Syndesmosenplastik bei chronischer Insuffizienz des distalen tibiofibularen Syndesmosenkomplexes

Objective Reconstruction of the three-point dynamic suspension of the fibula in the fibular groove of the tibia. Elimination of pain and functional disturbances. Prevention of posttraumatic osteoarthritis. Indications Chronic symptomatic insufficiency of the distal tibiofibular syndesmosis with widening of the mortise. Contraindications Poor skin and soft tissue conditions. Advanced osteoarthritis of ankle. Surgical Technique Reconstruction of the three most important ligaments of the distal syndesmosis complex: the anterior and posterior as well as the interosseous tibiofibular ligaments, with a halved, distally pedicled tendon of the peroneus longus tendon. Results Ten tenodeses (eight women, two men, average age 40 years) were done between January 1998 and December 1999. The syndesmosis insufficiency persisted after surgical treatment of eight pronation-eversion and two pronation-abduction fractures. Average duration of follow-up 11.4 months. Using the Karlsson score, the subjective and functional assessment of all patients reached 88 out of 100 points. One patient reached only 70 points on account of a preoperatively present dysesthesia in the territory of the tibial nerve giving rise to persistent pain.     

The cartilage of the tibiofibular joint: a source for autologous osteochondral grafts without damaging weight-bearing joint surfaces

Within the past few years, autologous osteochondral transplantation has become an established procedure in the therapy of articular cartilage defects of the knee. One significant disadvantage of this technique is the harvesting of grafts from the weight-bearing area. The tibiofibular articulation is less loaded. The purpose of this study was to evaluate the question of whether this joint is suitable as a donor site for osteochondral grafts. Ten fresh human knees were dissected to perform histology, immunohistochemistry, and thickness measurement of the tibiofibular cartilage. Favourable approaches and establishing of anatomical landmarks were investigated in 44 fixed tibiofibular joints. In knee extension, the shortest distance between the joint cleft and common fibular nerve was measured. A total of 389 bone specimens was analysed morphometrically (cartilage area, orientation of the joint line, signs of arthrosis). Histological and immunohistochemical examination showed hyaline cartilage and type II collagen. The area of cartilage amounted to 3.58 cm(2) (mean) at the tibia and at the fibula with a thickness of 1.6 mm (mean). The joint line is mainly orientated perpendicular to an axis course from craniomedioventral to caudolaterodorsal. Depending on the available instruments, two approaches are possible: from anteromedial or from posterolateral. The mean distance to the common fibular nerve was 19.5 mm. Signs of arthrosis were found in 1 of 10 fresh knee specimens and in 11.4% of the bone specimens. Transplantation into three patients showed no intra- or postoperative complications and a rapid and uneventful recovery. The proximal tibiofibular joint is an excellent donor site for autologous osteochondral grafts.     

Die so genannte Box-Osteotomie – eine neue Technik der proximalen Umstellungsosteotomie bei Gonarthrose

Objective Stable correction of a varus knee with osteoarthritis of the medial and patellofemoral compartments through a high tibial valgization osteotomy. Indications Painful osteoarthritis of the medial compartment with or without patellofemoral involvement in patients with varus knee. Contraindications Osteoarthritis of the lateral compartment. Varus exceeding 15° and flexion deformity exceeding 10°. Severe limitation of movement. Instability of knee. Uncooperative patient. Sugical Technique Transverse lateral approach. Resectio of proximal tibiofibular joint. Lateral wedge resection osteotomy, leaving an anterior bony ledge at the distal and a posterior ledge at the proximal fragment (box osteotomy). Anterior translation of distal fragment. Fixation with stepped staple. Cylinder cast for 6 weeks. Results Report on 16 patients (nine women, seven men, age 48–64 years) with a minimum follow-up of 30 months (maximum 6 years). Using the Hospital for Special Surgery (HSS) knee score, 93.75 of the patients had either an exellent or good result. The outcome was fair in one patient only. A longitudinal assessment using the HSS score showed a reduction in the mean score over the period of reporting.     

