Limb lengthening with a fully implantable mechanical distraction intramedullary nail

AIM: The morbidity of fixator-assisted distraction osteogenesis should be reduced by intramedullary lengthening devices. The ISKD (intramedullary skeletal kinetic distractor) is a new, fully implantable mechanical lengthening nail. In a prospective cohort trial the possibilities and limitations of the device used on femur and tibia are examined. METHODS: 22 patients with a mean age of 25 (range: 16-46) years were treated with an ISKD for femoral (n = 16) and tibial (n = 6) lengthening. The average leg length discrepancy was 48 (range: 25-80) mm. The follow-up was 21 (range: 7-37) months. Clinical and radiological results and complications were evaluated. RESULTS: The results of femoral and tibial applications of the ISKD are different. At the tibia, in three patients a pseudarthrosis occurred and slow callus formation was observed twice. An equinus contracture became evident in 2 patients. At the femur, in one case the lengthening was not accomplished with the device. Five patients were manipulated under anaesthesia at least once to achieve the aim of distraction. Three of these patients received retrograde implantation of the ISKD. An infection or interlocking screw failure was not observed either at the femur or the tibia. CONCLUSION: The ISKD reduces fixator-associated problems but incorporates its own difficulties which are mainly based on the guidance of the device. Careful patient advice in monitoring the lengthening process is mandatory. At the femur 8 cm of lengthening can be achieved but the nail tends to "block". Proper reaming and osteotomy techniques are important. A lengthening of more than 1 mm/day is recommended to prevent early consolidation. At the tibia weak callus formation and soft tissue contractures occur, therefore not more than 4 cm lengthening should be planned, the distraction speed has to be reduced noticeable below 1 mm/day and the initial immobilisation should be for more than a week.     

Femur lengthening with a telescopic intramedullary nail ISKD--method presentation and early clinical results

INTRODUCTION: Limb discrepancy over 4 cm is an indication for limb lengthening. Surgical techniques rely on osteotomy, external stabilisation and gradual distraction. The ISKD (Intramedullary Skeletal Kinetic Distractor) nail allows distraction osteogenesis and no external fixator is required. AIM OF PAPER: Aims of paper are: presentation of limb elongation method with the ISKD device, and presentation of early own results. MATERIAL AND METHODS: Material consists of 5 patients, age 14-16 years, 3 boys and 2 girls, who underwent femur lengthening with the ISKD nail between 2005 and 2007. We evaluated: initial shortening, surgical procedure, complications, amount of lengthening, lengthening rate, distraction index, time of treatment and mobility of adjacent joints. RESULTS: Initial shortening was 4-11 cm. No surgical complications were observed, mean time of surgery was 145 minutes, mean blood loss--200 ml. In three patients difficulties with initial distraction required manipulations under general anaesthesia. Distraction was complicated in 3 cases--in two patients premature consolidation was noted; in one case the distraction rate was too high. Mean lengthening rate in the study group was 0.7 mm/day (0.6-0.7 mm/day). Mean distraction index was 41.7 days/cm (26.2-55 days/cm). Full weight bearing was allowed after mean 234 days (210-275 days). Transient decrease of adjacent joint mobility was observed. CONCLUSION: The fully implantable, telescopic ISKD eliminates the need of external fixation and associated complications. Early results of limb lengthening with ISKD are encouraging. Careful patient selection and preoperative planning is required. Further studies and longer follow-up periods are needed.     

Tibial lengthening using a humeral intramedullary nail combined with a single-plane external fixator for leg discrepancy in sequelae of poliomyelitis

The sequelae of poliomyelitis are the common causes of leg discrepancy. Tibial lengthening is an effective way to solve this problem but it is associated with a high rate of complications. In this study, we combined the use of humeral nail and external fixator in tibial lengthening with the purpose of reducing lengthening complications. Compared with the cases lengthened by a single-plane external fixator alone, this combined strategy was found to be beneficial in maintaining the tibial alignment. Therefore, it can be recommended as a good technique for tibial lengthening in patients with sequelae of poliomyelitis.     

