Surgical treatment of Monteggia variant fracture dislocations of the elbow in adults: surgical technique and clinical outcomes.

PURPOSE: Monteggia variant defined as Monteggia fracture dislocation with radial head or neck fracture, coronoid fracture, ulnohumeral joint dislocation or combination of these injuries. The aim of this study was to evaluate clinical outcomes of surgical treatment of Monteggia variant fracture dislocations with focus on the operative technique and management of associated radial head fractures. METHODS: Between January 2008 and January 2014, 22 patients (7 men, 15 women) with a mean age of 58.9 years (45-77 years) and unilateral Monteggia variant were included. The mean follow-up was 4.1 years (2.2-6.6 years). Patients underwent clinical and functional assessment using the Mayo Elbow Performance Index and the Oxford Elbow Score. RESULTS: Eighteen patients had radial head fractures; in five patients the fracture fragment involved less than one-third of the radial head and the fragment was excised, in four patients the radial head fracture was fixed with headless screws and in nine patients the radial head was replaced. At review the mean Mayo Elbow Performance Index was 76.6 (20-100) and the Oxford Elbow Score 35 (4-48). CONCLUSIONS: Our experience suggests that satisfactory outcomes can be obtained in the treatment of the complex Monteggia variant fracture dislocations by recognising the injury pattern and addressing all components of the injury in order to achieve elbow stability.

Arthroscopic "Remplissage" for shoulder instability: a systematic review.

PURPOSE: Large Hill-Sachs lesions engaging the glenoid rim predispose to recurrent anterior instability and failure of isolated labrum repairs. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement. This systematic review assessed the outcomes and complications of arthroscopic remplissage for anterior shoulder instability. METHODS: A search of the MEDLINE, EMBASE and evidence-based medicine Cochrane databases was conducted. Data were extracted by two reviewers in a standardised manner. Redislocation, instability and complication rates were calculated and expressed as percentages with 95 % confidence intervals. RESULTS: Of 4,284 studies identified, eight articles with a total of 207 patients were analysed. Mean redislocation rate was 4.2 ± 3.9 % (range 0-15 %), and mean recurrent instability rate 3.2 ± 3.8 % (0-15 %). Posterosuperior shoulder pain and stiffness were the only complications described. Overall, there was a mean reduction in external rotation in adduction of 5.6° (-40 to +30), reduction in external rotation in abduction of 11.3° (-50 to +7) and reduction in internal rotation of 0.9 (-4 to 0) vertebral levels. CONCLUSIONS: Arthroscopic remplissage alongside anterior labrum repair seems successful in treating recurrent shoulder instability in the presence of large or engaging Hill-Sachs lesion. However, the available literature consists mainly of heterogeneous case series. There is a need for a high-quality randomised trial to compare remplissage with other commonly used techniques for recurrent instability associated with substantial Hill-Sachs defects such as the Latarjet procedure. LEVEL OF EVIDENCE: Systematic review, Level IV.

Medium term outcomes of planovalgus foot correction in children using a lateral column lengthening approach with additional procedures 'a la carte'.

BACKGROUND: We report our medium term outcomes following surgery for symptomatic planovalgus malalignment in children. The technique we describe commences with lateral column lengthening and includes subsequent bony and soft tissue procedures which are carried out 'a la carte' in response to the underlying pathology and the behaviour of the foot to the lateral column lengthening. METHODS: Surgery was undertaken on twenty five symptomatic planovalgus feet in 15 patients at a mean age of 12 years and 6 months (5 years 7 months to 16 years and 3 months). The case-mix was principally idiopathic pes planovalgus but included overcorrected club foot and skewfoot deformity. Following lateral column lengthening (using a tricortical interpositional os calcis bone graft) the 'a la carte' elements of the surgery undertaken included both bony and soft tissue elements: heel shift; medial cuneiform osteotomy with iliac crest tricortical bone grafting, peroneus brevis/peroneus longus transfer; plantar fascia release; tibialis posterior advancement. VAS FA and AOFAS scores, clinical findings and complications were recorded. RESULTS: Twelve patients (20 feet) were available for follow up at a mean of 4 years and 6 months years (2 years and 8 months to 6 years and 3 months). VAS FA and AOFAS scores were 82±17 (50-99), 87±14 (61-100) and 80±10 (62-100), respectively. In all patients the reconstituted medial arch was maintained. Three patients (5 feet) required a second corrective procedure. CONCLUSION: We propose lateral column lengthening with additional 'a la carte' procedures in the surgical treatment of symptomatic pes planovalgus in childhood as a reliable corrective surgical procedure on the basis of favourable medium term functional outcomes.

