/64) had previous osteoporotic fractures. 84% (54/64) of osteoporotic patients were utilising additional calcium and vitamin D therapy. Oral bisphosphonates were contraindicated in 94% (60/64) because of gastrointestinal upset, 3% (2/64) for headaches and 3% (2/64) for worsened BMD despite oral bisphosphonates. Following treatment 13% (8/64) of patients sustained further fractures. In inpatient administration 83% (21/82) pre-creatinine and 80% (66/82) post-creatinine measurements were appropriately assessed in comparison to 58% (11/19) and 79% (15/19) respectively for clinic patients. In inpatients administration 59% (48/82) pre-calcium and 63% (52/82) post-calcium measurements were appropriately assessed in comparison to 37% (7/19) and 68% (13/19) respectively for clinic patients. For GP follow-up of creatinine and calcium measurements, 90% had creatinine and 80% had calcium correctly assessed. Zoledronate was well tolerated with no jaw osteonecrosis in this cohort.
Zoledronate is a well tolerated treatment for osteoporosis in those patients intolerant of oral bisphosphonates. The use of zoledronate has more than doubled in the last 2 years. Stricter adherence to current guidelines is needed to prevent incipient adverse effects.
After 2 fatalities from this condition at our institution in 2005, a retrospective review of elective surgical records from the previous five years was undertaken and we established 16 further non-fatal cases of Ogilvie’s Syndrome. (This work was presented as a poster at the Christchurch NZOA 2005). We have since prospectively recorded any occurrence of Ogilvie’s Syndrome after elective orthopaedic surgery.
Over the last 2 years since the previous report, we have identified a further 8 cases of Ogilvie’s Syndrome, with one further fatality. This little-known condition is far more prevalent than thought, and is often not diagnosed despite severe consequences. All surgeons should be aware of this condition. Early recognition and intervention is critical to patient survival. Hallmarks of the clinical presentation will be discussed, along with acute management guidelines.
A unit of 12 orthopaedic surgeons serving a population catchment of 180,000 have collaborated to collect prospective data on a wide range of orthopaedic conditions, using well proven internationally validated scoring systems. All patients, rural and urban, public and private, in the region are being enrolled. This project is distinct from but complementary to National Joint Registry data. A benchmarking period of 2 years has been completed, and now prospective trials are being commenced. 4000 patient datasets have been obtained to date.
We report on the logistics of establishing a regional research program in a medium-sized New Zealand centre, and results achieved to date. We present our experience with a view to encouraging other centres to consider similar ventures.
Non-image based navigation has catalysed an ongoing revolution in total knee arthroplasty technique. Few systems, however, have been designed and subsequently analysed in UKA. A new system designed for use with the Oxford UKA prosthesis offers two ways to determine the ideal tibial resection depth for insertion of the tibial component of the prosthesis. Tibial resection may be calculated using femoral or tibial referencing. Clinical experience suggests that femoral referencing calculates tibial resection depth incorrectly. We set out to confirm whether femoral referencing is, in fact, less accurate than tibial referencing in calculating tibial resection depth in this new navigation system, and to determine factors responsible.
The navigated procedure for UKA was carried out on an artificial limb to the point of tibial resection using the latest Vector Vision-Biomet-BrainLAB navigation system. The depth of resection achieved was measured and the procedure repeated in multiple series using femoral and tibial referencing. Intraoperative flexion angle and joint space were altered to assess their effect on accuracy. Analysis of variance revealed that femoral referencing is less accurate than tibial referencing (p = 0.001). Though intraoperative hyperflexion and increased joint space width exacerbated the inaccuracy, their contribution did not achieve significance (p = 0.078 and p = 0.02, respectively).
We propose that femoral referencing be omitted as an option in the determination of tibial resection depth in this system. This study has revealed an inaccuracy in a commercially available navigation system that can result in a prolonged and more complicated procedure, suggesting that more stringent pilot assessment of orthopaedic products is needed.
Navigation in total knee replacement is now used more frequently. The proven benefits in comparison to a conventional knee replacement include reduced hospital stay, reduced blood loss, and improved component alignment. A retrospective study was carried out to evaluate the difference in post-operative pain outcomes between conventional and computer-assisted navigation knee arthroplasty in a high volume setting. Computer-assisted surgery may be more painful because of the extra pin holes required for the navigation. The amount of anti-emetic use between the two groups was also looked at as evidence exists that greater anti-emetic is used if pain levels are greater.
All the navigated arthroplasty operations were performed by one of two surgeons in a single hospital using a uniform surgical approach and navigation system. A single type of prosthesis was used in the conventional group. In the first part of the study, the navigated group consisted of 87 patients and the conventional group of 40 patients (total = 127 cases). In the second ‘antiemetic use’ study, the navigated group consisted of 71 patients and the conventional group of 39 (total = 110). The analgesic and anti-emetic use was collated for the 72-hour post-operative period. This was chosen so that any analgesic influence of the anesthetic would have been negated over this period.
Pain scores were measured over the 72 hour period at regular intervals using a visual analogue scale. Patients in the navigated group seemed to report less pain in the first 24 hours but this was later reversed. Interestingly, their pain scores were more constant during this period, whilst the conventional group exhibited greater variability. The actual difference in pain scores between the two groups was however not significant (p=0.33).
The amount of opioid used by patients in each group was the primary factor used to see if a difference exists between the two procedures. The assumption was made that a correlation exists between opioid usage and pain. The total opioid usage was calculated by using referenced opioid conversion calculations for intravenous and oral forms of morphine including weaker opioids such as codeine and tramadol.
The average opioid used in the conventional group was 164.8 mg whilst in the navigated it was 173.7mg. However using the Student’s t-test this difference was not significant with a p value = 0.69. The percentage of patients requiring opioid greater than 300mg in 72 hours was actually greater in the conventional group (15% vs 12.6%).
The average antiemetic use looking initially at cyclizine was 57.7mg in conventional and 50.4mg in the navigated. This difference was also not significant (p=0.59).
On analysis of the tourniquet times between the groups it was noted that the average time for a conventional operation was 89.6 minutes whilst it was 88.6 minutes in the other. This is in contrast to previous findings and it seems that the learning curve is improving at least in this high volume setting.
This paper suggests that there is no difference between the two groups with respect to pain experienced in the post-operative period.
Malalignment of more than three degrees in coronal plane was associated with poor outcome. Most of the alignment occurred in the tibial coronal plane alignment. Computer assisted surgery (CAS) in total knee arthroplasty (TKA) aimed to minimize malalignment. Most of the CAS-TKA results were using infrared tracking system. Electromagnetic navigation in total knee arthroplasty was developed in recent years. It aimed at high accuracy and easy signal detection. However, there was limited result being published.
From August, 2006 to March, 2008, 50 patients had TKA performed with Medtronic electromagnetic navigation (EM CAS-TKA). The results were compared with 50 matched patients who had TKA performed with conventional technique. The post-operative limb alignments were compared. More than three degrees deviation from neutral alignment was defined as outliers.
There was no significant difference in the age, sex distribution, pre-operative range of motion and pre-operative deformity between the two groups. EM-CAS TKA group had significantly less deviation from neutral in the tibial coronal plane (p < 0.001) and femoral sagittal plane (p = 0.006) plane than conventional group. There was no significant difference in femoral coronal plane and tibial sagittal plane alignment between the two groups (p = 0.069 and 0.185 respectively). There were significantly more outliers (> 3 malalignment) in tibial coronal plane (p = 0.004) and femoral sagittal plane (p = 0.049) in conventional group than EM-CAS TKA group. There was no significant difference in the outliers in femoral coronal plane, and tibial sagittal plane (p = 1 and 0.1 respectively). The mean tourniquet time of the EM-CAS TKA group, 95.7 minutes (range, 65 to 126 minutes), was significantly higher than the conventional group, mean 72.1 minutes (range, 45 to 120 minutes), p value < 0.001. There was no pin tract complication and infection in the electromagnetic navigation group.
Electromagnetic navigation had improved the tibial coronal plane and femoral sagittal plane alignment in total knee arthroplasty with less outlier. Better alignment may improve the survival of the prosthesis. The learning curve is short and it is easy to handle. Electromagnetic navigation has the potential application in minimally invasive total knee arthroplasty.
Uncemented total knee arthroplasty (TKA) implants were designed as an alternative to cemented implants. However, critical studies revealed a unique set of complications. At the same time, cemented prostheses continue to yield excellent results. To address some of the issues with uncemented implants, porous coatings were introduced. This follow-up study reports the early results of Plasmapore® coating in Navigated uncemented rotating platform TKA.
277 patients who had consecutively undergone a Navigated TKA procedure with the e.motion knee endoprostheses were followed up at the Bluespot Knee Clinic in Blackpool, UK. Of these 277 patients, 91 received an uncemented TKA between May 2005 and September 2007. The prosthesis is coated with a 350μm plasma-sprayed titanium layer. All procedures were carried out by the senior author (SACS). The Orthopilot navigation system was used to accurately restore the axial alignment of the implants.