Preliminary clinical and radiographic results with the Fixion intramedullary nail: an inflatable self-locking system for long bone fractures

We present a new inflatable self-locking intramedullary nailing system for the treatment of long bone fractures. The features of this system and the advantages of the technique include: fixation along the entire length of the nail, lack of proximal or distal interlocking screws, optional reaming, reduced exposure of the surgeon to X-ray and reduced operating room time. First preliminary clinical and radiographic results are reported. Out of 41 patients who received implants for closed fractures, 29 were available for follow-up. We observed fracture consolidation in all 29 cases (100%), with absence of nonunions, infections or rotational malalignments. Only in 2 (6.9%) cases were complication reported, consisting in the opening of the fracture after inflation of the nail. Good stability of the nail, however, assured a complete callus formation. We conclude that the use of this intramedullary nail is an innovative, effective, simple and minimally invasive treatment for long bone shaft fractures. Received: 17 January 2001/Accepted: 15 May 2001     

Use of totally implantable venous system in cancer patients. Surgical technique and initial clinical experience

The experience with a totally implanted venous system (TIVS) in 27 cancer patients (15 males and 12 women) is reviewed, stressing simplicity of the cut down technique, which was successfully performed in 92.7% of patients. The common: est complications are described; port infection (7.4%), subclavian vein thrombosis (3.7%), and cutaneous necrosis (3.7%) at the port level. It is concluded that TIVS is a useful device for prolonged drugs administration and the cut down technique is indicated especially in the outpatients setting.     

病段切除髓内腓骨移植结合骨延长技术治疗萎缩性骨不连

[目的]探讨一种新的治疗萎缩性骨不连的手术方式,即病段切除髓内腓骨移植结合骨延长技术联合应用,并观察其临床疗效。[方法]对2010年以来本院收治的21例外伤术后反复治疗不愈的萎缩性骨不连患者采用病段切除髓内腓骨移植结合骨延长技术进行治疗,其手术要点包括:切除骨不连断端活力不佳的骨段,取同侧腓骨节段行髓内移植,一期紧密对合胫骨断端,胫骨近端行截骨延长,观察其效果并分析总结。[结果]患者随访时间:12³6个月,平均(19.3±6.5)个月;延长长度3.236个月,平均(19.3±6.5)个月;延长长度3.2⁵ cm,平均(3.93±0.48)cm;愈合时间:45 cm,平均(3.93±0.48)cm;愈合时间:4⁶个月,平均(4.7±0.6)个月;ASAMI评价:骨愈合评价全部为优,优良率100%,功能评价11例为优,9例为良,1例为中,优良率95.2%。并发症方面:钉道感染6例,踝关节僵直1例。[结论]病段切除髓内腓骨移植结合骨延长技术对于萎缩性骨不连有着较好的疗效,可作为处理萎缩性骨不连的一种新的选择。     

Ilizarov's distraction osteogenesis using the mono-fixator system and initial clinical experiences with the injured lower leg

Distraction osteogenesis, as developed by Ilizarov, allows the limbs to be lengthened and intercalary defects to be filled by bone transport without the use of bone grafts. In five patients with traumatic sequelae (fractures of the lower leg), unilateral dynamic mono_fixation and a special distraction apparatus were used for application of the Ilizarov technique. With the distraction device, gradual distraction of the osteotomy surfaces (1/3 mm in three steps per day) is easy for the patients to perform. In three cases distraction osteogenesis was used to correct shortening of the lower leg and in two cases for bridging a tibial defect due to an infection in the plate osteosynthesis. In all cases, the course of treatment and bone healing were uneventful. Based on our first clinical experiences, we believe that mono_fixation provides appropriate stability and the distraction apparatus permits appropriate bone transportation for successful distraction osteogenesis in the tibia.     

双矩形髓内钉与加压钢板治疗肱骨干骨折的生物力学比较及疗效分析

目的 通过双矩形髓内钉和加压钢板两种不同内固定物治疗肱骨干骨折的生物力学对比，探讨有利于肱骨干骨折后的骨修复的内固定方法。方法 以成人尸体湿骨制备骨折模型，随机用双矩形髓内钉和加压钢板两种方法固定后进行四点弯曲试验、扭转试验和拉伸试验，并结合临床疗效分析。结果 测试数据经统计学检验，矩形髓内钉组的四点弯曲试验和扭转试验均优于钢板组（P＜0．01），结果有显著差异，而拉伸试验中矩形髓内钉和加压钢板组无显著差异（P＞0．05）。结论 在肱同干骨折的治疗中，对矩形髓内钉固定较加压钢板内固定更适合骨折愈合所需的生物力学环境，且临床效果较后者优。     

Early clinical results with a multiple synchronized pulse 1064 NM laser for leg telangiectasias and reticular veins.

