Zone I ruptures of the Achilles tendon and chronic ruptures in zone II with a gap of more than 6 cm are difficult to treat. We describe a technique that is very well suited to this type of rupture.
Materials and methods
Seventy-eight patients with chronic rupture of the Achilles tendon were operated on between January 1996 and December 2010. We used a modification of the Bosworth technique in which a strip of the gastrocnemius aponeurosis was taken, made into a tendon-like structure and passed through the calcaneum after making a drill hole; then it was sutured back to the proximal stump. The Leppilahti scoring system was used to evaluate these patients.
Sixty-two patients had excellent results, 8 had good results, 4 had fair results, 2 had poor results, and 2 were lost to follow-up at the end of 1 year. Nearly all patients resumed work at 6 months postoperatively, had normal walking and stair climbing, and regained normal dorsiflexion.
Our technique is ideally suited to zone I ruptures (where no distal stump is available for repair) and ruptures in zone II where end-to-end repair is not possible.
Achilles tendon; Chronic rupture; Strip of the gastrocnemius aponeurosis; Zone I ruptures
Pharmacological prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery, as well as in the treatment of femoral neck fractures, but few data exist in other fields of orthopaedics and traumatology. Thus, no guidelines or recommendations are available in the literature except for a limited number of weak statements about knee arthroscopy and lower limb fractures. In any case, none of them are a multidisciplinary effort as the one here presented. The Italian Society for Studies on Haemostasis and Thrombosis (SISET), the Italian Society of Orthopaedics and Traumatology (SIOT), the Association of Orthopaedic Traumatology of Italian Hospitals (OTODI), together with the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) and the Italian Society of General Medicine (SIMG) have set down easy and quick suggestions for VTE prophylaxis in a number of surgical conditions for which only scarce evidence is available. This inter-society consensus statement aims at simplifying the approach to VTE prophylaxis in the single patient with the goal to improve its clinical application.
Venous thromboembolism prevention; Anticoagulant prophylaxis; Mechanical prophylaxis; Bleeding risk; Arthroscopic surgery; Trauma surgery; Non-surgical traumatology
A multicenter retrospective analysis of patients treated for leg fractures was conducted to develop a score that correlates with fracture healing time and to identify the risk gradient for delayed healing.
Fifty-three patients were analyzed and considered healed when full weight bearing was possible. Patients were divided into those who healed within 180 days and those who took longer to heal. Risk factors associated with delayed healing, fracture morphology, and orthopedic treatments were recorded. The available literature was used to weight the relative risk associated with each factor; values were combined into a score evaluating the risk of delayed healing: L-ARRCO (a literature-based score where the risk of delayed bone healing is calculated using a specific algorithm). Other risk factors associated with delayed healing were then considered in order to calculate a new score, ARRCO. Continuous variables were compared between groups using Student’s heteroschedastic two-tail t test. Receiver operating characteristic (ROC) curves and the areas under the curves were calculated to determine the ability of this score to discriminate subjects with delayed healing.
The mean L-ARRCO scores of the patients who healed within and after 180 days were significantly different (5.78 ± 1.59 and 7.05 ± 2.46, respectively). The mean ARRCO scores of the patients who healed within and after 180 days were also significantly different (5.92 ± 1.78 and 9.03 ± 2.79, respectively). However, the area under the ROC curve was significantly smaller for L-ARRCO than for ARRCO (0.62 ± 0.09 versus 0.82 ± 0.07).
The ARRCO score is significantly associated with fracture healing time and could be used to identify “fractures at risk,” allowing early intervention to stimulate osteogenesis.
Leg fracture; Delayed healing; Risk factor score
The articular cartilage of the shoulder is not endowed with intrinsic repair abilities, so the detection of chondral lesions during arthroscopy may indicate that additional articular procedures are needed. The aim of the current study was to evaluate the benefits of arthroscopy in patients with early shoulder arthritis, and to assess which clinical and radiological features are correlated with better arthroscopic outcomes.