Men comprised 51% and women 49%. The mean age was 69 years and the mean BMI was 30. There were 50 right and 41 left knees. The mean operating time was 59 minutes. Of the 91 patients who received an uncemented e.motion TKA, 84 patients had at least 1 follow-up assessment. The average follow-up period for these 84 cases was 7 months. The integrated Knee Society Score (KSS) defined as the sum of functional and clinical KSS, was recorded for all 91 patients preoperatively and had a mean of 78. The KSS had increased to 182 after 4 months, 193 after 1 year and 198 after 2 years. Oxford score was recorded for 87 of the 91 patients preoperatively. The average preoperative score was 44. It had decreased to 18 after 4 months, and 16 after 1 year and 13 after 2 years.
Radiological examination showed no evidence of periprosthetic lucency and no subsidence.
There were 5 DVTs with 2 pulmonary embolisms, 2 cases of reflex sympathetic dystrophy, 2 stitch abscesses, 2 haematomas, and 9 cases of wound erythema. These preliminary findings compare favourably with published series of cemented TKAs. They have prompted a more detailed review which is in progress.
Recent studies suggest the use of computer navigation during TKA can reduce intraoperative blood loss. The purpose of this study was to assess if navigation affected blood loss after TKA in the morbidly obese patient (BMI> 40).
Total body blood loss was calculated from body weight, height and haemotocrit change, using a model which accurately assess true blood loss.
The computer navigated group comprised of 60 patients, 30 with BMI > 40 and 30 with BMI< 30. The matched conventional knee arthroplasty group consisted of 62 consecutive patients, 31 with BMI> 40 and 31 with BMI< 30 The groups were matched for age, gender, diagnosis and operative technique.
Following TKA, the mean total loss was 1014mls (521-1942, SD 312) in the computer assisted group and 1287mls (687-2356, SD 330) in the conventional group. This difference was statistically different (p< 0.001). The mean calculated loss of haemoglobin was 19 g/dl in the navigated group versus 25 g/dl in the conventional group; this was also significant at p< 0.01. The mean total loss was 1105mls in patients with a BMI> 40 in the navigated group compared to 1300mls in the conventional group (p< 0.01). A significant correlation was found between total blood loss and BMI (r=0.2, p< 0.05).
This study confirms a highly significant reduction in total body blood loss and calculated Hb loss between computer assisted and conventional TKA in obese patients. Therefore navigation-assisted TKA could present an effective and safe method for reducing blood loss and preventing blood transfusion in obese patients undergoing TKA.
Many studies have already been published to prove the improved accuracy in achieving the ideal post-operative long leg alignment when using computer navigation in total knee arthroplasty (TKA). Surgeons who use traditional instrumentation with a fixed distal femoral resection angle (most commonly 6°) assume little or no variation in the angle between the anatomical and mechanical axis of the femur (FMA angle) in different patients.
The aims of this study were to investigate the distribution of the FMA angle in pathological knees of patients about to undergo TKA and to analyse if there was any correlation between the FMA angle and the pre-operative lower limb alignment in the coronal plane (varus or valgus).
The study consisted of 158 consecutive patients undergoing 174 primary TKA between January and October 2007. All patients had pre-operative digital Hip-Knee-Ankle radiographs. The FMA angle and the mechanical femorotibial angle (MFT angle) were measured in all cases. Intra- and inter-observer variation was measured by second observer readings and repeated measurements.
The mean age of the study cohort was 69.9 years (SD 8.7 years). There were 75 male and 99 female knees. The repeatability for measurement of the FMA angle was good (intra-observer Intra Correlation Coefficient (ICC) = 0.91, inter-observer ICC = 0.85) and for the measurement of MFT angle was very good (intra-observer ICC = 0.99, inter-observer ICC = 0.99). There were 135 knees with a varus or neutral alignment and 39 knees with valgus alignment. The median alignment was 6.5° varus ranging from 23° varus to 16° valgus. The FMA angle was between 2° and 9°, with a median of 6°. The FMA angle was 6° in 35.4% of cases, 5° in 22.9% and 7° in 18.3%. There was a statistical significant correlation between the FMA angle and the pre-operative lower limb alignment (Pearson correlation coefficient = −0.5, p < 0.001), with valgus knees having on average a lower FMA angle. The group of females and males had statistically different FMA angles (Mann-Whitney, p < 0.001) with females having on average a lower FMA angle. Cluster analysis based on the original clinical definitions of severe varus, varus and valgus gave three groups of FMA angle for MFT angle < 8° varus, MFT angle of 8° varus to 1° valgus and MFT angle > 1° valgus. There was a statistically significant difference in median FMA angle between these three groups (Kruskal-Wallis, p < 0.001).
This study indicates that one of the main reasons why optimal post-operative coronal alignment cannot be achieved with a fixed distal femoral resection angle is the fact that the FMA angle has a wide, natural distribution. It is possible that better results may be achieved with traditional instrumentation by individual measurement of FMA angle for each patient pre-operatively and adjusting the distal femoral resection to account for this. However, with computer navigation the distal femoral cut is adjusted for each patient.
Previous studies of osteoarthritic knees have examined the relationship between the variables body mass index (BMI) and weight on the one hand and coronal plane deformity on the other. There is a consensus that weight and BMI are positively correlated to the degree and progression of a varus deformity. However, there does not appear to be a consensus on the effect of these variables on knees with a valgus deformity. Indeed, the view has been expressed that in knees with a severe deformity a relationship might not exist. A review of these studies reveals that in all cases, the alignment of the lower limb was obtained from a standing antero-posterior long leg radiograph. In no cases was the deformity in the sagittal plane measured. This study analyses the relationship between BMI, weight, deformity in the sagittal plane and valgus deformity.
The study group consisted of 73 patients with osteoarthritis and valgus knees. All of them had failed conservative treatment for their symptoms and were listed for navigated TKA. Their weight and height were measured two weeks preoperatively and the BMI calculated. At operation the coronal and sagittal deformities were measured using the Orthopilot® navigation system (BBraun Aesculap, Tuttlingen). The results were analysed using SPSS 15.
Regression analysis showed a significant relationship (p< 0.05) with a negative correlation between valgus deformity and weight. the correlation coefficient for flexed knees (−0.59) showed a moderately strong relationship whereas that for extended knees (−0.38) showed a relatively weak relationship.
It is acknowledged that there is an increased force on the lateral compartment with increased valgus deformity. a larger deformity causes a larger moment arm about the centre of the knee. this study has shown that at the time of surgery, individuals with lower weights have larger valgus deformities. we postulate, therefore, that when the moment due to the weight of the individual and the length of the moment arm exceeds a certain value, a symptomatic threshold is crossed. in the presence of a fixed flexion deformity, the force on the patella-femoral joint is increased, contributing further to the onset of discomfort.
Further investigation into the subsets of valgus knees appears to be warranted.
Oxford medial uni compartmental knee replacement is a common and widely accepted procedure that relies on accurate positioning and alignment of the implants for optimal outcome and longevity. Posterior slope of the tibial base plate has been shown to be an important factor affecting long term survivorship.
The aim of the study was to evaluate whether navigation increased the accuracy of Oxford knee replacements using the posterior slope of the tibial component as an index measure.
The posterior slope of tibial trays from 58 sequential Oxford medial unicondylar knee replacements over a two year period was checked on standard lateral x-rays against the recommended range.
There were 12 cases in the navigated and 46 in the conventional group across six Orthopaedic firms. The mean posterior slope for navigated and conventional implantations was 4.75 and 3.3 degrees respectively with the difference not being statistically significant. However, when considering the data for low volume surgeons, the mean posterior slope with and without navigation was 4.75 and 1.83 degrees respectively which was significant with a p value of 0.017. Navigation was also found to significantly decrease the chance of implanting the knee with the posterior slope outside the acceptable range (p=0.024). In both analyses the navigated cohort had a narrower data spread and fewer outliers compared to the conventional group. No other factors were found to significantly correlate with the posterior slope.
The study suggests that navigation might help low volume surgeons in increasing the accuracy and decreasing the incidence of extreme variations from the desirable range of implant positioning for unicompartmental knee replacements.
The orthopaedic unit at the Golden Jubilee National Hospital consists of eight consultant orthopaedic surgeons who have a varied practice with regard to navigated TKA with some surgeons using navigation for all cases, some for what are deemed difficult cases and others using it rarely or not at all. One mechanical jig-based system and two different navigation systems are in routine use. The results from the two navigated (nav 1 and nav 2) and non-navigated (non-nav) systems were audited and compared with published studies to determine whether the reported results from randomised controlled trials were reproduced in our routine practice. The primary outcome measure was the mechanical femorotibial (MFT) angle as measured by Hip-Knee-Ankle (HKA) radiographs. This is a standard outcome measure that allowed ready comparison with other studies.
