The impact of preoperative hip heterotopic ossification extent on recurrence in patients with head and spinal cord injury: a case control study

Background

The preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO.

Methodology/Principal Findings

A case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted.

Conclusions/Significance

The median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.

Failure of total knee arthroplasty with or without patella resurfacing

BACKGROUND AND PURPOSE

Patella resurfacing during primary total knee arthroplasty (TKA) is disputed and new prosthesis designs have been introduced without documentation of their survival. We assessed the impact on prosthesis survival of patella resurfacing and of prosthesis brand, based on data from the Norwegian Arthroplasty Register.

PATIENTS AND METHODS

5 prosthesis brands in common use with and without patella resurfacing from 1994 through 2009 were included n = 11,887. The median follow-up times were 9 years for patella-resurfaced implants and 7 years for implants without patella resurfacing. For comparison of prosthesis brands, also brands in common use with only one of the two treatment options were included in the study population (n = 25,590). Cox regression analyses were performed with different reasons for revision as endpoints with adjustment for potential confounders.

RESULTS

We observed a reduced overall risk of revision for patella resurfaced (PR) TKAs, but the statistical significance was borderline (RR = 0.84, p = 0.05). At 15 years, 92% of PR and 91% of patella non resurfaced (NR) prostheses were still unrevised. However, PR implants had a lower risk of revision due to pain alone (RR = 0.1, p < 0.001), but a higher risk of revision due to loosening of the tibial component (RR = 1.4, p = 0.03) and due to a defective polyethylene insert (RR = 3.2, p < 0.001). At 10 years, the survival for the reference NR brand AGC Universal was 93%. The NR brands Genesis I, Duracon, and Tricon (RR = 1.4-1.7) performed statistically significantly worse than NR AGC Universal, while the NR prostheses e.motion, Profix, and AGC Anatomic (RR = 0.1-0.7), and the PR prostheses NexGen and AGC Universal (RR = 0.4-0.5) performed statistically significantly better. LCS, NexGen, LCS Complete (all NR), and Tricon, Genesis I, LCS, and Kinemax (all PR) showed no differences in this respect from the reference brand. A lower risk of revision (crude) was found for TKAs performed after 2000 as compared to those performed earlier (RR = 0.8, p = 0.001).

INTERPRETATION

Although revision risk was similar for PR and NR TKAs, we found important differences in reasons for revision. Our results also indicate that survivorship of TKAs has improved.

Periprosthetic fractures: epidemiology and future projections

Periprosthetic fractures are fractures that occur in association with an orthopaedic implant, most often used for joint arthroplasty or fracture fixation. They are associated with significant morbidity and increased mortality in some cases. The incidence of periprosthetic fractures appears to be increasing as a result of increasing patient longevity, more demanding activity levels that persist into advanced age for some patients, and as a result of the increasing rate of revision arthroplasty which accompanies increasing patient longevity. Implant, surgeon, and patient factors all contribute to the risk of periprosthetic fracture. In this review, we intend to discuss current trends in periprosthetic fractures and risk factors associated with their development in the joint arthroplasty and fracture patient.

Reconstruction of acetabular posterior wall fractures

Background

The results after acetabular fracture are primarily related to the quality of the articular reduction. We evaluated the results of internal fixation of posterior wall fractures with using three-step reconstruction.

Methods

Thirty-three patients (mean age at the time of injury, 47.9 years; 28 males and 5 females) were followed for a minimum of 2 years after surgery. The three-step reconstruction included 1) preservation of soft tissues and reduction of the marginally impacted osteochondral (articular) fragments using screws, 2) filling the impacted cancellous void with a bone graft, and 3) reinforcement with buttress-plating. Clinical evaluation was done according to the criteria of D'aubigne and Postel, while the radiological criteria were those of Matta. The associated injuries and complications were evaluated.

Results

The clinical results were excellent in 15 (45.5%) patients and they were good in 5 (15.2%), (i.e., satisfactory in 60.7%), while the radiologic results were excellent in 10 (30.3%) and good in 14 (42.4%) (satisfactory in 72.7%). Heterotopic ossification was common, but this did not require excision, even without prophylactic treatment with indomethacin. Deep infection was the worst complication and this was accompanied by a poor outcome.

Conclusions

This study confirms that three-step reconstruction facilitates accurate and firm reduction of displaced posterior wall fractures of the acetabulum. Therefore, we anticipate less long-term arthrosis in the patients treated this way.

Modified Kocher-Langenbeck approach for the stabilization of posterior wall fractures of the acetabulum

This article describes a modification of Kocher-Langenbeck approach for the treatment of select posterior wall fractures of acetabulum. The technique aims at achieving osteosynthesis by creating two windows: between the gluteus medius and piriformis superiorly and between the external rotators and ischial tuberosity inferiorly. The approach spares the division of external rotators and of the abductors of the hip, thus preventing iatrogenic damage to the vascularity of the head of the femur and of the fracture fragments. The reconstruction plate can be slid under the piriformis and the short external rotators, thus preserving the soft tissue sleeve of the hip posteriorly. The gluteus minimus is not stripped from the ilium. The technique is ideally suited for isolated, displaced, noncomminuted posterior wall fractures of acetabulum of less than 10 days' duration without marginal impaction. The technique is biologic, takes a shorter operative time in our hands, and prevents further damage to vascularity of the head of the femur and heterotopic ossification.