Protective effects of a selective neutrophil elastase inhibitor (sivelestat) on lipopolysaccharide-induced acute dysfunction of the pulmonary microcirculation.

OBJECTIVE: The purpose of this study was to evaluate the effect of a neutrophil elastase inhibitor, sivelestat, on lipopolysaccharide-induced acute lung injury through analysis of hemodynamic changes in the pulmonary microcirculation. DESIGN: Randomized animal study. SETTING: Medical school laboratory. SUBJECTS: Twenty-seven Wistar rats (15 rats for microspectroscopic observations, 12 rats for measurements of neutrophil elastase activity and wet-to-dry ratio). INTERVENTIONS: Thoracosternotomy was performed on male Wistar rats under continuous anesthesia and mechanical ventilation. Rats were divided into three groups (n = 5 each groups) on the basis of the reagent used: lipopolysaccharide group (100 microg/kg lipopolysaccharide intravenously), sivelestat group (10 mg/kg sivelestat; 100 microg/kg lipopolysaccharide intravenously), and control group (saline only, intravenously). MEASUREMENTS AND MAIN RESULTS: We measured morphologic changes and hemodynamic variables, including tissue blood flow, erythrocyte velocity, erythrocyte count, thickness of interalveolar septa, and leukocyte adhesion in the pulmonary microcirculation, with a video-rate (33 msec/frame) dual-spot microspectroscopy system (DSMSS) and a laser-Doppler flowmeter. Blood-free wet-to-dry ratio and neutrophil elastase activity in bronchoalveolar lavage fluid, serum, and supernatant of lung homogenate were measured in another set of experiments (n = 4 for each group). Sixty minutes after lipopolysaccharide administration, severe thickening of the interalveolar septa was observed in the lipopolysaccharide but not the sivelestat group. In the lipopolysaccharide group, DSMSS measurements of erythrocyte velocity and hemoglobin oxygenation in single capillaries were decreased significantly (vs. control p < .05, vs. sivelestat p < .01), whereas tissue blood flow and erythrocyte velocity measurements from laser-Doppler flowmeter were increased significantly (vs. control p < .05, vs. sivelestat p < .01). The number of adherent leukocytes was increased significantly in the lipopolysaccharide group at 30, 45, and 60 mins after lipopolysaccharide administration (vs. control p < .01, vs. sivelestat p < .05). The number of adherent leukocytes did not increase in the sivelestat group. The wet-to-dry ratio was significantly higher in the lipopolysaccharide group than in control (p < .05) and sivelestat (p < .05) groups. Neutrophil elastase activities in the bronchoalveolar lavage fluid, serum, and lung tissue were all significantly lower in the sivelestat group than in the lipopolysaccharide group (p < .05). CONCLUSIONS: Lipopolysaccharide induces leukocyte adhesion in the pulmonary microcirculation, resulting in decreased tissue hemoglobin oxygen and alveolar and interstitial edema. The selective neutrophil elastase inhibitor sivelestat reduces neutrophil elastase activity and attenuates acute changes in the pulmonary microcirculation.

New experimental model of crush injury of the hindlimbs in rats.

