Reverse Sural Flap with Bifocal Ilizarov Technique for Tibial Osteomyelitis with Bone and Soft Tissue Defects

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases.     

End-Stage Hindfoot Arthrosis: Outcomes of Tibiocalcaneal Fusion Using Internal and Ilizarov Fixation

End-stage post-traumatic pantalar arthrosis from ankle, pilon, and talus fractures has often been complicated by infection, bone loss, and a soft tissue deficit. Patients can present with neuropathy, diabetes, tobacco use, and previously failed arthrodesis. Fusion in this population has been challenging, with nonunion rates up to 30%, often leading to amputation. We reviewed the results of a standardized protocol that combined simultaneous internal fixation with the Ilizarov technique to achieve fusion in high-risk patients. With institutional review board approval, a retrospective review of the patients treated with simultaneous internal fixation and an Ilizarov frame was undertaken. The records and radiographs allowed identification of the comorbidities and the presence or absence of successful fusion. Complications were acknowledged and treated. Fifteen patients had undergone the procedure. The mean follow-up period was 27.9 (range 9 to 67) months. Thirteen patients (86.67%) had had previous fusion failure. Twelve patients (80%) had developed post-traumatic arthrosis, 5 (33.33%) of whom had open injuries. All patients had 1 comorbidity, and 10 (66.67%) had multiple, including rheumatoid arthritis, diabetes (types 1 and 2), and smoking. Four patients (26.67%) presented with deep infection and bone loss. Union was achieved in 11 (73.33%), with 12 (80%) patients experiencing profound pain relief. Seven patients (46.67%) required symptomatic hardware removal. Three patients (20%) eventually underwent below-the-knee amputation for recalcitrant nonunion. Statistically significant correlations were found between smoking and wound infection and revision and between nonunion and amputation. Our results have indicated that combined internal fixation with Ilizarov application can provide a strong surgical option for the management of end-stage, pantalar arthritis. More studies are needed to compare the cohort outcomes and gait analysis in these patients with those who have chosen below-the-knee amputation.     

Biomechanical comparison of stability of tibiotalocalcaneal arthrodesis with two different intramedullary retrograde nails

BackgroundThe aim of the study was to compare the initial construct stability of two retrograde intramedullary nail systems for tibiotalocalcaneal arthrodesis (TTCF) (A3, Small Bone Innovations; HAN, Synthes) in a biomechanical cadaver study.MethodsNine pairs of human cadaver bones were instrumented with two different retrograde nail systems. One tibia from each pair was randomized to either rod. The bone mineral density was determined via tomography to ensure the characteristics in each pair of tibiae were similar. All tests were performed in load-control. Displacements and forces were acquired by the sensors of the machine at a rate of 64 Hz. Specimens were tested in a stepwise progression starting with six times ±125N with a frequency of 1 Hz for 250 cycles each step was performed (1500 cycles). The maximum load was then increased to ±250N for another 14 steps or until specimen failure occurred (up to 3500 cycles).ResultsAverage bone mineral density was 67.4 mgHA/ccm and did not differ significantly between groups (t-test, p = .28). Under cyclic loading, the range of motion (dorsiflexion/plantarflexion) at 250N was significantly lower for the HAN-group with 7.2 ± 2.3 mm compared to the A3-group with 11.8 ± 2.9 mm (t-test, p < 0.01). Failure was registered for the HAN after 4571 ± 1134 cycles and after 2344 ± 1195 cycles for the A3 (t-test, p = .031). Bone mineral density significantly correlated with the number of cycles to failure in both groups (Spearman-Rho, r > .69, p < 0.01).ConclusionsThe high specimen age and low bone density simulates an osteoporotic bone situation. The HAN with only lateral distal bend but two calcaneal locking screws showed higher stability (higher number of cycles to failure and lower motion such as dorsiflexion/plantarflexion during cyclic loading) than the A3 with additional distal dorsal bend but only one calcaneal locking screw. Both constructs showed sufficient stability compared with earlier data from a similar test model.Clinical relevanceThe data suggest that both implants allow for sufficient primary stability for TTCF in osteoporotic and consequently also in non-osteoporotic bone.Level of evidenceNot applicable, experimental basic science study.     

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.     