Materials and methods
Out of a total of 2,707 shoulders, 61 arthroscopies were performed on patients aged 30–55 years suffering from a painful early arthritic shoulder. We performed a retrospective study of 47 of those 61 patients with osteoarthritis at Samilson–Prieto stage I or II. SST and Constant score were used as outcome measures. Arthroscopic circumferential capsulotomy was performed to release the soft tissues and increase the joint space. Glenoid chondral lesions were caregorized according to location (anterior, posterior, centered) and size (small, large, total) and treated with microfractures; in the last 11 patients, we placed a engineered hyaluronic acid membrane, Hyalograft® C, on the surface of the glenoid. Postoperative care included mobilization the day after surgery, with the arm protected in a sling for two weeks. Follow-up examinations were performed at 3, 6, 12, and 24 months after surgery. The clinical and radiographic data collected were compared with those obtained at the last examination.
The mean Constant score increased from 43.8 points to 79.1, and the mean SST score increased from 4.9 points to 9.4 points. Clinical outcomes improved significantly in 44 patients (93.6 %). The three patients (6.4 %) with the lowest scores showed progression of arthritis. Age, gender, glenohumeral distance, and presence of engineered hyaluronic acid membrane were not related to clinical scores. Recovery of range of motion as well as small and centered cartilage lesions were statistically associated with improved outcome.
The main finding was that soft tissue procedures (including capsulotomy and synovectomy) associated with glenoid microfractures are only suitable for patients with early arthritis and preserved humeral head shape, particularly in cases with small and centered glenoid cartilage lesions.
Early arthritis; Shoulder; Arthroscopy; Cartilage lesions
The preoperative bone defect and the reconstruction of the center of rotation of the hip are critical in acetabular revision surgery. Uncemented oblong cups are employed in order to manage these issues. We analyzed the clinical results and rates of revision of two different uncemented oblong cups, the reconstruction of the center of rotation of the hip, as well as the rate of radiological loosening and possible risk factors.
Materials and methods
Forty-five patients (46 hips) underwent acetabular revision surgery using two different uncemented oblong cups. We assessed the clinical results and the survival rate for revision and aseptic loosening. Intraoperative bone loss was classified according to Paprosky, and acetabular reconstruction was assessed according to Ranawat. The mean follow-up was 7.2 years (range 4–11 years).
There were four re-revisions (three due to aseptic loosening); the survival rate for re-revision due to aseptic loosening was 60.1 % at seven years. The mean distance between the center of the femoral head prosthesis and the approximate center of the femoral head improved from 21.5 to 10.2 mm. Thirteen cups showed radiological loosening; the survival rate for radiological loosening at seven years was 40.54 %. A smaller postoperative horizontal distance was correlated with cup loosening.
Although optimal acetabular reconstruction can be achieved by using oblong uncemented cups in revision hip surgery, the clinical and radiological results are not encouraging. Excessive medialization of the cup may increase the rate of loosening.
Revision hip arthroplasty; Cementless cup; Reconstruction; Outcome
The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only a few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant in comparison with a standard anatomic stemmed shoulder prosthesis.
Materials and methods
The Constant score, the DASH score, the active range of motion (abduction, anteversion, external rotation), and the radiological results were examined in 82 patients with primary osteoarthritis of the shoulder treated with either the Total Evolutive Shoulder System® (Biomed, France) stemless shoulder prosthesis or the Affinis® (Mathys, Switzerland) stemmed shoulder prosthesis to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 32 ± 4 months after surgery.
There was no significant difference in the Constant scores of the groups treated with the stemless shoulder prosthesis (65.0 ± 11.0 points) and the stemmed shoulder prosthesis (73.2 ± 11.3 points; P = 0.162). The estimated blood loss (P = 0.026) and the mean operative time (P = 0.002) were significantly lower in the group with the stemless shoulder prosthesis.
The use of the stemless shoulder prosthesis yielded good results which, in a mid-term follow-up, were comparable with those provided by a standard anatomic shoulder prosthesis. Further investigations are needed regarding the long-term performance of this prosthesis.