The effect of haematoma aspiration on intra-articular pressure and pain relief following Mason I radial head fractures

BACKGROUND

The aspiration of the accompanying haematoma by Mason type I radial head fractures is advocated by several authors to achieve an analgesic effect. The purpose of this study was to investigate the effect of haematoma aspiration on intra-articular pressure and on pain relief after Mason I radial head fractures.

MATERIALS AND METHODS

A total of 16 patients (10 men and six women, age 23-47 years) with an isolated Mason I radial head fracture were subjected to haematoma paracentesis. Initially, intra-articular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. After haematoma aspiration, a new pressure measurement without moving the needle was performed. Pain before and after haematoma aspiration was evaluated by using an analogue 10-point pain scale.

RESULTS

Intra-articular elbow pressure prior to haematoma aspiration varied from 49 to 120 mmHg (median, 76.5 mmHg), while following aspiration, it ranged from 9 to 25 mmHg (median, 17 mmHg). The median quantity of the aspired blood was 2.75 ml (range, 0.5-8.5 ml). Patients reported a decrease in the visual analogue score (VAS) for pain from 5.5 (4-8) before to 2.5 (1-4) after aspiration. Decrease for both pressure and pain was statistically significant (p=0.005).

CONCLUSION

The formation of an intra-articular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intra-articular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief.

Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up

BACKGROUND

The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device.

METHODS

Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score.

RESULTS

All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points.

CONCLUSION

The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Gorham-Stout disease affecting both hands: stabilisation during biphosphonate treatment

The Gorham-Stout syndrome is a rare condition in which spontaneous, progressive resorption of bone occurs. The aetiology is poorly understood. We report a patient with osteolysis of the metacarpal bones in both hands due to an increased number of stimulated osteoclasts. This suggests that early potent antiresorptive therapy with bisphosphonates may prevent local progressive osteolysis.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Troublesome heterotopic ossification after central nervous system damage: a survey of 570 surgeries

Background

Heterotopic ossification (HO) is a frequent complication after central nervous system (CNS) damage but has seldom been studied. We aimed to investigate features of HO for the first time in a large sample and the rate of early recurrence of HO in terms of the time of surgery.

Methodology/Principal Findings

We retrospectively analyzed data from an anonymous prospective survey of patients undergoing surgery between May 1993 and November 2009 in our institution for troublesome HO related to acquired neurological disease. Demographic and HO characteristics and neurological etiologies were recorded. For 357 consecutive patients, we collected data on 539 first surgeries for HO (129 surgeries for multiple sites). During the follow-up, recurrences requiring another surgery appeared in 31 cases (5.8% [31/539]; 95% confidence interval [CI]: 3.8%–7.8%; 27 patients). Most HO requiring surgery occurred after traumatic brain injury (199 patients [55.7%]), then spinal cord injury (86 [24.0%]), stroke (42 [11.8%]) and cerebral anoxia (30 [8.6%]). The hip was the primary site of HO (328 [60.9%]), then the elbow (115 [21.3%]), knee (77 [14.3%]) and shoulder (19 [3.5%]). For all patients, 181 of the surgeries were performed within the first year after the CNS damage, without recurrence of HO. Recurrence was not associated with etiology (p = 0.46), sex (p = 1.00), age at CNS damage (p = 0.2), multisite localization (p = 0.34), or delay to surgery (p = 0.7).

Conclusions/Significance

In patients with CNS damage, troublesome HO and recurrence occurs most frequently after traumatic brain injury and appears frequently in the hip and elbow. Early surgery for HO is not a factor of recurrence.

Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation

INTRODUCTION

Management of neglected perilunate dislocations is controversial. The various procedures such as open reduction and internal fixation (ORIF), proximal row carpectomy, lunate excision, and wrist arthrodesis have been advocated. The aim of our study was to evaluate the functional outcome of neglected perilunate dislocations managed by ORIF.

MATERIALS AND METHODS

Over a period of 10 years (1996 to 2006), 14 patients with neglected perilunate dislocations (undiagnosed or untreated for 6 weeks or more) were managed by ORIF. Six patients had dorsal trans-scaphoid perilunate dislocation, 6 patients had volar lunate dislocation while the remaining two had a dorsal perilunate dislocation The results were evaluated by clinical scoring system of Cooney et al.

RESULTS

The average followup was 4.1 years (range 2-12 years). All except one of the patients operated earlier than 5 months had good results. Of the four patients operated after 5 months, two had a fair result while two had a poor outcome. Chondral damage to the capitate was noted intraoperatively in both the cases with poor outcomes. The two patients were found to have avascular necrosis (AVN) of the lunate; however, functional outcome was fair in both, and both were able to return to their profession.

