Does bone marrow affect the radiological outcome when added to biphasic ceramic graft in treatment of benign bone lesions?

PURPOSE: The aim of this study is to describe the role of bone marrow aspirate in treatment of the benign bone lesions by comparing two groups of patients (16 patients in each group) with benign bone lesions treated with surgical curettage and filling the defect with either composite ceramic graft hydrated with bone marrow aspirate "group 1" or composite ceramic graft alone without a bone marrow aspirate "group 2". MATERIALS AND METHODS: The mean age was 19.7 years (group 1) and 18.5 years (group 2). The mean size of the cavitary bone lesions was 29.2 cm(2) (group 1) and 25.9 cm(2) (group 2). The mean follow-up period was 47 months. RESULTS: The percentage of ceraform resorption had increased from 31.3% at 6 months to 75.4% at 36 months for group 1 patients and from 20.9% at 6 months to 60.3% at 36 months for group 2 patients. The percentage of bone trabeculation through the cavitary defects had increased from 30.3% at 6 months to 85.5% at 36 months for group 1 patients and from 18.9% at 6 months to 72.0% at 36 months for group 2 patients. The mean of the percentage of ceraform persistence at 36 months after its implantation was 24.6% for group 1 patients and 39.7% for group 2 patients. CONCLUSION: Adding bone marrow aspirate to ceraform biphasic ceramic had hastened the rate of its resorption and had decreased the rate of its persistence.

Distal soft tissue realignment and proximal metatarsal countersinking osteotomy for moderate to severe hallux valgus.

BACKGROUND: Hallux valgus is a common condition and surgical correction has remained a challenge. OBJECTIVE: To evaluate the results of distal soft tissue realignment and proximal 1st metatarsal countersinking osteotomy for the treatment of moderate to severe hallux valgus deformity. MATERIALS AND METHODS: This prospective study included 33 ft in 28 patients. The deformity was moderate in 27 ft (23 patients), severe in six ft (five patients) and bilateral in five patients. All operations were performed as a primary procedure with an average duration of follow-up of 28.2 months (range 10-45 months). RESULTS: The average hallux valgus angle was improved from 32.5° to 8° and the first intermetatarsal angle from 16.5° to 7.7°. According to the symptomatic score of Broughton and Winson, 22 ft (18 patients) were rated excellent, nine good and two poor. The average American Orthopedic Foot Ankle Society score at the final follow-up was 89.3 (range 65-100). Recurrence of the valgus deformity was seen in three patients and hallux varus in two patients. CONCLUSIONS: The current procedure proved to be effective to correct all components of hallux valgus deformity regardless of its severity.

Surgical treatment of displaced intra-articular calcaneal fracture using a single small lateral approach.

The objective of this study was to evaluate the outcome of semi-open reduction and minimal internal fixation through a single small lateral approach as a minimally invasive technique for treatment of displaced intra-articular calcaneal fractures. This prospective study was conducted on eighteen patients (16 men and 2 women). The average age was 37.7 (22-55). The most common cause of injury was a fall from height in fourteen patients. Patients were operated on within a mean time of 4.8 days of admission (1-11 days) and were followed up for an average period of 24.1 months (6-39 months). Patients were evaluated clinically using the Creighton-Nebraska Heath Foundation Assessment score of Crosby and Fitzgibbons (J Bone Joint Surg (Am) 72-A:852-859, 1990). The scoring system proposed by Knirk and Jupiter was used for radiological assessment of the posterior subtalar joint (Knirk and Jupiter in J Bone Joint Surg (Am) 68-A: 647-659, 1986). The skin incision healed in all cases without necrosis, infection, or sural nerve injury. All fractures healed after an average of 8 weeks (7-10 weeks), and patients returned to the routine daily activities after an average time of 4.3 months (3-7 months). In conclusion, semi-open reduction and minimal internal fixation through a small lateral approach is an effective treatment for carefully selected cases of displaced intra-articular calcaneal fractures.

Percutaneous Kirschner-wire fixation for displaced distal forearm fractures in children.

A prospective study was conducted to evaluate the efficacy of percutaneous Kirschner-wire fixation for the management of high-risk distal forearm fractures in children. Thirty two children (22 boys & 10 girls) with displaced fractures of the distal third of the radius with or without ulnar fractures were managed by closed reduction and percutaneous Kirschner-wire fixation. Their average age was 10.1 years (4-16 years). The fracture was open (Grade 1) in two cases (6.3%). Antegrade intramedullary Kirschner-wire fixation was done for distal radial fractures in 71.9% of cases. Patients were evaluated clinically and radiologically after an average duration of follow-up of 28.6 months. Patients with residual angulation more than 15 degrees, limitation of forearm or wrist movement more than 20 degrees, persistent pain or clinical deformity were considered to have unsatisfactory results. Satisfactory results were obtained in 87.5% of all cases. The residual radioulnar and dorsovolar angulations were significantly related to the decrease in forearm rotation and the unsatisfactory results. High-risk distal forearm fractures in children should be treated by primary percutaneous Kirschner-wire fixation supplemented by cast immobilisation.

