Treatment of intertrochanteric fractures in geriatric patients with a modified external fixator

Forty-two geriatric patients who had an intertrochanteric fracture were treated with a semicircular modification of the Ilizarov frame designed by Cattaneo and Catagni between January 1997 and September 2001. Twenty-five of the patients were female, 17 male. The average age of the patients was 77.5 years (range, 63-99). No intraoperative complication occurred. Deep pin-track infection was found in four patients and varus deformity was observed in two patients and shortening of less than 2 cm in 10 patients. Fixator removal was achieved in a mean time of 12 weeks (range, 10-18). No implant failure, refracture or stiffness of knee and hip joint movements was recorded. We concluded that the treatment of intertrochanteric fractures of the elderly patients with our modification provides significant advantages such as minimal operative and anaesthetic risks, no blood loss, early weight-bearing, short hospitalisation time and rapid union time.     

Use of continuous horizontal mattress suture techniques in microsurgery: an experimental study in rats

PURPOSE: The purpose of this study was to determine whether the continuous horizontal mattress suture technique can replace the continuous simple suture technique and to compare the results with other microvascular suture procedures. METHODS: Sixty-four femoral arteries of 32 Sprague-Dawley rats were used in this study. The animals were divided equally into 4 groups with 16 anastomoses in each group. The arteries (0.8-1.0 mm diameter) were anastomosed by using the continuous horizontal mattress suture technique in group I, interrupted horizontal mattress suture technique in group II, simple interrupted suture technique in group III, and simple continuous suture technique in group IV. At the end of the anastomosis time, leakage, and patency were assessed and graded in all groups. On the 14th day after surgery the rats were killed and 5 patent specimens from each group were examined under light microscopy for histology. One specimen from each group was prepared for scanning of the endothelial surface under electron scanning microscopy. RESULTS: Group I anastomoses were performed the most quickly. Groups I and III anastomoses had 100% patency rates. Under light microscopy the edge eversion was apparent consistently and under electron microscopy all endothelial surfaces were intact and no suture material was seen in groups I and II. In group III some suture material was covered by endothelial cells and lumen surfaces were torn; endothelization also was rough compared with groups I and II. In group IV suture material was seen in the lumen because of a loose suture knot. The endothelium also was not regular. CONCLUSIONS: The horizontal mattress suturing technique is the only technique in which the suture material never contacts the lumen. Continuous horizontal mattress suture technique is superior to the other microvascular procedures and is the safest and fastest procedure for microvascular anastomosis in rats.     

External fixation reconstruction of the residual problems of benign bone tumours

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov’s contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier’s disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.     

Newly discovered mutations in the GALNT3 gene causing autosomal recessive hyperostosis-hyperphosphatemia syndrome

Background and purpose Periosteal new bone formation and cortical hyperostosis often suggest an initial diagnosis of bone malignancy or osteomyelitis. In the present study, we investigated the cause of persistent bone hyperostosis in the offspring of two consanguineous parents.Methods Clinical assessment, imaging, and direct sequencing were used to elucidate the etiology of the condition seen in the patient.Results Radiological examination revealed periosteal reaction, diaphysitis, and cortical hyperostosis, suggesting osteomyelitis or a bone neoplasm. The clinical and radiological features were also reminiscent of hyperostosis with hyperphosphatemia (HHS), a rare autosomal recessive disease manifesting with recurrent, transient, and painful swelling of the long bones. The identification of two novel heterozygous pathogenic mutations in the GALNT3 gene confirmed a diagnosis of HHS.Interpretation Molecular analysis represents an invaluable tool in the differential diagnosis of persistent cortical hyperostosis.     

Intercostal nerve blockade versus thoracic epidural analgesia for post thoracotomy pain relief

Background Post thoractomy pain is a major source of concern in the postoperative period. The purpose of this study was to evaluate the effectiveness of intraoperative temporary intercostal nerve blockade versus thoracic epidural analgesia for control of post thoracotomy pain. Methods 40 patients undergoing elective pulmonary resection through a postero lateral thoractomy were randomly allocated to receive epidural analgesia using 0.25% bupivicaine (Group A, n=20) or temporary intercostal nerve blockade using 0.25% bupivicaine (Group B, n=20). Adequacy of analgesia was assessed over a period of 24 hours using a visual analogue score and an observer verbal ranking scale. Results Pain scores were similar in both the groups for the first 4 hours after surgery. Thereafter, the pain scores were significantly higher (p<0.05) in Group B as compared to Group A for the remainder of the observation period. There was significantly higher (p<0.01) usage, of nonsteroidal analgesic consumption in Group B. No neurological complications were encountered, in both the study groups. Conclusion We conclude that in the early postoperative period there is no significant difference in pain relief in both the techniques but there after, epidural analgesia significantly reduces post thoracotomy pain.     

