Strategies in Trauma and Limb Reconstruction

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2009 | October | Volume 4 | Issue 2

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Original Article

Roland Ivo, Jens Dargel, Dietmar Pennig

Treatment of chronically unreduced complex dislocations of the elbow

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:7] [Pages No:49 - 55]

Keywords: Chronic elbow dislocation, Hinged external fixation, Elbow distraction, In situ neurolysis of ulnar nerve

   DOI: 10.1007/s11751-009-0064-1  |  Open Access |  How to cite  | 

Abstract

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107° (range, from 100° to 110°). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.

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Original Article

Andreas Heinrich Tiemann, Gunther O. Hofmann

Principles of the therapy of bone infections in adult extremities

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:8] [Pages No:57 - 64]

Keywords: Osteitis, Osteomyelitis, Surgical therapy

   DOI: 10.1007/s11751-009-0059-y  |  Open Access |  How to cite  | 

Abstract

Septic diseases of the bone and immediately surrounding soft tissues can be differentiated into osteitis or osteomyelitis. Both are a most serious diagnosis in modern traumatology and orthopaedic surgery. The basis for treatment is a highly specific, problem-adapted therapy with a defined strategy, the paramount goal being to preserve the stable weightbearing bones, maintain a good mechanical axis with correctly working muscles and joints, and avoid permanent disability. “State-of-the-art” therapy of osteitis and osteomyelitis has two priorities: (a) Eradication of the infection; (b) Reconstruction of bone and soft tissue. Surgical treatment with resection of the affected bone segments and soft tissue, followed by reconstructive methods continues to be the main basic therapy, and is supported by local and systemic antibiotics and adjuvant methods such as hyperbaric oxygen. This article provides an overview of the diagnostic features and different surgical procedures as well as the current literature in order to reach the above named goals.

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Original Article

Elsayed Ibraheem Elsayed Massoud

Fixation of subtrochanteric fractures

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:7] [Pages No:65 - 71]

Keywords: Subtrochanteric fracture, Dynamic hip screw, Biomechanics

   DOI: 10.1007/s11751-009-0058-z  |  Open Access |  How to cite  | 

Abstract

The subtrochanteric region has certain anatomical and biomechanical features that can make fractures in this region difficult for the treating surgeon. The preferred type of device is a matter of debate. Increased understanding of mechanical characteristics of the dynamic hip screw (DHS) has reduced the incidence of complications. Our hypothesis is based on the technical optimization of the DHS application. We prospectively studied 37 patients with subtrochanteric fractures with a mean age of 42.9 years. We utilized a two-stage protocol: initially, conversion of the comminuted fractures into two part fractures; then application of the implant with a technique that allowed dynamization of the DHS. Clinical and radiographic data were used to assess the outcome at 12 months. Fracture healing was obtained for all cases in a mean time of 11.64 weeks. One patient had 1.5 cm shortening of the injured limb. No implant failure was reported. All patients resumed pre-injury activities of daily living. It was concluded that the patients who were treated with the technical optimization of the DHS application achieved a close-to-normal anatomy following surgery and maintained this state throughout the follow-up period.

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Original Article

K.-H. Frosch, T. Sawallich, G. Schütze, A. Losch, T. Walde, P. Balcarek, F. Konietschke, K. M. Stürmer

Magnetic resonance imaging analysis of the bioabsorbable Milagro™ interference screw for graft fixation in anterior cruciate ligament reconstruction

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:7] [Pages No:73 - 79]

Keywords: Anterior cruciate ligament, Graft fixation, Interference screw, Milagro™ screw, Magnetic resonance imaging