CONCLUSION

We observed favorable functional results of ORIF in neglected perilunate dislocations up to 5 months after injury. The development of AVN or midcarpal arthritis was not a major disabling factor as long as stability of wrist has been restored. Beyond 5 months, an alternative surgical procedure such as proximal row carpectomy should be contemplated as results of ORIF have not been good uniformly.

Transverse fractures of the olecranon: a biomechanical comparison of three fixation techniques

INTRODUCTION

The gold standard for treating transverse olecranon fractures is tension band fixation. A problem with this technique is migration of the K-wires leading to premature hardware removal. The aim of this study is to compare stability provided by two new techniques designed to eliminate the problem with backing out of K-wires, with that of the recommended tension band technique, performed with a biomechanical in vitro investigation. Our hypothesis was that the two new techniques would provide at least equal stability as the traditional tension band fixation.

METHODS

Transverse olecranon osteotomies were created in human cadaveric elbows to simulate a type 21-B1.1 fracture. Three groups of 8 specimens were instrumented with: (1) recommended AO tension band technique; (2) modified K-wires with eyelets and tension band; (3) staples across the fracture with tension band. Each elbow was tested in a 90° flexed position. The triceps tendon was sinusoidally loaded by applying two load steps at 500 and 700 N for 4000 cycles each. Relative movements between the fragments were determined.

RESULTS

At the end of the first and second load step the displacement of the osteotomy at the posterior ulnar side was significantly less for the staples across the fracture with tension band as compared to both other groups. There were no significant differences between groups 1 and 2.

CONCLUSION

Since clinical results depend partly on stable fixation, it is concluded that using staples in the clinical situation might provide better results than the currently recommended tension band technique.

Rehabilitation of traumatic brain injury

Rehabilitation following traumatic brain injury (TBI) is best provided by an interdisciplinary team of health care providers that takes advantage of the unique skills of multiple specialists, as well as their combined strengths that address problems that cut across disciplines. The setting where rehabilitation is provided is determined by the medical stability of patients, their ability to tolerate intensive therapies, and their likelihood of community reintegration within a reasonable period of time. Successful rehabilitation requires prompt recognition and treatment of TBI-related medical, cognitive, and behavioral problems to promote recovery and enhance community reintegration, using a combination of rehabilitation modalities and medications.

Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today

Despite the remarkable advances achieved within the boundaries of the new discipline of Pelvic surgery, pelvic ring disruptions remain challenging and complex problems in orthopaedics. The long-term complications related to reconstruction techniques of these injuries have motivated researchers and surgeons to explore various alternative treatment modalities. Several biomechanical studies have addressed these issues. We performed a medline search including studies published during the last 30 years. Our search yielded 114 studies, 39 of which met the pre-specified inclusion criteria and were further critically analysed and discussed regarding the biomechanical aspects of pelvic ring reconstruction techniques. Based on observational approach and evaluation of the studies specific keypoints are highlighted comprising the clinical translation of the biomechanical supported findings.

The use of osteo-articular allografts for reconstruction after resection of the distal radius for tumour

Several techniques have been described to reconstruct a mobile wrist joint after resection of the distal radius for tumour. We reviewed our experience of using an osteo-articular allograft to do this in 17 patients with a mean follow-up of 58.9 months (28 to 119).

The mean range of movement at the wrist was 56° flexion, 58° extension, 84° supination and 80° pronation. The mean ISOLS-MSTS score was 86% (63% to 97%) and the mean patient-rated wrist evaluation score was 16.5 (3 to 34). There was no local recurrence or distant metastases. The procedure failed in one patient with a fracture of the graft and an arthrodesis was finally required. Union was achieved at the host-graft interface in all except two cases. No patient reported more than modest non-disabling pain and six reported no pain at all. Radiographs showed early degenerative changes at the radiocarpal joint in every patient.

A functional pain-free wrist can be restored with an osteo-articular allograft after resection of the distal radius for bone tumour, thereby avoiding the donor site morbidity associated with an autograft. These results may deteriorate with time.

Neglected Basal cell carcinomas in the 21st century

Although tumors on the surface of the skin are considered to be easily recognizable, neglected advanced skin neoplasms are encountered even in the 21st century. There can be numerous causes of the delay in the diagnosis: fear of the diagnosis and the treatment, becoming accustomed to a slowly growing tumor, old age, a low social milieu, and an inadequate hygienic culture are among the factors leading some people not to seek medical advice. The treatment of such advanced neoplasms is usually challenging. The therapy of neglected cases demands an individual multidisciplinary approach and teamwork. Basal cell carcinoma (BCC), the most common cutaneous tumor, usually develops in the elderly, grows slowly, and has an extremely low metastatic potential; these factors are suggesting that BCCs might well be the “ideal candidates” for neglected tumors. Five neglected advanced cases of BCC were diagnosed in our dermatological institute between 2000 and 2009. The clinical characteristics and treatment modalities of these neoplasms are discussed, together with the possible causes of the neglect.