Anatomical evaluation of the modified posterolateral approach for posterolateral tibial plateau fracture

Objective

The study was undertaken to evaluate the efficacy and safety of a posterolateral reversed L-shaped knee joint incision for treating the posterolateral tibial plateau fracture.

Methods

Knee specimens from eight fresh, frozen adult corpses were dissected bilaterally using a posterolateral reversed L-shaped approach. During the dissection, the exposure range was observed, and important parameters of anatomical structure were measured, including the parameters of common peroneal nerve (CPN) to ameliorate the incision and the distances between bifurcation of main vessels and the tibial articular surface to clear risk awareness.

Results

The posterolateral aspect of the tibial plateau from the proximal tibiofibular joint to the tibial insertion of the posterior cruciate ligament was exposed completely. There was no additional damage to other vital structures and no evidence of fibular osteotomy or posterolateral corner complex injury. The mean length of the exposed CPN was 56.48 mm. The CPN sloped at a mean angle of 14.7° toward the axis of the fibula. It surrounded the neck of the fibula an average of 42.18 mm from the joint line. The mean distance between the opening of the interosseous membrane and the joint line was 48.78 mm. The divergence of the fibular artery from the posterior tibial artery was on average 76.46 mm from articular surface.

Conclusions

This study confirmed that posterolateral reversed L-shaped approach could meet the requirements of anatomical reduction and buttress fixation for posterolateral tibial plateau fracture. Exposure of the CPN can be minimized or even avoided by modifying the skin incision. Care is needed to dissect distally and deep through the approach as vital vascular bifurcations are concentrated in this region. Placement of a posterior buttressing plate carries a high vascular risk when the plate is implanted beneath these vessels.     

Die Transplantation autogener Knorpelzellen in Gelenkflächendefekte des Kniegelenks

Objective Repair of articular cartilage defects of knee to restore a pain-free joint function. Indications Full-thickness chondral or osteochondral posttraumatic lesions and osteochondritis dissecans defects that have not been successfully repaired with methods such as debridement, drilling, and microfracturing. Contraindications Osteoarthritis. Rheumatoid arthritis. Sugical Technique During arthroscopy, the cartilage lesion is evaluated, and cartilage slices weighing 200–300 mg are harvested from the upper medial femoral condyle, a minor load bearing area. The chondrocytes are isolated enzymatically and grown in culture to increase the cell number during approximately 2 weeks. During the second operation, an arthrotomy is performed through a medial or lateral parapatellar approach. The defect is carefully debrided. A periosteal patch is obtained from proximal tibia, placed over the defect and sutured to the surrounding cartilage. The suture line is sealed with fibrin glue, and the chondrocytes are injected into the defect under the patch. Results Recently, Peterson has presented results in 213 patients with a follow-up between 2–10 years. He reported good to excellent results in 90% of 57 patients with single femoral condyle lesions, in 84% of 32 patients with osteochondritis dissecans and in 74% of 27 patients with femoral condyle lesions in combination with anterior cruciate ligament reconstruction. In 32 patients the patella was grafted and 22 improved, in twelve patients the trochlea was grafted and seven improved, and in 53 patients multiple lesions were grafted and 42 improved. Second-look arthroscopies were performed in 46 patients, 26 of them were biopsied; the transplanted tissues showed a hyaline-like appearance in 21 patients (80%).     

Osteosynthese distaler Femurfrakturen mit dem Less Invasive Stabilizing System (LISS)

