Treatment of scaphoid fractures and pseudarthroses with the human allogeneic cortical bone screw. A multicentric retrospective study.

BACKGROUND: Allograft bone screws are rarely described for the fixation of the scaphoid. When fresh fractures are treated, metal screws are mainly used; when pseudarthrosis is the indication, plates in combination with vascularized or non-vascularized bone grafts are mainly used. The necessity of metallic screw removal is under debate, but it is mandatory for plates because of movement restrictions due to the plate. The use of biomaterials in scaphoid fracture fixation was described as leading to union rates of between 64 and 100%. Brcic showed the incorporation of an allogeneic cortical bone screw at 10 weeks postoperative, along with revascularization and stable osteosynthesis with primary bone healing, without any signs of immunological rejection. The purpose of this retrospective study was to explore the results obtained using an allogenic cortical bone screw (Shark Screw®) in patients with fresh scaphoid fracture fixation and pseudarthroses with respect to union rates and time to union. PATIENTS AND METHODS: We retrospectively analyzed 75 patients: 31 with fresh fractures and 44 pseudarthrosis patients. The Shark Screw® was used for the fixation of the scaphoid in the fresh-fracture and pseudarthrosis patients. We evaluated the union rate, complication rate and time to union. RESULTS: Using the human allogeneic cortical bone screw for scaphoid fracture fixation led to a high union rate (94-96%). There were two nonunions in the fresh fracture group and two nonunions in the pseudarthrosis group. The complication rate was 1.3% (1 patient). Median time to union was 16, 18 and 29 weeks for the fresh-fracture, pseudarthrosis and delayed-union patients, respectively. The treatment of fresh scaphoid fractures and pseudarthroses showed similar union rates to those described in the literature, uses a shorter and less invasive surgical method with no need for hardware removal, and has a low complication rate. CONCLUSION: Using the human allogenic cortical bone screw (Shark Screw®) led to similar union rates in fresh fractures-but better union rates in pseudarthrosis patients-compared to those presented in the literature for other scaphoid fracture fixation techniques, and it enabled a short and low-invasive procedure without any donor site morbidity and without the necessity to remove the hardware in a second surgery. The pseudarthrosis patient group showed a particularly strong benefit from this new procedure. The physiological bone metabolism remodels the cortical bone screw without scars. LEVEL OF EVIDENCE: III: retrospective cohort study, therapeutic investigation of a treatment.

A human, allogeneic cortical bone screw for distal interphalangeal joint (DIP) arthrodesis: a retrospective cohort study with at least 10 months follow-up.

INTRODUCTION: The prime requisites of a good digital arthrodesis are a painless and stable union in a proper position. Arthrodesis of the distal interphalangeal joint of the fingers is not without potential complications including nonunion, malunion, and deep tissue infections. The Shark Screw® is a human, cortical bone allograft for osteosynthesis and an alternative to metal or bioabsorbable devices in orthopedics and trauma surgery. The primary hypothesis is that the fusion and complication rate, using the Shark Screw®, is at least similar to those reported in the literature, using metal or bioabsorbable screws. MATERIAL AND METHODS: This retrospective cohort study analyzes the fusion and complication rate and the patient satisfaction of distal interphalangeal joint arthrodesis of 27 fingers with the human allogeneic cortical bone screw. Complications, Disabilities of Arm, Shoulder, and Hand Questionnaire (Quick-DASH) score and Michigan Hand Outcomes Questionnaire (MHQ) score, grip and pinch strength and fusion angle were investigated. RESULTS: The mean follow-up was 23 months. At 6 weeks after surgery, fusion was obtained for all fingers. There was no surgical complication that required revision surgery. An average fusion angle of 13.6° ± 10.7° was measured. VAS pain score decreased significantly from 6.9 before surgery to 0.14 after surgery. The Quick-DASH score decreased from 10.7 to 7.8. The MHQ score improved in all sub-scores. CONCLUSION: The complication rates, using the Shark Screw® for DIP joint arthrodesis, are lower compared to the results reported in the literature for other surgical techniques. Complications related to the human allograft cortical bone screw itself were not observed. The bone screw is completely remodeled into the host bone and further hardware removal is not necessary. LEVEL OF EVIDENCE: IV.