Innovative techniques for the osteosynthesis of distal humeral fractures

Adequate restoration of the mechanical alignment, anatomic reduction of the articular surface, and stable fixation allowing early motion of the elbow joint are the primary goals in the treatment of distal humeral fractures. The purpose of our study is the comparison of the effectiveness between distal humeral locking compression plates (LCP) and conventional reconstruction and one third tubular plates. Between January 2008 and January 2009, 11 consecutive patients (4 men and 7 women) with distal humeral fractures were treated with plates in our hospital; eight patients were treated with LCP distal humeral plates and three cases were fixed with a combination of 1/3 tubular plates and reconstruction plates. They were all followed up for 12 months using the functional score of Cassebaum and radiologically with standard X-rays. Good to excellent results were obtained in 6/11 patients with a mean range of motion of 115°. At this small cohort of patients no significant differences between the two fixation methods was identified regarding clinical outcome, complications and function of the affected limb.

Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries

BACKGROUND

The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury.

METHODS

During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but <2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images.

RESULTS

The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of >2.5 cm during the stress examination, which changed their treatment from nonoperative to operative.

CONCLUSIONS

Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.

Symphysiotomy for feto-pelvic disproportion

BACKGROUND

Symphysiotomy is an operation in which the fibres of the pubic symphysis are partially divided to allow separation of the joint and thus enlargement of the pelvic dimensions during childbirth. It is performed with local analgesia and does not require an operating theatre nor advanced surgical skills. It may be a lifesaving procedure for the mother or the baby, or both, in several clinical situations. These include: failure to progress in labour when caesarean section is unavailable, unsafe or declined by the mother; and obstructed birth of the aftercoming head of a breech presenting baby. Criticism of the operation because of complications, particularly pelvic instability, and as being a 'second best' option has resulted in its decline or disappearance from use in many countries. Several large observational studies have reported high rates of success, low rates of complications and very low mortality rates.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of symphysiotomy versus alternative options for obstructed labour in various clinical situations.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3) and PubMed (1966 to 31 August 2010).

SELECTION CRITERIA

Randomized trials comparing symphysiotomy with alternative management, or alternative techniques of symphysiotomy, for obstructed labour or obstructed aftercoming head during breech birth.

DATA COLLECTION AND ANALYSIS

Planned methods included evaluation of studies against objective quality criteria for inclusion, extraction of data, and analysis of data using risk ratios or mean differences with 95% confidence intervals. The primary outcomes were maternal death or severe morbidity, and perinatal death or severe morbidity.

MAIN RESULTS

We found no randomized trials of symphysiotomy.

AUTHORS' CONCLUSIONS

Because of controversy surrounding the use of symphysiotomy, and the possibility that it may be a life-saving procedure in certain circumstances, professional and global bodies should provide guidelines for the use (or non-use) of symphysiotomy based on the best available evidence (currently evidence from observational studies). Research is needed to provide robust evidence of the effectiveness and safety of symphysiotomy compared with no symphysiotomy or comparisons of alternative symphysiotomy techniques in clinical situations in which caesarean section is not available; and compared with caesarean section in clinical situations in which the relative risks and benefits are uncertain (for example in women at very high risk of complications from caesarean section).

Articular step-off and risk of post-traumatic osteoarthritis. Evidence today

The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.

Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures

PURPOSE

This retrospective, institutional review board approved study with no patients excluded was designed to test the hypothesis that the prone position is advantageous for repair of acetabular fractures, via a posterior approach.

METHODS

In 104 consecutive cases fixed by open reduction and internal fixation using the Kocher-Langenbeck approach, 50 were performed in the prone position and 54 in the lateral position by four attending surgeons at a level I trauma center. These cases were assigned to each surgeon according to the call schedule and positioned on the operating table depending on the preference of the assigned surgeon. Arbeitsgemeinschaft fuer Osteosynthese/Association for the Study of Internal Fixation (AO/ASIF) classification and radiologic outcome were evaluated by standard radiographs of the hip and computerized tomography scans, demographic data were taken from the medical records. Except for the time from injury to surgery (p = 0.003), both groups were comparable, nevertheless the fractures were more severe in the prone one.

RESULTS

With equivalent radiologic outcomes according to Matta, Brooker, Epstein, and Helfet between both groups, a significantly higher rate of infection (p = 0.017) and need for revision surgery (p = 0.009) were found in the prone group.

CONCLUSION

No advantage to either position for the posterior approach to acetabular fractures could be found. Because most of the severe fractures were performed prone, we propose that the larger number of more difficult fractures in this group may cause an increased likelihood of loss of reduction. The higher infection rate in the prone group may be caused by the longer inpatient wait for definitive fixation, leading to a higher risk of nosocomial colonization.

Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?

Background

The purpose of this prospective consecutive multicenter study was to investigate whether the type of surgical approach (medial parapatellar (MPA) or lateral parapatellar with tibial tubercle osteotomy (TubOT)) influences the early clinical and radiological outcomes of primary total knee arthroplasty (TKA).