Stemless shoulder prosthesis; Shoulder; Arthroplasty; Osteoarthritis
Patients with low back pain frequently demonstrate recumbent magnetic resonance imaging (MRI) alterations not always related to homogeneous clinical symptoms. The purpose of this study was to evaluate and quantify the statistical significance of variations of some anatomical parameters of the lumbosacral spine and reveal occult disc pathologies from recumbent to upright position in patients with acute and chronic low back pain.
Materials and methods
Fifty-seven patients complaining of low back pain (27 women, 30 men) underwent dynamic lumbosacral MRI with a 0.25-T tilting system (G-scan Esaote). We settled five parameters for which variations have been evaluated: lumbosacral angle, lordosis angle, L3–L4 intersomatic disc height, L3–L4 interspinous processes distance, and widest anteroposterior dural sac diameter. Images were obtained in both recumbent and upright positions.
Statistically significant differences [one-way analysis of variance (ANOVA), p = 0.0043] were found between each pair of values of parameters sampled in recumbent and upright positions. In 70 % of patients, on visual qualitative analysis only, an increment of disc protrusions and/or spondylolisthesis was found in the upright position; in three cases, in the upright position only, an interarticular pseudocyst was found.
Dynamic MRI with an open-configuration, low-field tilting MRI system is a feasible and promising tool to study degenerative pathology of the spine. Moreover, in cases of low back pain with negative MRI in the recumbent position or in patients with pain in the upright position only, tilting MRI permits visualization of occult spine and disc pathologies in patients with acute or chronic low back pain.
Upright MRI; Novel diagnostic tool; Low back pain; Lumbar instability; Disc degeneration
Volkmann’s ischemic contracture is a less common but crippling condition affecting the extremities. Once the condition sets in, the prognosis always remains guarded, even after long and intensive physiotherapy and various restorative surgical techniques. This study was undertaken to evaluate the long-term functional results of the Max Page muscle slide operation in patients with Volkmann’s ischemic contracture of the forearm of moderate degree (Tsuge classification).
Materials and methods
Nineteen patients treated between 1997 and 2009 were evaluated. The functional outcome (measured as the dexterity score, hand grip strength, sensibility, and appearance) was analyzed postoperatively. The pre- and postoperative values were compared using a paired t test. The final results were graded as good, fair, and poor.
The average age at the time of presentation was 18 years (range 3–25 years). Tight external splintage for injuries around elbow and forearm was the primary factor. The mean period of follow-up was 3.53 years. Fifteen patients were able to achieve good functional results. Three had fair and one had poor results. All three variables showed significant improvements postoperatively. Wound dehiscence was the most common complication. One patient needed a second surgery to restore good hand function.
The Max Page muscle sliding operation to treat Volkmann’s ischemic contracture of moderate degree gives good functional results. The procedure is simple and easy to perform. Adequate muscle release and proper postoperative physiotherapy are key to achieving good results.
Max Page release; Volkmann’s contracture; Tight external bandage
In recent years, several reports have suggested an association between the use of bisphosphonates and subtrochanteric insufficiency fractures. Research from animal studies and in some cases from histomorphometric data collected from patients provide evidence of a possible pathophysiological mechanism behind this phenomenon. Despite this, it has not yet been possible to confirm a causal relationship. The small number of cases, the lack of consistency in defining these atypical fractures, the absence of homogeneity between studies, and the fact that most data available are derived from retrospective observational studies, are some of the difficulties encountered in the evaluation of evidence. Despite the proven benefit of bisphosphonates at providing protection against osteoporotic fractures, caution should be used before continuing therapy for longer than 5 years.
