Fractures of the distal third of the humerus with palsy of the radial nerve: management using minimally-invasive percutaneous plate osteosynthesis.

Fractures of the distal third of the humerus may be complicated by complete lesions of the radial nerve which may be entrapped or compressed by bone fragments. Indirect reduction and internal fixation may result in a permanent nerve lesion. We describe the treatment of these lesions by insertion of a bridge plate using the minimally-invasive percutaneous technique. Six patients were operated on and showed complete functional recovery. Healing of the fractures occurred at a mean of 2.7 months (2 to 3) and complete neurological recovery by a mean of 2.3 months (1 to 5). In one patient infection occurred which resolved after removal of the implant.

Triage methodology for the evaluation of implant-bone interfaces.

Stainless steel plugs coated with and without Al2O3, TiO2 and Nb2O5 were inserted into canine femora in order to develop a methodology of rapid identification of appropriate specimens for deeper analysis of implant-bone interfaces. This approach is especially meaningful in areas where research funds are scarce. After a maximum follow-up period of 52 wk, bone segments containing plugs were radiographed using conventional techniques, high resolution techniques (which allowed a good preliminary evaluation) and microradiography. Analysis by X-ray fluorescence spectrometry indicated release of the materials by the implants. Microdensitometry of the microradiographs allowed a precise thickness determination of the tissue formed around the implants.

Inflammatory reaction of rat striated muscle to particles of carbon fiber reinforced carbon.

1. Carbon fiber reinforced carbon (CFRC) was implanted in rats as particles measuring 30 microns or 11 microns, denoted as CFRC-A and CFRC-B, respectively. Titanium (Ti) and vitreous carbon (VC) were used as controls. Ti was used with the same particle size as CFRC (Ti-A or Ti-B). The VC particles measured 11 microns. All materials were separately sterilized on ethylene oxide before use. 2. One hundred and ten female Wistar rats, weighing 180 to 220 g, were divided into six groups of 4 to 5 animals each, according the time of the observation (1, 2, 4, 8, 16 and 52 weeks). 3. Under aseptic conditions, one 3-0 curette full of CFRC-A or CFRC-B was implanted into the right triceps surae muscle in each animal and the same quantity of Ti-A (paired with CFRC-A) or Ti-B or VC (paired with CFRC-B) was implanted into the left muscle. 4. Histological analysis did not show necrosis of muscular tissue nor exudative reaction during the acute phase. 5. During the chronic phase the particles induced a chronic inflammatory infiltration containing fibroblasts, macrophages and giant cells. VC and CFRC-B induced the lowest inflammatory infiltration and CFRC-A induced the highest one. 6. We suggest that the longer carbon fiber fragments contained in CFRC-A may be responsible for this more intensive reaction, which may restrict the medical use of the preparation.

Biomechanical and histological evaluation of hydrogel implants in articular cartilage.

We evaluated the mechanical behavior of the repaired surfaces of defective articular cartilage in the intercondylar region of the rat femur after a hydrogel graft implant. The results were compared to those for the adjacent normal articular cartilage and for control surfaces where the defects remained empty. Hydrogel synthesized by blending poly(2-hydroxyethyl methacrylate) and poly(methyl methacrylate-co-acrylic acid) was implanted in male Wistar rats. The animals were divided into five groups with postoperative follow-up periods of 3, 5, 8, 12 and 16 weeks. Indentation tests were performed on the neoformed surfaces in the knee joint (with or without a hydrogel implant) and on adjacent articular cartilage in order to assess the mechanical properties of the newly formed surface. Kruskal-Wallis analysis indicated that the mechanical behavior of the neoformed surfaces was significantly different from that of normal cartilage. Histological analysis of the repaired defects showed that the hydrogel implant filled the defect with no signs of inflammation as it was well anchored to the surrounding tissues, resulting in a newly formed articular surface. In the case of empty control defects, osseous tissue grew inside the defects and fibrous tissue formed on the articular surface of the defects. The repaired surface of the hydrogel implant was more compliant than normal articular cartilage throughout the 16 weeks following the operation, whereas the fibrous tissue that formed postoperatively over the empty defect was stiffer than normal articular cartilage after 5 weeks. This stiffness started to decrease 16 weeks after the operation, probably due to tissue degeneration. Thus, from the biomechanical and histological point of view, the hydrogel implant improved the articular surface repair.

Validation of a standardised gait score to predict the healing of tibial fractures.