Demographic data and post-operative MFT angles were collected retrospectively for each patient. The HKA digital radiographs (stored on a Picture Archive and Communication system) were taken six to twelve weeks post-operatively. The MFT angle was measured using a standardised protocol, which used the method of Mose to find the centre of the femoral head, the highest point in the femoral notch as the centre of the knee and the middle of the talus for the centre of the ankle. Repeated measurements were taken to identify intra- and inter-observer error.
There were 86 patients in the nav 1 series, 95 in nav 2 and 95 in non-nav. Mean age was nav 1 = 70, nav 2 = 69 and non-nav = 71. Mean BMI was nav 1 = 34, nav 2 = 31.5 and non-nav = 30. Male to female ratio was nav 1 = 51:35, nav 2 = 44:51 and non-nav = 30:65. Intra- and inter- observer comparison showed a maximum difference of 1° for the measurement of MFT angle. For series nav 1 74% of TKAs had a MFT angle in the range ±3°, for series nav 2 this was 85% and for the non-nav series it was 68%.
Much of the literature on RCTs for navigation vs. non navigation outcomes in TKA indicates that over 93 % of patients undergoing navigated TKA have a mechanical axis alignment within the ±3° range, with non-navigated techniques having 73–87% within this range [
Our aim was to determine the effects of tibial component malrotation and posterior slope on knee kinematics following Scorpio cruciate retaining total knee replacement in cadaver specimens.
The movements of the hip, thigh and lower leg were monitored in 3D using a validated infra-red Computer Navigation System via bone implanted trackers. Ten normal comparable cadaver specimens were mounted in a custom rig allowing 3D assessment of kinematics under various loading conditions. The specimens then underwent Navigated TKR as per normal operating surgical protocols however an augmented tibial component was implanted. This allowed the researchers to precisely modify the rotation of the tibial component around its predetermined central axis, as well as to alter the posterior slope of the component. A pneumatic cylinder was used to provide a simulated quadriceps extension force while the knee was tested with a variety of applied loads including anterior and posterior draw, abduction and adduction, internal and external rotation.
TKR kinematics are significantly different from those of the native knee (p< 0.05). Increasing tibial posterior slope resulted in an incremental posterior position of the femur (p< 0.05), deviation of the neutral path of motion (p< 0.05) and alteration of the normal AP envelope of laxity (p< 0.05). Tibial component malrotations over 10 degrees resulted in increasing deviations of the neutral movement path of motion (p< 0.05) without significantly affecting the envelope of laxity. Tibial component malrotations of more than 10 degrees, when combined with a posterior slope of six degrees or more, resulted in prosthetic subluxation under certain loading conditions.
This study has demonstrated significant differences in knee kinematics before and after total knee implantation. Increasing values of internal and external rotation, as well as posterior slope of the tibial tray resulted in further deviations of total knee kinematics from normal by altering the neutral path of motion and the soft tissue envelope, with combined misalignments resulting in the greatest deviations from normal with prosthetic subluxation in some cases. Deviations from normal kinematics may result in increased ligament tension and incongruence or dysfunction of the component articulations, with the generation of sheer forces in the gait cycle. These may contribute to premature wear and loosening. Surgeons should be aware of this when considering the addition of posterior slope or assessing tibial component positioning in TKR.
Individuals learn to master new motor skills (such as learning a new surgical technique) by evaluating available feedback to alter future performance. Continuous concurrent augmented feedback is supplementary information presented to the learner throughout the performance of a task. An example of this type of feedback is the visual information provided by computer navigation during arthroplasty surgery. This type of feedback is a potentially powerful tool for learning because it theoretically guides the learner to the correct response, reduces errors, and reinforces correct actions. However, motor learning theory suggests that this type of feedback may impair learning because of development of dependence on the additional feedback or distraction from intrinsic feedback. In the current era of reduced number of training hours it is essential to assess the role of computer navigation on trainees.
Our objective was to determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty. We conducted a systematic review and critical appraisal of the literature. There is some evidence from randomised controlled trials that navigation use by trainees facilitates accurate placement of arthroplasty components compared to conventional instrumentation. There is no evidence that training with computer navigation impairs performance in retention tests (re-testing on same task after an interval of time) or transfer tests (re-testing in different conditions i.e. without concurrent feedback).
We conclude that although there are significant limitations of the published literature on this topic there is no available evidence that supports concerns regarding the theoretical detrimental effects of computer navigation on the learning curve of arthroplasty trainees.
There have been mixed reports of the contribution of the anterior cruciate ligament (ACL) to the overall envelope of tibial rotational stability. The effect of single bundle ACL reconstruction on the separate components of internal and external rotational stability respectively is also unclear.
We determined the internal and external rotation, and antero-posterior movement of the knee before and after single bundle computer assisted reconstruction of the anterior cruciate ligament (ACL) in 57 patients. The Orthopilot® ACL (v2) software (BBraun, Aesculap) was used.
The mean overall range of tibial rotation was also significantly reduced from 30.5 degrees to 16 degrees (p< 0.0001). The mean internal rotation was significantly reduced from 16 degrees to 8 degrees (p< 0.0001). Mean external rotation was also significantly reduced from 15 degrees to 8 degrees (p< 0.0001). Unlike previous studies we did not find a greater reduction of internal rotation compared with external rotation. The mean antero-posterior movement of the tibia was significantly reduced from 12mm to 4mm (p< 0.0001).
The results of this study seem to indicate that computer assisted single bundle ACL reconstruction results in a significant intraoperative improvement in both internal and external rotatory stability as well as a significant improvement in antero-posterior stability.
Unicompartment knee arthroplasty (UKA) was proven to be one of the standard treatments of medial compartment osteoarthritis. The key to success was restoration of pre-operative alignment. Overcorrection of coronal (AP) alignment may predispose to early osteoarthritis in the contralateral compartment, change in post-operative tibial slope may predispose to proximal tibial bone collapse and loosening of tibial prosthesis. Minimally invasive surgery (MIS) in UKA was developed quickly in the last ten years. However, MIS has limited access to visualize the surgical field and limb alignment. Computer navigation may help the surgeon to place the component in more accurate position. We aim to study the radiological alignment of computer assisted MIS UKA.
Eighteen patients with UKA (PreservationTM, all poly tibia, DePuy Orthopaedics Inc, Warsaw, IN) implanted using MIS technique were studied prospectively. The CiTM system (DePuy International Ltd, Warsaw IN) were used for computer navigation. Five male and 13 female patients were studied. The mean age of the patients was 58.2 (range, 45 to 70). All patients had medial compartment osteoarthritis with varus deformity. The postoperative coronal (AP) alignment and tibial slope of the operated limb were compared with the pre-operative alignment for any significant difference.
The mean pre-operative and post-operative radiographic coronal (AP) alignment of the operated limb were 8.4° varus (range, 2° to 12°) and 7.2° varus (range, 1° to 15°) respectively, the difference was not significant (p = 0.537). The mean pre-operative and post-operative tibial slope were 6.8° (range, 3° to 11°) and 5.8° (range, 3° to 10°) respectively, the difference was not significant (p = 0.066). The post-operative tibial slope correlated well with the intra-operative tibial slope recorded by computer after bone cut was made (Cronbach’s Alpha = 0.771). The mean tourniquet time was 124 minutes (range, 94 to 140 minutes).
There was no significant difference in pre-operative and post-operative coronal alignment of the operated limb. Computer assisted MIS UKA could reproduce the pre-operative coronal alignment and tibial slope. Restoration of the pre-operative limb alignment in coronal plane and tibial slope was crucial to the survival of UKA. Computer navigation could help the surgeon to position the component during minimally invasive surgery. However, the learning curve of computer assisted MIS UKA was steep.
Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous methods.
We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. During the entire procedure, the tool navigator was used frequently to reconfirm the location and the depth of burring. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.
The age of the patients varied from 10 years to 27 years. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it was attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.
Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.
Computer-assisted surgical techniques in knee replacement procedures have been shown to increase the accuracy of implant positioning and reduce the incidence of alignment and soft-tissue balancing “outliers”. The use of this technology as a training tool is less widely reported. However, the recent implementation of the EWTD 48-hour working week for junior doctors has focussed attention on the issues of surgical training and experience. Recent evidence from trainee logbooks has shown a significant downward trend in operative exposure and this is forcing changes in the principles of how training should be delivered. Trainees are actively required to demonstrate operative competence in order to progress but are increasingly faced with limited opportunities to acquire these skills. On the other hand, trainers also face difficulties with the prospect of supervising less accomplished trainees which raises ethical issues of patient protection. We present a trainee’s perspective of experience gained in a unit routinely using computer-assisted technology and highlight the potential to enhance the learning process.
