Talonavicular Dislocation-What Lies Beneath?

BACKGROUND: The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management. METHODS: We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them. RESULTS: There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively. CONCLUSIONS: Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.

Iliac Crest Regeneration: A Retrospective Study of 14 Years of Follow-up.

STUDY DESIGN: This is a retrospective study analysis. OBJECTIVE: The purpose of our study was to evaluate the healing process of the ilium after being used as a bone graft donor site in the treatment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Iliac crest bone grafts have been proven to be the most reliable means for solid fusion in spine surgery. Nevertheless, few reports in the literature describe the ability of the iliac crest to regenerate. METHODS: Thirty-one patients with a mean age of 15.1 years had undergone posterior spinal fusion for idiopathic scoliosis. An autogenous bone graft was harvested from the right posterior iliac crest in all cases. Computed tomography scans of the pelvis were performed preoperatively and shortly after operation to evaluate the presence of any deformity and the size of the defect formed during surgery, respectively. All patients were reexamined 14 years postoperatively, and computed tomography scans were performed to evaluate the status of ossification at the donor site. RESULTS: In 21 cases (67.74%), bone deficits were fully restored (mean volume 12.053 cm), whereas partial regeneration was present in the remaining 10 cases (mean volume 8.766 cm). Hounsfield units (HUs) revealed that cancellous bone quality had been restored in 21 cases, whereas cysts with sclerotic bone margins were present in the remaining 10 cases. Immature patients [Risser sign (RS) 3, 4] have greater ability in restoring bone stock compared with patients with almost complete growth (RS 5; P<0.001). In addition, the gluteus maximus muscle preserved its volume and quality in cases with complete bone restoration (volume 51.3 cm, HU 55.9) compared with cases with partial regeneration (volume 43.43 cm, HU 38.35; P<0.001). CONCLUSIONS: The iliac wing of skeletally immature patients has considerable ability to fully regenerate and could probably be used as a graft donor site again.

Lumbar Discectomy: Generic Outcome Measures for Specific Outcome Prediction: A Short-term, Observational, Pilot Study.

STUDY DESIGN: We followed a longitudinal observational design with 2 assessment points, presurgery and postsurgery, in 83 consecutive patients undergoing single-level lumbar discectomy. OBJECTIVE: Prognostic data can be gathered from commonly used generic outcome measures to identify patients at risk of persistent leg pain-associated chronicity, following lumbar discectomy SUMMARY OF BACKGROUND DATA:: Suboptimal results observed, following open lumbar discectomy, have been connected to the interplay among presurgery pain characteristics, functional and psychosocial adaptations like persistent pain, disability, and depression. Outcome predictive qualities have been recently attributed to well-known outcome measures. However, most studies on prognostic indicators use multiple tools designs, inhibiting clinical application. Here we elaborate on predictive indications identified in 2 generic patient-rated questionnaires, Short Form-36 (SF-36) and McGill Pain, as many of their domains can evaluate factors related to unfavorable outcomes. METHODS: For the prognostic value calculations, multivariate logistic [Short-Form McGill Pain Questionnaire (SF-MPQ)] and linear regression models (SF-36) were fitted to investigate the association between presurgery and postsurgery scores. In all models, the presurgical score at question was assigned as the dependent variable while age, sex and presurgery score at question were the independent variables. RESULTS: Overall, a statistically significant amelioration in both SF-MPQ and SF-36 scores was observed postsurgically. For the SF-MPQ leg cramping, gnawing, burning, and aching pain symptoms, when present presurgically, were the least responsive to treatment. For the SF-36, mental scores overall were less responsive than physical equivalents postoperatively, while general health perception improved only marginally. Differences in pain level scores did not correlate with an equivalent reduction in postsurgery anxiety and depression indices. CONCLUSIONS: SF-MPQ and SF-36 can assist in treatment decision, as they can readily identify patients at risk of unfavorable outcomes even in primary/clinical settings. The above findings additionally suggest a wider scope of clinical use for the above questionnaires allowing parallel processing and interpretation of the same patient data. LEVELS OF EVIDENCE: Level I.

