Mitchell's osteotomy augmented with bio-absorbable pins for the treatment of hallux valgus: A comparative finite element study.

BACKGROUND: There is an inadequacy of conventional means to assess the surgical outcomes of a bunion surgery. We used the Finite Element Analysis for evaluating the typical Mitchell's procedure outcomes with or without bio-absorbable pins. METHODS: We developed a 3D FE model based on the CT images of a female volunteer with hallux valgus. A typical procedure was simulated on the foot model and two pins were virtually inserted for enhancing the fixation. We validated our model by comparing the predicted pressure results with the plantar pressure measured by a specific platform. RESULTS: The comparison of the plantar pressure distribution revealed similar patterns. A greater displacement was observed on the medial side of the osteotomy, but it was decreased after using pins. The maximum average pressure under the 1st metatarsal head was decreased after the osteotomy. The respective pressure under the 3rd and 5th metatarsal head was decreased more after using pins, while, under the 2nd and 4th metatarsal head, an increase was developed. CONCLUSION: The use of pins had no significant influence on the healing process but gave additional stability inside the osteotomy and could be used in cases where enhancement is needed. The surgeon should be familiar with the expected stress rising to the other metatarsal, considering the concomitant pathology or the additional interventions that should be performed.

Vanishing bone disease (Gorham-Stout syndrome): A review of a rare entity.

Vanishing bone disease (Gorham-Stout syndrome) is a rare entity of unknown etiology, characterized by destruction of osseous matrix and proliferation of vascular structures, resulting in destruction and absorption of bone. Despite the extensive investigation of the pathogenetic mechanisms of the disease, its etiology hasn't been clarified and several theories exist. The syndrome can affect one or multiple bones of the patient, including the skull, the upper and lower extremities, the spine and pelvis. The clinical presentation of a patient suffering from vanishing bone disease includes, pain, functional impairment and swelling of the affected region, although asymptomatic cases have been reported, as well as cases in which the diagnosis was made after a pathologic fracture. In this short review we summarize the theories regarding the etiology as well as the clinical presentation, the diagnostic approach and treatment options of this rare disease.

Posterior stabilization of cervical spine injuries using the Roy-Camille plates: a long-term follow-up.

AIM: Posterior cervical spine fixation has undergone tremendous advancement in recent years. The purpose of this study is to present our experience with the Roy-Camille instrumentation for posterior cervical stabilization after injury in a long-term follow-up. PATIENTS AND METHODS: From 1985 to 1995, 76 patients with a lower cervical spine traumatic lesion were treated in a single institution by posterior plate stabilization using the Roy-Camille plates (R-C plates). Fifty-four men and 22 women with a mean age of 43.2 years were involved. In 59 patients the injuries were due to a road traffic accident, in 14 cases the fall from a high was responsible, while in two cases the injuries were due to sport activities. There were four bilateral dislocations, nine unilateral dislocations, 56 fracture dislocations, five fracture separations of a lateral mass and two burst fractures. Neurological lesions were present in 65 patients (9 ASIA A, 16 ASIA B, 22 ASIA C, 18 ASIA D and 11 ASIA E). All patients had minimum follow-up of 7 years. Fifty-nine patients were followed up for a mean period of 21 years (14-27 years). RESULTS: Stability was obtained in all but two cases. Reoperation was done in two cases: in one for the correction of the lost reduction and in a second for the reinsertion of a screw irritating a nerve root. No case in the ASIA A group showed neurological improvement, a fact observed in the other groups. CONCLUSIONS: The R-C plates were used in the last quarter of the last century. This technique showed good short-time results, and we have shown good results in a long-term follow-up as well. The literature referred to this technique was favorable, as far as the biomechanical behavior and also clinical application concern. The question about this plating system abundance still remains unanswered.

Thalidomide prolongs survival after experimental musculoskeletal injury, through an effect on mononuclear apoptosis.