Navigation systems provide constant visual and numerical feedback via a computer simulated interpretation. Initially this displays relevant functional anatomy, helps in the identification of anatomical landmarks and demonstrates sagittal and coronal plane deformities which can be difficult to accurately assess “by eye”. Computer-assisted systems have the benefit of displaying only bony anatomy which improves visualisation. This can then be compared to the palpable, clinical deformity on the table. The geometry of the native knee is also made clear with the navigation system leading to a better understand of the objectives of TKR. There are some aspects of the biomechanics of the knee which are difficult to appreciate, such as the changes in varus-valgus alignment during flexion and extension. This may be very subtle and difficult to pick up manually but can look quite dramatic on the computer.
The position of cutting jigs which are held to the bone by pins can be altered by inadvertently lifting or hanging on them with the saw, when making the bone cuts. Additionally the cut can be altered by advancing the cutting block closer to the bone, for example if cutting the tibia with a posterior slope. Both these effects can be quantified by using the navigation tools to confirm the cut that has been made. Trainers can have the benefit of seeing the alignment and confirming the cuts made by a trainee without having to get closely involved with the operation. Cementation technique is also open to scrutiny with the ability to compare pre and post cementation alignment.
The positive feedback obtained from computer assisted surgery is educational to the trainee, by giving an undisputable computer generated graphic of what they are doing during the different stages of total knee arthroplasty. It also shows what has been achieved at the end of the procedure. This can give both the trainer and trainee more confidence in the procedure and ensures patient safety.
As further improvements in surgical accuracy are made possible by computer-aided surgery, there is a demand for new pre- and post- surgical assessment and more accurate intra-operative registration techniques. Ultrasonic palpation is being used in navigated hip surgery but as yet little work had been published on the identification of anatomical landmarks used in knee surgery with this technique. The aim of this study was to investigate the accuracy of the identification of the femoral condyles with ultrasound in both saline and in tissue mimicking material (TMM).
The system comprised of an image free navigation system (OrthoPilot, B Braun Aesculap) synchronized with a standard B-mode ultrasound system (Echoblaster 128, TELEMED) used with passive trackers. Bony anatomy was represented by two sawbone phantoms; one involving an isolated femur and one simulated knee joint. Both phantoms had fiducial markers in the form of steel pins inserted into the condylar eminences of the femur, providing sharply defined structural interfaces for determination of inter-condylar distance (ICD). Initial testing was completed in a waterbath filled with saline (NaCl 4500ppm) maintained at 22°C. Further testing used both sawbone phantoms encased in TMM. To gain accurate dimensions of the ICD, 3D models of both sawbone phantoms were created using a high-resolution non-contact 3D digitiser (Konica Minolta Sensing Inc.) and measurements taken using Geomagic software. Measurements for all test set-ups were repeated and mean (SD) values calculated.
The mean ICD measurement (SD) of the isolated femur from the high resolution 3D model was 53.6mm (1.2mm) (n=4). The ICD for the isolated femur in the saline water bath was 48.8mm (0.7mm) (n=5). For the isolated femur encased in TMM the mean ICD was 54.6mm (0.7mm) (n=4) with the probe positioned parallel to the shaft of the femur and 52.2mm (0.4mm) (n=5) with the probe held perpendicular to the femur. For the second phantom, which consisted of an articulated knee joint, the mean ICD measured from the high-resolution 3D model was 43.5mm (1.0mm) (n=5). When encased in TMM, the mean ICD derived from the navigation system was 42.6mm (1.4mm) (n=5).
Average ICD measurements for phantoms encased in TMM were within 1mm of that determined by high resolution, non-contact 3D digitization. However, results in the saline waterbath were less accurate, with an average difference of 4.8mm in ICD measurement. We believe these differences largely reflect the digitisation error associated with manual registration of the fiducial markers and highlights the difficulty in using this method and taking measurements within one scanned plane. Hence we are now developing a new method of automatic registration that uses multiple scans and will hopefully provide a more accurate outcome.
Computer-assisted technology has provided surgeons with intra-operative quantitative measurement tools that have led to the development of soft-tissue balancing algorithms based on surgeon-applied varus-valgus stress. Unfortunately these forces tend not to be standardised and the resultant algorithms may at best be surgeon-specific. Furthermore, these techniques are only available intra-operatively and rely on the rigid fixation of trackers to bone. The aim of this study was to develop a non-invasive computer-assisted measurement technique and assess the variation in collateral knee laxity measurements between different clinicians.
An image-free navigation system was adapted for non-invasive use by developing external mountings for active infrared trackers. A leg model with rigid tracker mountings was designed and manufactured for comparison. Multiple kinematic registrations of alignment were made for both the model and the right leg of a volunteer to quantify the soft tissue artefacts. Repeatability of the system was assessed by performing two registration processes on eight volunteers. Collateral knee laxity was assessed on a single volunteer by 16 participants of varying experience each applying a maximum varus and valgus knee stress. Two surgeons performed repeated examinations to assess intra-observer variation.
For repeated registrations of alignment, the SD of the non-invasive mounting (0.8°) was only a third higher than the leg model (0.6°) and the actual range was only 1° larger. The repeated alignment measurements on the volunteers showed a high level of agreement with an intraclass correlation coefficient of 0.93. Varus-valgus stress values showed poor inter-observer variation with a wide range of angles for both varus (1° to 7°) and valgus stress (0.5° to 5°). A Mann-Whitney test between the two sets of repeated tests showed that both varus stress and overall laxity were significantly different (p< 0.0001) but that valgus stress was marginal (p=0.052). Intra-observer measurements overall appeared more consistent.
Soft tissue artefacts did not significantly reduce the repeatability of the assessment of coronal knee alignment using a navigation system and this provided a non-invasive technique for assessing coronal knee laxity. The perception of an ‘end-point’ varied significantly between different clinicians and although there may be a role for surgeon-specific algorithms, to use this quantitative data more widely there is a need to standardise the forces and moments applied.
A 10° deviation from the ideal cup orientation in Metal on Metal (MoM) bearing couples leads to increased wear and the subsequent risk of early revision surgery. We assessed the accuracy of orthopaedic trainees and consultants in achieving optimal acetabular cup orientation.
49 trainees and 18 consultants were asked to orientate an acetabular component to 40° inclination and 20° anteversion in 3 consecutive pelvic models:
osteoarthritic (OA), OA with anterior pelvic tilt, OA with soft tissue cladding, the task most realistic of a surgical scenario.
The trainee group experience in performing hip arthroplasty procedures ranged from novice to expert (> 100 procedures performed). Performance was measured using an image based navigation system.
Average angular error in all tasks was less than 10°, but the range in anteversion or inclination was up to 65°. Eighteen percent of trainees were +/− 10° of the target orientation in Station A, 29% in B and 2% in C. Forty four percent of consultants achieved the safe zone in A, 16% in B and 0% in C. There was no significant difference in accuracy between the two groups in any of the tasks (p> 0.01). There was no correlation between experience and angular accuracy.
We have been unable to demonstrate trainees have the ability to achieve the optimal cup orientation in a clinically relevant safe zone. A similar range of error is found in experienced surgeons. Focused training or intra-operative computer assistance may provide the solution to improving accuracy in this core orthopaedic skill.
A robust frame of reference is required to accurately characterize pathoanatomy in the proximal femur and quantify the femoral head-neck relationship. A three dimensional (3D) femoral neck axis (FNA) could serve such a purpose, but has not yet been established in the current literature.
The primary aim of this study was to develop and evaluate a reliable method of determining the 3D femoral neck axis. Secondly, we wanted to quantify the translational relationship between the femoral head and neck in normal and cam type hips.
Pelvic computed tomographic scans (CT) and radiographs were retrieved from our database of patients who had undergone navigated hip surgery or CT colonography. All patients had given informed consent for their medical files and imaging to be used for research purposes, as approved by the institutional review board.
Pre-operative scans were performed using the Siemens Sensation 64 slice scanner (Siemens Medical Solutions, Erlangen, Germany). The Imperial Protocol developed at the authors’ orthopaedic unit was applied, allowing acquisition of Digital Imaging and Communications in Medicine (DICOM) files of 0.75mm thickness.
Normal and cam type hips (n=30) were identified for analysis. ‘Normal’ hips (n=15) were defined in asymptomatic patients with no previous history of hip disease, and, no obvious abnormality on radiographs or CT. The ‘cam’ hip type (n=15) was defined by the presence of an anterior osseous bump at the head-neck junction, and an alpha angle greater than 50° on hip radiographs.
DICOMs were converted to 3D stereolith (STL) images using validated commercial image processing and analysis software (3-Matics, Materialise Group, Leuven, Belgium).
In order to determine the 3D-FNA, a best fit sphere was applied to the femoral head with a root mean square error of less than 0.5mm. The border between sphere and femoral neck defined the head -neck junction. The bone surface was marked here (including the anterior bump in cam hips) and at the neck base, providing two anatomical rings that defined the superior and inferior limits of the femoral neck. The centre point of each ring was calculated. A line connecting these points defined the femoral neck axis, and was verified on a DICOM viewer in sagittal, axial and coronal planes. The offset between the femoral head centre and neck axis was measured.
