Corrective osteotomies of femur and tibia: which factors influence bone healing?

INTRODUCTION: Corrective osteotomies of the lower limb are standard procedures in orthopedic surgery. Still, there is only limited research on factors affecting bone healing after osteotomies. We hypothesize that especially the location of the osteotomy, smoking status and BMI affect bone healing. MATERIAL AND METHODS: The healing process of 547 patients who underwent osteotomies of the lower limb (259 female, 288 male; average 40.6 years, range 14-77) was evaluated. To assess bone healing, participants were divided into three groups by bone healing duration ( < 5/5-8/ > 8 months). Differences in healing duration related to the anatomic level of the osteotomy (diaphysis vs. metaphysis), age, gender, smoking status, BMI, and modus of the osteotomy (open vs. closed wedge) were tested for significance using an ordinal regression analysis. RESULTS: A significant correlation between bone healing and the anatomical level of the osteotomy on femur and tibia and the patients' smoking status was found. The odds of the diaphysis considering bone healing was 0.187 (95% CI, 0.08-0.44) times that of the metaphysis (Wald χ2(1) = 14.597, p < 0.000). The odds ratio of smokers considering bone healing was 0.192 (95% CI, 0.11-0.33) times that of non-smokers (Wald χ2(1) = 35.420, p < 0.000). All other analyzed factors did not show a significant correlation with bone healing. CONCLUSIONS: Smoking status and the localization of the osteotomy on femur and tibia (diaphysis vs. metaphysis) are significantly correlated with bone healing duration. In line with current literature emphasizing the detrimental effect of smoking on bone healing, our findings should encourage surgeons to think twice about the indication to perform osteotomies on smokers. Furthermore, if applicable, osteotomies should be performed in the metaphyseal areas of femur and tibia.

[Deformities around the knee after growth plate injuries: Analysis and correction]. / Kniegelenknahe Deformitäten nach Epiphysenverletzungen: Analyse und Korrektur.

INTRODUCTION: Growth plate injuries of the distal femur and the proximal tibia are rare, but may induce deformities around the knee. The type of primary injury and the patient's age at the time of injury influence the extent and complexity of the deformity. PATIENTS AND METHODS: Twelve patients (median age = 12 years; range = 7-16 years) experienced growth plate injuries of the knee, followed by post-traumatic deformities. In fully developed growth plates, the deformities were subjected to a comprehensive and standardized analysis. Eleven patients had deviations in the frontal plane and 9 patients in the sagittal plane. Ten patients had relevant length differences and 7 patients had torsional deviations. One of the deformities was unidimensional, one was two-dimensional, six were three-dimensional, and four were four-dimensional. Ten corrective osteotomies were performed in the femoral aspect and 5 in the tibial aspect. Three patients needed bifocal osteotomies. Eight osteotomies were performed with an oscillating saw and 7 osteotomies with a drill hole and chisel. Acute correction could be achieved in 4 cases and continuous correction by means of callus distraction in 5 cases, whereas 3 patients needed combined procedures. RESULTS: One arterial injury had to be treated immediately by performing acute vascular surgery. A pin tract infection healed after early removal of the external fixator for distraction. Delayed bone healing necessitated a local revision with cancellous bone grafting. The goals of correction and acceptable knee function were achieved in all patients. CONCLUSION: Growth plate injuries frequently cause very complex deformities. A comprehensive and structured analysis of the deformity and customized acute/continued corrective procedures are essential for a satisfactory anatomic and functional outcome.

[Compartment syndrome caused by rhabdomyolysis in the context of pychogenic polydipsia]. / Kompartmentsyndrom nach Rhabdomyolyse im Rahmen einer psychogenen Polydipsie.

Psychogenic polydipsia leading to severe hyponatremia is well documented in the literature. This electrolyte disorder can result in encephalopathy, cerebral edema and epileptic seizures. Another rare effect is rhabdomyolysis with all its well known complications (e.g. renal failure, hyperkalemia and cardiac arrhythmia) and even resulting in compartment syndrome due to severe muscle edema. We present the case of a patient with severe hyponatremia caused by psychogenic polydipsia leading to rhabdomyolysis and compartment syndrome.