The effect of overlapping on the primary stability of osteochondral grafts in mosaicplasty

Our goal was to determine the primary stability of overlapping osteochondral grafts used in mosaicplasty by studying the effect of overlapping in an ex vivo model. Osteochondral grafts, 10 mm in diameter, were transplanted from the trochlea of cow femurs to the weight-bearing area of the lateral femoral condyle with 0, 15, or 30% overlap. The grafts were pushed in with a probe at a rate of 2 mm/min, and load (N)-displacement (mm) curves were recorded. In Group I (control, 0% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 572.3 +/- 273.6 and 999.3 +/- 427.6 N, respectively. In Group II (15% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 263.6 +/- 91.7 and 746.6 +/- 88.0 N, respectively. In Group III (30% overlap), insertion 1 and 2 mm below the cartilage level could be reached at 179.4 +/- 31.2 and 657.0 +/- 106.5 N, respectively. The loads that were necessary to produce a 1-mm dent in the grafts were significantly different between Groups I and II and Groups I and III (p < 0.05). These results suggest that stability may be reduced by graft overlapping in mosaicplasty surgery. The results of this ex vivo animal study contribute to a more complete understanding of the primary stability of osteochondral grafts in an overlapping position as well as postoperative protocols.     

Distal tibial reconstruction with use of a circular external fixator and an intramedullary nail. The combined technique

BACKGROUND: Distal tibial reconstruction with use of an external fixator when there is bone loss, limb-length discrepancy, and/or ankle instability is associated with many problems. The technique of limb-lengthening, ankle arthrodesis, and segmental transfer over an intramedullary nail has been introduced to overcome these problems. The present study investigates this combined technique. METHODS: Between 2002 and 2005, six patients, who ranged from seventeen to seventy years old, underwent distal tibial reconstruction and ankle arthrodesis with use of a circular external fixator and an intramedullary nail to treat a distal tibial defect following resection for chronic osteomyelitis or tumor or to treat a limb-length discrepancy combined with ankle instability. Functional and radiographic results were evaluated, with use of the criteria described by Paley et al., at an average follow-up of thirty-four months. RESULTS: The mean size of the bone defects in three patients was 5.3 cm (2, 7, and 7 cm), and the mean amount of the limb-shortening in four patients was 5.25 cm (range, 4 to 6 cm). The mean external fixation time was 3.5 months, and the mean external fixator index was 0.57 mo/cm. There was no recurrence of infection in the two patients with osteomyelitis. All six patients had excellent bone results, and the functional results were excellent for two patients and good for four patients. There were four complications, three of which were categorized, according to Paley, as a problem (a difficulty that occurs during lengthening and is resolved without operative intervention) and one that was categorized as an obstacle (a difficulty that occurs during lengthening and needs operative treatment). CONCLUSIONS: The combined technique is an improvement over the classic external fixation techniques of distal tibial reconstruction with ankle arthrodesis. It reduces the duration of external fixation, thus increasing patient acceptance, and it is associated with a low complication rate facilitating more rapid rehabilitation.     

Open reduction and internal fixation of Mason type III radial head fractures with and without an associated elbow dislocation

PURPOSE: The purpose of this study was to evaluate the treatment of patients with Mason type III radial head fracture with and without elbow dislocation by open reduction with internal fixation, collateral ligament repair, and early mobilization. An additional purpose was to investigate whether there is any effect of elbow dislocation on the severity and functional outcome. METHODS: Twenty-five patients were treated with open reduction with internal fixation using low-profile miniplate and screws for comminuted fracture of the radial head. Eighteen fractures were Mason type III, and 7 fractures were Mason type III with elbow dislocation. There were 5 women and 20 men with a mean age of 34 years. The mean follow-up time was 27 months. Patients were reviewed for functional ability, physical examination, and radiographic assessment. RESULTS: The mean functional index in Mason type III fracture and Mason type III fracture with elbow dislocation was 87 for both groups. The mean range of motion at the elbow joint was calculated as 5 degrees extension to 136 degrees flexion for Mason type III and 7 degrees extension to 133 degrees flexion for Mason type III with elbow dislocation. The mean pronation and supination for all patients were 74 degrees and 67 degrees , respectively. CONCLUSIONS: Selected Mason III radial head fractures and fracture dislocations could be stabilized satisfactorily with internal fixation. Meticulous surgical technique, combined with rigid internal fixation, can allow early motion of the forearm and elbow after fixation of Mason type III radial head fractures with and without elbow dislocation and ligamentous injury. We believe there is still a role for prosthetic replacement in comminuted Mason III radial head fractures that cannot reliably be treated with open reduction and internal fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.