Methods

Ligament balancing primary TKA with a rotating platform was performed in 143 knees (m:w = 1:1.6; mean age 69 ± 8 years). The TKA was done by a lateral parapatellar subvastus approach with stepcut osteotomy of the tibial tubercle (53%; n = 76, group A) or medial parapatellar approach (47%; n = 67, group B). The outcome was assessed at 1 and 2 years postoperatively by the American Knee Society score (KSS) and the knee society total knee arthroplasty roentgenographic evaluation and scoring system (TKA-RESS). The patient's pain level and satisfaction was noted by a visual analogue scale (VAS). Data were analyzed by an independent statistician with a level of significance of p < 0.05. The Wilcoxon two sample test (two-sided) was used to investigate differences of patients between group A and B pre- and postoperatively. The paired t-test was used to evaluate differences over course of time within each group. For comparison of radiological alignment a Chi²-test was performed.

Results

Although having a lower degree of preoperative flexion (112° ± 15° versus 115° ± 15°) patients in group A showed a significantly (p = 0.027) higher degree of flexion (118° ± 10°) at their last follow-up than patients in group B (114° ± 10°). Patients in group A showed a significantly better mean VAS pain (p = 0.0001) and satisfaction (p = 0.0058) at 2 years follow-up. The pain free walking distance was significantly (p = 0.036) longer for group A than group B. Patients treated with a lateral approach were significantly more stable in terms of valgus stress (p = 0.049). The Knee society score was significantly (p = 0.0009) higher at two years follow up in group A compared to group B. The postoperative mechanical alignment and positioning of the prosthesis were not significantly different. Patients in group B presented with significantly (p = 0.0017) more tibial radiolucencies (> 2 mm) at their last follow-up than patients in group A. There was no prosthesis related revision in either group. The revision rate in group A (4%) was higher than in group B (1.5%), which was mainly due to two cases of traumatic secondary displacement of the tibial tubercle and need for refixation.

Conclusions

The TubOT led to slightly better functional results and less pain two years after primary TKA. It is however not clear if the improved outcome can outweigh the longer operation time and higher risk of early complications and revisions. Long-term studies are necessary to show whether there is any difference in prosthesis longevity between both types of approach.

Management and outcome of periprosthetic fractures after total knee arthroplasty

BACKGROUND

The incidence of periprosthetic fractures after total knee arthroplasty is continuously rising because of an increasing number of knee joint replacements and an enhanced survivorship of the elderly population after knee arthroplasty. The purpose of this study was to analyze the practicability and effectiveness of the various treatment methods for management of periprosthetic fractures after total knee arthroplasty, and to determine the clinical and radiographic long-term results of patients following surgical and nonoperative treatment of these injuries.

METHODS

We reviewed the clinical and radiographic records of 41 patients (31 women and 10 men; average age, 78.6 years) with periprosthetic fractures after total knee arthroplasty between 1992 and 2008. Thirty-seven patients showed a periprosthetic fracture of the distal femur, and four patients had a periprosthetic proximal tibial fracture. Thirty-six patients underwent operative stabilization by plate fixation (n = 18), intramedullary nailing (n = 15) or revision arthroplasty (n = 3), and five patients were treated nonoperatively by long-term cast immobilization.

RESULTS

Twenty-eight patients returned to their preinjury activity level and were satisfied with their clinical outcome. In 10 patients, we saw a relevant decrease of knee function and severe limitations in gait and activities of daily living. Three patients died related to surgery. Successful fracture healing within 6 months was achieved in 33 (87%) of 38 patients. Failures of reduction or fixation occurred in 8 (21%) of 38 patients. Reoperation due to technical failures was necessary in three patients.

CONCLUSIONS

Compared with current data in literature, we had a satisfactory outcome in following individualized treatment of periprosthetic fractures after knee joint replacement. Referring to the wide field of treatment options and high rates of complications, periprosthetic femoral fractures around the knee commonly constitute a challenging problem for the treating surgeons and require an adequate analysis of fracture etiology and a corresponding transfer into an individual treatment concept.

Ulnar translocation after excision of a Campanacci grade-3 giant-cell tumour of the distal radius: an effective method of reconstruction

Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm (5.5 to 15). All the patients were followed to bony union and 12 were available at a mean follow-up of 26 months (10 to 49). The mean time to union was four months (3 to 7) at the ulnocarpal junction and five months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of pronation and supination. The remaining patient developed a radio-ulnar synostosis. The mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients had a soft-tissue recurrence, but with no bony involvement. They underwent a further excision and are currently well and free from disease. Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. It avoids the need for a microvascular procedure while retaining rotation of the forearm and good function of the hand.

Biomechanical study of posterior wall acetabular fracture fixation using acetabular tridimensional memory alloy-fixation system

BACKGROUND

We developed the acetabular tridimensional memory alloy-fixation system (ATMFS), which is made of NiTi shape memory alloy, according to the specific mechanical properties of biological memory material, nitinol alloy and measured distribution of contact area and pressure between the acetabulum and the femoral head of cadaveric pelvis.

METHODS

Six formalin-preserved cadaveric pelvis were used for this investigation. Pressure-sensitive film was used to measure contact area and pressure within the anterior, superior, and posterior regions of the acetabulum. The pelvis were loaded under the following four conditions: (1) intact; (2) following a creation posterior wall fracture defect; (3) following reduction and standard internal fixation with reconstruction plate; (4) following reduction and internal fixation with a new shape memory alloy device named ATMFS. A posterior wall fracture was created along an arc of 40-90 degrees about the acetabular rim.