Atypical; Insufficiency fracture; Subtrochanteric; Bisphosphonates
Bony defects in the spine are divided into three main types: spondylolysis, pediculolysis, and laminolysis. Lumbar spondylolysis is a well-known stress fracture that occurs frequently in adolescent athletes. Pediculolysis means stress fracture of the pedicle, which sometimes occurs subsequent to unilateral spondylolysis. Laminolysis is a rarely reported stress fracture similar to spondylolysis and pediculolysis that sometimes causes low back pain (LBP). However, its pathomechanism has not been elucidated. Recently, we encountered four adolescent athletes with symptomatic laminolysis. Mean age was 15.8 (range 15–17) years. All subjects reported severe LBP exacerbated by extension of the lumbar spine, and radiology revealed two types of laminolysis: hemilaminar type and intralaminar type. To elucidate the mechanisms of each type, we reviewed a biomechanical study, and found that the hemilaminar type was thought to be subsequent to contralateral spondylolysis, while the intralaminar type might be a result of a stress fracture due to repetitive extension loading.
Laminolysis; Spondylolysis; Retroisthmic cleft; Lumbar spine; Laminar fracture; Stress fracture
Computer-assisted total knee replacement (TKR) has been shown to improve radiographic alignment and therefore the clinical outcome. Outliers with greater than 3° of varus or valgus malalignment in TKR can suffer higher failure rates. The aim of this study was to determine the impact of experience with both computer navigation and knee replacement surgery on the frequency of errors in intraoperative bone cuts and implant alignment, as well as the actual learning curve.
Materials and methods
Three homogeneous groups who underwent computer-assisted TKR were included in the study: group A [surgery performed by a surgeon experienced in both TKR and computer-assisted surgery (CAS)], B [surgery performed by a surgeon experienced in TKR but not CAS], and C [surgery performed by a general orthopedic surgeon]. In other words, all of the surgeons had different levels of experience in TKR and CAS, and each group was treated by only one of the surgeons. Cutting errors, number of re-cuts, complications, and mean surgical times were recorded. Frontal femoral component angle, frontal tibial component angle, hip–knee–ankle angle, and component slopes were evaluated.
The number of cutting errors varied significantly: the lowest number was recorded for TKR performed by the surgeon with experience in CAS. Superior results were achieved in relation to final mechanical axis alignment by the surgeon experienced in CAS compared to the other surgeons. However, the total number of outliers showed no statistically significant difference among the three surgeons. After 11 cases, there were no differences in the number of re-cuts between groups A and C, and after 9 cases there were no differences in surgical time between groups A and B.
A beginner can reproduce the results of an expert TKR surgeon by means of navigation (i.e., CAS) after a learning curve of 16 cases; this represents the break-even point after which no statistically significant difference is observed between the expert surgeon and the beginner utilizing CAS.
Navigation future; Total knee replacement; Learning curve; Black box; Cutting errors; Computer assistance
Glenohumeral instability is a common problem in young and active patients. Both open and arthroscopic procedures have proven to be effective options. In cases with large bone defects on the glenoid side or on the humeral head or in contact sports, arthroscopy leads to a high risk of recurrence. We report the results of the modified Latarjet procedure in a population of 26 soccer players affected by chronic anterior instability. To our knowledge there are no previous reports on the results of this procedure when used in a homogeneous group of sportsmen.
Materials and methods
Twenty-six patients (28 shoulders) were retrospectively reviewed. We analyzed the roles of the players, the levels at which they played, and the average amount of hours that they trained before their injury and after surgery. Moreover, the type of bone loss detected on a preoperative imaging study and its relevance to the patient’s sporting comeback was recorded.
Eight-five months after surgery the mean Duplay score was 89.3; most of the players came back to the play at the same sporting level. Ninety-three percent of the patients were happy or very happy with their functional results. One patient underwent a redislocation.
Our series is the first in the literature to refer to a homogeneous group of soccer players. According to our results, and other series, the Latarjet procedure seems to be the gold standard in the treatment of chronic anterior instability in patients with large bone defects and in sportsmen playing contact sports.
Glenohumeral instability; Bone loss; Soccer; Latarjet procedure; Bankart repair
Multiplanar complex C3-type unstable distal femoral fractures present many challenges in terms of approach and fixation. This prospective study investigates a possible solution to these problems through double plating with autogenous bone grafting via a modified Olerud extensile approach.