The 3D image and axis were further analysed to examine the femoral head-neck relationship, using customized software developed at our institution and previously validated in previous research projects.
To standardize rotational alignment, the femoral neck was aligned vertically in two planes by creating an axis between the tip of the greater trochanter and the center of the lesser trochanter. The aligned proximal femur was viewed end on, and the version of the head relative to the neck determined by calculating the angle between the head centre and a vertical marker placed at the 12 o’clock position. Angles below 180° demonstrated anteversion, while those above 180° demonstrated retroversion.
Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and limb dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between the anatomic and mechanical axes. We have found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We have devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.
Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (𝛉) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.
We have examined the utility and reproducibility of the new method using one hundred normal femurs. Θ=81+/− sd 2.5°. As expected, 𝛉 correlated with femoral length (r=0.74). P (expressed as the percentage of the distal from the medial edge of the joint block to the intersection) = 61% +/− sd 8%. P was not correlated with 𝛉.
Intra-and inter-observer errors for these measurements are within acceptable limits and observations of twenty paired normal femora demonstrate similar values for 𝛉 and p on the two sides.
We have employed this technique in a variety of distal femoral deformities, including vitamin D resistant rickets, growth arrest, fibula hemimelia, post-traumatic deformity and Ellis-van Creveld syndrome. We find the system universally applicable and reliable.
Differing descriptions of patellar motion relative to the femur have resulted from many in-vitro and in-vivo studies. The aim of this study was to examine the tracking behaviour of the patella. We hypothesized that patellar kinematics would correlate to the trochlear geometry and that differing previous descriptions could be reconciled by accounting for differing alignments of measurement axes.
Seven normal fresh-frozen knees were CT scanned and their kinematics with quadriceps loading was measured by an optical tracker system and calculated in relation to the previously-established femoral axes. CT scans were used to reliably define frames of reference for the femur, tibia and the patella. A novel trochlear axis was defined, between the centres of best-fit medial and lateral trochlear articular surfaces spheres.
The path of the centre of the patella was circular and uniplanar (RMS error 0.3mm) above 16°±3° knee flexion. The distal end of the median ridge of the patella entered the groove at 6° knee flexion, and the midpoint at 22°. This circle was aligned 6.4° ± 1.6° (mean± SD) from the femoral anatomical axis, 91.2°±3.4° from the epicondylar axis, and 88.3°±3° from the trochlear axis, in the coronal plane. In the transverse plane it was 91.2°±3.4° and 88.3°±3° from the epicondylar and trochlear axes. Manipulation of the data to different axis alignments showed that differing previously-published data could be reconciled. When the anatomic axis of the femur was used to align the coordinates, there was an initial medial and then a lateral translation. Comparing this with the uniplanar and circular path of the center of the patella, it shows that the orientation of the femoral coordinate system affects the description of the patellar medial-lateral translation.
This study has shown the effect of using different coordinate systems on reporting the patellar translation. Choosing a femoral reference that is more in line with the plane of the circular path of motion and the trochlear groove in the coronal plane diminishes the reported subsequent lateral translation of the patella. Once the frame of reference had been aligned to the trochlear axis, there was minimum medial-lateral translation of the patella.
A profound understanding of the pathoanatomy of the patellofemoral joint is considered to be fundamental for navigated knee arthroplasty. Previous studies used less sophisticated imaging modalities such as photography and plain radiographs or direct measurement tools like probes and micrometers to define the morphology of the trochlear groove, with differing results. This may be due to the complexity of the biomechanics and the geometry of this joint. Our primary goal was to compare normal, osteoarthritic and dysplastic PFJs in terms of angles and distances. To do this we first had to establish a reliable frame of reference.
Computed tomography scans of 40 normal knees (> 55 years old), 9 knees with patellofemoral osteoarthritis (group A) and 12 knees with trochlear dysplasia (group B) were analyzed using 3D software. The femurs were orientated using a robust frame of reference. A circle was fitted to the trochlear groove. The novel trochlear axis was defined as a line joining the centres of two spheres fitted to the trochlear surfaces, lateral and medial to the trochlear groove. The relationship between the femoral trochlea and the tibiofemoral joint was measured in term of angles and distances (offsets). T-test for paired samples was used (p< 0.05). The study was approved by the institutional review conforming to the state laws and regulations.
The normal trochlear groove closely matched a circle (RMS 0.3mm). It was positioned laterally in relation to the mechanical, anatomical, and trans-condylar axes of the femur. It was not co-planar with any of the three axes. After aligning to the new trochlear axis, the trochlear groove appeared more linear than when other axes were used. In comparison to the normal knees; the medial trochlear was smaller in group A (p=0.0003)- see figure 2. The lateral trochlear was smaller in group B (p=0.04). The trochlear groove was smaller in groups B (p=0.0003). Both trochlear centers in groups A+B were more centralized (p=0.00002–0.03). The medial trochlear center was more distal in group A (p=0.03) and the lateral trochlear center was more distal in group B (p=0.00009). The trochlear groove started more distal in group B (p=0.0007).
A better understanding of the 3-dimensional geometry can help better treat or even prevent the progression of disease to the stage of patellofemoral osteoarthritis. In osteoarthritic and dysplastic patellofemoral joints, the trochlea is both smaller and more distally located along the femur. These two factors may contribute to excessive loads that lead to early joint wear. These differences could have biomechanical implications and give us an insight into why joints fail. The data collected may also help in improving current designs and current navigational and surgical techniques used for the treatment of patellofemoral osteoarthritis.
The recognition of the correct pattern and severity of deformity in knee osteoarthritis has important implications in its surgical management. Our unit routinely uses standing long leg films and computer navigation. However, these modalities are not widely available and most surgeons rely on clinical assessment and short films. Our experience is that clinical assessment can give the opposite impression of the true deformity pattern particularly among obese patients and there is evidence that short knee films are not reliable. Our study aims to compare clinical, radiographic and computer measurements of knee deformity, assess the influence of Body Mass Index and asses the relationship between coronal and flexion deformity.
We measured 52 consecutive knees prior to arthroplasty using clinical, long leg radiographs and computer navigation methods. Systematic clinical measurement was done with patient standing. Standing radiographs stored in a Picture Archiving System were measured by two independent observers. The senior surgeon performed computer measurement while applying axial load to the foot to simulate weight bearing.
Using long leg films as baseline, clinical and X-ray measurement had a mean error of 0.8° (−12 to +12). Seven clinically valgus knees turned out varus on X-ray. Mean BMI for this group was the same as the rest. Using navigation as baseline, clinical and navigation coronal measurements had a mean error of 0.3° (+9 to −10.5). Four clinically valgus knees turned out varus with navigation. Mean BMI for this group was the same as the rest. Flexion deformity was similar between clinical and computer measurement. Three clinically normal knees showed significant varus in both X-ray and navigation. Compared directly, radiographic and navigation coronal deformity showed significant difference in the degree of deformity but not in the pattern of deformity. There was no correlation between BMI and both the error in clinical assessment of coronal deformity and navigation coronal alignment. If flexion deformity was > 5°, higher BMI indicates higher flexion deformity. There was a weak correlation between navigation coronal and flexion deformity.
Although error in clinical measurement did not reach statistical significance, based on our result, clinical assessment can give an incorrect pattern of deformity in up to 13% and hence should not be the sole basis of assessing deformity. Contrary to expectation, BMI did not influence error of clinical assessment or severity of coronal deformity. It however appeared to influence larger flexion deformities. The discrepancy between radiographic and navigation measurements reflects the absence of true weight bearing with navigation even though we tried to simulate this by applying axial load to the foot.
When navigating patellofemoral/unicompartmental knee surgery, the surgeon makes assumptions based upon algorithms developed for total knee arthroplasty. In this study we set out to show how variable the normal knee is. Minor anatomical variations in the shape of our knee may make a big difference in terms of orientation and joint wear patterns. Tibial patho-morphology has been described as a factor that predisposes to medial compartment osteoarthritis of the knee (anteromedial-OA), yet this is limited to 2D analysis. We aimed to describe the 3D morphology of both the tibial and femoral components of the medial compartment of the knee. We hypothesized that morphological differences do exist between normal knees and those predisposed to osteoarthritis.
