Regional migratory osteoporosis of the knee: a literature overview.

The purpose of this article is to review the clinical syndrome of regional migratory osteoporosis (RMO) of the knee and to highlight all the important aspects of diagnosis and management that can be helpful to the physician. RMO is a rare, self-limiting disease characterized by migrating arthralgia, bone marrow edema and osteoporosis. The pathogenesis of RMO remains controversial and is not yet fully elucidated. A thorough presentation of the disease is conducted with presentation of the clinical features (progressive pain and local tenderness), differential diagnosis and appropriate diagnostic criteria. The role of MRI is underlined and strategies for the treatment of RMO are presented.

Histological and biochemical evidence related to the collagen quality in torn rotator cuff tendons.

This study investigates the histological background of torn rotator cuff tendons, evaluates the stability of newly synthesized collagen by measuring the hydro-xyproline content and attempts to correlate these findings with the clinical outcome after reconstruction of the rotator cuff. Sixty-one patients underwent reconstruction for a -rotator cuff tear. They were evaluated preoperatively with the Constant-Murley score, MRI and ultrasound. Biopsy samples were taken from chronic rotator cuff tears and histological analysis was performed. Hydroxyprolin presence was evaluated in various -tissues. Mean follow-up was 46 months. Histological analysis revealed collagen fragmentation and thinning (90.2% of patients), myxoid degeneration (88%), hyaline degeneration (50.8%), chondroid metaplasia (44.3%), calcification (24.7%), fatty infiltration (20.4%) and vascular proliferation (62.3%). Hydroxyproline was under-represented in newly synthesized collagen in 57% of patients. In the majority of the patients with a low hydroxyproline/collagen ratio the histological findings were abnormal. None of the findings was related to the clinical outcome with a statistical significance. Histological and biochemical findings reflected the poor quality of the tendon. The good clinical outcome did not depend on the histological or biochemical findings but rather on the meticulous surgical reconstruction and physical therapy.

RhBMP-7 for the treatment of nonunion of fractures of long bones.

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients' quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Autologous (non-vascularised) fibular grafting with recombinant bone morphogenetic protein-7 for the treatment of femoral head osteonecrosis: preliminary report.

This preliminary study evaluates a combination of bone morphogenetic protein (BMP)-7 and non-vascularised autologous fibular grafting (AFG) for the treatment of osteonecrosis of the femoral head. BMP-7/AFG combination was applied in seven pre-collapse femoral heads (five Steinberg stage II, two stage III) in six patients. Pre- and post-operative evaluation included clinical (Harris hip score (HHS), visual analogue scale (VAS) for pain) and radiological assessment (radiographs, quantitative CT) at a mean follow-up of 4 years (2 to 5.5). A marked improvement of function (mean HHS increase of 49.2) and decrease of pain level (mean VAS decrease of 5) as well as retention of the sphericity of the femoral head was noted in five hips at the latest follow-up, while signs of consolidation were apparent from the third post-operative month. One patient (two hips) required bilateral total hip replacement at one year post-operatively. In the series as a whole, quantitative-CT evaluation revealed similar densities between affected and normal bone. Heterotopic ossification was observed in four hips, without compromise of the clinical outcome. In this limited series AFG/BMP-7 combination proved a safe and effective method for the treatment of femoral head osteonecrosis, leading to early consolidation of the AFG and preventing collapse in five of seven hips, while the operative time and post-operative rehabilitation period were much shorter compared with free vascularised fibular grafts.

Early results of a novel technique using multiple small tantalum pegs for the treatment of osteonecrosis of the femoral head: a case series involving 26 hips.

The introduction of a trabecular tantalum rod has been proposed for the management of early-stage osteonecrosis of the femoral head but serves as a single-point of support of the necrotic lesion. We describe a technique using two or three 4.2 mm (or later 4.7 mm) tantalum pegs for the prevention of collapse of the necrotic lesion. We prospectively studied 21 patients (26 hips) with non-traumatic osteonecrosis of the femoral head treated in this manner. Of these, 21 patients (24 hips) were available for radiological and clinical evaluation at a mean follow-up of 46 months (18 to 67). Radiological assessment showed that only eight hips deteriorated according to the Association Research Circulation Osseous classification, and four hips according to the Classification of the Japanese Investigation Committee of Health and Welfare. Functional improvement was obtained with an improvement in the mean Harris hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean Merle D'Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18), a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6 (0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1) to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum of 18 months, three were considered as failures at the final follow-up, having required total hip replacement. One of the hips without full follow-up was also considered to be a failure. In more than two-thirds of the surviving hips a satisfactory clinical outcome was achieved with promising radiological findings. The estimated mean implant survival was 60 months (95% confidence interval 53.7 to 66.3).

Digital coverage with flaps from the same or neighboring digits.