BACKGROUND: Crush injury (CI) remains a life-threatening condition. Because there is a shortage of animal models of CI, we purposed to develop a reproducible model of CI of hindlimbs in rats and to evaluate correlation between the volume of muscles traumatized and the severity of CI. METHODS: The right or both hindlimbs of anesthetized rats were compressed for 6 hours under blocks weighing 3 kg. This was followed by 3 hours of reperfusion. Serum lactate, base excess (BE), and potassium (K) were measured at 10 minutes after cannulaton (baseline), immediately before release (compression), and 3 hours after release (reperfusion). Serum creatine phosphokinase (CK), lactate dehydrogenase (LDH), aspartate transferase (AST) and alanine transferase (ALT) were measured at baseline and reperfusion. Muscles and kidneys were evaluated morphologically. In a separate group of animals treated in the same way, survival rate was monitored for 168 hours. RESULTS: Unilateral CI did not induce serious systemic impairment. Bilateral CI resulted in severe lactic acidosis. Serum K levels increased similarly and significantly in both groups. Serum CK levels correlated strongly with the volume of muscles traumatized. Bilateral CI produced a sharp increase in serum LDH, AST and ALT levels by the end of experiment. Signs of direct cellular damage and ischemia-reperfusion injury were found in histology specimens. In bilaterally crushed rats there were patent signs of acute tubular necrosis at 24 hours after insult. All rats with unilateral CI survived, whereas mortality rate reached 58.3% in rats with bilateral CI. The majority of these animals died within 24 hours after compression. CONCLUSIONS: We developed a valid experimental model of severe CI of the hindlimbs in rats. Systemic responses to CI and the severity of CI appeared to correlate strongly with the volume of muscle traumatized.

Mild hypothermia reduces expression of heat shock protein 60 in leukocytes from severely head-injured patients.

BACKGROUND: Infectious complications are among the most serious problems that occur in severely head-injured patients treated with mild hypothermia. The mechanism underlying the susceptibility to infection has not been clarified. Heat shock protein (HSP) 60 has been reported to play an essential role in innate immunity. Thus, we conducted a study to clarify the impact of mild hypothermia on the expression of HSPs in polymorphonuclear leukocytes (PMNLs) in severely head-injured patients. METHODS: Between September 1997 and November 1999, 17 severely head-injured patients with a Glasgow Coma Scale score of 8 or less at admission in whom intracranial pressure could be maintained below 20 mm Hg by conventional therapy were randomly assigned to two treatment groups: a mild hypothermia group (HT group, nine patients) and a normothermia group (NT group, eight patients). The HT group was subjected to mild hypothermia (intracranial temperature, 34 degrees C) for 48 hours followed by rewarming at a rate of 1 degrees C per day for 3 days, whereas the NT group was subjected to normothermia (intracranial temperature, 37 degrees C) for 5 days. Blood samples were serially obtained at three time points; days 0 to 1, days 2 to 5, and days 6 to 14 after head injury. We measured the expression of HSP27, HSP60, HSP70, and HSP90 by flow cytometry. RESULTS: The two groups were similar with respect to prognostic factors, and there was no difference in clinical outcome. The expression of PMNL HSP60 in the HT group was significantly lower in all three time periods compared with that in the NT group (p < 0.05), whereas expression of the other HSPs did not differ significantly between the groups. The incidence of infectious complications was significantly increased in the HT group over that in the NT group (p < 0.05). In in vitro studies, PMNLs from 10 healthy volunteers were incubated at 37 degrees C, 34 degrees C, or 26 degrees C for 1 hour with sodium arsenite (100 micromol/L), an HSP inducer. The expression of HSP60 at 26 degrees C and 34 degrees C was significantly lower than that at 37 degrees C (p < 0.05), whereas expression of the other HSPs did not differ significantly at 26 degrees C, 34 degrees C, or 37 degrees C. CONCLUSION: Mild hypothermia reduces the expression of HSP60 in PMNLs from severely head-injured patients. Thus, mild hypothermia may suppress innate immunity.