[Cement-free and cemented Excia hip shaft prosthesis: comparison of intermediate term results]. / Zementfreie und zementierte Excia-Hüftprothesenschäfte: Vergleich der mittelfristigen Ergebnisse.

AIM OF THE STUDY: For fixation of total hip prostheses, cemented and cement-free techniques are available. Normally, anchoring techniques and the definitive endoprosthesis model are determined preoperatively based on the available information, such as the quality of bone. Some newer endoprosthesis models utilize the same instruments for both implantation techniques. In this way it is possible to decide on the final anchoring technique intraoperatively. Because such a combined endoprosthesis system has been used in our clinic for 10 years, we were interested in the clinical results at the intermediate stage. MATERIAL AND METHODS: In a prospective, non-randomized study 105 pairs from a continuing series were formed from 105 cases treated with cement-free prostheses and the latest cemented shaft implants from the same year. In this way a total of 210 hip shaft endoprostheses from the years 2002 to 2006 were included in the study. After an average time period of 6.3 years (range 4.5-8.2 years) the patients were recalled for a follow-up examination. The clinical results, early and late complications were analyzed. The immediately postoperative X-ray images and those from the follow-up examination were evaluated by an independent external expert with respect to primary positioning, migration and any signs of loosening. RESULTS: At the follow-up examination at an average of 6.3 years the quota was 73%. The indications for cement-free/cemented total hip endoprosthesis were: primary arthritis 87%/98%, secondary arthritis 10%/2% and others 3%/0%. At the time of the last follow-up examination 4 and 14 patients, respectively, had died. The visual analog scale (VAS) for pain was given as 0.72/0.78. The Harris hip score improved from 54/48 to 93/90 points. The implant-related survival rate was 99.5%. Due to a periprosthetic fracture one of the cemented shafts had to be removed. Luxation occurred in 3/2 cases, respectively, of which 4 could be conservatively treated. In one cement-free case a head elongation and a change to an inlay with an anti-luxation shoulder was necessary. A fracture of the trochanter major was conservatively treated and an intraoperative shaft fissure was stabilized with wire cerclage and titan banding. The radiological evaluation showed no implant loosening or statistically significant differences in the shaft positioning. DISCUSSION: Short and intermediate clinical and radiological results showed no differences in patients of similar average age in the sixth decade of life. The significant improvements in the Harris hip score and the range of movement could be confirmed in the intermediate term and are comparable to other current implants. It can be concluded that an intraoperative decision on the fixation technique based on the macroscopically visible bone quality supports the reliably good results of both methods.

[Congenital knee dislocation in Larsen syndrome treated by arthroplasty]. / Endoprothetische Versorgung einer kongenitalen Kniegelenkluxation bei Larsen-Syndrom.

A 59-year-old woman with bilateral congenital knee dislocation due to Larsen syndrome was treated by arthroplasty. To prevent neurovascular deficiency and major loss of bone substance, a continuous joint distraction was performed by unilateral external fixation. After a period of 25 days and a leg lengthening of 4.5 cm, a constrained total knee endoprosthesis was implanted. Both operations and their postoperative courses were free of complications. A previously planned lengthening of the Achilles tendon was unnecessary.

[Arthroscopy prior to osteotomy in cases of unicondylar osteoarthritis]. / Die Arthroskopie vor kniegelenknahen Korrekturosteotomien bei unikompartimenteller Gonarthrose.