Objective Stable internal fixation of distal femur with an implant resisting angular forces. The technique is minimally invasive, relies on a monocortical screw fixation and obviates the need for bone grafting. Indications Distal femur fractures of types A and C according to the AO classification. Periprosthetic femur fractures after total knee and hip arthroplasty. Contraindications Local infection, osteitis. Sugical Technique For intraarticular fractures: anterolateral parapatellar approach to the knee joint, anatomic reduction and temporary fixation of the articular fragments with Kirschner wires. Closed reduction aligning the block of articular fragments with the shaft. Submuscular introduction of the LISS plate with the help of an aiming device and its adaptation to the femur. Through stab incisions the screws are inserted leading to a stable anchorage of the plate. For extraarticular fractures: stab incisions over the lateral femoral condyle. Results In a prospective study, results of 54 fresh fractures of the distal femur in 51 patients (28 men, 23 women) operated between February 1997 and February 2000 could be assessed. The patients' average age at the time of injury was 53 (20–93) years. 48 patients suffered from type 33 fractures. Six type 32 fractures were encountered. Ten fractures were open. Six patients fractured their femur above or below a total joint replacement. We noted the following complications: one heterotopic ossification, two deep thrombophlebites with lung embolism and three infections. A loosening of the proximal screws occurred in four patients. 40 patients could be followd up clinically and radiologically, of these 32 after more than 6 months and 27 after more than 1 year. The Neer score of the 27 patients examined after > 1 year amounted to an average of 73.9 (33–88) points, with six excellent, 14 satisfactory, six unsatisfactory results and one poor result. The Lysholm score amounted to 80.5 (40–100) points.     

Realignment-lengthening osteotomy for malunited distal fibular fracture

Purpose

Persistent displacement of ankle fractures increases the stresses on the articular cartilage and leads to degenerative arthritis. Correction of the ankle mortise restores the normal ankle biomechanics and should prevent the development of degenerative joint disease.

Methods

Seventeen patients were treated for symptomatic ankle joint due to malunited distal fibular fracture. There were eleven male and six female patients. Their ages ranged from 23 to 54 years (median 34 years). The procedure included transverse fibular osteotomy for restoration of the lateral malleolar alignment, acute distraction of the osteotomy to restore the fibular length with interpositional graft and reduction of subluxation of the distal tibio-fibular articulation. Internal fixation of the osteotomy was performed with plate and screws and trans-syndesmotic screws.

Results

Fibular lengthening was performed in all cases and ranged from six to 12 mm (median eight millimetres). The American Orthopaedic Foot and Ankle Society score preoperatively ranged from 40 to 74 (median 60) and at follow up ranged from 50 to 95 (median 79). Progression of ankles arthrosis occurred in one patient leading to ankle arthrodesis as a secondary procedure. Results were satisfactory in 12 cases (70.6 %), and unsatisfactory in five cases (29.4 %) due to stiffness and pain in the ankle joint. The follow-up ranged from 24 to 45 months (median 31 months).

Conclusion

Corrective osteotomy of fibular malunion produces considerable improvement provided that the patient does not have significant degenerative changes before surgery. The use of athrodiastasis of the ankle as a secondary procedure may be of value to improve the outcome.     

Der sog. Midvastus-Zugang zur Implantation von Kniegelenkendoprothesen

Objective Approach to the knee for total knee arthroplasty with the goal to avoid tendency to lateralization and extension lag. Indications Implantation of total knee components. Revision surgery after total knee arthroplasty. Contraindications Morbid obesity. For revision surgery: preoperative knee flexion of < 60°. Surgical Technique Anterior midline incision, blunt separation of the distal part of the obliquely running fibers of the vastus medialis over an extent of at least 5 cm. The muscle incision ends at the proximal and medial corner of the patella and is continued distally along the medial patellar border ending at the tibial tuberosity. After opening of the joint, the patella is dislocated laterally thus exposing the articular surfaces. After insertion of the components, superficial adaptation of the muscle fibers and wound closure in layers. Results Of 297 total knee implants 276 knees (92.9%) could be followed up for an average of 36.2 (19–56) months. 153 knees were in women and 123 in men with an average age of 66.3 (33–81) years. In none of the operations a lateral release became necessary. The results were based on the score of the American Knee Society. The score showed 52.3 points preoperatively and 90.6 at follow-up. 95% of the patients had an excellent or good functional result. Tangential radiographs of the patella with the knee in 30° of flexion showed in 91% a central position in the patellar groove.     