FINDINGS

Creation of a posterior wall defect resulted in increased load in the superior acetabulum (1422N) as compared to the intact condition (762N, P=0.007). Following reduction and internal fixation, the load distributed to the superior acetabulum (1486N) was not statistically different from the defect condition. Following the fixation with ATMFS, the load seen at the superior region of the actabulum (936N) was less than fixation with reconstruction plate and was not different from intact state (P=0.4).

INTERPRETATION

These data indicate that the use of ATMFS as a fracture internal fixation device resulted a partial restoration of joint loading parameters toward the intact state. ATMFS fixation may result in a clinical benefit.

Plate osteosynthesis for severe olecranon fractures

PURPOSE

To review outcomes of 10 patients who underwent plate osteosynthesis for severe olecranon fractures.

METHODS

Records of 7 men and 3 women aged 33 to 73 years who underwent plate osteosynthesis for severe olecranon fractures were reviewed. All had some degree of soft-tissue injury; 6 presented with associated fractures. Seven patients were treated with a limited contact dynamic compression plate, and the remaining 3 received a locking compression plate. Patients were followed up for fracture healing, range of motion, nerve damage, heterotopic ossification, infection, hardware complaints, and the need of a secondary surgical procedure. The Mayo Elbow Performance Score (MEPS) was determined at the final follow-up. The patient-answered questionnaire (PAQ) portion of the Liverpool Elbow Score (LES) was evaluated 2 to 37 months later by telephone.

RESULTS

All patients had bone union. None had nerve damage or heterotopic ossification. Patients 4, 6, and 8 with type-IIIB fractures developed deep infections and severe soft-tissue swelling; all had been treated with the limited contact dynamic compression plate. Four patients underwent plate removal owing to hardware complaints. One patient underwent a secondary procedure to restore complete range of elbow motion. The mean MEPS score was 84 (range, 35-100); 5 patients attained excellent scores, one good, 2 satisfactory, and 2 unsatisfactory. The mean PAQ portion of the LES score was 31 (range, 23-36).

CONCLUSION

Plate osteosynthesis achieves satisfactory results for severe olecranon fractures. The deep infection rate is higher in patients with severe soft-tissue injury.

Teriparatide improves early callus formation in distal radial fractures

BACKGROUND

Teriparatide (parathyreoid hormone; PTH 1-34) increases skeletal mass in humans and improves fracture healing in animals. A recent randomized multicenter trial of nonoperated distal radial fractures showed a moderate shortening of the time to restoration of cortical continuity by treatment with 20 microg (low-dose) teriparatide per day, but not with 40 microg (high-dose). As radiographic cortical continuity appears late in the healing process, perhaps too late for clinical relevance, we studied the qualitative appearance of the callus 5 weeks after fracture.

METHODS

One third of the patients of the international trial were treated at Linköping University Hospital. The multicenter trial did not evaluate early callus formation. We therefore made a blinded qualitative scoring of the callus at 5 weeks in our 27 patients. Callus formation was arbitrarily classified as rich, intermediate, or poor.

RESULTS

9 patients were classified as rich (none had received placebo, 3 low-dose teriparatide, and 6 high-dose teriparatide). 9 patients were classified as intermediate (1 had received placebo, 5 low-dose, and 3 high-dose). 9 patients were classified as poor (7 had received placebo, 1 low-dose, and 1 high-dose) (p < 0.001).

INTERPRETATION

This is a post hoc subgroup analysis of an outcome variable, which was not in the official protocol. The results must therefore be interpreted with caution. However, in combination with the results of the larger trial, the data suggest that radiographic quality at an early time point might be a sensitive variable, perhaps better than time to cortical continuity. Moreover, teriparatide appeared to improve early callus formation in distal radial fractures.

Can bone healing in distraction osteogenesis be accelerated by local application of IGF-1 and TGF-beta1?

Because complications of distraction osteogenesis are largely related to the long duration of therapy, increasing efforts were reached to shorten treatment by using osteoconductive replacement materials incorporating bioactive molecules such as IGF-1 and TGF-beta1. The controlled release of IGF-1 and TGF-beta1 from coated biodegradable poly(D,L-lactide) implants could stimulate fracture healing locally. We investigated the effect of locally applied IGF-1 and TGF-beta1 from IGF-1/TGF-beta1-enriched polylactide membranes on fracture healing in a sheep model of delayed callus formation. Twenty-eight sheep were used for this study. Callus distraction of 1 mm/day by means of a unilateral fixator was continued for 30 days. At the beginning of the subsequent consolidation phase, either growth factors were applied locally or the defect was packed with cancellous bone, or both. The groups treated with growth factors were compared to a control group. The consolidation phase lasted for 60 days and both tibiae were dissected for histological and histomorphometric analyses. This investigation found a reduced absolute callus area in the lengthening zone in all treatment groups. The two treatment groups that received a membrane coated with growth factors showed distinctly higher relative bone areas than the groups treated with an uncoated membrane or packing of the osteotomy defect with cancellous bone. The differences in bone areas were not statistically significant. Application of the growth factors accelerated bone healing and achieved results comparable with those of established treatment methods (packing with autologous cancellous bone). The best results were achieved with a combination of both methods.