Materials and methods
Twelve patients with closed C3-type injuries were included; eight of them were male, and their mean age was 33.5 years (range 22–44 years). Mechanism of injury was road traffic accident (RTA) in nine patients and fall from height in the other three cases. Eight cases were operated during the first week and four cases during the second week after injury. Mean follow-up was 13.7 months (range 11–18 months).
Mean radiological healing time was 18.3 weeks (range 12-28 weeks), and all cases had good radiological healing without recorded nonunion or malunion. Clinically, two cases (16.7 %) had excellent results, five cases (41.7 %) had good results, three cases (25 %) had fair results, and two cases (16.7 %) had poor results. No cases developed skin necrosis, deep infection, bone collapse, or implant failure. However, two cases (16.7 %) had limited knee flexion to 90° and required subsequent quadricepsplasty.
Use of this modified highly invasive approach facilitated anatomical reconstruction of C3-type complex distal femoral fractures with lower expected complication rate and acceptable clinical outcome, especially offering good reconstruction of the suprapatellar pouch area. It can be considered as a standby solution for managing these difficult injuries.
Highly unstable C3-type distal femur fracture; Extensile approach; Distal femur double plating; Multiplanar femoral condyle fractures
The present study introduces a new surgical technique and the results of a case series of patients with humeral shaft nonunion.
Materials and methods
Fifteen patients with diagnosis of diaphyseal nonunion of humerus were operated by a bridge-plate technique. A 4.5-mm plate is slid on the anterior surface of the humerus, submuscular to the brachial muscle. With the plate over the anterior surface of the humerus, screws are inserted from anterior to posterior on the ends of the plate. When there is a small bone gap, an iliac autologous graft is inserted. Minimum follow-up was 1 year.
Bone healing was obtained in all patients: 1.5 months postoperatively in 11 patients, 2 months in 3 patients, and 3 months in 1 patient. There were no postoperative infections, there was one case with loosening of the screws and plate, and there were no nerve injuries.
The present technique avoids wide dissection, radial nerve isolation, and periosteum stripping. The anterior minimally invasive bridge-plate technique for treatment of humeral shaft nonunion is a safe procedure and obtained bone healing in all patients in this series.
Nonunion; Humerus; Bridge plate; MIPO
Fixation of pertrochanteric fracture is undoubtedly an additional trauma after the fracture itself. In elderly patients, it might have an important impact on the whole organism. In the literature we find various techniques to perform this type of surgery. Up to now, there are no parameters validated for quantification of the invasiveness of a surgical procedure; it is therefore still not demonstrated that any method is less invasive than any other. In an effort to find a way to quantify the invasiveness of a surgical procedure, inflammatory markers were collected in patients undergoing fixation of trochanteric fracture with gliding hip screw [dynamic hip screw (DHS)] using either a conventional (DHS conv) or minimally invasive (DHS MIO) technique.
Two groups of patients were investigated prospectively; 36 of them were treated with conventional DHS technique and 32 with minimally invasive technique. Mean age was 84.7 ± 7.20 and 82.78 ± 7.71 years, respectively. Fracture type was classified according to the AO classification. Interleukin (IL)-6, IL-10, IL-8, and tumor necrosis factor (TNF)-α were measured 1 h before and 1 h after surgery. Student’s t test, chi-square test, and multivariate logistic regression were used for statistical analysis.
