More adverse events than expected in the outcome after use of the reamer-irrigator-aspirator.

PURPOSE: The reamer-irrigator-aspirator (RIA) system is described as having high success rates and only few complications. The RIA was originally designed to ream the intramedullary canal in a single step prior to the placement of an intramedullary nail for femur fixation. Its purpose was to collect and evacuate marrow contents during reaming to prevent embolism into the systemic circulation. Marrow evacuation is also used to stimulate healing in nonunion fractures, segmental bone defects, and osteomyelitis. Despite the described success rates, we experienced severe adverse events. Our aim was to describe these events and point out possible complications. METHODS: A retrospective study of all consecutive patients treated for nonunion fractures, bone defects, or osteomyelitis from October 2007 to March 2010. All patients were treated with the RIA system. We analyzed demographic characteristics, consolidation on X-rays, time from injury to healing, complications, and postoperative pain caused by the reaming procedure. RESULTS: We included 32 patients (21 males) with an average follow-up of 277 days. Successful healing was achieved in 66 % of all patients, and 18 % suffered from postoperative pain. A complication due to the use of the RIA system was registered in 31 % of the patients. Recorded complications were bone defects, signs of lung embolism, a myocardial infarction, and fissure fractures. CONCLUSIONS: The RIA system has benefits in the treatment of nonunion and osteomyelitis defect, but is not without risk. Meticulous surgical technique is mandatory and peroperative constant monitoring of patients and the assembled device is mandatory.

Free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty.

The purpose of this article is to present our experience with free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty in case of insufficient soft tissue prior to operation ('prophylactic indication'). Fourteen patients who underwent simultaneous flap surgery in the context of total knee arthroplasty because of insufficient soft tissue are reviewed in a retrospective clinical study. The following criteria were examined: (1) aetiology of the soft-tissue defect, (2) number of previous operations, (3) status of the knee extensor mechanism classified as complete, partial or missing, (4) primary wound healing, (5) complications and (6) active range of motion (ROM). Insufficient soft tissue resulted from multiple previous operations in 10 patients and large post-traumatic defects in four patients. All patients had 5-23 (mean 10.2) previous operations before free latissimus dorsi transfer. The status of the extensor mechanism was complete in one, partial in nine and missing in four patients. Primary wound healing could be achieved in eight patients. After free latissimus dorsi transfer, skin breakdown at the recipient site occurred in five patients. Secondary skin grafting was carried out in four patients and a fasciocutaneous flap in one patient. There were three late recurrences of infection, with ultimate removal of the knee prosthesis and conversion to arthrodesis. Average active ROM prior to surgery was for extension/flexion 0-9-28 degrees . One year after surgery the average active ROM was 0-6-75 degrees . A free myocutaneous latissimus dorsi flap transfer is rarely indicated in total knee arthroplasty and should only be considered for defects which cannot be covered by a pedicled (medial gastrocnemius) flap. Free latissimus dorsi transfer makes prosthesis implantation possible, prevents postoperative knee stiffness because of soft tissue and/or scar constriction and shows a low rate of severe complications in patients with a high risk of wound-healing problems. Moreover, transfer of well-vascularised tissue will improve trophicity in the knee region, and thus make future operations in this region easier.

[A new extension device for treatment of tibial fractures]. / Ein neuer Extensionsapparat zur Behandlung von Unterschenkelfrakturen.

By means of a newly developed traction frame it is possible to maintain the reduction of a tibial fracture while implementing an internal or external fixation. This traction frame makes it even possible to perform intramedullary nailing of tibial fractures on a normal operation table.

Os trigonum and soleus tertius anomaly.

A case of both an os trigonum and a soleus tertius anomaly is presented in a patient with chronic posteromedial ankle pain. A resection of the os trigonum was performed, with complete relief of symptoms. The diagnosis and therapy are discussed, and the literature is reviewed.