A total of 20 normal (group A) and 20 pre-OA knees (group B) were included. Group A consisted of contra lateral knees of young patients (< 55 years) awaiting hip surgery and group B of asymptomatic contra lateral knees of patients awaiting unicompartmental knee arthroplasty (UKA). Using 3D reconstructions from CT scans, we analyzed the tibiofemoral joint, which consists of the femoral condyles and the tibial plateau. The femur was aligned to the transcondylar and anatomical axes. The medial femoral extension facet (MFEF) was modeled as a segment of a sphere. The offsets between the MFEF centre and the medial femoral flexion facet centre were measured. The MFEF radius and the MFEF 2D arc angle in the sagittal plane were also measured. The tibias were aligned for flexion-extension and varus-valgus to a flat portion of the flexion facet (flexion facet plane), which lie’s roughly perpendicular to the tibial mechanical axis. To control for axial rotation, the anatomical tibial axis was used. A model of analysis was developed by rotating several increments towards and away from the midline to obtain several sagittal section images. For each sagittal section the medial tibial extension facet (MTEF) slope angle, its length, and the medial tibial submeniscal plane (MTSP) angle and length were analyzed. The relative length proportions of the MTEF, medial tibial flexion facet and MTSP were also measured.
The MFEF was larger and more offset in pre-OA knees. Pre-OA knees also had a significantly larger MFEF arc angle than normals (p< 0.05). The MTEF appeared similar between normal and pre-OA knees. The submeniscal plane was highly variable between subjects but on average horizontally inclined (median 0o, range −15–14o) and formed a crescent shape anteriorly. There was no significant difference in tibial measured parameters between normal and pre-OA tibias (p> 0.05). The method showed good reproducibility using intraclass correlation coefficient (ICC value> 0.9) and Bland-Altman plot analysis.
This study gives the CAOS surgeon some interesting insights into the anatomical variation of the normal knee. We have found evidence of a predisposing patho-morphology to medial-OA in the femoral condyle, but not the tibia. There is evidence of an enlarged flatter extension facet on the medial femoral condyle in the pre-OA knees, with no significant difference in the geometry of the medial tibial plateau, which is now reliably defined based upon a flexion plateau frame of reference.
Cam femoroacetabular impingement (FAI) is currently treated by resecting the femoral cam lesion. Some surgeons advocate additional anterosuperior acetabular rim resection. However, the exact acetabular contribution to cam-FAI has yet to be described. Using 3D-CT analysis, we set out to quantify the acetabular rim shape and orientation in this condition, and to determine the roles of these factors in cam-FAI.
The acetabula of twenty consecutive cam hips (defined by α-angle of Notzli greater than 55° on plain radiographs) undergoing image based navigated surgery. These were compared with twenty normal hips (defined as disease free sockets with a normal femoral head-neck junction) obtained from a CT colonoscopy database.
Using 3D reconstruction software, the pelvis was aligned to the anterior pelvic plane (APP). Starting at the most anterior rim point, successive markers were placed along the rim. A best-fit acetabular rim plane (ARP) was derived, and the subtended angle (SA) between each rim marker and a normal vector from the acetabular centre was calculated. Values above 90° indicated a peak, with less than 90° representing a trough. Inclination and version were measured from the APP.
Our results showed that the rim profile of both cam-type and normal acetabular is an asymmetric succession of three peaks and three troughs. However, the cam-type acetabulum is significantly shallower overall than normal (Mean SA: 84±5° versus 87±4°, p< 0.0001). In particular, at anatomical points in the impingement zone between 12 and 3 o’clock, the subtended angle of cam hips were never higher than normal, and, in fact, at certain points were lower (iliac eminence: 90±5° vs. 93±4° p=0.0094, iliopubic trough: 79±5° vs. 83±4° p=0.0169, pubic eminence 83±7° vs. 84±4° p=0.4445). The orientation of cam and normal hips were almost identical (Inclination: 53±4°vs. 51±3° p=0.2609 and Anteversion: 23±7° vs. 24±6° p=0.3917).
We concluded that cam-type acetabula are significantly shallower than normal. The subtended angles at all points around the hip were lower, and in particular, in the impingement zone between 12 and 3 o’clock not one cam had a subtended angle over 90°. We have therefore been unable to support the hypothesis of mixed-type FAI in cam-type hips.
Bony rim resection in cam hips therefore runs the risk of rendering the acetabulum more morphologically abnormal and even functionally dysplastic. We do not recommend acetabular rim resection in patients with pure cam-type impingement, and await the longer-term results of this practice with apprehension.
Pincer femoroacetabular impingement (FAI) is cited as being the result of a socket that is either too deep or retroverted, or both. Using 3D-CT analysis, we set out to quantify the acetabular rim shape and orientation to determine the roles of these two factors in FAI.
Twenty pincer acetabulae were selected from patients undergoing image based navigated surgery, where the lateral centre edge angle was greater than 40° on plain radiographs. The normal group of disease free sockets were obtained from a CT colonography database.
Using 3D reconstruction of their CT scans, a novel method of mapping the acetabular rim profile was created. The pelvis was aligned to the anterior pelvic plane. Starting at the most anterior rim point, successive markers were placed along the rim. A best fit plane (ARP) through the acetabulum was derived, and the subtended angle (SA) between each rim marker and a normal vector from the acetabular centre was calculated. Values above 90° indicated a peak, with less than 90° representing a trough. Inclination and version were measured from a horizontal plane and the ARP, in the coronal and axial view respectively.
The results showed that asymmetric acetabular rim profiles in normal and pincer hips were very similar. However, pincer hips are significantly deeper overall (Mean SA 96±5° vs. 87±4° p< 0.00001) and at each anatomical point of the three eminences (pubic [SA: Normal 84±4° vs. Pincer 94±7° p< 0.00001], iliac [SA: 93±4° vs. 100±6° p=0.00021] and ischial [SA: 92±3° vs. 102±8° p=0.00005]) and two troughs (ilio-pubic [SA: Normal 83±4° vs. Pincer 94±8° p=0.00001] and ilio-ischial [SA: 92±3° vs. 102±8° p=0.00002]).
The orientation of normal and pincer were almost identical (Inclination: 51±3° vs. 51±6° p=0.54 and Version: 24±6° vs. 25°±7° p=0.67).
We conclude that the rim shape of pincer hips follows the same contour as normal hips. In agreement with current radiographic diagnosis, pincer-type hips are characterised by a deeper acetabulum. This ‘overcoverage’ of the femoral head confirms the biomechanical model of pincer-type impingement.
Both inclination and version in these two groups were almost identical, with no truly retroverted acetabulum seen. Pincer impingement resulting from ‘acetabular retroversion’ is a concept currently based upon radiographic signs that we have been unable to confirm in this small 3D study using the subtended angle as the key descriptor of acetabular morphology.
In Total Knee Arthroplasty (TKA) restoring the mechanical alignment of the knee joint is essential. This can be improved by considering the individual variability in the angle between the mechanical and anatomical axes of the femur (FMA angle). However with the traditional instrumentation and the use of the most common fixed distal femoral resection angle of 6° we assume little or no variation in the FMA angles in different patients. In a previous study we showed that the FMA angle had a wide distribution and that there was a good correlation between the FMA angle and the pre-operative lower limb alignment in the coronal plane. Our hypothesis was that improved post operative limb alignment would be achieved with traditional instrumentation by individual measurement of the FMA angles pre-operatively and adjusting the distal femoral resections accordingly. In the study we compared the post-operative coronal limb alignment for a cohort of patients with a variable distal femoral resection angle to the previous cohort of fixed distal femoral resection angle.
The study consisted of 103 patients undergoing 103 consecutive primary TKAs between October 2008 and March 2009. All patients had pre- and post-operative Hip-Knee-Ankle digital radiographs and had TKAs performed using a variable distal femoral cut angle. The FMA angle and the mechanical femoro-tibial (MFT) angles were measured in all cases. Inter-observer variation was measured by second observer readings. We compared our results with the group of 158 consecutive patients undergoing 174 primary TKAs operated between January and October 2007 using fixed distal femoral resection angle.
Patient demographics of the two cohorts (age, gender, BMI) were similar.
The pre-operative coronal deformity for the variable cohort was less than the fixed, mean 3.7° varus (SD 5.8°) compared to 4.7° varus (SD 7.9°). The FMA angles for the variable cohort ranged from 4° to 8°, (the fixed cohort from 2° to 9°). The variable valgus resection angles cohort showed a correlation between FMA and pre-operative MFT angles as had previously been shown in the fixed cohort (r = −0.499 and r = −0.346 respectively). Post op alignment showed that accuracy within ±5° increased from 86% (fixed resection angle group) to 96% (variable resection group). When using the more commonly quoted accuracy of within ±3°, this changed from 67% (fixed resection angle group) to 85% (variable resection group). These improvements were statistically significant (chi-squared 0.025 and 0.002, respectively). To further evaluate the effect of using variable angles we analysed the improvement of each of the different groups of deformity identified in the previous study (> 8° varus, 8° varus to 1° valgus, > 2° valgus). The range was reduced in both the extreme varus and valgus groups with the variable angles. The most significant improvement was found in the valgus group with the median reducing from 3° to 2° and range from 14° to 8°.