Marknagelung und ipsilateraler Fibulatransfer zur Rekonstruktion von segmentalen Knochendefekten an der Tibia

Objective Reconstruction of large diaphyseal segmental defects in the tibia allowing for early functional rehabilitation. Indications Segmental diaphyseal defects of the tibia secondary to trauma, infection or tumor resection. Contraindications Insufficient proximal or distal tibial segments to permit stable fixation with a locked intramedullary nail. Absent fibula. Uncontrolled sepsis. Inadequate function of foot. Surgical Technique Bony resection. Locked intramedullary nailing. Ipsilateral fibular transfer. Bone grafting/bone graft substitute. Results Eight patients with segmental tibial defects were treated with intramedullary nailing of the tibia and ipsilateral fibular transfer. All patients were bearing full weight by 14 weeks following transfer of the fibula. There were six early complications in five patients and five late complications in four. They were attributed either to the index pathology or the surgical technique and all were manageable. Time to consolidation depended on the primary injury and the extent of surgery.     

Partielle Verdoppelung eines Fußes

The Problem Complex deformity with partial duplication of the left foot in an 8-month-old girl with numerous other congenital deformities. Marked broadening of the foot due to three additional toe rays and tarsal bones. The Solution Resection of the three intermediate supernumerary toe rays and narrowing of the foot by wedge resection of the corresponding tarsal bones. Fibular transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament around the two metatarsals adjacent to the cleft. Surgical Technique Elliptic dorsal and plantar incision around the three supernumerary toes and their excision. Through partial excision of the tarsal bones, the width of the foot is reduced. Lateral transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament using one extensor tendon of a supernumerary toe to hold both parts of the foot in close approximation. The extensor tendon of the second remaining toe counted from fibular that runs in an abnormal direction is attached to the proximal tendinomuscular stumps of the excised toes. The skin tag at the fibular side of the foot is resected. Result Eleven years later, the girl is able to wear normal shoes and has minimal complaints after prolonged walking. The scars are barely visible and not sensitive to pressure. The mobility of the fibular toes is slightly reduced; also the range of motion of the subtalar joint is limited by 50%. The radiologic aspect of some tarsal bones is unusual, but with smooth articular surfaces.     

Knorpeldefekte am Kniegelenk und autogene osteochondrale Zylindertransplantation

Objective Complete, lasting coverage of chondral defects of femoral condyles with hyaline cartilage. Indications Pain, disturbance of function due to chondral defects of weight-bearing joint sections grade III and IV according to Outerbridge and osteochondritis dissecans stage 4 and 5 according to Rodegerdts &; Gleissner. Contraindications Arthritis, infection, preexisting and persisting instability, axial malalignment. Surgical Technique Anteromedial or anterolateral arthrotomy to evaluate the size of the chondral defect, removal of the cartilage defect by cutting out cartilage-bone cylinders with the Twin Diamond Transplantation Technique (TDTT). Harvesting of appropriately sized cartilage-bone cylinders with healthy hyaline cartilage from non-weight-bearing areas of the posterior or anterior articular surface with the TDTT. Transplantation of the cartilage-bone cylinder “press-fit” into the prepared defect without further fixation. Refilling of the defects caused by harvesting with corresponding periosteum-covered bone cylinders from the iliac crest or with bone substitute materials. Results In 1996 and 1997, 20 patients with cartilage damage of a femoral condyle were treated by osteochondral cylinder transplantation. All 20 patients were questioned as to their subjective assessment of the outcome and reexamined 6, 12, and 24 months postoperatively. The evaluation of the results was performed using Meyers and Lysholm scores and the Tegner activity scale 3, 6, 12, and 24 months postoperatively. Five women and 15 men had cartilage defects measuring from 3.22 to 4.25 cm². 24 months postoperatively, 17 patients felt significant and three patients slight improvement. According to the evaluation criteria of the Meyers score, results in five patients were considered excellent, in 13 good, and in two moderate. According to the Lysholm score, 15 patients were judged as being excellent and five as being good, and according to the Tegner activity scale, nine were considered excellent, nine good, and two moderate. Reasons for the two moderate results were remaining activity-related pain and knee flexion limited to 120°. In both patients an additional osteochondral cylinder had been harvested from the posterior aspect of a femoral condyle.     