BACKGROUND: Osteotomy around the knee is an established procedure in orthopaedic surgery. However, there is no consensus regarding whether the patient should have arthroscopy prior to osteotomy in the same operative session. PATIENTS AND METHODS: This prospective study included 300 cases of osteotomy around the knee with routine arthroscopy. During arthroscopy, the indication for osteotomy was checked first. Then the cartilage status was determined to modify the type and degree of osteotomy correction accordingly. Finally, therapeutic procedures were performed in cases of intraarticular pathology. RESULTS: The indication for osteotomy was rejected in 51 cases because of worse cartilage status than expected. Twelve patients received immediate or early endoprosthetic treatment. In 208 cases, the degree of correction was modified, in five cases at the level of the osteotomy. For the 288 nonendoprosthetic sessions, there were 268 arthroscopies with therapeutic treatments. CONCLUSION: This study demonstrated that arthroscopy is indispensable for checking the indications for osteotomy, modifying the type and degree of correction, and performing therapeutic procedures.

Arthroscopy prior to osteotomy around the knee?

INTRODUCTION: Osteotomy around the knee is well established in orthopaedic surgery in cases of congenital/posttraumatic leg deformities with mono-compartment osteoarthritis of the knee. However, there is no consensus whether there should be an arthroscopy prior to osteotomy in the same operative session, either for diagnostic or therapeutic reasons. PATIENTS AND METHODS: This prospective study included 340 cases of osteotomy around the knee with a routine arthroscopy. During arthroscopy indication for osteotomy was checked first. Then cartilage status was determined to modify type and degree of correction osteotomy accordingly. Finally therapeutic procedures were performed in cases of intraarticular pathologies. RESULTS: Indication was rejected in 47 cases with ten patients receiving endoprosthetic treatment. In 157 cases the degree of correction was modified, in eleven cases the level of osteotomy. Under the 330 non-endoprothetic sessions there were 316 arthroscopies with therapeutic treatments. CONCLUSION: This study could demonstrate that arthroscopy in the same session is indispensable, to check the indication for osteotomy, to modify type and degree of correction according to cartilage status and to perform therapeutic procedures.

[Osteosynthesis of displaced fractures of the greater tuberosity with the Bamberg plate]. / Osteosynthese dislozierter Tuberculum-majus-Frakturen mit der Bamberger Platte.

OBJECTIVE: Internal fixation of displaced fractures of the greater tuberosity allowing functional aftercare. INDICATIONS: Displaced fractures of the greater tuberosity >5 mm. Displaced fractures of the greater tuberosity >3 mm in athletes or overhead workers. Multiply fragmented fractures of the greater tuberosity. CONTRAINDICATIONS: Displaced 3­ or 4­part fractures of the proximal humerus. Nondisplaced fractures of the greater tuberosity. SURGICAL TECHNIQUE: Exposure of the fracture of the greater tuberosity by an anterolateral approach. Open reduction and temporary retention with a Kirschner wire or a "Kugelspieß" or reinforcement of the supraspinatus tendon and distal retention. Bending and positioning of the Bamberg plate and fixation by conventional or locking screws. Optional fixation of the rotator cuff to the plate. Exact monitoring of the implant position using the image intensifier to avoid inadequate distalization of the greater tuberosity. POSTOPERATIVE MANAGEMENT: Arm sling (e. g. Gilchrist) for 2 weeks. Start passive assisted exercise on postoperative day 1. Movement allowed up to the pain threshold. Physiotherapeutic treatment to prevent adhesions and capsular shrinking. RESULTS: In all, 10 patients with displaced fractures of the greater tuberosity underwent osteosynthesis using the Bamberg plate. After a follow-up of at least 6 months, a Constant-Murley score of 94.2  points (range 91-98 points) was achieved. The patients' average age was 45.6 years (range 29-68 years).

[Torsional osteotomy : Operative treatment of patellofemoral maltracking]. / Die Torsionsosteotomie : Behandlung des patellofemoralen Maltracking.