BACKGROUND: The 1064 nm wavelength penetrates tissue and blood vessels with little absorption by melanin. OBJECTIVE: To perform a study examining the effects of 1064 nm laser used in pulses from 4 msec to 16 msec on leg telangiectasias ranging in size from 0.5 to 3 mm. METHOD: In this initial trial, 50 sites on 30 patients were enrolled and treated with a multiple synchronized pulse laser at 1064 nm. The primary parameter utilized was a single 10-16 msec pulse. Improvement was judged by comparison of digital images at 1 month, 2 months, and 3 months posttreatment. Improvement was judged, based on size and number of vessels remaining. Side effects were noted as present or absent at each visit. RESULTS: Immediate contraction or darkening followed by urtication and visible total vessel closure as indicated by absence of blanching and visual elimination of the vessel border occurred in most of the treated sites. Two 3 mm diameter vessels were confirmed to be closed without flow by Duplex ultrasound visualization, using a 10 MHz transducer. Bruising from vessel rupture was seen in approximately 50% of the cases. No epidermal injury was noted in any sites, even in Fitzpatrick skin Types IV. At 3 months follow-up, 75% improvement was noted at treatment sites. CONCLUSIONS: Initial clinical results with a new multiple synchronized pulsed 1064 nm laser indicate that this longer wavelength supplied at pulses of up to 16 msec appears to be a valuable modality for immediate closure and subsequent elimination of leg ectatic veins. Epidermal injury is unlikely, as the near infrared wavelength has minimal interaction with melanin.     

Beyond implantable first generation cardiac prostheses for treatment of end-stage cardiac patients with clinical results in a multicenter.

After 30 years of research and development effort for both ventricular assist device (VAD) and total artificial heart (TAH) in the United States, they have been demonstrating effectiveness in the bridge to transplantation and destination therapy. Smaller size, long-term durable second generation and third generation blood pumps are now being tested in animals and moving to clinical applications. These are now combined with genetic engineering, tissue engineering and regenerative medical therapy techniques to provide newer treatment methodologies for end-stage cardiac patients. In Japan, heart transplantation was restarted in 1999, but to date only 13 transplants have been performed. Shortage in donor hearts is hindering the prevalence of heart transplantation. Over a dozen of end-stage cardiac patients are waiting for heart transplantation in hospital with a paracorporeal pneumatic VAD. Although implantable VADs have been imported from the USA, they have not acquired a wide clinical use yet because of their large size and high cost. There is a great need for development of a compact, low cost, totally implantable VAD and TAH in Japan to improve the quality of life of end-stage cardiac patients. This paper reviews the current status of the first generation pulsatile VAD and TAH as a bridge to transplantation and destination therapy around the world, followed with a review of the second and third generation blood pumps beyond the limitations of the first generation systems. Future recommendations are also discussed to improve the systems in Japan.     

Measurement of anterior-posterior displacement of the knee. A comparison of the results with instrumented devices and with clinical examination

Thirteen subjects who had normal knees and fifteen patients who had a chronic rupture of the anterior cruciate ligament were tested in order to compare the measurements of tibiofemoral displacement as recorded by four commercial devices: the Acufex knee-signature system, the Genucom knee-analysis system, the Medmetric KT-1000 arthrometer, and the Stryker knee-laxity tester. Anterior and posterior displacement were measured at forces of eighty-nine newtons (twenty pounds) and 133 newtons (thirty pounds). We found significant differences in reproducibility of measurement among the devices. The Acufex, Medmetric, and Stryker devices had more reproducible measurements, and they could be used to identify 80 to 90 per cent of the normal subjects and anterior cruciate-deficient patients. The Genucom device had poorer reproducibility of measurement, and it tended to register greater differences in displacement between the right and left knees of normal subjects.     

Stabilization of the lower thoracic and lumbar spine with the internal spinal skeletal fixation system and a cross-linkage system. First results of treatment.

Since 1986, 19 patients with 21 fractures of the thoracic and lumbar spine have been treated with the AO Internal Spinal Skeletal System. Of these fractures, 17 were burst fractures, 2 were seatbelt fractures and 2 were fracture-dislocations. All the patients in the series had a minimum follow-up of 12 months. There were 4 important losses of correction and two deep infections. In the majority of patients the postoperative reduction deteriorated during follow-up. The addition of 1 or 2 DTT appears to give the system more stability.     

