The "Pillow" Technique for Thumb Carpometacarpal Joint Arthritis: Cohort Study With 10- to 15-Year Follow-Up.

PURPOSE: Arthritis of the carpometacarpal joint of the thumb is common, and there are many studies regarding its treatment. We investigated the long-term outcome of interposition arthroplasty with a fascia lata allograft (pillow technique), without ligament reconstruction, to treat thumb carpometacarpal arthritis. The technique consisted of complete trapeziectomy, use of alloplastic tensor fascia lata, and K-wire immobilization for 5 weeks. METHODS: The outcomes of 31 thumbs in 24 female patients were measured at a mean follow-up of 12.5 years (range, 10-15 years). RESULTS: Grip strength, key pinch, pulp-to-pulp pinch, tripod pinch, and range of motion were all improved. The Disabilities of the Arm, Shoulder, and Hand median score, which was only measured postoperatively, was an average of 5 (range, 0-52.6). No extrusion of the graft material was noted, and no revisions were performed. CONCLUSIONS: Our results indicate that a fascia lata allograft can be used as an interposition material in thumb carpometacarpal arthroplasty. This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures.

OBJECT: Despite promising early clinical results, the long-term outcome of the use of expandable titanium cages to reconstruct the anterior column after traumatic burst fractures is still unknown. The purpose of this prospective study was to assess the clinical and radiological outcomes of the use of expandable titanium cages 5 years postoperatively. METHODS: Eighty patients with traumatic thoracolumbar burst fractures (T4-L5) underwent posterior stabilization followed by anterior corpectomy and reconstruction using expandable titanium cages with or without additional anterior plating. After 5 years, fusion was evaluated by means of plain radiographs and CT scans, and the patients' scores on the Oswestry Disability Index (ODI), their neurological status, and clinical results were assessed. RESULTS: Forty-five (56%) of the 80 patients could be examined after 5 years. There was a relatively high rate of complications related to thoracotomy (26%), but there were no complications directly related to the cages. Revision surgery was required in 1 case. The average postoperative loss of correction was only 2.4° due to minimal subsidence of the cages. No cage showed a radiolucent line or instability in flexion-extension views. Bony fusion, as assessed by CT scan, was achieved in 41 patients (91%). On clinical examination, 96% of all patients were ambulatory and showed minimal restriction of spinal range of motion; 71% did not need analgesic medication at all; and 67% were able to work. The average ODI score was 12. Thirty-one percent of patients complained of some kind of anterior approach-related complications. CONCLUSIONS: Combined anteroposterior stabilization of thoracolumbar burst fractures with expandable titanium cages is a relative safe procedure with satisfactory radiological and clinical long-term outcome. High fusion rates can be achieved, with only minor loss of correction, typically occurring in the 1st year. However, open thoracotomy carries the risks of additional complications and development of post-thoracotomy syndrome.

Additional anterior plating enhances fusion in anteroposteriorly stabilized thoracolumbar fractures.

INTRODUCTION: To prospectively evaluate the potential radiological and clinical effect of the additional application of an anterior plate in anteroposteriorly stabilized thoracolumbar fractures. PATIENTS AND METHODS: 75 consecutive patients with unstable thoracolumbar fractures underwent posterior (internal fixator) and anterior stabilization (corpectomy cage with local autologous bone grafting). 40 (53.3%) patients received an additional anterior plate (Group A), while 35 (46.6%) (Group B) did not. Plain X-rays and CT-scans were obtained pre- and postoperatively, after 12 months and at the last follow-up (mean 32 months, range 22-72). Loss of reduction, cage subsidence to adjacent vertebrae, fusion rates and clinical results were evaluated. RESULTS: 66 (87%) patients (36 Group A; 30 Group B) were available for follow-up. Patients in both groups were comparable regarding age, gender, comorbidities, localization and classification of fracture. Average loss of reduction was 2.4° in Group A, and 3.1° in Group B (not significant). Cage subsidence did not differ significantly between both groups, too. However, after 12 months the rate of continuous osseous bridging between endplates was significantly higher in Group A (63% vs. 25%) (p<0.05). After 32 months this difference was even higher (81% vs. 33%) (p<0.001). The bony fusion mass was located beneath or around the anterior plate in 94% of patients. There was no significant difference in clinical outcome. CONCLUSIONS: Additional anterior plating in anteroposteriorly stabilized thoracolumbar fractures leads to significant faster fusion but does neither influence reduction loss nor cage subsidence. The anterior plate serves as a pathway for bone growth and increases biomechanical stability, resulting in a higher fusion rate.