Delayed foreign-body reaction to absorbable implants in metacarpal fracture treatment.

BACKGROUND: First-generation bioabsorbable implants have been associated with a high complication rate attributable to weak mechanical properties and rapid degradation. This has led to the development of stronger devices with improved durability. However, the modern implants have raised concerns about potential late-occurring adverse reactions. QUESTIONS/PURPOSES: This retrospective study addressed the following questions: Can absorbable implants consisting of trimethylene carbonate, L-lactide, and D,L-lactide provide adequate fixation for healing of a metacarpal fracture? Will these implants obviate a second removal operation? What complications can occur in the reaction to implant breakdown? PATIENTS AND METHODS: Twelve unstable, displaced, metacarpal fractures were studied in 10 consecutive patients (seven men, three women; mean age, 36.4 years; range, 18-75 years). The fractures were treated with absorbable plates and screws consisting of the aforementioned copolymers and designed to resorb in 2 to 4 years. Nine patients (10 fractures) were available for clinical and radiographic followups (mean, 45.7 months; range, 34-61 months). RESULTS: Fracture healing was uneventful in all cases. Four patients experienced a foreign-body reaction during the second postoperative year and required surgical débridement to remove implant remnants. Histologic examination confirmed the diagnosis of a foreign-body reaction. Two other patients reported a transient local swelling that subsided without treatment. CONCLUSIONS: Our results indicate these absorbable implants for metacarpal fractures achieved adequate bone healing but simply postponed the problem of foreign-body reactions. Patients treated with bioabsorbable implants should be advised of potential late complications and should be followed for at least 2 years, possibly longer.

Condylar buttress plate versus fixed angle condylar blade plate versus dynamic condylar screw for supracondylar intra-articular distal femoral fractures.

PURPOSE: To compare outcomes of 3 fixation techniques for intra-articular distal femoral fractures. METHODS: Records of 59 men and 49 women aged 16 to 80 (mean, 47) years who underwent internal fixation for 116 type-C (complete intra-articular) distal femoral fractures were retrospectively reviewed. According to the AO classification, 25 fractures were type C1 (23 closed and 2 open), 71 type C2 (69 closed and 2 open), and 20 type C3 (16 closed and 4 open). Based on implant availability at the time, all surgeries were performed by a single surgeon using a condylar buttress plate (n=38), a fixed angle (95 degrees) condylar blade plate (n=24), or a dynamic condylar screw (n=54). The mean follow-up period was 11 (range, 4-19) years. At the latest follow-up, functional outcome was classified according to Schatzker and Lambert criteria. RESULTS: Functional outcomes were excellent in 64 (55%) of the fractures, good in 37 (32%), moderate in 9 (8%), and poor in 6 (5%). Outcomes in patients treated by the dynamic condylar screw were significantly superior to those treated by the condylar buttress plate (p=0.016) or condylar blade plate (p=0.001). Good-to-excellent results were achieved in 96% vs 84% vs 71% of these patients, respectively. Complication rates were lower in the dynamic condylar screw group than the other 2 groups (pseudarthrosis, 5% vs 11% vs 25%; varus deformity, 4% vs 26% vs 25%; knee stiffness, 0% vs 5% vs 8%, respectively). No implant failure was encountered. CONCLUSION: Dynamic condylar screw fixation for distal femoral fractures achieves better functional outcomes and lower complication rates.

Reliability and validity of the adapted Greek version of scoliosis research society - 22 (SRS-22) questionnaire.