Biomechanical and anatomical considerations in lumbar spinous process fixation—an in vitro human cadaveric model

Background contextAlthough multiple mechanisms of device attachment to the spinous processes exist, there is a paucity of data regarding lumbar spinous process morphology and peak failure loads.PurposeUsing an in vitro human cadaveric spine model, the primary objective of the present study was to compare the peak load and mechanisms of lumbar spinous process failure with variation in spinous process hole location and pullout direction. A secondary objective was to provide an in-depth characterization of spinous process morphology.Study designBiomechanical and anatomical considerations in lumbar spinous process fixation using an in vitro human cadaveric model.MethodsA total of 12 intact lumbar spines were used in the current investigation. The vertebral segments (L1–L5) were randomly assigned to one of five treatment groups with variation in spinous process hole placement and pullout direction: (1) central hole placement with superior pullout (n=10), (2) central hole placement with inferior pullout (n=10), (3) inferior hole placement with inferior pullout (n=10), (4) superior hole placement with superior pullout (n=10), and (5) intact spinous process with superior pullout (n=14). A 4-mm diameter pin was placed through the hole followed by pullout testing using a material testing system. As well, the bone mineral density (BMD) (g/cm³) was measured for each segment. Data were quantified in terms of anatomical dimensions (mm), peak failure loads (newtons [N]), and fracture mechanisms, with linear regression analysis to identify relationships between anatomical and biomechanical data.ResultsBased on anatomical comparisons, there were significant differences between the anteroposterior and cephalocaudal dimensions of the L5 spinous process versus L1–L4 (p<.05). Statistical analysis of peak load at failure of the four reconstruction treatments and intact condition demonstrated no significant differences between treatments (range, 350–500 N) (p>.05). However, a significant linear correlation was observed between peak failure load and anteroposterior and cephalocaudal dimensions (p<.05). Correlation between BMD and peak spinous processes failure load was approaching statistical significance (p=.08). 30 of 54 specimens failed via direct pullout (plow through), whereas 8 of 54 specimens demonstrated spinous process fracture. The remaining cases failed via plow through followed by fracture of the spinous process (16 of 54; 29%).ConclusionsThe present study demonstrated that variation in spinous process hole placement did not significantly influence failure load. However, there was a strong linear correlation between peak failure load and the anteroposterior and cephalocaudal anatomical dimensions. From a clinical standpoint, the findings of the present study indicate that attachment through the spinous process provides a viable alternative to attachment around the spinous processes. In addition, the anatomical dimensions of the lumbar spinous processes have a greater influence on biomechanical fixation than either hole location or BMD.     

Lisffane损伤的手术治疗策略

目的：总结Lisfranc损伤切开复位内固定的临床经验,评价手术治疗效果。方法：自2010年3月～2012年5月,35例Lisfranc骨折脱位的患者接受切开复位内固定术,平均年龄33．5岁,损伤按Quenu—Kuss分型,A型（同向移位）15例,B型（部分移位）13例,C型（分裂移位）7例。采用1-2个足背纵行直切口。内固定材料包括克氏针和螺钉及接骨板。结果：35例损伤患者得到0．5—2年（平均1．2年）的随访。感染2例,2例发生创伤后关节炎,无1例克氏针松动。依据美国矫形足踝协会（AOFAS）足评分标准对患足术后的功能进行评定。好22例,较好10例,差3例。结论：切开复位治疗Lisfranc骨折脱位可取得良好效果。     

复位股骨大粗隆顶点骨折对PFNA治疗不稳定股骨粗隆间骨折预后的影响

目的评估应用股骨近端防旋髓内钉（PFNA）内固定治疗合并股骨大粗隆顶点局部骨折的不稳定股骨粗隆间骨折术中将股骨大粗隆顶点局部骨折复位对预后的影响。方法合并股骨大粗隆顶点局部骨折的不稳定股骨粗隆间骨折46例,股骨大粗隆顶点局部骨折复位固定26例（复位组）,未复位固定20例（未复位组）。比较2组手术时间、术中出血量、术后第2天血红蛋白及白蛋白水平、骨折愈合时间、术后并发症及末次随访时髋关节功能Harris评分。结果复位组较未复位组手术时间更长、术中出血量更多,差异有统计学意义（P〈0.05）;但复位组在术后并发症及末次随访时髋关节的功能恢复方面明显优于未复位组,差异有统计学意义（P〈0.05）;而2组在骨折愈合时间、术后第2天血红蛋白及白蛋白水平方面差异无统计学意义（P〉0.05）。结论复位固定移位的股骨大粗隆顶点骨折能够提高PFNA主钉进针定位的准确性,降低股骨大粗隆外侧壁继发性骨折的发生率,改善术后髋关节功能,减少术后隐性出血量。     