BACKGROUND: This study was conducted to investigate the effects of intravenous thalidomide administration in an experimental model of musculoskeletal trauma. We hypothesized that because thalidomide inhibits secretion of tumor necrosis factor alpha (TNF-α), survival of animals that received thalidomide would be significantly prolonged. MATERIAL AND METHODS: After an open fracture of the right femur, 24 rabbits were randomly assigned to control and thalidomide groups. Intravenous therapy with thalidomide was started 30 min after fracture. Hemodynamic monitoring of all animals was performed for 4 h. Survival was recorded and bacterial growth in blood and organs was measured after animal death or sacrifice. Blood was sampled for TNF-α measurement and for isolation of peripheral blood mononuclear cells (PBMCs). Apoptosis of PBMCs was measured by flow cytometry. RESULTS: Survival was significantly prolonged in the thalidomide group. Apoptosis of PBMCs was increased in the control group compared with the thalidomide group at 24 h. There were no differences in vital signs, blood and tissue cultures, and serum TNF-α concentration between the two groups. CONCLUSIONS: Intravenous thalidomide prolonged survival in an experimental model of severe musculoskeletal injury in rabbits. Its mechanism of action did not involve TNF-α suppression but prevention of mononuclear apoptosis. In view of these promising results, further research is needed to clarify the immunomodulatory mechanism of action of thalidomide and its potential use for the management of severe trauma.

Cemented Müller straight stem total hip replacement: 18 year survival, clinical and radiological outcomes.

AIM: To present the 18 year survival and the clinical and radiological outcomes of the Müller straight stem, cemented, total hip arthroplasty (THA). METHODS: Between 1989 and 2007, 176 primary total hip arthroplasties in 164 consecutive patients were performed in our institution by the senior author. All patients received a Müller cemented straight stem and a cemented polyethylene liner. The mean age of the patients was 62 years (45-78). The diagnosis was primary osteoarthritis in 151 hips, dysplasia of the hip in 12 and subcapital fracture of the femur in 13. Following discharge, serial follow-up consisted of clinical evaluation based on the Harris Hip Score and radiological assessment. The survival of the prosthesis using revision for any reason as an end-point was calculated by Kaplan-Meier analysis. RESULTS: Twenty-four (15%) patients died during the follow-up study, 6 (4%) patients were lost, while the remaining 134 patients (141 hips) were followed-up for a mean of 10 years (3-18 years). HSS score at the latest follow-up revealed that 84 hips (59.5%) had excellent results, 30 (22.2%) good, 11 (7.8%) fair and 9 (6.3%) poor. There were 3 acetabular revisions due to aseptic loosening. Six (4.2%) stems were diagnosed as having radiographic definitive loosening; however, only 1 was revised. 30% of the surviving stems showed no radiological changes of radiolucency, while 70% showed some changes. Survival of the prosthesis for any reason was 96% at 10 years and 81% at 18 years. CONCLUSION: The 18 year survival of the Müller straight stem, cemented THA is comparable to those of other successful cemented systems.

Effects of foot posture on fifth metatarsal fracture healing: a finite element study.

The goal of this study was to evaluate the effects of maintaining different foot postures during healing of proximal fifth metatarsal fractures for each of 3 common fracture types. A 3-dimensional (3D) finite element model of a human foot was developed and 3 loading situations were evaluated, including the following: (1) normal weightbearing, (2) standing with the affected foot in dorsiflexion at the ankle, and (3) standing with the affected foot in eversion. Three different stages of the fracture-healing process were studied, including: stage 1, wherein the material interposed between the fractured edges was the initial connective tissue; stage 2, wherein connective tissue had been replaced by soft callus; and stage 3, wherein soft callus was replaced by mature bone. Thus, 30 3D finite element models were analyzed that took into account fracture type, foot posture, and healing stage. Different foot postures did not statistically significantly affect the peak-developed strains on the fracture site. When the fractured foot was everted or dorsiflexed, it developed a slightly higher strain within the fracture than when it was in the normal weightbearing position. In Jones fractures, eversion of the foot caused further torsional strain and we believe that this position should be avoided during foot immobilization during the treatment of fifth metatarsal base fractures. Tuberosity avulsion fractures and Jones fractures seem to be biomechanically stable fractures, as compared with shaft fractures. Our understanding of the literature and experience indicate that current clinical observations and standard therapeutic options are in accordance with the results that we observed in this investigation, with the exception of Jones fractures.