BACKGROUND: Patellofemoral maltracking may congenitally be caused by excessive internal maltorsion of the femur and/or excessive external maltorsion of the tibia. OBJECTIVE: Pain relief, femoropatellar stability, well-balanced charge of femoral and patellar cartilage. INDICATIONS: Anterior knee pain, patellar instability, associated with "inwardly pointing knee" syndrome. CONTRAINDICATIONS: Open physes, > 50 years, chronic/fixed patella luxation, congenital connective tissue and bone healing disorders. SURGICAL TECHNIQUE: Analysis of leg geometry and patellofemoral anatomy. Knee arthroscopy. Supracondylar external torsional osteotomy of the femur: medial approach, ventral shift of vastus medialis muscle. Definition of osteotomy plane. Torsion control. Complete transversal osteotomy. Acute external torsional correction. Fixation with internal plate. Supratuberositary internal torsional osteotomy of the tibia: exposure of lateral tibial head, detachment of the tibialis anterior muscle. Partial chisel osteotomy of the proximal tibial tuberosity. Definition of supratuberositary osteotomy plane. Torsion control with Schanz screws. Bending of a DC plate (DCP). Complete transversal osteotomy. Acute internal torsional correction and fixation with prebent DCP. With internal torsional correction > 10°, decompression of the peroneal nerve and proximal tibialis anterior fasciotomy. POSTOPERATIVE MANAGEMENT: Neurovascular and muscle function follow-up. On postsurgery day 1, drainage removal, x-ray control, mobilization. Partial weight bearing (20 kg) for 4 weeks with stepwise load increments. Active/passive exercises. Thromboprophylaxis. RESULTS: In 25 patients, 30 external torsional osteotomies of the supracondylar femur with 13.8° (5-26°); in 45 patients, 53 internal torsional osteotomies of the supratuberositary tibial head with an average 10.8° (5-18°). No persisting compartment syndrome or infection. One non-union healed after revision. One dysfunction of the peroneal nerve resolved with time. No subluxation or redislocation of the patella. Anterior knee pain decreased significantly in both groups.

Trauma severity-dependent changes in AT III activity.

Trauma may cause a relevant reduction in antithrombin (AT) III activity, which is associated with adverse events. The very early changes in AT III activity after accident trauma are still unclear and possible relations with Interleukin (IL)-6, which is known to interact with AT III, have not been investigated so far. Upon approval of the IRB/IEC, 30 patients were enrolled with multiple injuries (ISS 9-75). Groups were performed according to injury severity, IL-6 concentration, and survivors versus non-survivors. Blood samples were collected at the scene of accident then at 2, 4, 6, 12, and 24 h and at day 3, 5, 10 and 15. No patient received AT III concentrates. In all groups a reduction in AT III activity occurred, which was most pronounced in very severe injuries. The activity re-increased spontaneously and steadily in all groups regardless of the IL-6 concentration. There was no clear impact of the AT III activity on survival.

Chest trauma and its impact on the release of vasoactive mediators.

Every year, major chest injury is involved in 56% of deaths in trauma victims. Blunt chest trauma apparently plays a crucial role in trauma-induced death of multiply injured patients. Therefore, the aim of this study was to evaluate the impact of different types of injuries, including lung tissue damage, on the release of various prostanoids. In a prospective study, the release of arachidonic acid (AA) metabolites was estimated in patients suffering blunt chest trauma alone, i.e., single thoracic injury, and in multiple injured patients including blunt chest trauma. The results were compared with those of patients suffering from single long bone fractures of the leg without additional injury. The plasma concentrations of the AA metabolites, prostacyclin, thromboxane, prostaglandin F2 alpha, and prostaglandin M were determined immediately after admission and in hourly and daily intervals thereafter. Despite clearly different injury scores, elevated levels of circulating AA metabolites were found in the plasma in all patients. This study reveals that any trauma increases significantly the release of prostanoids into the peripheral blood without regard to the impact of tissue damage. This phenomenon is, however, most pronounced following lung injury. On the basis of these results we suggest that there is a specific impact of those mediators in blunt chest trauma. The prostanoids apparently are suitable to describe and even to monitor the extent of thoracic trauma, thus giving additional information in some respect to the individual outcome.

Is interleukin 6 an early marker of injury severity following major trauma in humans?

