Primary total knee arthroplasty for periarticular fractures

We present a series of 6 patients with periarticular fractures of the knee that were treated by primary total joint arthroplasty. These fractures around in 6 elderly women, three in the proximal tibia and three in the distal femoral. All the patients had osteoarthritis and osteopenia. In five patients, a hinged total knee arthroplasty was performed, and in one case an unconstrained prosthesis was performed. Cementing techniques were used in all. Postoperatively, immediate mobilization with full weight bearing was initiated. No radiographic or clinical evidence of loosening was seen, and the functional outcome was satisfying. The results suggest that another treatment option for intra-articular distal femoral or intra-articular proximal tibial fractures in elderly patients with severe osteopenia and osteoarthritis is primary total knee arthroplasty. Furthermore, this primary total knee arthroplasty may require some degree of constraint.

Determination of bone and tissue concentrations of teicoplanin mixed with hydroxyapatite cement to repair cortical defects

A highly specific and sensitive isocratic reversed-phase high performance liquid chromatography (HPLC) method for the determination of the major component of teicoplanin in tissue is reported. Comparing fluorescamine and o-phthalaldehyde (OPA) as derivatizing agents, the derivative formed with the latter exhibits superior fluorescence intensity allowing detection of femtomole quantities. Pretreatment for tissue samples is by solid-phase extraction which uses Bakerbond PolarP C(18) cartridges and gives effective clean up from endogenous by-products. Linearity was given from 0.6 to 100 ng per injection. The coefficient of variation did not exceed 5.8% for both interday and intraday assays. It was found that when bone defects are repaired with a hydroxyapatite-teicoplanin mixture, the antibiotic does not degrade, even when it is in the cement for several months. The stability of teicoplanin in bone cement was determined fluorodensitometrically.

The diagnostic dilemma of traumatic rupture of the diaphragm

BACKGROUND

Traumatic rupture of diaphragm is caused by blunt or penetrating trauma. Early diagnosis is difficult, and complications such as visceral herniation may arise. A 10-year evaluation of all diagnostic procedures used in patients with surgically proved traumatic rupture of the diaphragm is presented.

METHODS

A review of all patients with surgically proved diaphragmatic injury from 1988 to 1998 was conducted. All diagnostic methods were analyzed in terms of their ability to identify diaphragmatic rupture.

RESULTS

During the study period, 31 patients with a mean age of 34 years were treated. Of these patients, 20 sustained blunt trauma and 11 experienced penetrating trauma. The initial chest x-ray was diagnostic for 6 of the 31 patients, nonspecific for 15 of the patients, and normal for 10 of the patients. In no case was sonography diagnostic. Thoracoabdominal computed tomography (CT), performed in 22 of the patients, led to diagnosis for 5 patients and unspecific findings for 17 patients. Statistical analyses showed no significant difference between initial chest x-ray and thoracoabdominal CT. No significant difference between blunt or penetrating trauma or between left-side and right-side ruptures could be recognized with any diagnostic tool.

CONCLUSIONS

All the diagnostic methods investigated in this study showed unsatisfying results, and traumatic rupture of the diaphragm seems to remain a diagnostic dilemma. Endoscopic techniques not tested in this study and discussed controversially may offer a good chance for early diagnosis and repair of the injured diaphragm.

The effect of different isolation techniques on human osteoblast-like cell growth

Surgical treatment of post-traumatic or neoplastic bone defects often represents a problem in orthopaedic routine. Autologous tissue always stands for the first choice material. The recent therapeutic approaches for tissue repair of bone defects attempt to mimic the natural process of bone repair by delivering a source of cells capable of differentiating into osteoblasts. In this study two different types of human osteoblast cell harvesting were compared in primary cell culture to evaluate the best way to obtain cells for clinical use. Numerous articles describe the characteristics of each one of these systems, but there is no report comparing the influence of these different isolation techniques on cell growth. Cultures from 22 bone specimens obtained from donors were established in two different ways and their proliferation was compared. An enzymatic procedure to extract human osteoblasts (hOBcol) was used in one group; spontaneous cells outgrowth, human osteoblasts (hOBsog) was expected in the other group. Cells of both groups were characterised as osteoblasts by immunohistochemical staining with Bone Morphogenetic Protein-2,4 (BMP-2,4), expression of collagen type I as well as the amount of alkaline phosphatase activity (ALP) detected in the cell cultures. We found that the time needed in primary cultures till confluence was dependent on the age of the donors as well as on the method of cell harvesting. Cells from under 65-year old donors were growing significantly faster by the hOBcol method as compared to hOBsog 20.57 +/- 2.99 days vs. 30.00 +/- 4.36. Cells harvested from donors older than 65 years of age needed 23.88 +/- 2.95 in the hOBcol compared to 34.25 +/- 4.27 days in the other group. In the experimental cultures, after one passage with trypsin/EDTA, there was a significant difference between the two groups. There was an improved cell growth in the hOBsog group found on days 8, 9 and 10 of cultivation. Immunohistochemical staining as well as ALP activity were similar in both groups. In conclusion this study evaluated an important step for a tissue engineering approach to the repair of bone defects, which may have clinical applications in post-traumatic orthopaedic surgery.