It seems logical to use a variable distal femoral resection angle based on the patient’s individual anatomy. By doing so, our results show significant improvement of postoperative limb alignment compared to traditional method of using fixed distal femoral resection angle. In units where preoperative long leg film radiographs are available, measuring the FMA angle and setting the distal femoral resection angle guide accordingly improves the postoperative limb alignment. However, where long leg radiographs are not available, changing the distal femoral resection angle according to the pre-operative varus-valgus deformity is likely to improve the post operative limb alignment. (e.g. 4°–5° distal femoral resection angle for preoperative valgus, 6° for preoperative mild/moderate varus, and 7°–8° for preoperative severe varus).Computer navigation, however, enables us not only to use customised distal femoral cut for each patients, but it also provides many other useful information such as dynamical limb alignment through motion, component rotation, soft tissue balancing.
Computer navigation has the potential to revolutionise orthopaedic surgery. It is widely accepted that component malalignment and malrotation leads to early failure in knee arthroplasty. We aimed to assess the use and reliability of computer navigation in both total (TKR) and unicompartmental (UKR) knee replacement surgery.
We analysed 40 consecutive UKRs and 40 consecutive TKRs. All procedures were carried out with the Brain-LAB navigation system and all were carried out by one consultant orthopaedic surgeon. Preoperative aim was neutral tibial cuts with 3 degrees posterior slope. Coronal and sagittal alignment of tibial components were measured on postoperative radiographs. Patients were also scored clinically with regards to function and pain.
In the TKR group, mean tibial coronal alignment was 0° (range 1 to −2.) Mean sagittal alignment was 2° posterior slope (range 0 to 4.) In the UKR group, mean tibial coronal alignment was 0.55° (range 0 to −3.) Mean sagittal alignment was 2.1° posterior slope (range 0 to 4°.) Clinical outcome scores were very satisfactory for the majority of patients, with far superior functional scores in the UKR group.
Our results demonstrate very accurate placement of the prosthesis in both the TKR and UKR group with computer navigation. There is a very narrow range with no outliers, (all within +/−3 degrees of desired alignment.) Functional outcome scores are good. We advocate the use of computer navigation in unicompartmental as well as total knee replacment surgery, in order to minimise early failures.
As well as improved component alignment, recent publications have shown that navigation systems can assess knee kinematics and provide a quantitative measurement of soft tissue characteristics. In particular, navigation-based measures of varus and valgus stress angles have been used to define of the extent of soft-tissue release required at the time of the placement of the prosthesis. However, the extent to which such navigation-derived stress angles reflect the restraining properties of the collateral ligaments of the knee remain unknown. The aim of this cadaveric study was to investigate correlations between the structural properties of the collateral ligaments of the knee and stress angles measured with an optically-based navigation system.
Nine fresh-frozen cadaveric knees (age 81 ± 11 years) were resected 10-cm proximal and distal to the knee joint and dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femoral and tibial were rigidly secured within a test system which replicated the lower limb and permitted kinematic registration of the knee using the standard workflow of a commercially available image free navigation system. Frontal plane knee alignment and varus-valgus stress angles in extension were acquired. The manual force required to produce varus-valgus stress angles during clinical testing was quantified with a dynamometer attached to the distal tibial segment. Following assessment of knee laxity, bone–ligament–bone specimens were prepared and mounted within a uniaxial materials testing machine. Following 10 preconditioning cycles specimens were extended to failure. Force and crosshead displacement were used to calculate principal structural properties of the ligaments including ultimate tensile strength and stiffness as well as the instantaneous stiffness at loads corresponding to those applied during varus-valgus stress testing. Differences in the structural properties of the collateral ligaments and the varus and valgus laxity of the knee were evaluated using paired t tests, while potential relationships were investigated with scatter plots and Pearson’s product moment correlations.
There was no significant difference in the mean varus (4.3 ± 0.6°) and valgus laxity measured (4.3 ± 2.1°) for the nine knees or the corresponding distal force application required during stress testing (9.9 ± 2.5N and 11.1 ± 4.2N, respectively). Six of the nine knees had a larger varus stress angle compared to the valgus angle. There was no significant difference in the stiffness of the medial (63 ± 15 N/mm) and lateral (57 ± 13 N/mm) collateral ligaments during failure testing. The medial ligament, however, was approximately two fold stronger than its lateral counterpart (780 ± 214N verse 376 ± 104N, p< 0.001). While the laxity measures of the knee were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments.
The findings of the current study suggest that computer-assisted measures of passive knee laxity are largely independent of the ultimate strength and stiffness of the collateral ligaments. The force applied during manual stress testing of the knee, however, was strongly correlated with the instantaneous stiffness of the collateral ligaments suggesting users may attend to the low-stress behaviour of the ligaments. Nonetheless the force applied during stress testing varied between knees, as did the resultant angular deviation. Therefore to make use of the quantified data given by navigation systems, further work to understand the relationships between applied force, resultant stress angles and clinical outcomes for knee arthroplasty is required.
Total knee arthroplasty (TKA) is one of the commonest orthopaedic procedures. Traditionally the surgeon, based on experience, releases the medial structures in knees with varus deformity and lateral structures in knees with valgus deformity until subjectively they feel that they have achieved the intended alignment. The aim of this prospective study was to record the frequency of medial and lateral releases for computer navigated TKAs.
Seven four consecutive patients operated on by a single surgeon were included in this study. All patients had TKA using either Stryker or Orthopilot computer navigation systems. The implants used were Scorpio NRG or Columbus. The biomechanical axis was taken as the reference for distal femoral and proximal tibial cut. The trans-epicondylar axis was taken as the reference for frontal femoral and posterior condylar cuts. A soft tissue release was undertaken after the bony cuts had been made if the biomechanical axis did not come to within 2° of neutral as shown by computer readings in extension. The post-operative alignment was recorded on the navigation system and also analysed with long leg hip knee ankle radiographs.
There were 43 female and 31 males in the study, 34 left and 40 right knees with an age range of 43 to 87 years. The range of pre-operative deformities on long leg radiographs was 15° varus to 27° valgus with a mean of −5.0° and SD 7.4°. Only two patients needed a medial release. None of the patients needed a lateral release. The fixed flexion deformities needed posterior release. None of the patients needed lateral release for patellar tracking. Post-operative alignment was available for 71 patients. The post implant navigation value was within 2° of neutral in all cases. The mean biomechanical axis on radiographs was 0.1° valgus with a SD 2.1° and range from 6° varus to 7° valgus. From the radiographs six patients were outside the ±3° range.
If one sticks to biomechanical axis and transepicondylar axis as the reference for bony cuts, there will be minimal requirement for medial or lateral soft tissue release. According to our results the use of computer navigation gives a low frequency of medial and lateral release in total knee replacement. Other authors have also found that navigation data can help to give a lower rate of soft tissue release, such as Picard et al. who had decreased their soft tissue release to 25%.
Arthritic knees, for the purpose of surgical correction during arthroplasty, are generally thought to be either varus knees or valgus knees and soft tissue releases are done in accordance with the same concept. This view is dependent on the clinical deformity in extended knee and the plain AP radiograph of the extended knee. This concept is now challenged by the observations from our study of the arthritic knee kinematics using computer aided navigation when performing total knee replacement arthroplasty. We performed 283 total knee replacements with computer aided navigation. Imageless navigation was used with Stryker and Orthopilot systems. Bone trackers were fixed to the bones and through real time infrared communication the data was collected. The knee kinematics were recorded before and at the end of surgery. This included measurement of biomechanical axis with the knee extended and then gradually flexed. The effect of flexion on the coronal alignment was recorded real time on the computer. The results were then analysed and compared with plain radiographic deformity on long leg films.
Majority of the knees did not behave in a true varus or valgus fashion. We classified the deformity into different groups depending on the behavior of the knee in coronal plane as it moves from extension to flexion. 2 degree was taken as minimum deviation to signify change, as the knee bends from full extension to flexion. The classification system is as follows
Deformity - Varus/Valgus to start with in extension
Deformity remains the same as the knee flexes Increasing deformity as the knee flexes
Decreasing deformity but does not reach neutral in flexion Decreasing deformity reaches neutral in flexion
Decreasing deformity and crosses to opposite (Varus to valgus or valgus to varus) deformity in flexion
Deformity first increases and then decreases but does not reach neutral Deformity first increases and then decreases to neutral Deformity first increases and then decreases to cross over to opposite deformity in flexion
Traditional releases of medial or lateral structures without realising the true picture of what happens when the knee is flexed, may not be correct. From our study it is clear that not all arthritic varus or valgus knees behave in the same way. Some of the releases we perform conventionally may not be required or need to be modified depending on the knee kinematics.
Reconstructive knee arthroplasty in patients with limb deformity can be a daunting and complex task. These patients are often younger and so post traumatic osteoarthritis poses a real challenge. In view of their relative youth, bone preservation would be favourable; however accurate implantation of components is essential. Formulation of a well calculated plan and accurate execution is essential for successful surgery.