Retrograde intramedullary nailing of femoral shaft fractures. A prospective study

Purpose of the study. Antegrade intramedullary nailing is seen as a most effective method in the management of femoral fractures. However, complications may arise due to the surgical approach.Can these disadvantages be avoided by using a retrograde approach? Material and methods. In a prospective study 70 femoral fractures in 62 patients were stabilised using a long intramedullary nail by a retrograde approach. Results. We were able to re-examine 50 patients (57 fractures) 13,3 (3–36) months after the operation.Apart from one non-union by infection, all fractures healed in time. Flexion of the knee joint was within a normal ROM in 81% of shaft fractures 12 months or more after the operation, as was the case in 44% of distal fractures. A inhibition of extension was not found in any patient.Two patients had a femoral shortening of up to one centimeter.We observed no rotational malalignement of more than 5°.The clinical results were excellent in 89% of shaft fractures, and in 50% of supra-/diacondylar fractures. In 18 cases a nail removal was already performed, thereby allowing an arthroscopical follow-up inspection of the knee joint.No knee pathology due to nailing was found in either case. Conclusion. Our results show the advantages of retrograde intramedullary nailing in comparison to the antegrade method.     

Wear patterns of tibiofemoral articulation in osteoarthritic knees: analysis and review of literature

Introduction

Osteoarthritis is a degenerative joint disease characterized by progressive erosion of the articular cartilage. The sites of erosion of articular cartilage have been reported, but no explanation for this particular pattern has previously been suggested.

Aims

To analyze the gross features of lesions, together with their frequency of occurrence and situation, and wear relationship with individual body profile.

Materials and methods

Data collected from the dissection of 102 cadavers at a tertiary hospital.

Results

Wear patterns on the tibial surface show that the areas involved in the majority of cases include middle medial and middle lateral regions of the tibial plateau. There also seemed to be a strong correlation between age, body mass index and the wear pattern. The incidence of posteromedial erosions on the tibial plateau was mainly seen in the ACL-deficient knee. Also, incidence of lateral meniscus tears was found to be higher in the ACL-deficient knees.

Conclusion

In osteoarthritis of the knee joint, the middle third of both the femoral and tibial articular surfaces is most commonly involved in wears, followed by anteromedial and posterolateral compartments both for tibial and femoral surfaces. The wear patterns in the ACL-deficient knee changes due to altered loading characteristics.     

Biocompatible heterogeneous porous gel matrix NeuroGelTM promotes regeneration of rat sciatic nerve within tubular silicone prosthesis (experimental study)

Background

The purpose of this study was to investigate the ability of NeuroGel? to promote and enhance the regeneration of rat sciatic nerve within a 10-mm gap using silicone tubular prosthesis, and to evaluate and compare the regeneration outcomes versus autologous grafting.

Methods

The 10-mm gap of rat sciatic nerve was bridged through silicone tubular prosthesis filled with dehydrated NeuroGel?, and NeuroGel? saturated with rat NGF-B (NG30-NGG60, NGgfB30-NGgfB60). To assess the regeneration of the peripheral nerve we utilized three general and most commonly applied methods: electrophysiologic, hystomorphometric, and functional methods.

Results

The average M-wave amplitude (A_MW index), or the intermediary index of the number of regenerated axons, in animal groups NGG60 and NGgfB60 60 days post-op was: 2.44?±?0.57 mV and 1.87?±?0.48 mV. These indices were statistically lower compared to the indices obtained after autologous grafting. The average impulse conduction velocity along motor fibers (V_MF index), or the intermediary index of myelination rate, was: 13.3 mm/ms and 13.3 mm/ms, respectively, statistically equal to indices obtained after autologous grafting. The average density (D) of regenerated fibers (direct numerical indicator in contrast to intermediary A_MW index) in animal groups NGG60 and NGgfB60 was: 4,920?±?178.88 and 5,340?±?150.33 per mm², respectively. These indices were statistically higher versus indices obtained after autologous grafting. Myelination rates of regenerated fibers in animal groups NGG60 and NGgfB60 were 73 and 86 %, respectively. They were also statistically higher. The average sciatic functional index (SFI) in NGG60 and NGgfB60 was: ?25.57?±?3.05 and ?24.124?±?4.8, respectively, which is statistically equal to indices obtained after autologous grafting.