   DOI: 10.1007/s11751-009-0063-2  |  Open Access |  How to cite  | 

Abstract

Ligament graft fixation with bioabsorbable interference screws is a standard procedure in cruciate ligament replacement. Previous screw designs may resorb incompletely, and can cause osteolysis and sterile cysts despite being implanted for several years. The aim of this study was to examine the in vivo degradation and biocompatibility of the new Milagro™ interference screw (Mitek, Norderstedt, Germany). The Milagro™ interference screw is made of 30% ß-TCP (TriCalcium phosphate) and 70% PLGA (Poly-lactic-co-glycolic acid). In the period between June 2005 and February 2006, 38 patients underwent graft fixation with Milagro™ screws in our hospital. Arthroscopic ACL reconstruction was performed using hamstring tendon grafts in all the patients. MR imaging was performed on 12 randomly selected patients out of the total of 38 at 3, 6 and 12 months after surgery. During the examination, the volume loss of the screw, tunnel enlargement, presence of osteolysis, fluid lines, edema and postoperative screw replacement by bone tissue were evaluated. There was no edema or signs of inflammation around the bone tunnels. At 3, 6 and 12 months, the tibial screws showed an average volume loss of 0, 8.1% (±7.9%) and 82.6% (±17.2%, P < 0.05), respectively. The femoral screws showed volume losses of 2.5% (±2.1%), 31.3% (±21.6%) and 92.02% (±6.3%, P < 0.05), respectively. The femoral tunnel enlargement was 47.4% (±43.8%) of the original bone tunnel volume after 12 months, and the mean tunnel volume of the tibial tunnel was −9.5% (±58.1%) compared to the original tunnel. Bone ingrowth was observed in all the patients. In conclusion, the resorption behaviour of the Milagro™ screw is closely linked to the graft healing process. The screws were rapidly resorbed after 6 months and, at 12 months, only the screw remnants were detectable. Moreover, the Milagro™ screw is biocompatible and osteoconductive, promoting bone ingrowth during resorption. Tunnel enlargement is not prevented in the first months but is reduced by bone ingrowth after 12 months.

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Original Article

Michail Beltsios, Olga Savvidou, John Kovanis, Panagiotis Alexandropoulos, Panagiotis Papagelopoulos

External fixation as a primary and definitive treatment for tibial diaphyseal fractures

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:7] [Pages No:81 - 87]

Keywords: External fixation, Definitive treatment, Open tibial fractures, Threatened compartment, Syndrome, Multiply injured patients

   DOI: 10.1007/s11751-009-0062-3  |  Open Access |  How to cite  | 

Abstract

The aim of this study was to evaluate the effectiveness of unilateral external fixator as primary and definitive treatment for open tibial fractures, fractures with severe soft tissues injuries, threatened compartment syndrome, and in multiply injured patients. Two hundred and twenty-three tibial shaft fractures (212 patients) were treated. In open fractures, union was achieved in 25 weeks, while in closed in 21. There were 18 nonunions, 21 delayed unions, 4 malunions, 58 pin infections and 3 osteomyelitis. A reoperation was performed in 42 patients. Fat embolism was diagnosed in three patients, pulmonary embolism in five and deep venous thrombosis in 14. The external fixator was definitive treatment in 87.27%. Unilateral external fixators can be used as primary and definitive treatment for complicated tibia shaft fractures. Re-operation or change of the method must be performed only when there is a delay in callus formation.

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Original Article

Byron E. Chalidis, George E. Petsatodis, Nick C. Sachinis, Christos G. Dimitriou, Anastasios G. Christodoulou

Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:6] [Pages No:89 - 94]

Keywords: Tibia, Fracture, Open fracture, Intramedullary nail, Nonunion, Dynamization, Exchange nailing

   DOI: 10.1007/s11751-009-0065-0  |  Open Access |  How to cite  | 

Abstract

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.

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Original Article

Kajetan Klos, Thomas Drechsel, Florian Gras, Claudia Beimel, Andreas Tiemann, Gunther O. Hofmann, Thomas Mückley

The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:8] [Pages No:95 - 102]

Keywords: Talectomy, Tibiocalcaneal arthrodesis, Retrograde, Intramedullary nail, Ankle arthrodisis, Hindfoot

   DOI: 10.1007/s11751-009-0067-y  |  Open Access |  How to cite  | 

Abstract

Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis.

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CASE REPORT

Freih Odeh Abu Hassan, Maha Shomaf

Intramuscular myxoma of the hypothenar muscles

[Year:2009] [Month:October] [Volume:4] [Number:2] [Pages:4] [Pages No:103 - 106]

Keywords: Myxoma, Hand, Neoplasm, Hypothenar

   DOI: 10.1007/s11751-009-0061-4  |  Open Access |  How to cite  | 

Abstract

Intramuscular myxomas of the hand are rare entities. Primarily found in the myocardium, these lesions also affect the bone and soft tissues in other parts of the body. This article describes a case of hypothenar muscles myxoma treated with local surgical excision after frozen section biopsy with tumor-free margins. Radiographic images of the axial and appendicular skeleton were negative for fibrous dysplasia, and endocrine studies were within normal limits. The 8-year follow-up period has been uneventful, with no complications. The patient is currently recurrence free, with normal intrinsic hand function.

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