Titanium elastic nail fixation for paediatric femoral and tibial fractures.

The aim of this prospective study was to evaluate the results of treatment of paediatric femoral and/or tibial diaphyseal fractures with titanium elastic nails (TENs). Sixty six patients with 48 femoral and 25 tibial fractures were followed-up for 15 to 24 months. The outcome rating system proposed by Flynn et al was used to evaluate the final results. Most patients (56.1%) were operated between 2 to 4 days after injury; a traction table was used in 54.8% of cases. The average operative time was 28 minutes, and the average hospital stay was 5.7 days. Postoperative immobilisation was used in 30% of cases, mostly with femoral fractures. The fractures united in an average time period of 85 days; 89% had united within 3 months. The nails were removed in 87.8% of cases after an average of 5.9 months. The following complications were noted: soft tissue and skin problem (9.1%) in relation to nail ends at the entry points, limb-length discrepancy (9.1%), malunion (4.5%). Based on Flynn et al's outcome rating system, 75.8% of the results were excellent, 24.2% were satisfactory and there were no poor results. With good knowledge of the technique of TEN fixation for paediatric femoral and tibial fractures, excellent and satisfactory results were achieved in all cases, with few minor complications. TENs can give stable fixation allowing early mobilisation and shorter hospitalisation with less disruption of patient and family life.

Telescoping versus non-telescoping rods in the treatment of osteogenesis imperfecta.

A retrospective study was undertaken to evaluate and compare the results of telescoping (group I) versus non telescoping rods (group II) in the treatment of osteogenesis imperfecta. Thirty-three lower limb segments in ten patients were studied (14 segments in group I and 19 segments in group II). The surgical techniques of Sofield and Miller (1959) and Lang-Stevenson and Sharrard (1984) for rod insertion were used. All cases were assessed clinically regarding mobility status, growth and limb-length, refracture, and infection. They were also assessed radiologically regarding rod migration, bone outgrowing the rod, incorrect T-piece placement, breakage and bending of rods. The average duration of follow-up was 86.2 months (range: 6 to 8 years). Mobility status and bone growth were better in group I than in group II patients. The overall implant related complication rate was 28.6% in group I in comparison to 68.4% in group II. Rod migration was twice more common in group II than in group I. Bone outgrowing the rod and breakage of rods with fracture was seen in group II only. The three-year survival rate for telescoping rods was 92.9% in contrast to 68.4% for non telescoping rods. The reoperation rate was 7.2% in group I and 31.6% in group II. From this comparative study it was clear that the results were significantly better after Sheffield rods with regard to mobility status, longevity of the rod, and the frequency of complications requiring reoperations. Also most of the complications were related to the technique of rod insertion and the type of rod.

Biphasic ceramic bone substitute mixed with autogenous bone marrow in the treatment of cavitary benign bone lesions.

A prospective study was performed on 34 patients to evaluate the efficacy and safety of a composite bone substitute formed of hydroxyapatite and tricalcium phosphate (Ceraform) with or without gentamycin sulphate (Ceraform-Genta) plus autogenous bone marrow aspirate in the treatment of cavitary bone defects related with benign bone lesions. At the end of the follow-up period, all patients were evaluated clinically for pain and a daily living activity score, and radiologically regarding the time and quality of bone healing, using a modified Neer grading system. Satisfactory clinical outcome without pain or impairment of daily living activities was seen in 97.1% of patients. Radiologically, 70.6% of the lesions were completely healed and 26.5% showed partial healing; one patient had local recurrence according to the modified Neer grading system. The average time to healing was 19.9 weeks and all reported complications were minor, unrelated to the composite graft itself, and did not affect the functional outcome. The composite ceramic used in this study proved to be a safe and effective bone graft substitute; its use appeared at least as effective as other treatment modalities for benign bone lesions.

Extracapsular base of neck osteotomy versus Southwick osteotomy in treatment of moderate to severe chronic slipped capital femoral epiphysis.

The aim of this study was to evaluate the results of extracapsular base of neck osteotomy and Southwick osteotomy from clinical and radiologic points of view. This retrospective study included 35 hips in 33 patients who presented with moderate to severe slipped capital femoral epiphysis (SCFE) between 1995 and 2001. These patients were divided into two groups according to the type of osteotomy: group A patients (n = 15) were treated by extracapsular base of neck osteotomy and group B patients (n = 18) were treated by modified Southwick osteotomy. Follow-up averaged 3.5 years (range 1-6 years). Clinical and radiologic evaluations were done before and after surgery. All patients were finally evaluated according to the modified Southwick criteria. Group A had 86.7% satisfactory results; group B had 90% satisfactory results. There was no statistically significant difference between the type of osteotomy and the final outcome. The authors believe that both types of osteotomy are equally safe and effective procedures, with minimal risks of avascular necrosis and chondrolysis, in the treatment of moderate to severe chronic SCFE.