Early increase of serum angiopoietin-2 are associated with early progression to death in experimental injury.

Severe trauma induces systemic inflammatory response syndrome (SIRS) through the release of proinflammatory mediators. Angiopoietin-2 (Ang-2) is over-produced in sepsis and leads to dysfunction of endothelial cells and subsequent multiple organ dysfunction. In order to define the role of Ang-2 in lethal injury, 45 rabbits were studied; eight were administered anesthesia; 11 were sham-operated and 26 were subject to femoral injury. Concentrations of Ang-2, malondialdehyde (MDA), tumor necrosis factor-alpha (TNFα) and endotoxins (LPS) were determined in serum and of Ang-2 in tissues; vital signs and overall survival were recorded. Bacterial growth was quantitatively assessed in liver, spleen and lung of animal that died. Survival of injured animals was shorter than sham operated ones. Serum concentrations of Ang-2 at 4 h was greater among animals where death supervened early, i.e. within 48 h after injury than among rabbits that died later. That was also the case for systolic, diastolic and mean arterial pressures. Serum MDA and TNFα and tissue bacterial growth did not differ between rabbits that died early and rabbits that died late. Serum LPS remained below the limit of detection. These results suggest that circulating Ang-2 participates in the pathogenesis of SIRS after injury connected with early haemodynamic instability.

Serum kinetics of soluble triggering receptor expressed on myeloid cells-1 differs in relation to the type of arthroplasty.

CONTEXT: Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) participates in the inflammatory process. PURPOSE: To describe changes of sTREM-1 in the serum after hemiarthroplasty (HA) and total hip arthroplasty (THA). METHODS: Serial blood samples were drawn from 122 patients with hip fracture. Interleukin-6 (IL-6), sTREM-1, and C-reactive protein (CRP) were measured. RESULTS: IL-6 and CRP were similarly increased after both HA and THA. sTREM-1 was increased early in HA and late after THA. The only parameter that was higher among patients who developed systemic inflammatory response syndrome was IL-6. CONCLUSIONS: Kinetics of sTREM-1 differs among patients undergoing HA of the hip and those undergoing THA.

Intra-articular morphine enhances analgesic efficacy of ropivacaine for knee arthroscopy in ambulatory patients.

The aim of this double-blind, randomized control trial was to compare the effectiveness of intra-articular ropivacaine alone or with morphine or ketoprofen for controlling pain after arthroscopic knee surgery. One hundred fifty-six patients scheduled for elective knee arthroscopy were recruited. All patients received general anesthesia and were randomly assigned to 4 groups to receive intra-articular ropivacaine 40 mg (group R), ropivacaine 24 mg plus morphine 8 mg (group R+M), ropivacaine 36 mg plus ketoprofen 100 mg (group R+K), or normal saline (group N/S). Pain, sedation, orientation, nausea, vomiting, and urine retention were recorded at 0, 1, 2, 4, 8, 12, and 24 hours postoperatively. Pain was evaluated by a 10-cm visual analog scale (VAS). When the pain was >2, a suppository of 400 mg paracetamol plus 10 mg codeine plus 50 mg caffeine was given. Results showed that at 4 hours postoperatively, pain differed significantly among the 4 groups (P<.001), with less pain recorded in the R+M group. Similarly, the number of suppositories administered postoperatively to the R+M group was significantly less (P<.001) vs the other groups. Patients who received ropivacaine and morphine or normal saline had a higher incidence of nausea and vomiting vs the other groups (P=.001 and P=.036, respectively). The combination of intra-articular ropivacaine and morphine is associated with less pain after knee arthroscopy during early recovery but with a higher incidence of nausea and vomiting. However, the addition of ketoprofen to ropivacaine provides relatively satisfactory pain relief, but with fewer side effects compared to morphine.

Eicosapentanoic acid prolongs survival and attenuates inflammatory response in an experimental model of lethal trauma.