[Alloplastic augmented femoral reinserted anterior cruciate liganent. Value of 2 channel augmentation for postoperative rehabilitation]

The rupture of the anterior cruciate ligament (ACL) near its femoral origin is a common injury of the knee and can lead to lesions of the meniscus due to instability and to early gonarthrosis. One procedure applied in current orthopaedic practice to prevent such impairment of knee joint function is ACL repair reinforced with a synthetic intraarticular ligament. In this study we used twelve knees of cadavers and after sectioning the ACL in each repaired it according the Marshall technique with USP 1 PDS II sutures. We augmented the repair in each case with a 3-mm PET (Trevira hochfest) band inserted by the through-the-condyle (TTC) procedure and attached without preload to the femoral and tibial condyle with a 4-mm staple. We then measured the length of the ACL, the length of the Marshall sutures-ACL complex, the partial lengths, and the deviation angles and adherence-friction force of the 3-mm PET augmentation device, and applied the law of Hooke to calculate the load-sharing between the USP 1 PDS II sutures-ACL complex and the 3-mm PET band and between the ACL and the 3-mm PET band, respectively. We also evaluated the load on the femoral and the tibial fixation of the augmentation device. The results showed that the 3-mm PET band took over 60% of an externally applied load on the knee during the hypothetic period of ACL healing and 27% of the force acting on the knee thereafter. It was calculated that a maximum of 75% of the load taken over by the augmentation device was at the tibial staple and only up to 45% of the force at the femoral one. With due consideration for the requirement for absolute protection ("stress shielding") of the healing ACL but also for the aim of early postoperative accelerated functional rehabilitation without casts, splints or other restrictions of joint movement, we believe that a pretensioned 3-mm PET band is the best choice, since augmentation without preload cannot fulfil these requirements.

[Indications for the interlocking nailing in open fractures]

The history of intramedullary nailing leads us to assume that septic complications arising from the treatment of open fractures through marrow nailing are largely due to reaming and need no longer to a full extent be put down to treatment by locking nailing. Locking nailing of an open fracture (all three degrees) of the femur can be recommended as long as the periosteum is not exposed over large segments, and coverage with soft tissue is possible. Locking nailing of the lower leg can only be recommended with open fractures of the first degree. With fractures of the second and third degrees the fixateur externe is the treatment of choice.

[Phlebography of the femoral head following femoral neck fracture]

The incidence of avascular necrosis (AVN) of the head of the femur after transcervical fracture is 30-60%, depending on the diagnostic methods used. A poor outcome in AVN is not inevitable, since early diagnosis and treatment with prolonged non-weightbearing can produce satisfactory revascularisation without deformity. Nineteen patients with fractures of the femoral neck treated with internal fixation were assessed after operation by per-osseous phlebography. Weightbearing was allowed, irrespective of the state of union of the fracture, only if this test was positive. Of 13 patients who were allowed to bear weight after consolidation of the fracture, only one developed avascular necrosis. A further six patients were treated by non-weightbearing for up to eight months. Only one, in whom the fracture did not unite, developed avascular necrosis. The average time to union was 3.2 months, and the time to weightbearing was 4.1 months. This small difference, taking into account the low incidence of AVN (2 out of 19 or 10.5%, has led us to suggest a fresh approach to fractures of the femur neck in which the indications for immediate arthroplasty are restricted if the patient can tolerate prolonged non-weightbearing. Revascularisation may be assessed with phlebography and weightbearing allowed when this becomes positive. This approach should diminish the incidence of advanced AVN of the femoral head, and widen the indications for internal fixation.

[Subtalar arthrodeses and arthrodeses of the ankle joint (author's transl)]

We present a check-up study of five arthrodeses of the ankle joint and five subtalar arthrodeses. The arthrodeses of the ankle joint were indicated because of hard pains after bimalleolar fractures and fractures of the pilon tibial. Subtalar arthrodeses were indicated in posttraumatic arthritis of the calcaneus after intraarticular fractures of the calcaneus. Resection-compression-arthrodesis following Charnley was used for the ankle joint, subtalar arthrodesis was done by the technic of using a corticocancellous bone graft from the iliac crest. With an average postoperative follow-up period of four years four from five patients in every group had a good results. In cases clear indication the early arthrodesis should be preferred.