BACKGROUND: The SRS-22 is a valid instrument for the assessment of the health related quality of life of patients with Idiopathic scoliosis. The SRS-22 questionnaire was developed in USA and has been widely used in the English speaking countries. Recently it has been translated and validated in many other languages. The purpose of this study is to evaluate the reliability and validity of the adapted Greek version of the refined Scoliosis Research Society-22 Questionnaire. METHODS: Following the steps of cross - cultural adaptation the adapted Greek version of the SRS-22 questionnaire and a validated Greek version of the SF-36 questionnaire were mailed to 68 patients treated surgically for Idiopathic Scoliosis. 51 out of the 68 patients returned the 1st set of questionnaires, while a second set was emailed to 30 randomly selected patients of the first time responders. 20 out of the 30 patients returned the 2nd set. The mean age at the time of operation was 16,2 years and the mean age at the time of evaluation was 21,2 years. Descriptive statistics for content analysis were calculated. Reliability assessment was determined by estimating Cronbach's alpha and intraclass correlation coefficient (ICC) respectively. Concurrent validity was evaluated by comparing SRS-22 domains with relevant domains in the SF-36 questionnaire using Pearson's Correlation Coefficient (r). RESULTS: The calculated Cronbach's alpha of internal consistency for three of the corresponding domains (pain 0.85; mental health 0.87; self image 0.83) were very satisfactory and for two domains (function/activity 0.72 and satisfaction 0.67) were good. The ICC of all domains of SRS-22 questionnaire was high (ICC>0.70), demonstrating very satisfactory or excellent test/retest reproducibility. Considering concurrent validity all correlations were found to be statistically significant at the 0.01 level among related domains and generally demonstrated high correlation coefficient. CONCLUSION: The adapted Greek version of the SRS-22 questionnaire is valid and reliable and can be used for the assessment of the outcome of the treatment of the Greek speaking patients with idiopathic scoliosis.

Management of posttraumatic arthritis of the wrist with radiolunate fusion enhanced with a sliding autograft: a case report and description of a novel technique.

Although in rheumatoid cases radiolunate fusion presents with satisfying results, in cases with posttraumatic carpal distortion, the variability of injury pattern can influence the type of fixation and the rate of bony union. In this case report, we present an alternative technique of radiolunate fusion for the management of posttraumatic arthritis, which combines the traditional procedure with a corticocancellous autograft, created from the dorsal side of the radius that slides over the bones to be fused. That procedure provides the best environment for the bones to heal and an additional stabilizing effect on the radiolunate construct, thus better preserving the normal intercarpal relationships and wrist height. Patient's clinical and radiological outcome was very satisfactory until the last follow-up.

Mid-term results of hydroxyapatite-coated threaded cup implanted without supplementary supporting screws.

We retrospectively reviewed the clinical, radiographic, and survivorship outcomes in a series of 180 patients that underwent 204 primary Total Hip Arthroplasties with the use of a second generation threaded hydroxyapatite-coated acetabular cup that was implanted without any supplementary supporting screws. At an average follow-up period of 10.2 (range: 8-14) years, one hundred and seventy-four patients (198 cups) were available for assessment. All patients underwent detailed physical and radiographic examination; their functional status was evaluated according to the Harris Hip Score (HHS). Following their digitization, all radiographs were further reviewed in order to determine the existence of any migration of the acetabular cup. Osteolytic lesions, radiolucent lines or zones of increased bone density were also recorded and classified according to the system of DeLee & Charnley. The modified Engh's criteria were used in order to evaluate the stability of the prosthesis. The patients' mean HHS at their latest follow-up visit (97.24 points) was statistically significantly better than the preoperative mean score of 40.31 points (p<0.001). Radiographic analysis showed "stable with bone ingrowth" fixation (modified Engh's criteria) of all implants with no significant migration of the cup (mean cranial migration: 0.597 mm, mean horizontal migration: 0.607 mm, mean observed difference of the cup's inclination angle: 0.26 degrees). No areas of significant osteolysis were found. The cumulative survival rate of the implants was 97.05%. Our results suggest that second generation hydroxyapatite-coated threaded acetabular cups can be successfully implanted (and achieve excellent results) without the use of any supplementary supporting screws.

Cementless total hip arthroplasty for osteonecrosis of the femoral head after allogenic bone marrow transplantation.

From 1998 until 2004, we performed 26 consecutive cementless total hip arthoplasties in 15 patients who had developed advanced avascular necrosis of the femoral head after allogenic bone marrow transplantation. The average age at transplantation was 31.1 years, and the mean age at implantation was 33.6 years. Follow-up period ranged from 2 to 8 years with an average of 56.4 months. The mean D'Aubigne-Postel score improved from 7.5 points preoperatively to 17 points postoperatively. The overall result was excellent in 92.3%, good in 3.8%, and fair in 3.8% of cases. There were no radiological signs of components loosening and no severe complications. Cementless total hip arthroplasty appears as a favorable alternative for the treatment of avascular necrosis of the femoral heads after allogenic bone marrow transplantation.