In an attempt to define the efficacy of intravenously administered n-3 polyunsaturated fatty acids (PUFAs) in an animal model of lethal trauma following femur fracture, an intravenous solution of eicosapentanoic acid (EPA) - one n-3 PUFA - was administered in 25 rabbits; 13 were controls and 12 were treated with EPA 30 min after fracture. Vital signs were recorded and serum concentrations of tumor necrosis factor-alpha (TNFalpha) and respiratory burst of neutrophils were assessed. Survival of controls was 7.7% and of animals treated with EPA 50% (log-rank: 5.162; p: 0.023). Vital signs of both groups did not differ. Oxidative burst of neutrophils was greater among EPA-treated animals compared with controls at 48 h (p: 0.010). Serum levels of TNFalpha of the former group were decreased compared with the latter at 48 h (p: 0.019). Bacterial growth of enterobacteriaceae from liver and spleen after death or euthanasia was lower among EPA-treated rabbits than controls. These results suggest that EPA possesses considerable immunomodulatory activities improving survival in a model of lethal trauma. Restoration of oxidative burst conferring efficient phagocytosis of evading bacteria seems the most probable mechanism of action.

Investigation on the distal screw of a trochanteric intramedullary implant (Fi-nail) using a simplified finite element model.

Numerous studies have been published concerning the characteristics and the behaviour of the intramedullary devices in the treatment of the intertrochanteric hip fractures. However, there is still room for further exploration and exploitation concerning the implant behaviour with respect to the parts of the implant assembly (nail, lag screw and distal screw). Towards this direction, the present paper aimed at revealing the effect of the position of the distal screw on the mechanical behaviour of the fixation device. For this purpose, a simplified model was developed and analysed with the finite element method. In total, five different locations for the distal screw were examined. In all cases, the bone was fixed at its distal end while the external load was applied at the tip of the lag screw towards the hip and in the form of orthonormal force components applied individually. The results of the FE analyses were illustrated in appropriately formed plots revealing the sensitivity of the behaviour of the implant with respect to the location of the distal screw. The main conclusion derived from the present investigation was that moving the distal screw apically decreases the stresses on the distal screw but increases the stresses on the lag screw. In turn, this indicates the existence of a location for the distal screw that compromises these two effects in an optimum way.

Recurrent intra-articular osteoid osteoma of the hip after radiofrequency ablation: a case report and review of the literature.

We present a case of a 53-year-old woman with recurrent intra-articular osteoid osteoma of the hip 6 months after initial treatment with percutaneous radiofrequency ablation. En bloc surgical excision of the osteoid osteoma and prophylactic internal fixation for impending stress fracture was performed. The patient is pain free, has returned to normal function and there is no sign of recurrence at the one-year follow-up. Intraarticular osteoid osteoma, present a diagnostic challenge and often they are misdiagnosed. Minimally invasive ablation techniques can fail in significant percentage and then surgical excision with histological confirmation remains the definitive treatment of choice.

Proximal tibial stress fractures associated with primary degenerative knee osteoarthritis.

Tibial stress fractures are not rare--they have been extensively studied in young athletes and soldiers and in elderly people with rheumatoid arthritis, osteoporosis, Paget's disease, pyrophosphate arthropathy, and hyperparathyroidism--but they seldom occur in patients with severe primary degenerative knee osteoarthritis. The etiology, diagnosis, and optimal treatment of these fractures remain a challenge. In this article, we review the English-language literature on the symptoms, diagnosis, treatment options, and final outcomes of these fractures, and we report 2 new cases of proximal tibial stress fractures in elderly women with severe primary degenerative knee osteoarthritis.

In vitro elution of daptomycin by a synthetic crystallic semihydrate form of calcium sulfate, stimulan.

A synthetic crystallic semihydrate form of calcium sulfate, Stimulan, was evaluated as a biodegradable carrier for the daily in vitro elution of daptomycin. Daptomycin and Stimulan were admixed at a ratio of 95:5. Elution lasted for 28 days. Eluted concentrations peaked on days 1 and 11, when the mean values were 1,320.1 and 949.2 microg/ml, respectively. The lowest eluted concentration was detected on day 28. These results support the application of the system described in experimental models of osteomyelitis.

Undiagnosed osteoid osteoma of the spine presenting as painful scoliosis from adolescence to adulthood: a case report.