HYPOTHESIS: Interleukin 6 (IL-6), a multifunctional cytokine, is expressed by various cells after many stimuli and underlies complex regulatory control mechanisms. Following major trauma, IL-6 release correlates with injury severity, complications, and mortality. The IL-6 response to injury is supposed to be uniquely consistent and related to injury severity. Therefore, we designed a prospective study starting as early as at the scene of the unintentional injury, to determine the trauma-related release of plasma IL-6 in multiple injured patients. PATIENTS AND METHODS: On approval of the local ethics committee, 94 patients were enrolled with different injuries following trauma (Injury Severity Score [ISS] median, 19; range, 3-75). The patients were rescued by a medical helicopter. Subsets were performed according to the severity of trauma--4 groups (ISS, <9, 9-17, 18-30, and >32)-and survival vs nonsurvival. The first blood sample was collected at the scene of the unintentional injury before cardiopulmonary resuscitation, when appropriate. Then, blood samples were collected in hourly to daily intervals. Interleukin 6 plasma levels were determined using a commercial enzyme-linked immunosorbent assay test. The short-term phase protein, C-reactive protein, was measured to characterize the extent of trauma and to relate these results to IL-6 release. RESULTS: As early as immediately after trauma, elevated IL-6 plasma levels occurred. This phenomenon was pronounced in patients with major trauma (ISS, >32). Patients with minor injury had elevated concentrations as well but to a far lesser extent. In surviving patients, IL-6 release correlated with the ISS values best during the first 6 hours after hospital admission. All patients revealed increased C-reactive protein levels within 12 hours following trauma, reflecting the individual injury severity. This was most pronounced in patients with the most severe (ISS, >32) trauma. CONCLUSIONS: To our knowledge, this is the first study that elucidates the changes in the IL-6 concentrations following major trauma in humans as early as at the scene of the unintentional injury. The results reveal an early increase of IL-6 immediately after trauma. Moreover, patients with the most severe injuries had the highest IL-6 plasma levels. There is strong evidence that systemic IL-6 plasma concentrations correlate with ISS values at hospital admission. Therefore, IL-6 release can be used to evaluate the impact of injury early regardless of the injury pattern.

Is the activity of soluble CD14 enhanced following major trauma?

BACKGROUND: The molecule CD14 acts as a receptor for the protein-bound endotoxin (lipopolysaccharide [LPS]) complex and mediates the cellular effects of LPS. The soluble formation, sCD14, is supposed to neutralize circulating LPS (i.e., LPS antagonist) or transfer LPS effects to endothelial cells (i.e., LPS agonist). OBJECTIVE: To elucidate the release of sCD14 per se in patients with major trauma in the early posttrauma period. Our a priori hypothesis was that sCD14 release depends on the plasma LPS concentration simultaneously measured. PATIENTS: In a prospective study, 65 patients with multiple injuries (Injury Severity Score, 9-75) were enrolled. The patients were rescued by the medical helicopter service and directly admitted to our clinics. The plasma concentrations of sCD14 (enzyme immunoassay) and LPS (chromogenic limulus amebocyte lysate test) were analyzed. The first blood sample was collected immediately at the accident site. The following samples were drawn at intervals from 2 hours to daily for 2 weeks. RESULTS: Sixty-one patients survived the observation time. Immediately after trauma, their mean sCD14 level was not different from that of healthy individuals. Two hours later, a pronounced increase of sCD14 was observed and sustained throughout the observation period. Even nonsurvivors showed an increased sCD14 release, but less pronounced. In all patients, plasma LPS levels were elevated during the first 12 hours. CONCLUSIONS: Major trauma caused an increased release of sCD14. This elevation, however, was not correlated to LPS levels or to the severity of trauma (estimated by trauma scores). We found no evidence that sCD14 levels are of prognostic value regarding survival. Furthermore, the release of sCD14 did not occur in an LPS-neutralizing manner, but rendered possible an LPS-independent mechanism.

Aneurysmal bone cyst of the cervicothoracic spine: computed tomographic evaluation of the value of preoperative embolization. Case report.