OBJECTIVE: Several flaps can be dissected from the same or neighboring digits for the reconstruction of relatively large soft tissue digital defects. MATERIAL AND METHODS: In a 6-year period, 106 large soft tissue digital defects were reconstructed with the use of flaps in 101 patients. For the reconstruction of 75 fingertip defects 73 neurovascular, island or advancement flaps (42 homodigital, 18 heterodigital, 13 advancement) and 2 thenar flaps were used. The 31 defects of the proximal and middle phalanges were reconstructed with 3 intermetacarpal and 28 cross-finger flaps (17 de-epithelialized and 11 classic for dorsal and palmar defects respectively). RESULTS: All flaps survived. Subjectively, the results were rated as good or excellent in 69 of 73 distal defects reconstructed with neurovascular island or advancement flaps and in 29 of 31 proximal defects treated with cross-finger and intermetacarpal flaps. The mean DASH score was 4.1 and 3.34 for the neurovascular island/advancement flaps and the cross-finger flaps respectively. CONCLUSIONS: This study elucidates the indications and presents the advantages and disadvantages of flaps used for reconstruction of proximal and distal digital defects. Good results can be obtained with appropriate flap selection and meticulous surgical technique.

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone.

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Skeletal muscle hydatid cysts presenting as soft tissue masses.

Muscle hydatidosis is rare, accounting only for 3-5% of all cases. We present a case series of 9 patients (8 male, one female, mean age 59.3 years, range 48-75 years) with primary echinococcosis of skeletal muscles. The cysts presented as soft tissue masses in 8 patients, whereas in one, the cyst was an incidental finding on a CT scan performed for investigation of a lung problem. All hydatid cysts were confined into muscles, without affecting the bone. The location was the thigh region in 6 patients (quadriceps in 4, biceps in 2), the popliteal fossa (gastrocnemius) in one, the humerus (triceps branchii) in one and the shoulder (infraspinatus) in one patient. MRI showed multi-vesicular cysts in all patients. Indirect hemagglutination serological test was positive in 6 out of 9 cases. En block surgical excision of the cysts was undertaken in all patients. Two patients received antihelminthic chemotherapy preoperatively. Histopathologic findings confirmed the diagnosis. No recurrence occurred during the follow-up period (1-8 years). Skeletal muscle echinococcosis should be considered in the differential diagnosis of limb masses, especially in endemic countries. A meticulous history taking and MRI imaging are essential, while pericystectomy is an effective method of treatment.

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.

Purulent flexor tenosynovitis: factors influencing the functional outcome.

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

Restoration of function and sensitivity utilizing a homodigital neurovascular island flap after amputation injuries of the fingertip.

Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two-point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries.

Scaphoid nonunions treated with vascularised bone grafts: MRI assessment.

PURPOSE: To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts for treating scaphoid nonunions. MATERIALS AND METHODS: Vascularized bone grafts from the distal radius were used to treat 47 scaphoid nonunions resulting from fractures or enchondromas. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of conventional radiographs obtained in all cases, 15 patients were also assessed postoperatively with MRI at 3 months. From these 15 patients, eight were assessed preoperatively with MRI whereas nine had serial MRI evaluations at 6 and 12 months. The clinical follow-up time of this subgroup of 15 patients ranged from 6 to 27 months. RESULTS: All patients showed clinical signs of union within 12 weeks form the procedure and at the latest follow-up they experienced complete (10 cases) or almost complete (five cases) relief from pain. Both plain and contrast-enhanced MRI obtained at 3 months showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 12 patients at both sides of the graft and in three patients between the graft and proximal pole. At 3 months plain MRI showed nonunion in four patients (two between graft and proximal pole, two between graft and distal pole and one at both sides of the graft) whereas contrast-enhanced MRI revealed only one case of nonunion between graft and proximal pole. Four patients were considered to have osteonecrosis of the proximal pole intraoperatively. Two of them showed necrosis of the proximal pole with preoperative and postoperative plain radiographs and three of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all four scaphoids. MRI also revealed bone marrow oedema of the carpal bones surrounding the scaphoid in 14 cases. Serial MRI at 6 and 12 months, obtained in nine patients, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases. CONCLUSION: Contrast-enhanced MRI is able to demonstrate the early union after treatment of scaphoid nonunions with vascularised bone grafts allowing thus earlier mobilisation. In addition, MRI can assess the viability of the proximal pole and the graft as well as the postoperative bone marrow oedema-like lesions of the surrounding bones.

Longstanding nonunions of scaphoid fractures with bone loss: successful reconstruction with vascularized bone grafts.

Vascularized bone graft from the dorsum of distal radius was used to treat 22 nonunions of scaphoid fractures, with a mean delay of 4 years from the initial injury. Four of the eight patients with associated scapho-styloid arthritis also underwent a closing wedge osteotomy of the distal radius. Follow-up time ranged from 14 to 74 months. Union was accomplished in 6 to 12 weeks and wrist range of motion and grip strength improved postoperatively in all patients. Complete absence of pain was noted in 16 patients and the other six, all of whom had arthritic wrist changes or carpal collapse, only experienced pain with strenuous activities. The simple graft dissection, the avoidance of anastomoses and the lack of donor site morbidity are additional advantages to this surgical technique, which is successful even in cases with an avascular proximal pole.

Surgical anatomy of spinal accessory nerve: is trapezius functional deficit inevitable after division of the nerve?