Preoperative levels of interleukins showed no significant differences between the two groups. In contrast, the postoperative blood level of IL-6 in patients operated with DHS conv technique (78.41 ± 67.04 pg/ml) was on average higher than in patients operated by DHS MIO technique (39.02 ± 37.36 pg/ml), the mean difference being 39.39 pg/ml [95 % confidence interval (CI) 12.65–66.13 pg/ml; p = 0.0045]. Multivariate logistic regression (backward method with limit of significance 0.05) confirmed that patients operated by conventional technique were significantly more likely to have increased IL-6 after surgery than those operated by MIO technique. IL-8 was measured in only 36 patients (20 for DHS conv, 16 for DHS MIO). No significant differences were found between the two groups; however, there was a drastic decrease postoperatively (p < 0.0001) regardless of the type of surgery performed. IL-10 and TNF-α were tested in all subjects, but did not show significant differences between the two groups. Average length of incision was significantly different (4.61 cm, 95 % CI 3.50–5.71 cm; p < 0.001) between the two groups, being 11.65 ± 2.64 cm for DHS conv and 7.05 ± 1.77 cm for DHS MIO. Similarly, average units of red blood cells (RBCs) transfused [performed for hemoglobin (Hb) <9 g/dl and/or hematocrit (HCT) <27 %] was higher (2.22 ± 0.99) in the DHS conv group compared with the DHS MIO group (1.09 ± 1.20), with average difference of 1.13 (95 % CI 0.59–1.66; p < 0.001).
This attempt to quantify the invasiveness of internal fixation for trochanteric fracture comparing two techniques (DHS conv versus DHS MIO) based on inflammatory markers (IL-6) has given encouraging results. Measurement of systemic inflammatory response to local tissue damage caused by osteosynthesis using IL-6 as marker seems to confirm the lower invasiveness of MIO techniques. These results for trauma cases seem in line with those published for hip prosthesis. Ongoing further studies analyzing the effect of nailing will confirm or invalidate these preliminary results.
Quantification of surgical trauma; Measuring surgical trauma; Gliding hip screw; Minimally invasive technique; Interleukins
Matrix metalloproteinases are catabolic enzymes that play a key role in the articular cartilage degeneration evident in degenerative and inflammatory conditions of articular cartilage. The aim of this study is to assess the ability of pravastatin to modify matrix metalloproteinase (MMP) messenger RNA (mRNA) expression and enzyme activity in a culture of normal human chondrocytes stimulated by interleukin-1β.
Materials and methods
Normal human chondrocytes were stimulated with interleukin (IL)-1β for 6 h to induce MMP expression, simulating a catabolic state, and then treated with pravastatin (1, 5 and 10 μM) for a further 18 h before cell lysates and supernatants were harvested. Cells stimulated with IL-1β but not treated with pravastatin served as controls. Real-time polymerase chain reaction (PCR) was used to assess expression of MMP-3 and MMP-9 mRNA. MMP enzyme activity was assessed using a fluorescent MMP-specific substrate. Statistical analysis was performed using analysis of variance (ANOVA).
MMP-3 and MMP-9 mRNA expression was reduced at all concentrations tested with statistically significant trends in reduction (p = 0.002 and <0.001, respectively). Analysis of culture supernatants revealed that pravastatin treatment led to a reduction in total MMP activity but not to a statistically significant degree (p = 0.07).
Treatment with pravastatin of stimulated human chondrocytes leads to significant down-regulation of selected MMP genes and a non-significant reduction in MMP enzyme activity. Our results provide further evidence that statins may have a role to play in future treatment of disease affecting articular chondrocytes.
Articular cartilage; Statins; Matrix metalloproteinases
Blood transfusion is often required in total knee replacement; various methods of blood preservation have been studied. The best solution is to reduce the loss of blood during and after surgery.
Materials and methods
We designed this study to evaluate the hemostatic efficacy and safety of fibrin tissue adhesive (Quixil) in patients receiving total knee arthroplasty [low contact stress (LCS, DePuy, Warsaw, IN, US) cementless total knee replacement (TKR)] with a prospective, randomized, standard treatment controlled study. Thirty-five patients were randomized to receive treatment with fibrin tissue adhesive (treatment group), and 35 were randomized to be managed with postoperative blood recovery and reinfusion (control group). Blood loss in suction drain, decrease in hemoglobin values, and transfusions were recorded.
A significant reduction in apparent total blood loss was detected in the treatment group compared with the control group. There was also a lower decrease in hemoglobin level, although this difference was not significant. When fibrin tissue adhesive was administered, the need for transfusions was lower. No major adverse events were recorded in our series.