We report on a novel method which combines 3D CT joint analysis and computer navigation to define the deformity present pre-operatively and determine whether the proposed reconstruction is feasible. If the reconstructive surgery is feasible, an accurate calculation the correction required is performed. The planned surgery is executed using computer aided navigation surgery.
Eight patients have benefited from the technique. Four patients presented with isolated medial compartment osteoarthritis and intact anterior cruciate ligament. These patients underwent 3D CT joint analysis and computer assisted navigation surgery to accurately implant unicondylar knee replacements.
Four Patients presented with two or three compartment disease. These patients underwent similar 3D CT analysis and navigated Total Knee Replacement.
The series demonstrates the merits of 3D CT joint analysis to accurately define deformity and therefore determine pre-operatively feasibility of corrective surgery proposed. The technique is then complimented by computer assisted navigation surgery to ensure the proposed surgical plan is accurately executed.
It is generally accepted that Hip-Knee-Ankle (long-leg) radiographs are a good measurement tool for biomechanical axis of the knee and they have been used as the outcome measure for many studies. Most of the surgeons recommend having pre operative and post operative long leg radiographs for total knee replacement surgery, although practice is not as common. We studied the biomechanical axis on long-leg films and compared it with computer navigation.
The objectives were to find out repeatability of measurements of biomechanical axis with inter observer readings on long leg radiographs and to compare biomechanical axis measurements with Navigation values obtained during total knee replacement surgery.
Our institution routinely uses long-leg radiographs for total knee replacement (TKR) surgery both pre- and post-operatively. A series of 209 patients who had navigated TKR between Jan 2007 and 2008 were selected. Stryker and Orthopilot systems for navigation were used. The intra-operative biomechanical axis measurements from the computer navigation files both pre-and post- implant were recorded. The long leg films were measured with a defined protocol from the digital images on PACS system. Centre of the head of femur was taken as the upper point. For the knee centre the midpoint of a line joining the distal femoral notch centre and upper tibia was used. For the ankle centre midpoint of the upper talar margin was used. An angle between the three points represented the radiological biomechanical axis. To investigate inter-observer error, two observers measured the pre- and post-operative biomechanical axis on long leg radiographs independently on 57 patients.
For the inter-observer measurements on 57 patients, the intraclass correlation coefficient was 0.99 for pre-operative radiographs and 0.98 for post-operative radiographs. Maximum difference between the two observers was 2° in four cases. All other cases showed the same readings or 1° difference.
There was a strong correlation, which was statistically significant, between the pre-operative radiographic and navigated measurements with Pearson correlation coefficient of 0.810 (p< 0.001). The maximum difference between the radiographic and navigated measurement was 24 degrees. The relationship between the postoperative measurements was weaker but statistically significant with Pearson correlation coefficient of 0.323 (p< 0.001). The maximum difference between the two methods of measurement was larger 15.5.
It can be concluded from this study that biomechanical axis on a long leg radiograph is a repeatable measure with good inter-observer correlation.
Although it is statistically significantly correlated with navigated readings, the absolute values may be different with both the methods. This raises the question on the reliability of long leg radiographs for the prediction of true biomechanical axis. Most of the larger value differences had a fixed flexion deformities (9 – 45 degrees). This can affect the readings on the long leg radiographs and make the deformity look either smaller or bigger. Also as our knee kinematic study has proven that the deformity does not remain the same in flexion as it was in extended knee that could also account for the difference in the readings. Other reasons for difference in the pre operative readings could be weight bearing status and surgical opening of the joint before taking the pre operative biomechanical axis measurements. Difference in the post operative readings could be attributed to weight bearing status, time length between navigation and radiographic measurements (6–12 wks), scarring of the soft tissues in the time and flexed posture of knee in the early post operative period.
Surgical long shape tools, such as the arthroscopic hooked probe, are used during knee-arthroscopy procedures by surgeons to manipulate tissues and diagnose problems. These procedures allows surgeons to assess the physical properties of tissues (such as wear, tear, inflammation, stiffness, etc), which are impossible to evaluate using real-time video observation or MRI and CT mapping. This study focuses on the dynamic properties of the hooked probe and its ability to deliver tactile information, created at the tip of the hook as the tissue is being manipulated, to the handle where the surgeon is grasping the instrument.
From previous studies, it is known that when a probe comes into contact with hard tissues, such as bones, vibrations can occur that enhance the tactile feedback. To better understand the importance of the dynamic influence on the tactile feedback, initially a vibration analysis of the probe (Model 8399.95 by Richard Wolf UK Ltd) was performed; a stepped sine sweep was carried out to evaluate the dynamic behaviour of the probe, including its resonance response frequencies and the damping behaviour. Several vibration modes were identified in a range up to 2000Hz parallel and perpendicular to the probe. The measurement values were correlated to a finite element model of the probe and an error of less than 5% was found for all relevant resonance response frequencies, thereby validating the accuracy of the model.
Measurement and simulation results show that tapping on different materials excites different modes of the probe at different levels, leading to a tactile feedback that harder materials “shift” the probe resonances to higher levels. To verify this, a tapping experiment was performed and the resulting vibrations, while tapping on different materials, were recorded. The study shows that the dynamic behaviour of the probe are somewhat influenced by the fact that the probe is being held in hand leading to a slight reduction in its natural frequencies.
A study on an individual’s ability to discriminate between the stiffness of different materials while tapping on them using an arthroscopy hooked probe is currently underway. Ten subjects are being asked to sort five materials (silicon, latex, rubber, plastic, steel) from the softest to the hardest by simple tapping. During the test, each subject is exposed to two materials each time, iteratively until the sort is complete. The subjects are blindfolded and white noise is played through headphones, to blur the sounds of tapping. The resulting dynamic response of the probe is recorded, using an accelerometer, along with the impact forces on the material, measured by a force sensor. Results to date show that subjects can distinguish quite accurately between the soft materials (silicon and latex), but find it difficult to distinguish between stiffer materials (plastic and steel), but comprehensive statistics are not yet available.
Proximal load fixation in THA is paramount for maximum bone preservation and thus longevity of the implant. Conventional femoral stems may not achieve satisfactory proximal fixation in proximal/ distal femoral canal mismatch as in champagne type of femur, mal-united fractures, excessively bowed femur and some young large patients. Such mismatch can lead to uneven loading and a higher incidence of loosening or periprosthetic fracture. This risk is becoming higher with the recent trend to mini-invasive surgery. As an alternative to standard stem, the short stem femoral prosthesis was originally developed in the 1950’s and has recently been making a resurgence as a design conducive to the minimal invasive techniques, and allows for greater preservation of the natural anatomy. Our objective is to measure the clinical and radiological outcomes of the Metha® hip short stem (a cementless, metaphyseal fix conserving diaphysis implant) with computer assisted technique and minimal invasive surgical approach.
This study is a single center, open label, data collection study of 35 consecutive subjects undergoing OrthoPilot® navigation, Metha® stem plasmapore cup system with minimal invasive muscle sparing surgical approach. (B. Braun Aesculap; Tuttlingen, Germany). Pre-Operatively an IRB Informed Consent, no exclusion specific to the implant, Harris Hip Evaluation and routine hip/pelvis plain xray was performed. Post-Operatively, a CT Scan within 6 months, repeat Harris Hip Score (HHS) Evaluation. The implant is made of titanium alloy with plasmapore coating in @ 2/3 of the implant (< 8 cm engages in proximal femur with a total length average of 10.75 cm)(range 9.75–11.75). The bearing surface is metal/ highly cross linked polyethylene. Size 32 head of modular neck with plasmapore shell. All cases were done thru muscle sparing anterolateral mini invasive approach.
At 6 months ± 1 month with an average age = 67, BMI= 37 (one was 360 pounds), Harris score was 46 preop and 96 post op.No thigh pain, No dislocation, Trendelenberg negative. Patient satisfaction was high. One fell had a non displaced fx of the neck that did not require revision but slowed full weight bearing for 6 weeks. One subsided in a 360 pound patient after he went full wt bearing while getting out of the shower a week after surgery. This was revised with a standard stem. The tip of two implants was discovered to have penetrated the proximal femur with no symptoms at 3 months period and no restriction to weight bearing during that period. This happened in the first 5 cases in which we modified technique with no other penetrations. Xray/CT scan showed no subsidence good bony ingrowth no radiolucency or loosening. The two penetrated corteses showed intense bony overgrowth on the two protruded tips of stem.
We conclude that cementless metaphyseal short stem with proximal plasmapore coating is associated with excellent clinical and radiological results. The technical errors we faced in the early two cases were identified and avoided by using awl canal finder with suction tube palpation of canal and direct visualization of the metaphyses before hammering the broach. The combination of the short stem prosthesis, modularity of the neck, computer assisted technique and minimal invasive arthroplasty is expected to reduce recovery time, increase the potential for successful restoration of function and add to the longevity of the prosthetic joint.