[Therapy of Dupuytren's contracture with collagenase - Evidence-based Consensus Statement of Austrian Surgical Societies]. / Therapie der Dupuytren'schen Kontraktur mit Kollagenase.

Dupuytren's contracture (DC) or Dupuytren's disease (DD) is a progressive fibro-proliferative disease of palmoplantar connective tissue, resulting in characteristic nodal and/or cord formation from collagen disposition. When the disease progresses, the thickening and shortening of the cords eventually leads the affected fingers to being pulled into flexion, which may be associated with marked disability, especially with bilateral disease. DD is relatively common in Europe, with the highest prevalence in Nordic countries. In Austria approx. 200 000 people are affected. The incidence increases with increasing age, with men being more often and earlier affected than women. The aetiology of DC is not completely clear, but it seems to be multifactorial; twin and familial studies confirm a genetic predisposition. The natural course of the disease can vary between relatively benign and massive progression and recurrence. In most cases, there is a fluctuating course. The DC is not curable; treatment methods range from minimally invasive to open surgical procedures. Collagenase Clostridium histolyticum (CCH) is a nonsurgical, enzymatic injection treatment for adult patients (≥ 18 years) with a palpable cord and has been approved in Europe since 2011. Clinical studies and practical experience of individual centres confirm the efficacy and safety of CCH treatment of DC. The present consensus statement was prepared under the auspices of the Austrian Society of Hand Surgery with the participation of the Austrian Society for Trauma Surgery, the Society of Orthopaedics and Orthopaedic Surgery as well as the Society for Plastic, Aesthetic and Reconstructive Surgery. On the basis of current literature and the experts' experience, it describes the various surgical procedures, with particular reference to collagenase treatment and provides guidance for their use. The statement is intended not only to illustrate the state of the art of current treatment, but also to support the achievement of uniform high quality standards in the treatment of DC in surgical centres and specialised medical practices throughout Austria.

Biomechanical evaluation of suture-tendon interface and tissue holding of three suture configurations in torn and degenerated versus intact human rotator cuffs.

PURPOSE: The purpose of this study was to biomechanically evaluate suture-tendon interface and tissue holding of three sutures in torn and degenerated versus intact human rotator cuffs. METHODS: Sixty-three human rotator cuff tendons were divided into torn degenerated group (TDG), n = 21 and intact group (IG), n = 42. Ultimate tension load (UTL) and cyclic loading were tested for three arthroscopic sutures: simple, horizontal, and massive cuff sutures (MCS). RESULTS: Ultimate tension load was significantly higher (p < 0.05) for the MCS (194 ± 68 N) in comparison with the simple (105 ± 48 N) and horizontal sutures (141 ± 49 N) in IG. In TDG, UTL was not significantly higher (n.s.) for MCS (118 ± 49 N), simple (79 ± 30 N), and horizontal sutures (107 ± 28 N) in comparison with IG. MCS (118 ± 49 N) showed no significantly superior UTL in comparison with the simple and horizontal sutures in the TDG. MCA elongation was 0.6 ± 0.7 mm in the IG and 1.3 ± 0.7 mm in the TDG, while horizontal suture elongation was 0.7 ± 0.4 mm in the IG and 1.3 ± 0.5 mm in the TDG. Simple suture elongation was 1.1 ± 0.5 mm in the IG and 1.6 ± 0.7 mm in the TDG. CONCLUSION: Human torn and degenerated rotator cuffs have poor tissue quality, significantly lower UTL and higher cyclic elongation in comparison with intact cuffs regardless of the type of suture used for repair, which invites the need for repair techniques that grasps greater tissue volume in addition to augmentation techniques. CLINICAL RELEVANCE: Clinicians better use repair techniques that grasp greater tissue volume (e.g. MCS, modified Mason-Allen cross bridge, double-row cross bridge, etc.) when repairing the torn and degenerated rotator cuffs.

The "cruciate suture" for arthroscopic meniscal repair: a new technique.