Diagnosis and treatment of a C2-osteoblastoma encompassing the vertebral artery.

INTRODUCTION: Osteoblastoma is a rare, benign bone tumor that accounts for approximately 1% of all primary bone tumors and 5% of spinal tumors, mostly arising within the posterior elements of the spine within the second and third decades of life. Nonspecific initial symptoms mainly neck or back pain and stiffness of the spine remain often undiagnosed and the destructive nature of the expanding tumor can cause even neurological deficits. CT and MRI scans constitute the basic imaging modalities employed in diagnosis and preoperative planning with the former delineating the location and osseous involvement of the mass and the latter providing appreciation of the effect on soft tissues and neural elements. MATERIALS AND METHODS: In our case a 23-year-old male presented with persisting head and neck pain, after being involved in a car collision a month ago. Although the initial diagnostic imaging, including plain X-rays and MRI scan failed to reveal any pathological findings, the persistence of the symptoms led to repeating imaging (CT and MRI) that showed the existence of a benign osseous tumor of the C2 lamina that was destructing the surrounding osseous structures and encompassing the right vertebral artery. The suspicion of an osteoblastoma was raised and the decision for surgical removal of the tumor was made for treating the persistent symptoms and preventing a possible neurological deficit or vascular lesion. A marginal tumor resection was performed through a posterior approach, followed by an anterior instrumented fusion. Histological examination confirmed the diagnosis of an osteoblastoma. RESULTS: The recovery of the patient was uneventful and a significant symptom subsidence was reported following surgery. Eighteen months postoperatively the patient remains pain free without any indications for tumor recurrence. CONCLUSION: This case delineates the difficulties in diagnosing this tumor, as well as the challenges and problems encountered in its surgical management, and also the favorable prognosis when adequately treated.

Autologous bone marrow grafting combined with demineralized bone matrix improves consolidation of docking site after distraction osteogenesis.

BACKGROUND: Distraction osteogenesis is used for the reconstruction of extensive osseous defects. Delay in docking site consolidation results in significant prolongation of this surgical procedure. The primary aim of the present study was to retrospectively compare three different treatment options, all aimed at improving and accelerating docking site consolidation. We further sought to clarify whether the application of autologous bone marrow cells combined with demineralized bone matrix would substantially improve docking site consolidation. METHODS: Between 1995 and 2008, forty-three patients (mean age, 38.28 years) were managed with bone transport for the treatment of a tibial bone defect (mean length, 9.49 cm). The patients were divided into three groups according to the "docking site procedure" used: closed compression (Group A), surgical debridement of the docking site and application of autologous iliac bone graft (Group B), or surgical debridement and local application of bone marrow concentrate and demineralized bone matrix (Group C). Docking site consolidation was assessed both radiographically and clinically, and the results were statistically analyzed. RESULTS: The median "healing time" required for docking site consolidation was significantly longer in the compression group as compared with the demineralized bone matrix plus bone marrow group (p = 0.021), whereas there was no difference between the other groups. There was no significant difference among the groups in terms of complication rates (p = 0.702). Docking site consolidation was completed prior to regenerate consolidation in nine of the ten patients in Group C and in 13.6% of the patients in Group B, whereas in all of the remaining patients, completion of regenerate healing always preceded docking site consolidation. CONCLUSIONS: The application of demineralized bone matrix and autologous bone marrow is at least equivalent to autologous cancellous bone graft in terms of substantially reducing docking site healing time compared with closed compression alone. The application of demineralized bone matrix and autologous bone marrow is an effective treatment option, with minimal donor site morbidity, for reducing consolidation time of the docking site in tibial defects treated with distraction osteogenesis.