In this report, the management of an aneurysmal bone cyst in the cervicothoracic region of an 8-year-old girl is described. Aneurysmal bone cyst is a histologically benign lesion that is often extremely vascular. In the spine, it can cause extensive bone destruction and compress neural structures. Because this lesion may involve all parts of a vertebra, full delineation of the lesion before its excision is important in planning the surgical approach. The value of preoperative embolization to reduce tumor vascularity, allowing total excision, and the improved radiological evaluation of this lesion with computed tomographic scanning are demonstrated.

Congenital dislocation of the hip in children. Comparison of the effects of femoral shortening and of skeletal traction in treatment.

Preoperative skeletal traction as an aid in reduction of congenital hip dislocation in the older child has been associated with an unacceptably high incidence of avascular necrosis, redislocation, and poor results. In contrast, femoral shortening as an aid in reduction has yielded a high rate of very satisfactory results, and may be essential for obtaining a stable, physiological, non-compressive reduction. We have analyzed the complications and the radiographic and functional outcomes of treatment in thirty-nine hips. It was clearly demonstrated that femoral diaphyseal shortening was preferable to traction as an aid in the operative reduction of a congenitally dislocated hip in children who were more than three years old.

Pemberton pelvic osteotomy and varus rotational osteotomy in the treatment of acetabular dysplasia in patients who have static encephalopathy.

Forty-four patients (fifty-two hips) who had static encephalopathy and acetabular dysplasia were managed with a Pemberton osteotomy as part of a comprehensive operative approach. Thirty-three patients had quadriplegia and were unable to walk; the remaining eleven patients had diplegia and could walk. The age at the time of the operation ranged from four years and five months to sixteen years and five months, as an open triradiate cartilage is a prerequisite for the Pemberton procedure. Concomitant operative procedures included a varus rotational osteotomy in fifty of the involved hips, a soft-tissue release in thirty-seven hips, and an open reduction in thirteen hips. The mean center-edge angle preoperatively was -11 degrees (range, -80 to 17 degrees), which improved to a mean of 27 degrees (range, 5 to 62 degrees) at the time of the latest follow-up. The mean duration of follow-up was four years (range, two years to eight years and eight months). At the time of writing, none of the hips had redislocated but one hip had subluxated. Eight of the hips had been painful preoperatively, but none of these was painful at the time of the most recent follow-up. One patient who had not had pain in the hip preoperatively had pain at the time of the follow-up evaluation. There were no complications attributable to posterior uncovering of the hip. The age of the patient at the time of the operation had no discernible effect on the result.

Radiographic features of hand and wrist surgery excluding arthroplasties.

The normal and abnormal radiographic appearances of various hand and wrist surgical procedures have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

Radiographic features of hand and wrist arthroplasties.

The normal and abnormal radiographic appearances of various arthroplasties of the hand and wrist have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

[Computed tomographic torsion-angle and length measurement of the lower extremity. The methods, normal values and radiation load]. / Computertomographische Torsionswinkel- und Längenmessung an der unteren Extremität. Methodik, Normalwerte und Strahlenbelastung.

Complex corrective osteotomies in the lower extremities require precise preoperative planning. Fifty patients (37 male, 13 female) with an average age of 31 years (13 to 61 years) who had suffered fractures of the lower limbs and had been treated by osteosynthetic or conservative methods were studied, using a GE 9800 Quick CT; accurate and reproducible measurements of the angles of torsion of the femur and tibia were obtained. Digital images were produced to standardise the planes of measurement and to measure the length of the limb. The normal extremities of patients older than 18 years showed internal torsion of -20.4 +/- 9 degrees of the femur and external torsion of 33.1 +/- 8 degrees of the tibia. The most important clinical measurement is the intra-individual difference of the torsional angles. Amongst normals this is 4.3 +/- 2.3 degrees in the femur and 6.1 +/- 4.5 degrees in the tibia. Consequently, only angles greater than 9 degrees in the femur and 15 degrees in the tibia should be regarded as abnormal. Radiation exposure was measured by a LiF-thermoluminescence dosimeter on an Alderson phantom. Skin dose was 6.3 +/- 1.2 mGy and gonadal dose for females was 2.5 +/- 0.3 mGy and for males 0.7 +/- 0.1 mGy.