Prospective randomized clinical trial of open operative, minimally invasive and conservative treatments of acute Achilles tendon tear.

INTRODUCTION: The acute Achilles tendon rupture (AATR) is a common injury of great importance in an increasingly active society. When early functional treatment is established, recent literature shows comparable rates of re-rupture in conservative and surgical treatments of AATR. However, there is no study comparing the outcome using a dynamometer. The aim of this study is to evaluate the results of patients with AATR treated conservatively and surgically using a dynamometer. In addition, the data are compared to evaluation of the Achilles tendon with ultrasound. MATERIALS AND METHODS: Between 2012 and 2015, 90 patients (mean age 41 years, male-to-female ratio 81:9) with AATR were enrolled in a prospective, randomized, and monocentric study. Thirty patients were assigned to each of the three different treatment groups. Group OPEN received a conventional open suture of the Achilles tendon, group MIN received a minimally invasive suture and patients in group CONS were treated conservatively. Follow-up treatment was the same for all patients regardless of the group they were assigned to. Plantar flexion force was assessed using a dynamometer (Biodex® System 3 Pro, Biodex Medical Systems). Further evaluation included a physical test and ultrasound of the Achilles tendon. RESULTS: Sixty-nine patients were available for a 24-month follow-up. In each of the OPEN and MIN groups, there was one re-rupture. In the CONS group, there were two re-ruptures. A positive correlation between the Biodex® dynamometer measurement and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS-AH) could be found in all groups. Nevertheless, there were no significant differences between the treatment groups after 2 years. On sonography, all patients showed isolated structure loosening and a significantly thickened cross-sectional area compared with the non-injured opposite side, without differences between the groups. There was no correlation between the Biodex® measurement and sonographic outcome. CONCLUSION: At 24-month follow-up, no significant difference can be found in patients with AATR treated operatively or conservatively. It is, therefore, important to inform patients with AATR regarding the respective advantages and disadvantages of the individual treatment strategies. LEVEL OF EVIDENCE: Randomized controlled trial; level 1.

The Masquelet technique in traumatic loss of the talus after open lateral subtalar dislocation-A case report.

INTRODUCTION: Subtalar dislocations are rare injuries and treatment recommendations missing. Gross contamination and devascularisation are aspects supporting talectomy as potential treatment choice. Reconstruction in these cases can be challenging. The Masquelet technique presents one viable option. PRESENTATION OF CASE: A carpenter sustained a high energy chrush injury with traumatic open lateral talar dislocation qualifying as Gustillo Anderson type IIIc injury, a mangeled extremity index of 7 and gross contamination. The severity of soft tissue damage and contamination prompted the decision for talectomy before plastic coverage with a gracilis flap. Additionally a Masquelet procedure with cement spacer was initiated. After consolidation of the soft tissues a hindfoot arthrodesis with approximate preservation of leg length could be performed. In the course of treatment, the patient suffered no infection and could resume full weight bearing after nine months. The patient resumed his previous occupation with adapted workload and is satisfied with the treatment result. DISCUSSION: In the present case the principle options were talus preservation or talectomy with reconstruction. Talus preservation in the presence of gross contamination can be associated with the risk of infection, in addition there is a risk to develop secondary arthritis. For this individual patient the a fast and definite solution was important at this point in life. Surgeons therefore opted for talectomy. To optimally reconstruct leg length and optimize for arthrodesis the Masquelet technique was employed. CONCLUSION: The Masquelet technique is a viable option also in the emergency situation to preserve extremity length and optimize tissue viability.

Herniation pits and cystic-appearing lesions at the anterior femoral neck: an anatomical study by MSCT and microCT.

OBJECTIVE: To determine distinguishing features between herniation pits (HPs) and other cystic-appearing lesions at the anterior femoral neck in multi-slice computed tomography (MSCT) and micro-computed tomography (microCT) examinations. MATERIALS AND METHODS: Institutional review board approval was obtained to examine 37 proximal femora of 23 cadaveric specimens (mean age available in 19 cadavers, 83 years; range 68-100 years; 9 female, 8 male, 6 unknown). All 37 femora were investigated by MSCT. 23 femora, which revealed cystic-appearing lesions at the anterior femoral neck in MSCT examinations, were additionally examined by microCT. Cystic-appearing lesions were categorized by their location, sclerotic margin, demarcation and shape in MSCT with assessment of inter-observer agreement. Detailed cortical and trabecular properties were evaluated in microCT examinations. RESULTS: There were seven HPs in three femora. There were a number of abnormalities potentially imitating HPs, including focal osteoporosis (13 in 13 femora), degenerative changes (5 in 4 femora) and trabecular restructuring (5 in 4 femora) at the anterior femoral neck. HPs were differentiated on the basis of their subchondral/subcortical location, completely surrounding sclerosis, clear demarcation and round-to-oval shape in MSCT. Because of their location and their microscopic appearance, HPs seem to resemble intra-osseous ganglia at the anterior femoral neck. CONCLUSION: HPs have to be differentiated from other cystic appearing lesions at the anterior femoral neck to avoid overestimation of their incidence in the context of diagnosis of femoroacetabular impingement.