Presented here is a case of a young woman, with an undiagnosed osteoid osteoma of the spine, which presented with painful scoliosis in adolescence and was treated by bracing until her accession to adulthood. A more thorough investigation, years after the initial one, revealed the tumor. Surgical excision and stabilization offered the long-awaited cure. Misdiagnosis resulted in intractable pain for years, deformity, the discomfort of brace therapy, and the frustration of a prolonged yet ineffective treatment.

Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience.

A review of prospectively collected data in our trauma unit for the years 1998-2003 was undertaken. Adult patients who suffered multiple trauma with an Injury Severity Score (ISS) of >/=16, admitted to hospital for more than 72 hours and with sustained blunt chest injuries were included in the study. Demographic details including pre-hospital care, trauma history, admission vital signs, blood transfusions, details of injuries and their abbreviated injury scores (AIS), operations, length of intensive care unit and hospital stays, Injury Severity Score (ISS) and mortality were analysed. Fulfilling the inclusion criteria with at least one chest injury were 1,164 patients. The overall mortality reached 18.7%. As expected, patients in the higher AIS groups had both a higher overall ISS and mortality rate with one significant exception; patients with minor chest injuries (AIS(chest) = 1) were associated with mortality comparable to injuries involving an AIS(chest) = 3. Additionally, the vast majority of polytraumatised patients with an AIS(chest) = 1 died in ICU sooner than patients of groups 2-5.

Anatomic double-bundle versus single-bundle ACL reconstruction: a comparative biomechanical study in rabbits.

Thirty New Zealand white rabbits underwent anterior cruciate ligament (ACL) reconstruction in their right knees; 15 animals underwent a double-bundle anatomic ACL reconstruction using the medial third of the patellar tendon and the semitendinosus tendon. Additionally, 15 animals underwent ACL reconstruction, using a single-bundle semitendinosus tendon autograft. The knees of both groups were evaluated with a device similar to the KT1000 arthrometer onto which a dial indicator was attached (Mitutoyo dial indicator 2050) in 30 degrees and 90 degrees of flexion, preoperatively, after ACL resection and 3 months postoperatively. Statistical analysis of the results revealed that for 90 degrees of knee flexion, the mean estimated anterior shift for the double-bundle technique was 1.92 mm lesser than that of the single-bundle technique (P = 0.006). For 30 degrees of knee flexion, the mean anterior shift was again lesser than that of the single-bundle technique by 0.66 mm, but this difference was not statistically significant. The described double-bundle ACL reconstruction technique resulted in a more stable knee as far as the anterior tibial shift was concerned as compared to a single-bundle ACL reconstruction. This animal model may be potentially useful in the future for the study of other parameters influencing the outcome of the double-bundle ACL reconstruction.

The influence of osteoporosis in femoral fracture healing time.

AIM: In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed. PATIENTS AND METHODS: Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis. RESULTS: In all group A patients Singh score < or =4 and CBR>0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score > or =5 and CBR<0.48. Fractures of group A healed in 19.38+/-5.9 weeks (12-30) and in group B 16.19+/-5.07 weeks (10-28), P=0.02. CONCLUSIONS: Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process.

Fixation of Mitchell's osteotomy with bioabsorbable pins for treatment of hallux valgus deformity.

We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.

Osteoid osteoma of a metacarpal bone: a case report and review of the literature.

INTRODUCTION: Osteoid osteoma is a benign tumor of the growing skeleton. It presents with pain, which is usually worse at night. The radiographic features consist of a central oval or round nidus surrounded first by a radiolucent area followed by another area of sclerotic bone. In the hand, osteoid osteoma is more commonly located in the phalanges and carpal bones. The metacarpals are the least common sites for osteoid osteoma. CASE PRESENTATION: We present a case of an osteoid osteoma of the left third metacarpal bone in a 36-year-old woman. The clinical and radiographic findings along with the surgical management of the lesion are presented. The pain disappeared immediately after the operation. At the 2-year follow-up, the patient was pain-free and there was no evidence of recurrence. CONCLUSION: Physicians should be aware of the unusual presence and the atypical clinical presentation of this benign lesion in the metacarpal bones of the hand.