The effect of intraarticular combinations of tramadol and ropivacaine with ketamine on postoperative pain after arthroscopic meniscectomy

INTRODUCTION

The purpose of this prospective randomized study was to evaluate the effects of intraarticular combinations of tramadol and ropivacaine with ketamine in postoperative pain control of patients undergoing arthroscopic meniscectomy.

MATERIALS AND METHODS

We randomly divided 80 patients into four groups to receive intraarticular 50 mg tramadol (Group T), 50 mg tramadol with 0.5 mg kg(-1) ketamine (Group TK), 75 mg ropivacaine (Group R), 75 mg ropivacaine with 0.5 mg kg(-1) ketamine (Group RK) in 20 ml normal saline at the end of surgery. Postoperative analgesia was provided with patient-controlled analgesia with morphine. Postoperative pain scores, total morphine consumption amount and side effects were recorded at intervals of 0, 1, 2, 4, 8, 12 and 24 h after the operation.

RESULTS

Pain scores were higher in Group T when compared with Group R and Group RK at second and fourth hours, also compared with Group RK at zeroth, first, second, fourth and eighth hours. Total morphine consumption amount was found to be higher in Group T when compared to Group TK at eighth and twelfth hours and Group RK at eighth hours (P < 0.05). Total morphine consumption was lowest in Group TK (P < 0.05). There were no significant differences among the study groups regarding side effects.

CONCLUSIONS

Administration of intraarticular tramadol-ketamine combination was found to be more effective in decreasing postoperative daily analgesic consumption.

Management of traumatic sacral fractures: a retrospective case-series study and review of the literature

BACKGROUND

Being the result of high-energy trauma in most cases, traumatic sacral fractures are rare, difficult to recognise and frequently misdiagnosed. Furthermore they may lead to vascular injuries, mechanical instability, neurological impairment and increased morbidity. As a result, patients with traumatic sacral fractures may suffer major socio-economic consequences.

OBJECTIVE

This retrospective case-series study evaluated the functional, neurological, mental and emotional status of patients who had suffered traumatic sacral fractures and either followed conservative or underwent operative treatment at our department.

PATIENTS AND METHODS

We evaluated the clinical and radiographic results of all patients who had suffered traumatic sacral fractures between December 2003 and June 2007. The case-notes of all patients were reviewed, all co-existing injuries were registered and an ISS was calculated for each patient. At the latest follow-up visit, all patients completed the Short Form-36 questionnaire as well.

RESULTS

Sixteen patients (eleven male, five female) were included in this study. At the time of initial admission, the mean age of the patients was 30 years (range: 14-53) and the mean ISS was 33.2 points (range: 21-59). The mean follow-up period was 24.1 months (range: 13-40). Six patients were treated operatively (four patients diagnosed with some type of neurological impairment at their initial physical examination and two patients due to pelvic instability). The mean ISS of the patients who were treated operatively was 41.1 points (range: 21-59), whereas of those who were treated conservatively was 28.5 points (range: 21-45). No patient had any neurological deficit at his/her latest re-evaluation. Patients who were treated conservatively achieved the best scores in every domain of the SF-36 questionnaire, when compared with those who were treated operatively.

CONCLUSION

The diagnosis and management of sacral fractures may pose several dilemmas in everyday's clinical praxis. Patients suffering from traumatic sacral fractures who were treated conservatively seem to have better functional and mental/emotional outcomes, probably because their injuries were less severe than those of the patients who were treated conservatively.

Is chemical incompatibility responsible for chondrocyte death induced by local anesthetics?

BACKGROUND

Chondrolysis associated with intra-articular administration of local anesthetics has been attributed to chondrocyte death induced by the local anesthetics. The mechanism of how the local anesthetics cause chondrocyte death is not clear.

PURPOSE

This study was conducted to determine whether and how the local anesthetics cause chondrocyte death.

STUDY DESIGN

Controlled laboratory study.

METHODS

Bovine articular chondrocytes in suspension culture were treated for 1 hour with phosphate-buffered saline or phosphate-buffered saline/medium mixture (as controls); 1% lidocaine alone; 0.25% to 0.5% bupivacaine alone; phosphate-buffered saline with pH values of 4.5, 3.8, 3.4, and 2.4; or mixtures of the local anesthetics and cell culture medium or human synovial fluid. Chondrocyte viability was analyzed by flow cytometry using the LIVE/DEAD Viability/Cytotoxicity Kit.