The effect of haematoma aspiration on intra-articular pressure and pain relief following Mason I radial head fractures.

BACKGROUND: The aspiration of the accompanying haematoma by Mason type I radial head fractures is advocated by several authors to achieve an analgesic effect. The purpose of this study was to investigate the effect of haematoma aspiration on intra-articular pressure and on pain relief after Mason I radial head fractures. MATERIALS AND METHODS: A total of 16 patients (10 men and six women, age 23-47 years) with an isolated Mason I radial head fracture were subjected to haematoma paracentesis. Initially, intra-articular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. After haematoma aspiration, a new pressure measurement without moving the needle was performed. Pain before and after haematoma aspiration was evaluated by using an analogue 10-point pain scale. RESULTS: Intra-articular elbow pressure prior to haematoma aspiration varied from 49 to 120 mmHg (median, 76.5 mmHg), while following aspiration, it ranged from 9 to 25 mmHg (median, 17 mmHg). The median quantity of the aspired blood was 2.75 ml (range, 0.5-8.5 ml). Patients reported a decrease in the visual analogue score (VAS) for pain from 5.5 (4-8) before to 2.5 (1-4) after aspiration. Decrease for both pressure and pain was statistically significant (p=0.005). CONCLUSION: The formation of an intra-articular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intra-articular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief.

Distraction osteogenesis as a salvage method in infected knee megaprostheses.

Infection of total knee replacement represents a severe complication. Especially in cases of infected megaprostheses, treatment options are limited and even amputation may become unavoidable. We present two cases of infected knee hinged megaprostheses. Both were treated by prosthesis removal and debridement of all surrounding infected bone and soft tissue, followed by distraction osteogenesis for the bridging of the large bone defect which had resulted. Implant removal and surgical debridement were combined with Ilizarov frame application and femoral and tibial osteotomies in a one-stage procedure, for commencing distraction osteogenesis. After bone transportation was completed, arthrodesis of the knee in both cases was successful. Two years after completion of the treatment, both patients demonstrate a stable knee arthrodesis and a satisfactory clinical result. The described treatment plan represents an effective salvage method in cases of infected knee megaprostheses that can successfully address both the need for a stable arthrodesis and the avoidance of a severe leg-length discrepancy by bridging the extensive bone defect.

New trends in fixation of proximal humeral fractures: a review.

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Delayed foreign-body reaction to absorbable implants in metacarpal fracture treatment.

BACKGROUND: First-generation bioabsorbable implants have been associated with a high complication rate attributable to weak mechanical properties and rapid degradation. This has led to the development of stronger devices with improved durability. However, the modern implants have raised concerns about potential late-occurring adverse reactions. QUESTIONS/PURPOSES: This retrospective study addressed the following questions: Can absorbable implants consisting of trimethylene carbonate, L-lactide, and D,L-lactide provide adequate fixation for healing of a metacarpal fracture? Will these implants obviate a second removal operation? What complications can occur in the reaction to implant breakdown? PATIENTS AND METHODS: Twelve unstable, displaced, metacarpal fractures were studied in 10 consecutive patients (seven men, three women; mean age, 36.4 years; range, 18-75 years). The fractures were treated with absorbable plates and screws consisting of the aforementioned copolymers and designed to resorb in 2 to 4 years. Nine patients (10 fractures) were available for clinical and radiographic followups (mean, 45.7 months; range, 34-61 months). RESULTS: Fracture healing was uneventful in all cases. Four patients experienced a foreign-body reaction during the second postoperative year and required surgical débridement to remove implant remnants. Histologic examination confirmed the diagnosis of a foreign-body reaction. Two other patients reported a transient local swelling that subsided without treatment. CONCLUSIONS: Our results indicate these absorbable implants for metacarpal fractures achieved adequate bone healing but simply postponed the problem of foreign-body reactions. Patients treated with bioabsorbable implants should be advised of potential late complications and should be followed for at least 2 years, possibly longer.

Implant removal after posterior stabilization of the thoraco-lumbar spine.