Suction during orthopaedic surgery. How safe is the suction tip?

The use of a suction system is mandatory in most orthopaedic procedures. In the unlikely event of contamination of the system, deep wound infection could occur, jeopardising the operation. We have prospectively studied 50 patients who underwent elective and orthopaedic trauma procedures during which a suction system was used. At the end of each procedure the suction catheter tip was sent for culture and microbiology. The suction tips showed bacterial contamination in 27 cases (54%). Staphylococcus species were responsible in 21 cases (77.8%). The tip was contaminated in only 1/11 procedures lasting less than one hour (9.1%), as compared with 26/39 procedures when operative time exceeded one hour (66.7%). However, deep wound infection was recorded in only one case. We believe that despite the low risk of deep wound infection, changing the suction tip every hour in long orthopaedic procedures or using the on/off switch is well justified in an effort to minimise the chances of deep wound infection.

A Combined Repair Technique for Early Neglected Achilles Tendon Ruptures.

OBJECTIVE: This study presents the long-term results of a combined technique, using both Duthie's biological repair and a plantaris tendon transfer for the reconstruction of early neglected tendo Achilles ruptures. MATERIALS AND METHOD: Between January 2000 and November 2004, nine patients with an early neglected Achilles tendon rupture (≥ 4 and ≤ 12 weeks from injury), underwent surgical reconstruction. Eight patients were male and one female, their age was average 41 years and the median follow-up period was 3.66 years. The average clinical defect of the Achilles tendon was 4.33 cm. RESULTS: All patients were examined by the clinical ankle scoring system of Leppilahti et al. (Clin Orthop 346:152-161, 1998). Six patients presented excellent results and three patients had good results. All patients had equal plantarflexion and dorsiflexion with the healthy side and all of the study's patients returned to work 3 months postoperatively. An average muscle atrophy of 0.83 cm was documented compared with the uninjured side. Only four of nine patients (44.44%) had a normal one-legged jump. There were no complications postoperatively and no re-ruptures of the Achilles tendons. CONCLUSION: This combined method appears to be safe and effective, with a low risk for complications, allowing us to obtain excellent results for the majority of our patients.

Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years.

The results of operative treatment of acetabular fractures as well as its role in the occurrence of post-traumatic osteoarthritis (OA) are presented. From 1990 to 2000, 50 patients (32 male and 18 female), aging from 18 to 71 years (mean: 37.8 years) underwent an open reduction and internal fixation of their displaced acetabular fracture. They were reviewed at a mean of 5.8 years (2-10 years). A typical Kocher-Langebeck approach was selected in all the patients and in 14 cases a trochanteric osteotomy was added to enhance exposure. The fractures were classified according to the Letournel-Judet classification. The aim of the operation was the anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement, which was achieved in 39 of 50 cases. Post-operative protocol included low-molecular-weight heparin (LWMH) as antithrombotic prophylaxis and 75 mg of indomethacin against heterotopic ossification (HO). At the final follow-up, the patients were evaluated clinically according to D'Aubigne-Postel scoring system and radiologically based on the criteria described by Matta. The clinical results were excellent in 20 patients, good in 18, fair in 5 and poor in 7. The radiological results were excellent in 20 patients, good in 16, fair in 5 and poor in 9. Early post-operative complications included 2 peroneal nerve palsies and 3 wound infections and late complications included 1 patient with avascular necrosis of the femoral head (ANFH), 5 patients with grade III and IV heterotopic ossification according to Brooker classification and 12 patients with post-traumatic osteoarthritis of the hip joint. Although the rates of early and late complications were relatively common, the functional outcome was satisfactory in most of the cases and comparable with other larger series. We concluded that operative treatment of most of the displaced acetabular fractures--except of isolated anterior column or/and anterior wall - could be attempted via a single posterior approach, leading to good to excellent results in the majority of the cases.