The repair of critical-sized bone defects using expedited, autologous BMP-2 gene-activated fat implants.

The repair of bone defects can be induced experimentally with bone morphogenetic protein-2 (BMP-2) producing fat-derived stem cells, but this ex vivo tissue engineering method requires the isolation and long-term culture of autologous cells. To develop an expedited bone repair strategy, we transferred BMP-2 cDNA directly to autologous fat tissue fragments that were held in culture for only 24 h before implantation. We evaluated the ability of such gene-activated fat grafts to regenerate large segmental bone defects in rats. Fat tissue was harvested from 2 of 35 male Fischer 344 rats used for this study. The fat tissue fragments were incubated with an adenoviral vector carrying the cDNA encoding either BMP-2 or green florescent protein (GFP), or they remained unmodified. According to their group, the segmental femoral bone defects of 33 rats were filled press fit with either BMP-2-activated fat tissue, GFP-transduced fat tissue, or unmodified fat tissue. Another control group remained untreated. Femora were evaluated by radiographs, microcomputed tomography, biomechanical torsional testing, and histology. Radiographically and histologically, 100% of the femora treated with BMP-2-activated fat grafts were bridged at 6 weeks after surgery. The femora of this group exceeded the bone volume and the biomechanical stability of intact, contralateral femora. Control defects receiving no treatment, unmodified fat tissue, or GFP-transduced fat were filled with fibrous or adipose tissue, as evaluated by histology. The use of BMP-2 gene-activated fat tissue grafts represents an expedited and effective bone repair strategy that does not require the extraction and expansion of stem cells.

Healing of large segmental bone defects induced by expedited bone morphogenetic protein-2 gene-activated, syngeneic muscle grafts.

Numerous preclinical studies have shown that osseous defects can be repaired by implanting bone morphogenetic protein (BMP)-2-transduced muscle cells. However, the drawback of this treatment modality is that it requires the isolation and long-term (approximately 3 weeks) culture of transduced autologous cells, which makes this approach cumbersome, time-consuming, and expensive. Therefore, we transferred BMP-2 cDNA directly to muscle tissue fragments that were held in culture for only 24 hr before implantation. We evaluated the ability of such gene-activated muscle grafts to induce bone repair. Two of 35 male, syngeneic Fischer 344 rats used in this study served as donors for muscle tissue. The muscle fragments remained unmodified or were incubated with an adenoviral vector carrying the cDNA encoding either green fluorescent protein (GFP) or BMP-2. Critical-size defects were created in the right femora of 33 rats and remained untreated or were filled (press fitted) with either unmodified muscle tissue or GFP-transduced muscle tissue or with BMP-2-activated muscle tissue. After 6 weeks, femora were evaluated by radiography, microcomputed tomography (muCT), histology, and biomechanical testing. Six weeks after implantation of BMP-2-activated muscle grafts, 100% of the bone defects were bridged, as documented by radiographs and muCT imaging, and showed formation of a neocortex, as evaluated by histology. Bone volumes of the femora repaired by BMP-2-transduced muscle were significantly (p = 0.006) higher compared with those of intact femora and the biomechanical stability was statistically indistinguishable. In contrast, control defects receiving no treatment, unmodified muscle, or GFP-transduced muscle did not heal. BMP-2 gene-activated muscle grafts are osteoregenerative composites that provide an expedited means of treating and subsequently healing large segmental bone defects.

Quantification of Reaming Debris at the Fracture Gap of Diaphyseal A2 and A3 Fractures After Reamed Intramedullary Nailing of the Sheep Tibia.

BACKGROUND: The aim of this study was to visualize the intramedullary bone debris after reamed nailing of long bones. To date, there is no protocol to quantify bone debris in the fracture gap. The hypothesis was to show if there are differences between A2 and A3 fractures. METHODS: In this trial 17 sheep tibiae were used. On the medullary isthmus eight A2 und nine A3 fractures were produced. Afterwards, reposition, closure of the soft tissue and reaming procedure up to 10% of the bonecortex were done. For internal fixation, a plastic implant was used. The region of interest was scanned with the Micro-CT 80 and the fracture gap was contoured from a special software (SCANCO Medical AG, Switzerland). The threshold for the reaming debris was set at 549.9 mgHA/cm(3). The analysis of the bone debris located at the fracture gap was measured by percent of debris volume to gap volume. For statistical analysis the Wilcoxon test was used and a level of significance of p < 0.05 was chosen. RESULTS: The fracture gap width ranged from 0.3 to 1.7 mm in both groups. Comparing A2 and A3 fractures there was no significant difference concerning the percentage of reaming debris at the fracture gap. The Median of A2 fractures was 20.5 and 21% for A3 fractures. CONCLUSIONS: The results show reaming produces intramedullary bonegrafting. Despite different fracture planes of A2 and A3 fractures, no significant differences in the amount of reaming debris located at the fracture gap could be found. However the percental rate of reaming debris at the fracture gap of plain fractures is negligible. This research shows that there is potential for reaming debris to be applied effectively as a prophylactic and osteogenetic autograft. Together with the high stability of the intramedullary nail an all embracing concept of osteosynthesis could be established.