INTRODUCTION: Implant removal because of pain after posterior fusion in the thoracic and lumbar spine is a widely performed operation. We conducted a retrospective study to examine whether patients benefit from implant removal. PATIENTS AND METHODS: 57 patients (29 males, 28 females, mean age 46.5 years) who have undergone removal of pedicle screws because of pain and discomfort were interviewed 6-24 months postoperatively. Fracture was the initial diagnosis in 40% of the patients and degenerative spine disease in 58%. The following factors were evaluated: patient satisfaction and postoperative outcome, patients' native language and psychological background, operative data, hospital stay and complications. RESULTS: Pain decreased significantly from 62 to 48 on visual analogue scale postoperatively. Complications occurred in five patients (8.8%). 36 patients (61%) stated they had some benefit from the operation, but only seven patients (12%) were free of pain completely. 36 patients (63%) would undergo the same procedure again. Outcome in the subgroup of foreigners was significantly worse, though the psychological background did not affect the outcome. Preoperative diagnostic infiltration was helpful in 9 of 13 patients. CONCLUSION: Removal of pedicle screws because of back pain may be effective, but complete remission of symptoms could be achieved in only 12% of patients. However, 63% of patients would undergo hardware removal again. Preoperative diagnostic infiltration can help to predict the outcome but results are inconsistent. Communication difficulties may worsen the outcome. Surgeons should consider these results when planning implant removal and patients should be informed thoroughly to avoid too high expectations.

Cocultures of rat sensorimotor cortex and spinal cord slices to investigate corticospinal tract sprouting.

STUDY DESIGN: Experimental study of corticospinal axonal sprouting in an organotypic slice culture model. OBJECTIVE: To develop an in vitro model that simplifies the study of various factors regulating neuronal regeneration. SUMMARY OF BACKGROUND DATA: Spinal cord injury leads to permanent neurologic damage, mainly due to the inability of the adult central nervous system to regenerate. Much attention has been focused on promoting axonal regeneration and sprouting, either by exogenous administration of various neurotrophic factors or by the antagonization of factors inhibiting regeneration. METHODS: An in vitro system that allows coculture of slices from rat sensorimotor cortex and spinal cord (p4) was established. Two groups of cultures were investigated: In the first group, intact spinal cord slices were cultured adjacent to sensorimotor cortex slices, while in the second group the spinal cord slices were sagittally cut into halves, with the sectioned interface placed directly adjacent to the sensorimotor cortex, to prevent the spinal white matter from interference. Each group was further divided into 2 subgroups: The neurotrophin-3 (NT-3) group, where the culture medium contained 50 ng/mL NT-3 and the control group treated with normal culture medium. Sensorimotor cortex pyramidal neurons were anterogradely labeled with Mini-Ruby, a 10 kD biotinylated dextran amine. RESULTS: Cocultures of cortical and spinal cord tissue were propagated in vitro, and axonal sprouting occurred. The group of cocultures treated with NT-3 showed an improved cortical cytoarchitecture, and sprouting axons were more frequently observed. In NT-3-treated cocultures where spinal cord gray matter was directly opposed to cortical slices sprouting axons entered the adjacent spinal cord tissue. This phenomenon was not observed if spinal cord pia mater and white matter were opposed to the cortical slices, or if NT-3 was absent. CONCLUSION: Our data suggest that the absence of repellent factors such as white matter and the presence of neurotrophic factors promote axonal sprouting. Cocultures of sensorimotor cortex and spinal cord slices combined with anterograde axonal labeling could provide a valuable in vitro model for the simplified screening of factors influencing corticospinal tract regeneration.

One-stage thumb lengthening with use of an osteocutaneous 2nd metacarpal flap.

Traumatic thumb amputation represents an extremely disabling entity, thus rendering its reconstruction a procedure of paramount importance. A case of a patient, who sustained a traumatic amputation of his left index finger at the metacarpophalangeal joint and of his left thumb in the middle of the proximal phalanx 4 months ago and was initially treated elsewhere, is described. For the thumb reconstruction, an osteocutaneous flap of the radial side of the 2nd metacarpal, which consisted of a 3, 5-cm bony segment with the overlying skin and its blood and nerve supply was used. The flap was transferred and fixed with a plate and screws to the palmar-medial side of the stump of the thumb, while the 1st web space was deepened by removing the rest of the second metacarpal, while a partial skin graft was used to cover a remaining gap. Thumb functionality was restored immediately postoperatively, and the overall result was satisfactory.