Conclusions

Neurogel? strongly promotes the regeneration of rat sciatic nerve within silicone tubular prosthesis. After bridging a 10-mm gap through silicone prosthesis with Neurogel? or Neurogel? +NGF-B-modified intraluminal space, the myelination rate of regenerated axons of rat sciatic nerve appeared to be higher, and the axon count and functional recovery is similar to results seen with the autografting technique.     

Wound healing in forefoot amputations: The predictive value of toe pressure

A retrospective study of 136 men undergoing forefoot amputation was done to test the hypothesis that preoperative toe pressure (TP) could predict the likelihood of wound healing. Demographic data included age, smoking history, diabetes mellitus (DM), hypertension, hyperlipidemia, and coronary artery disease. Clinical data included infection, preoperative arterial Doppler data, TP, wound disposition, concomitant revascularization (REV), and healing outcome. Among diabetics, no primary amputation healed with a preoperative TP <38 mm Hg. Among REV diabetics, no healing occurred with a TP <40 mm Hg after bypass, but no failures occurred either with a TP >68 mm Hg or an increase in TP >30 mm Hg after bypass. Nondiabetic patients exhibited no threshold TP values. Univariate analysis revealed that DM and REV were significantly different in the healed (N=83) vs. nonhealed (N=53) populations ( p =0.027 and 0.034). In healed patients, mean TP (71.8 ± 3.5 mm Hg SEM) was significantly higher than in nonhealed patients (45.1 ± 4.3 mm Hg SEM,p =0.000). Logistic regression analysis identified age >60 years (p =0.03), DM (p =0.003), preoperative TP ( p <0.001), and REV ( p <0.001) as significant independent predictors of forefoot amputation healing. Healing probability was calculated and plotted vs. TP for subpopulations based on age, DM, and REV status for both primary forefoot amputation and amputation concomitant with bypass. In this study population, therefore, preoperative TP appeared to be a useful clinical tool for predicting the healing potential of both primary forefoot amputations and amputations plus concomitant bypass for any given patient.     

Autogene osteochondrale Transplantation (AOT) bei Knorpeldefekten am Femurkondylus

Objective Healing of localized cartilaginous defects at the knee to maintain or to restore function. Indications Localized traumatic or degenerative cartilaginous defects or lesions caused by osteochondritis dissecans of a femoral condyle. Contraindications Coexisting advanced osteoarthritis, be it acute or chronic. Surgical Technique Removal of osteochondral cylinders from the defect area; they are discarded. Harvesting of osteochondral cylinders corresponding in size to the defect cylinders from the edge of the patellofemoral compartment and insertion by press-fitting into the defect bed. Twinned diamond-studded cylindric trephines that are cooled through their lumen are employed. Ligamentous instabilities or axial malalignments must be corrected. Results We operated 52 patients (23 men, 29 women, average age 36.4 [17–72] years). The mean duration of follow-up amounted to 56 (12–84) months. Original diagnosis: traumatic cartilage defects in 15, osteochondritis dissecans in eleven, and unicompartmental arthritis in 26 patients. The most impressive results were seen in instances of traumatic lesions and osteochondritis dissecans as documented by Lysholm Score (improvement from 56 to 85.5 points) and the Knee Society Score (KSS), recorded after an average of 24 months (91.2 points). These patients are completely symptom-free and could return to their occupational and sporting activities. From the 26 patients with, sometimes extensive, osteoarthritis, twelve became symptom-free, eight were markedly improved, and six were not satisfied. Two of these six patients had to undergo a joint replacement; their defects were > 9 cm². The Lysholm Score improved from 46 to 81 points, and the KSS reached 85 points at follow-up.     