Meniscal repair has become the treatment of choice whenever a reparable tear is diagnosed. Fixation strength of the repair technique is always of paramount importance in comparison of various techniques, especially after the evolution of many arthroscopic all-inside devices. We present a new arthroscopic meniscal repair suturing technique called "cruciate suture." One 18-gauge needle and suture material are used. The needle is loaded with the suture material from its tip. The suture is folded at the tip of the needle, which is inserted to penetrate the skin obliquely to appear inside the joint, making a loop. The needle is retracted, while the suture is kept inside of it. The needle is reinserted at the same hole, appearing inside the joint and making a second loop. The needle is retracted completely. With the use of a probe, the loop at the second point is pulled through the loop at the first point, thereby forming a free end. The 2 limbs of the loop are pulled, thus driving the limb with the free end outside of the joint. The first oblique vertical suture is completed at this point. The needle is reloaded by the suture limb from the first point. The previous procedure is repeated, with use of the second skin hole and the third and fourth points to make the second oblique vertical suture. The cruciate suture is now complete. We tested the ultimate tension load (UTL) of the cruciate suture in comparison with that of the vertical suture (the gold standard). A total of 36 tests (18 for the cruciate suture and 18 for the vertical suture) were performed on human menisci. The mean UTL of the cruciate suture was measured at 110 N; the mean UTL of the vertical suture was 67 N.

MRI-controlled analysis of 104 patients with painful bone marrow edema in different joint localizations treated with the prostacyclin analogue iloprost.

BACKGROUND: Bone marrow edema (BME) is a common cause of pain of the musculoskeletal system. The aim of the study was to assess the efficacy of iloprost in the treatment of BME of different localizations and etiologies. PATIENTS AND METHODS: We reviewed 104 patients (54 male, 50 female) with BME. Their mean age was 52.8 +/- 14.7 years. BME was located 50 times in the knee, 19 times in the talus, 18 times in the femoral head and 17 times in other bones. Patients were allocated to three distinct etiological groups: 27 cases were estimated to have idiopathic BME, 16 post-traumatic BME and the other 61 BME secondary to activated osteoarthritis or mechanical stress. Therapy consisted of a series of five iloprost infusions with either 20, 25 or 50 microg of iloprost given over 6 hours on 5 consecutive days each. RESULTS: At the clinical follow-up four months after therapy, the pain level of the 104 patients at rest had diminished by a mean of 73% (p<0.0001): 64% of patients reported a reduction, 34% no change and 2% an increase in pain at rest. Pain under stress decreased by a mean of 59%, (p<0.0001): 76% of patients had less pain during activity, 22% no change from baseline and 2% an increased pain level. On MRI, 65% had significant reduction of BME size or complete normalization and 20% showed no change. Worsening of the MRI pattern was found in 2%. 13% were lost to MRI follow-up. Side effects were significantly reduced by lowering the daily dose from 50 to 20 microg, without impairment of therapeutic effect. CONCLUSION: The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of different etiologies.

A new arthroscopic technique for revision of the posterior compartment in symptomatic total knee arthroplasty.

Arthroscopy is effective in treating the symptomatic knee following total knee arthroplasty. A small number of patients complain about postoperative pain in the posterior compartment. Loose bodies and degenerated remnants of the menisci are the main reasons for this pain. We present a new technique for diagnostic and therapeutic arthroscopy of the posterior compartments in patients with symptomatic total knee arthroplasty. After standard anterior arthroscopy, a wide circular notchplasty is performed to allow easy access to the posterior lateral compartment of the knee joint and to apply a posterolateral working portal under direct arthroscopic control. If inspection of the posteromedial compartment is necessary, the loose tissue behind the posterior cruciate ligament is resected to gain access to the posteromedial compartment.

Bone marrow edema of the forefoot after chevron osteotomy--a rare cause of metatarsalgia: a case report.

Treatment options of bone marrow edema syndrome, which is associated with vascular disturbances, are protracted nonoperative treatment or core decompression which still demands several weeks until complete recovery. We obtained excellent results by the use of the vasoactive drug iloprost, a stable prostacyclin analogue, leading to a complete relief of symptoms in cases of bone marrow edema which had initially suggested early avascular necrosis of the second metatarsal head. The bone marrow edema of the second metatarsal bone was thought to be due to altered biomechanics following a distal first metatarsal chevron osteotomy. During the five days of iloprost infusion, the patient reported relief of rest pain. After therapy, the pedobarogram was normalized. The AOFAS forefoot score improved from 44 to 85 points after one month, and to 95 points after three months. At that time, the marrow showed normal signals. Without additional intervention the patient was able to resume normal activities.