Surgical treatment of a twice recurrent chondrosarcoma of the pubic symphysis: a case report and review of the literature.

The case of a patient with a second recurrence of a chondrosarcoma of the pelvis and pubic symphysis is presented, in order to show the difficulties of the surgical treatment and the long course of the tumor.A 56-year-old woman having already been operated upon twice within two decades, presented with a large, mass of the pubic symphysis, extending into the left proximal thigh.Preoperative imaging revealed a large tumor occupying the pubic symphysis and the pubic bones up to the ischial tuberosities, extending into the soft tissues of the inner surface of the left thigh and displacing the urinary bladder, the urethra and the vagina.Intraoperatively, a radical excision of the tumor was performed, including removal of the osseous substrate of the anterior pelvis. The anterior abdominal wall was supported with a special synthetic mesh secured on the osseous stumps in order to prevent visceral herniation. Histological examination showed grade I to II chondrosarcoma, while the patient's postoperative course was uncomplicated.At the latest follow-up two years postoperatively, the patient is pain-free and ambulatory with no signs of tumor recurrence, genitourinary complications or visceral herniation.

Mid-term results of internal fixation of proximal humeral fractures with the Philos plate.

OBJECTIVE: To report our experience from the use of the Philos plate for the treatment of three- and four-part proximal humeral fractures and to investigate factors influencing the final outcome. MATERIALS AND METHODS: Between April 2005 and September 2007, 29 Philos plates were implanted in 17 women and 12 men, with a mean age of 62.3 years (range: 28-80 years). Positioning of the plate was performed under fluoroscopic control, through a deltopectoral approach and with the patient in the beach chair position. 27 patients were available for follow-up (mean: 17.9 months; range: 12-39). Follow-up included plain shoulder radiographs and functional assessment with Constant-Murley score. RESULTS: Healing of the fracture occurred uneventfully within 6 months. In three patients, humeral head collapsed due to aseptic necrosis after fracture healing and the plate had to be removed in two cases. In one patient, fracture healing occurred in >10 degrees varus displacement. The clinical result according to the Constant-Murley score was 86 points (range: 58-112). CONCLUSIONS: Internal fixation with the Philos plate seems to be a reliable option in the operative treatment of upper end humeral fractures, especially in osteoporotic bone. It allows secure fracture fixation and quick shoulder mobilisation, while quick and uneventful fracture healing and very satisfactory clinical results are achieved.

Characterisation of transverse slice culture preparations of postnatal rat spinal cord: preservation of defined neuronal populations.

Spinal cord injury induces degenerative and regenerative processes and complex interactions of neurons with non-neuronal cells. In order to develop an in vitro tool for the investigation of such processes, we prepared and characterised spinal cord slice cultures (SCSC) from Wistar rats (p0-12). SCSC were sustained in vitro up to 12 days and characterised by immunohistochemistry. Calbindin+ neurons, distributed across the entire gray matter, were visible also after longer culture periods. NeuN+ neurons were best preserved in the dorsal horn whereas large NeuN+ and choline acetyltransferase+ motoneurons in the ventral horn vanished after 3 days in vitro. Nestin immunoreactivity was found in animals of all age groups, either in cells interspersed in the ependymal lining around the central canal or in cells resembling protoplasmic astrocytes. Glial fibrillary acidic protein+ astrocytes, initially restricted to the white matter, invaded the gray matter of SCSC early during the culture period. Microglial cells, stained by Griffonia simplicifolia isolectin B4, were rapidly activated in the dorsal tract and in the gray matter but declined in number with time. SCSC derived from p0 or p3 animals showed a better preservation of the cytoarchitecture than cultures derived from older animals. In summary, SCSC undergo degenerative changes, but they contain defined neuronal populations, the cytoarchitecture is partially preserved and the glial reaction is limited.