Pelvic clamps for controlling shock in posterior pelvic ring injuries. Application, biomechanical aspects and initial clinical results]

The antishock pelvic clamp provides direct reduction and compression of unstable posterior pelvic ring disruptions. This is effective in preventing excessive blood loss, which is common in these fractures. Comparable to a carpenter's C-clamp, this device is applied in less than 10 min and exerts transverse compression directly over the iliosacral region, reducing the displaced sacral fractures or SI joint diastasis. Early reduction closes the bleeding surfaces and restores the intrapelvic space, providing for earlier tamponade, further decreasing blood loss. The clamp does not interfere with a possible subsequent laparotomy or necessary diagnostic procedures. On 10 cadaveric pelvic specimens the bone yield under compression with the pelvic clamp ranged from 135 N to 685 N relative to the mechanical quality of the bone. This is sufficient to stabilize the posterior ring during further manipulation of the patient in the early phase. Details of the application technique and our clinical experience with the pelvic clamp in the first 17 patients are discussed.     

First clinical experience with the automatic positioning system and Leksell gamma knife Model C. Technical note

In May of 1999, the first Leksell Model C gamma knife was installed at the Gamma Knife Zentrum in Krefeld, Germany. The authors recount their experience with this latest technical gamma knife development. Until the end of 1999, extensive physical and technical tests were performed and the system's hardware and software were continuously improved and adapted to the user's needs. By the end of 1999, 163 GKSs had been performed using the new functionality of the Model C in manual or "trunnion" mode. The trunnions, the two parts of the system that fix the patient headframe to the gamma knife when the isocenter positions, are checked manually. During the same period the new automatic positioning system (APS) was extensively tested and refined so that the first APS treatment could be performed in January 2000. Fifty GKSs have been performed with the APS capability of the Model C. It was possible to use APS alone in 74% of surgeries whereas in 14% some shots were given with APS and some with trunnions. In 12%, GKS was scheduled and planned for APS, but due to unexpected technical (6%) or mechanical (6%) reasons the treatment had to be performed manually. At present there are some spatial restrictions with Model C in APS mode when compared with the Model B. The most significant restriction is the narrow space for the patient's shoulders, especially when deep-seated lesions are treated. Through mechanical changes of the APS motor housing and some modifications of and to the motor driven couch adjustment, these limitations will be reduced in the future. The APS treatment runs smoothly and fast. In no case did any relevant safety error occur during GKS. The more stringent mechanical limitations of the APS compared with the Model B means that frame placement on the head is more critical than before.     

Treatment of fractures of femur and tibia with the telescopic locking nail: design of a new implant and the first clinical results.

BACKGROUND: This study was carried out to evaluate the first clinical experiences with the telescopic locking nail (TLN). The TLN is a newly developed universal locking nail system for both femur and tibia that permits cyclic dynamic loading at the fracture site while weightbearing. The nail can also be used for static interlocking or for compression of the fracture elements. The nail is strong enough to permit immediate weightbearing, and the diameter of 9 mm allows unreamed introduction in many cases. MATERIALS: Seventy-one consecutive patients were treated with the TLN, 24 patients with femoral and 47 patients with tibial fracture or nonunion. RESULTS: Functional outcome, complication rate, and union rate were comparable to other interlocking nail systems. CONCLUSION: Its distinctive biomechanical properties and its universal application in both femur and tibia make the TLN a sophisticated, yet in practice simple, new asset in the practice of intramedullary nailing.     

Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures

ObjectivesThe optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome.MethodsThis was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1–4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified.ResultsReduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation.ConclusionsStraight IMN is a reliable treatment for displaced 2–part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.     

Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux.

Existing Roux-en-Y bile diversion procedures for duodenogastric reflux coupled with distal gastric resection or antrectomy and vagotomy have varied success due to interruption of the physiologic relationships between stomach and duodenum, the reduction of the gastric reservoir, the side effects of vagotomy, and the effect of the Roux limb on gastric emptying. A new bile diversion procedure, suprapapillary Roux-en-Y duodenojejunostomy, was studied, which eliminates the need for gastric resection to prevent jejunal ulcers by preserving duodenal inhibition of gastric acid secretion and the protective effects of duodenal secretion on the surrounding mucosa. Experimentally, the incidence of jejunal ulceration was significantly decreased by the preservation of the proximal duodenum. Clinically, bile diversion by suprapapillary Roux-en-Y duodenojejunostomy alleviates symptoms of duodenogastric reflux disease without being ulcerogenic (in the presence of normal gastric secretion) or prolonging gastric emptying.     

First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

ABSTRACT: BACKGROUND: Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed. METHODS: 13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection. RESULTS: Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session. After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of postoperative complications (respectively p 0.018 and p 0.028). CONCLUSION: Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.