Fibrin tissue adhesive reduced blood loss in TKR and seemed to significantly reduce the need for blood transfusion. Fibrin tissue adhesive can be an appropriate solution to enhance hemostasis and vessel sealing at the operative site in TKR, in order to reduce blood loss after surgery and the risk of complications.
Fibrin tissue adhesive; Blood loss; Total knee arthroplasty; Fibrin sealant
Implant stability is considered vital to long-time implant survival in total hip arthroplasty (THA), since loose implants are reported to be a major cause of hip revision. There is an association between early implant micromotion and increased risk of revision. More implant-specific data are needed to establish acceptable levels of early implant movement.
Materials and methods
Thirty-five patients (36 hips) undergoing Charnley THA were followed with repeated clinical, radiographic, and radiostereometric analysis (RSA) over 5 years. Twenty-three patients attended 5 years postoperatively.
The patient group was well functioning based on the radiological and clinical evaluations. The stems constantly moved up to 5 years postoperatively, with subsidence, retroversion, and varus tilt, based on the RSA.
Continuous movement of the Charnley stem was observed up to 5 years postoperatively in a well-functioning patient group. The migration data presented herein could be useful when defining acceptable migration limits for certain types of cemented femoral stems.
RSA; Charnley; THR; Five-year follow-up; Migration pattern
Fasciotomy for compartment syndrome is an emergent procedure that is usually done in the operating theater under general anesthesia. Delay in performing the procedure can lead to worse outcome. Various reasons can cause delay in performing the surgery. Bedside fasciotomy under local anesthesia can be done in these cases to avoid delay in compartment release.
Materials and methods
This was a retrospective study of 34 cases of acute compartment syndrome for which fasciotomy was done at the bedside under local anesthesia. The minimum follow-up period was 6 months.
All patients had immediate and marked improvement in pain. Thirty-three patients regained their normal muscle strength. Thirty-two patients regained normal range of motion of adjacent joints. One patient developed flexion contracture of the great toe. There was no deep infection, chronic osteomyelitis, or amputation. Superficial wound infection was noted in three patients; one patient had persistent foot drop.
Bedside fasciotomy under local anesthesia is a feasible, safe, and effective choice for treating compartment syndrome in patients with delayed presentation or those with anticipated delay to undergo surgery in the operating theater under general or regional anesthesia. The results of this study are encouraging, as all wounds healed satisfactory and there were no cases of deep infections. The formal release of compartments in the operating room under general anesthesia continues to be the standard of care. This is the first description in the literature for bedside fasciotomy under local anesthesia with a relatively large number of patients.
Compartment syndrome; Bedside; Fasciotomy; Local anesthesia; Fascial release; Urgent surgery
The implantation of a saddle prosthesis after resection of a pelvic tumor has been proposed as a simple method of reconstruction that provides good stability and reduces the surgical time, thus limits the onset of intraoperative complications. There are no studies in the literature of patients evaluated using gait analysis after being implanted with a saddle prosthesis. The present study is a retrospective case review aimed at illustrating long-term clinical and functional findings in tumor patients reconstructed with a saddle prosthesis.
Materials and Methods
A series of 15 patients who recieved pelvic reconstruction with a saddle prosthesis were retrospectively reviewed in terms of clinical, radiographic, and functional evaluations. Two patients were additionally assessed by gait analysis.
Long-term functional follow-up was achieved in only 6 patients, and ranged from 97 to 167 months. Function was found to be rather impaired, as a mean of only 57 % of normal activity was restored. Gait analysis demonstrated that the implant had poor biomechanics, as characterized by very limited hip motion.
Though the saddle prosthesis was proposed as advance in tumor-related pelvic surgery, the present study indicates that it yields unsatisfactory clinical and functional results due to both clinical complications and the poor biomechanics of the device. The use of a saddle prosthesis in tumor surgery did not provide satisfactory results in long-term follow-up. It is no longer implanted at our institute, and is currently considered a “salvage technique.”