下肢骨干骨折术后骨不连的原因分析及手术治疗

目的探讨下肢骨干骨折术后骨不连的原因、再次手术治疗方式及临床疗效。方法自2010-01—2012-06诊治下肢骨干骨折术后骨不连41例,分析骨不连原因,选择更换内固定物或保留髓内钉附加接骨板固定,并对营养不良型和萎缩型骨不连取自体髂骨植骨。结果骨不连分型：肥大型7例,营养不良型19例,萎缩型15例。27例原骨折固定技术存在明显力学错误,14例嗜烟。再次手术后获15~34（21.7±9.3）个月随访,术后切口均一期愈合。骨折均骨性愈合,股骨干愈合时间（8.6±3.3）个月,胫骨干愈合时间（9.3±4.4）个月。临床疗效按Johner-Wruhs评分标准：股骨干优良率90.0%,胫骨干优良率90.1%。结论骨折断端的血供被破坏、骨折不稳定、嗜烟是下肢骨干骨折术后骨不连的主要原因,针对不同原因骨不连而采用恰当的手术治疗能取得良好的疗效。     

导致桡骨远端骨折术后桡骨短缩的发生率及其危险因素分析

目的探讨桡骨远端骨折术后出现短缩的危险因素,进而提出预防措施,提高桡骨远端骨折手术的疗效。方法将桡骨远端骨折174例作为研究对象,依据是否发生骨短缩分为短缩组和对照组,对桡骨远端骨折术后发生短缩的相关危险因素进行分析。结果54例发生桡骨短缩f31．03％）。短缩组年龄≥60岁者比例明显高于对照组,短缩组合并骨质疏松者比例明显高于对照组,短缩组骨折类型为C型骨折者比例明显高于对照组,短缩组术中采用锁定加压接骨板内固定术患者数明显多于对照组,短缩组术中进行植骨患者数明显低于对照组,短缩组术后自主进行负荷锻炼患者比例明显高于对照组,差异均具有统计学意义（P〈0．05）。术后负荷锻炼指导和AO分型作为独立影响因素对桡骨骨折术后桡骨短缩发生有显著影响fP〈0．05）。结论桡骨远端关节内骨折术后桡骨短缩发生率较高。手术治疗时应对骨缩短的危险因素进行综合评估分析,并采取相应的防治措施,术后给予负荷锻炼指导,降低术后桡骨短缩的发生率。     

关节镜下复位可吸收空心钉内固定治疗胫骨髁间前嵴撕脱骨折

目的探讨膝关节镜下复位可吸收空心钉内固定治疗胫骨髁间前嵴撕脱骨折的方法及临床效果。方法自2009-04—2013-04,共诊治21例胫骨髁间前嵴撕脱骨折,关节镜下骨折块复位后,采用1或2枚可吸收空心钉内固定。结果术后切口均一期愈合,无膝关节感染、神经血管损伤及下肢深静脉血栓形成等并发症发生。术后均获随访12-18个月,平均13.4个月。术后3个月2例出现膝关节僵硬,屈伸受限,予麻醉下推拿松解后恢复至屈伸5°-110°。术后1年Lachman试验、前抽屉试验均为阴性。X线片及MR示：骨折对位愈合良好。末次随访时Lysholm评分为（91.67±0.76）分,IKDC评分为（96.13±0.87）分,均较术前显著提高,差异有统计学意义（t=53.130,P〈0.001;t=105.236,P〈0.001）。患者均恢复正常运动及生活能力。结论膝关节镜下复位可吸收空心钉内固定治疗胫骨髁间前嵴撕脱骨折具有微创、痛苦小、内固定相对牢固、操作简便、便于早期功能锻炼、术后关节功能恢复好等优点,临床效果良好。