RESULTS

In 1% lidocaine-alone or 0.25% to 0.5% bupivacaine-alone groups, the rate of cell death was 11.8% to 13.3% of bovine articular chondrocytes, whereas the phosphate-buffered saline control had 8.4% of cell death. Increased chondrocyte death was only found when the pH value of phosphate-buffered saline dropped to < or = 3.4. In contrast, when bupivacaine was mixed with cell culture medium, needle-like crystals were formed, which was accompanied with 100% death of chondrocytes. Lidocaine did not form visible crystals when it was mixed with culture medium, but the mixtures caused death of over 96% of chondrocytes (P < .001).

CONCLUSION

Less than 5% of chondrocyte death was attributable to the anesthetics when applied to the cells alone or in phosphate-buffered saline-diluted solution. Acidity (as low as pH 3.8) or epinephrine in the anesthetic solutions could not account for chondrocyte death. However, chemical incompatibility between the local anesthetics and cell culture medium or human synovial fluid may be the cause of chondrocyte death.

CLINICAL RELEVANCE

Intra-articular administration of lidocaine and bupivacaine is not an indicated usage of either anesthetic, although such a usage has become a common practice. Physicians should be aware of the potential incompatibility of the drug and synovial fluid.

Subcutaneus leiomyosarcoma of the neck: a case report

Introduction

Leiomyosarcomas are rare tumors. The most common site for head and neck leiomyosarcomas is the oral cavity, followed by sinonasal tract and skin. Subcutaneous leiomyosarcomas are thought to arise from small to medium-sized blood vessels in the subcutaneous tissue.

Case Presentation

A 67-year-old female patient underwent excision of a slow growing neck mass of the left posterior neck triangle after a thorough clinical and laboratory examination. The lesion was located in the subcutis and fine needle aspiration biopsy revealed malignant features. Histology revealed subcutaneous leiomyosarcoma and the patient is free from local recurrence and distant metastases 3 years after wide excision of the lesion.

Conclusions

The primary modality of therapy of subcutaneous leiomyosarcoma is surgery, adjuvant radiotherapy or chemotherapy may be used for control of local recurrence, in case of positive surgical margins, high-grade or large tumors.

Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures

Animal experiments show a dramatic improvement in skeletal repair by teriparatide. We tested the hypothesis that recombinant teriparatide, at the 20 microg dose normally used for osteoporosis treatment or higher, would accelerate fracture repair in humans. Postmenopausal women (45 to 85 years of age) who had sustained a dorsally angulated distal radial fracture in need of closed reduction but no surgery were randomly assigned to 8 weeks of once-daily injections of placebo (n = 34) or teriparatide 20 microg (n = 34) or teriparatide 40 microg (n = 34) within 10 days of fracture. Hypotheses were tested sequentially, beginning with the teriparatide 40 microg versus placebo comparison, using a gatekeeping strategy. The estimated median time from fracture to first radiographic evidence of complete cortical bridging in three of four cortices was 9.1, 7.4, and 8.8 weeks for placebo and teriparatide 20 microg and 40 microg, respectively (overall p = .015). There was no significant difference between the teriparatide 40 microg versus placebo groups (p = .523). In post hoc analyses, there was no significant difference between teriparatide 40 microg versus 20 microg (p = .053); however, the time to healing was shorter in teriparatide 20 microg than placebo (p = .006). The primary hypothesis that teriparatide 40 microg would shorten the time to cortical bridging was not supported. The shortened time to healing for teriparatide 20 microg compared with placebo still may suggest that fracture repair can be accelerated by teriparatide, but this result should be interpreted with caution and warrants further study.

Does patella resurfacing really matter? Pain and function in 972 patients after primary total knee arthroplasty

BACKGROUND AND PURPOSE

Resurfacing of the patella during primary total knee arthroplasty (TKA) is often recommended based on higher revision rates in non-resurfaced knees. As many of these revisions are insertions of a patella component due to pain, and since only patients with a non-resurfaced patella have the option of secondary resurfacing, we do not really know whether these patients have more pain and poorer function. The main purpose of the present paper was therefore to assess pain and function at least 2 years after surgery for unrevised primary non-resurfaced and resurfaced TKA, and secondary among prosthesis brands.

METHODS

Information needed to calculate subscales from the knee injury and osteoarthritis outcome score (KOOS) was collected in a questionnaire given to 972 osteoarthritis patients with intact primary TKAs that had been reported to the Norwegian Arthroplasty Register. Pain and satisfaction on visual analog scales and improvement in EQ-5D index score DeltaEQ-5D) were also used as outcomes. Outcomes were measured on a scale from 0 to 100 units (worst to best). To estimate differences in mean scores, we used multiple linear regression with adjustment for possible confounders.

RESULTS

We did not observe any differences between resurfacing and non-resurfacing in any outcome, with estimated differences of <or= 1.4 units and p-values of > 0.4. There was, however, a tendency of better results for the NexGen implant as compared to the reference brand AGC for symptoms (difference = 4.9, p = 0.05), pain (VAS) (difference = 8.3, p = 0.004), and satisfaction (VAS) (difference = 7.9, p = 0.02). However, none of these differences reached the stated level of minimal perceptible clinical difference.

INTERPRETATION

Resurfacing of the patella has no clinical effect on pain and function after TKA. Differences between the brands investigated were small and they were assumed to be of minor importance.