Level of evidence
Saddle prosthesis; Gait analysis; Tumor surgery; Bone tumors; Resection
One of the main criticisms of minimally invasive approaches in total knee arthroplasty has been their poor adaptability in cases of major deformity or stiffness of the knee joint. When they are used in such cases, excessive soft-tissue tension is needed to provide appropriate joint exposure. Here, we describe the “mini trivector approach,” which has become our standard approach for total knee replacement because it permits us to enlarge the indication for minimally or less invasive total knee replacement to many knees where quad sparing, a subvastus approach, or a mini quad or mini midvastus snip may not be sufficient to achieve correct exposure. It consists of a limited double snip of the VMO and the quadriceps tendon that reduces tension on the extensor mechanism and allows easier verticalization of the patella as well as good joint exposure.
Total knee replacement; Minimally invasive; Trivector
Existing classifications for heterotopic ossification (HO) do not include all HO types; nor do they consider the anatomy of the involved joint or the neurological injury. Therefore, we performed this study to propose and evaluate a classification according to the location of neurogenic HO and the neurological injury.
Materials and methods
We studied the files of 24 patients/33 hips with brain or spinal cord injury and neurogenic HO of the hip treated with excision, indomethacin, and radiation therapy. We classified patients according to the Brooker classification scheme as well as ours. Four types of neurogenic HO were distinguished according to the anatomical location of HO: type 1, anterior; type 2, posterior; type 3, anteromedial; type 4, circumferential. Subtypes of each type were added based on the neurological injury: a, spinal cord; b, brain injury. Mean follow-up was 2.5 years (1–8 years).
The Brooker classification scheme was misleading—all hips were class III or IV, corresponding to ankylosis, even though only 14 hips had ankylosis. On the other hand, our classification was straightforward and easy to assign in all cases. It corresponded better to the location of the heterotopic bone, and allowed for preoperative planning of the appropriate surgical approach and evaluation of the prognosis; recurrence of neurogenic HO was significantly higher in patients with brain injury (subtype b), while blood loss was higher for patients with anteromedial (type 3) and circumferential (type 4) neurogenic HO.
Our proposed classification may improve the management and evaluation of the prognosis for patients with neurogenic HO.
Neurogenic heterotopic ossification; Hip; Brain injury; Spinal cord injury
Use of antibiotic-loaded acrylic bone cement to treat orthopaedic infections continues to remain popular, but resistance to routinely used antibiotics has led to the search for alternative, more effective antibiotics. We studied, in vitro, the elution kinetics and bio-activity of different concentrations of meropenem-loaded acrylic bone cement.
Meropenem-loaded bone cement cylinders of different concentrations were serially immersed in normal saline. Elution kinetics was studied by measuring the drug concentration in the eluate, collected at pre-determined intervals, by high-performance liquid chromatography. Bio-activity of the eluate of two different antibiotic concentrations was tested for a period of 3 weeks against each of the following organisms: Staphylococcus aureus ATCC 2593 (MSSA), Enterococcus faecalis ATCC 29212, Pseudomonas aeruginosa ATCC 27853, Escherichia coli ATCC 25922, S. aureus ATCC 43300 (MRSA) and Klebsiella pneumoniae ATCC 700603 (ESBL).
Meropenem elutes from acrylic bone cement for a period of 3–27 days depending on the concentration of antibiotic. Higher doses of antibiotic concentration resulted in greater elution of the antibiotic. The eluate was found to be biologically active against S. aureus ATCC 2593 (MSSA), P. aeruginosa ATCC 27853, E. coli ATCC 25922 and K. pneumoniae ATCC 700603 (ESBL) for a period of 3 weeks.
The elution of meropenem is in keeping with typical antibiotic-loaded acrylic bone cement elution characteristics. The use of high-dose meropenem-loaded acrylic bone cement seems to be an attractive option for treatment of resistant Gram-negative orthopaedic infections but needs to be tested in vivo.
Local antibiotic delivery; Extended-spectrum beta-lactamase producers; Gram-negative; Orthopaedic infections; Antibiotic bone cement