Die Stabilisierung des luxierten Schultereckgelenks mit Bandnaht und Balser-Platte

Objective Reduction of dislocation and reconstruction of acromioclavicular joint by suturing the torn capsuloligamentous structures, temporary fixation with a Balser plate. Goal: restitution of form and function of shoulder girdle. Indications Primary acromioclavicular dislocation of Tossy type III or Rockwood type III in physically active patients. Acromioclavicular dislocations with additional muscle injuries of Rockwood type IV–VI. Remote painful dislocations without osteoarthritis. Here, consider patient's physical and occupational requirements. Lateral clavicle fractures with damage to clavicular ligaments. Contraindications Poor local skin condition or wounds. Symptomatic, moderate or severe osteoarthritis of acromioclavicular joint. Elevated surgical risk, poor health. Patient not agreeing to surgery. Cosmetic objections. Sugical Technique Anterior saber cut incision medial to acromioclavicular joint. Notching of insertion of deltoid muscle to expose the acromioclavicular ligaments. Placements of U-sutures in these ligaments. Refixation of intraarticular disk to clavicle with sutures. Selection of plate and subacromial insertion of its hook in close bony contact posterior to acromioclavicular joint. Radiographic control of hook and plate and of acromioclavicular joint. Plate fixation with cortex screws. Tying of the ligament sutures already in situ. Suture of joint capsule and of concomitant soft tissue disruptions. Drain. Wound closure. Results In a prospective study, 57/68 patients (62 men, six women, average age 40.3 [19–84] years) operated between 9/94 and 12/97 could be followed up clinically and sonographically after an average of 24.6 (12–49) months. Implant removal after 12 weeks. A full, painless shoulder mobility was seen in 50 patients. Sonography comparing both shoulders showed an average cranial clavicular subluxation of 0.3 mm and under a 10-kg load of 0.6 mm. Limitation of sports was reported seven times. A good to excellent result was obtained in 50 patients.     

Biomechanical analysis of the impact of fibular osteotomies at tibiotalar joint: A cadaveric study

Background:

Osteotomy of the fibula is a common orthopedic procedure performed for various indications, including harvesting fibula for grafting purposes. The effect of fibular osteotomy and need for tibiofibular syndesmotic fixation fusion at different levels on tibiotalar joint is matter of debate. We performed a biomechanical analysis of the impact of fibular osteotomies at different levels and whether the fixation of distal tibiofibular joint mitigates instability caused by the osteotomy.

Materials and Methods:

Six lower limb specimens from fresh adult cadavers were used to prepare leg-foot models. The specimens were assigned to six status according to the level of osteotomy and whether fixation of distal tibiofibular joint was performed or not. Each specimen was then loaded axially to 700 N by the material testing machine, and the tibiotalar joint contact area and peak pressure were measured using an electronic pressure sensor.

Results:

The contact area and the pressure of tibiotalar joint showed significant changes when compared to the normal specimen. All osteotomy specimens had a decreased tibiotalar contact area and an increased peak pressure. This positively correlated with proximity of level of osteotomy to the lateral malleolus.

Conclusions:

Through this study, we found that fibular osteotomy had an adverse effect in terms of decreasing the contact surface of tibiotalar joint that led to increased peak pressure in the joint. However, bone fusion and screw fixation of the distal tibiofibular joint reduced these adverse effects.     

Progress in the treatment of thoracic aortic aneurysms

Progress in the management of thoracic aortic aneurysm includes the following aspects:

1. the concepts of the disease itself, which is frequently generalized so that the second most common cause of late death is rupture of another aneurysm;
2. the diagnostic techniques used: computed tomographic scanning as well as aortography;
3. the medical treatment: with beta blockade and antihypertensive drugs in stable aortic injury in the patient with multiple critical injuries;
4. that hypothermic circulatory arrest with cardiopulmonary bypass and brain temperatures down to 16–20°C has increased successful aortic arch replacement from 50–75% to over 90%;
5. that rapid autologous transfusion by means of a modified Hemonetics machine can collect and process a unit of shed blood in 2–3 minutes and has reduced transfusion requirements by more than half;
6. the vigorous treatment of both consumptive and dilutional coagulopathies;
7. the new reconstructive techniques: involving composite valve graft replacement of the aortic valve, root, and arch as well as coronary artery reattachment;
8. that the use of viable tissue flaps in the treatment of infected aortic grafts as well as intravenous and local irrigation with antibiotics was successful in 8 of 9 of our cases;
9. that graft replacement with intensive antibiotic therapy was effective in 19 of 22 of our patients with mycotic thoracic aortic aneurysm.