The course of spinal accessory nerve in the posterior triangle, the innervation of the sternocleidomastoid and trapezius muscles and the contributions from the cervical plexus were studied in 20 cadaveric dissections. The nerve was most vulnerable to iatrogenic injuries after leaving the sternocleidomastoid. Direct innervation of trapezius by cervical plexus branches was noted in five dissections, whereas connections between the cervical plexus and the spinal accessory nerve were observed in 19 dissections. These were usually under the sternocleidomastoid (proximal to the level of division of the nerve in nerve transfer procedures). Although the contribution from the cervical plexus to trapezius innervation is considered minimal, trapezius function can be protected in neurotization procedures by transecting the spinal accessory nerve distal to its branches to the upper position of trapezius.

Surgical treatment of compression of the lateral antebrachial cutaneous nerve.

We describe an operation to relieve compression of the lateral antebrachial cutaneous nerve at the elbow. Between 1987 and 1997 we operated on seven patients, one with bilateral compression. In two the compression was associated with injury to biceps. A longitudinal or a transverse incision was carried out and the nerve was released from the deep fascia. Partial excision of the biceps aponeurosis was undertaken in the patients who did not have injury to biceps; some additional procedures were required for those patients with injuries. All patients had symptomatic relief.

Distal tibial epiphyseal fractures in adolescents.

The characteristic pattern of fusion of distal tibial epiphysis explains the special configuration of the fragments in the triplane fracture and the "juvenile" fracture of Tillaux in adolescents. The application of external rotation force produces Tillaux and triplane fractures of the lateral portion of the distal tibial epiphysis in patients with a mean age of 13.5 years. Eight patients, 13 to 15 years of age, with distal tibial epiphyseal fractures were treated in the last 12 years. Three of the fractures were classified as "juvenile" Tillaux fractures and five were triplane fractures. Open reduction and fixation of the tibia was accomplished by using either malleolar screws or K-wires. Follow-up time ranged from 1.5 to 11 years. All patients were evaluated subjectively and objectively after surgery. Objective evaluation included clinical assessment and radiographic evaluation. All patients regained full range of motion and no one complained of pain or joint stiffness. Radiographs confirmed that all fractures have healed without articular incongruity.

A glomus tumour with four recurrences.

A case of a glomus tumour of the distal segment of the ring finger, with four apparent recurrences in an 8-year period, is described. The patient was treated by two different surgeons (two and three times respectively) and obtained pain free intervals of between 4 and 11 months before recurrence. Histological examination confirmed the diagnosis of a glomus tumour in all five procedures. The location of the glomus tumour was defined preoperatively by high resolution MR imaging.

Neuromas and gaps of sensory nerves of the hand: management using vein conduits.

This study analyzed the efficacy of an interposed vein conduit graft in eliminating symptoms of painful neuroma of sensory nerves of the hand and preventing recurrence after excising the pathologic tissue and bridging the concomitant gap with the distal nerve segment. Twenty-three patients underwent reconstruction of 25 palmar sensory nerve gaps ranging from 12 mm to 28 mm, as well as 2 dorsal gaps of 32 mm and 35 mm, respectively. Eighteen patients had symptomatic painful neuromas. Subjective and objective evaluation criteria were employed for assessment and were compared with data obtained from primary direct suturing in 25 digital nerves of 21 patients. Electrophysiologic measurements, including sensory nerve action potential and conduction velocity, were similar, with both groups having values significantly lower than normal control values. Two-point discrimination measurements were slightly inferior for the vein conduit-reconstructed nerves compared with results attained after direct suturing. However, neuroma symptoms were eliminated, and in combination with the return of adequate sensibility, all but 1 patient resumed full hand function.

Major ablative procedures in orthopaedic surgery.

In the presence of the notable progress in limb-sparing techniques afforded by the developments in microsurgery and musculoskeletal oncology, major ablative surgery of the extremities still remains a last-resort, yet powerful tool in managing patients with primary tumors in whom wide excision is not possible, as well as in cases with severe trauma to the limbs. During the last thirteen years, eight major ablative procedures were performed at the Department of Orthopaedic Surgery of the University of Ioannina Medical School. Seven out of the eight procedures were performed in patients with primary malignant tumors either because the anatomical location or multiple recurrences of the tumor did not allow removal by wide local excision or by amputation at a lower level. In one patient, the procedure was related to a severe, mangling trauma. Four illustrative cases of the eight major ablative procedures performed are reported to highlight the current indications of this rarely used, complex, and extensive surgery. The characteristic cases presented are: hemipelvectomy in a patient with chondrosarcoma of the pelvis, disarticulation of the hip in a patient with a malignant histiocytoma of the supracondylar area of the knee, forequarter amputation in a patient with a basal cell carcinoma of the axilla, and disarticulation of the shoulder in a patient with an incomplete nonviable amputation at the level of the shoulder girdle associated with severe damage to the brachial plexus and axillary artery. After a five to over a ten year follow-up, six of the eight patients who where subjected to major ablative procedures are doing well and are satisfactorily active. These cases reflect the dilemma that orthopaedic surgeons geons still face in selecting limb salvage or major ablative surgery in cases of aggressive malignant tumors to severe trauma.