There is no absolute method of evaluating healing of a fracture of the tibial shaft. In this study we sought to validate a new clinical method based on the systematic observation of gait, first by assessing the degree of agreement between three independent observers regarding the gait score for a given patient, and secondly by determining how such a score might predict healing of a fracture. We used a method of evaluating gait to assess 33 patients (29 men and four women, with a mean age of 29 years (15 to 62)) who had sustained an isolated fracture of the tibial shaft and had been treated with a locked intramedullary nail. There were 15 closed and 18 open fractures (three Gustilo and Anderson grade I, seven grade II, seven grade IIIA and one grade IIIB). Assessment was carried out three and six months post-operatively using videos taken with a digital camera. Gait was graded on a scale ranging from 1 (extreme difficulty) to 4 (normal gait). Bivariate analysis included analysis of variance to determine whether the gait score statistically correlated with previously validated and standardised scores of clinical status and radiological evidence of union. An association was found between the pattern of gait and all the other variables. Improvement in gait was associated with the absence of pain on weight-bearing, reduced tenderness over the fracture, a higher Radiographic Union Scale in Tibial Fractures score, and improved functional status, measured using the Brazilian version of the Short Musculoskeletal Function Assessment questionnaire (all p < 0.001). Although further study is needed, the analysis of gait in this way may prove to be a useful clinical tool.

Polyvinyl alcohol hydrogel irradiated and acetalized for osteochondral defect repair: mechanical, chemical, and histological evaluation after implantation in rat knees.

Polyvinyl Alcohol (PVA) hydrogel plugs were implanted in artificial osteochondral defects on the trochlear groove of rat knees. After 0, 3, 6, 12, and 24 weeks of followup, samples containing the implants were mechanically evaluated by creep indentation test, chemically, and histologically by optical microscopy. The mechanical test pointed towards an increase of the implant creep modulus and the chemical analysis exhibited an increasing concentration of calcium and phosphorus within the implants over time. Optical microscopy showed no foreign body reaction and revealed formation, differentiation, and maintenance of new tissue at the defect/implant interface. The absence of implant wear indicated that the natural articular lubrication process was not disturbed by the implant. The performance of the irradiated and acetalized PVA was considered satisfactory for the proposed application.

Treatment of chronic radial head dislocations in children.

From 1990 to 2005 our department treated nine patients with chronic radial head dislocation by an ulnar osteotomy and indirect reduction by interosseous membrane. The patients varied in age from 2 years and 8 months to 10 years, and the time from the injury to operation ranged from 40 days to 3 years. The range of functional motion and carrying angle was restored in all nine patients, and no complications, such as recurrent dislocation, infection, or neurovascular injury were observed. This technique has proven to be a successful approach to treating such cases, with a low range of complications and good functional results.

Inherited risk factors for thrombophilia among children with Legg-Calvé-Perthes disease.

An inherited tendency to hypercoagulability has been suggested as a cause of vascular thrombosis resulting in Legg-Calvé-Perthes disease (LCPD). Here we carried out an investigation of the most common inherited risk factors for hypercoagulability including the mutation in the factor V gene (factor V Leiden), the transition 20.210G-->A in the prothrombin gene, and also the homozygosity for the 677C-->T transition in the methylenetetrahydrofolate reductase gene (MTHFR). The investigation was carried out among 61 Brazilian children with LCPD, who were compared with 296 individuals from the general population. The prevalence of the factor V Leiden mutation was higher in LCPD patients than in the controls (4.9 vs. 0.7%; p = 0.03). However, no patient had the prothrombin gene variant, and no difference was found between patients and controls when homozygosity for MTHFR-T (3.2 vs. 2.6%: p = 0.64) was determined. These data suggest that in our population, the heterozygosity for factor V Leiden was the only inherited risk factor associated with the development of LCPD.

Biomechanical and histological evaluation of hydrogel implants in articular cartilage

We evaluated the mechanical behavior of the repaired surfaces of defective articular cartilage in the intercondylar region of the rat femur after a hydrogel graft implant. The results were compared to those for the adjacent normal articular cartilage and for control surfaces where the defects remained empty. Hydrogel synthesized by blending poly(2-hydroxyethyl methacrylate) and poly(methyl methacrylate-co-acrylic acid) was implanted in male Wistar rats. The animals were divided into five groups with postoperative follow-up periods of 3, 5, 8, 12 and 16 weeks. Indentation tests were performed on the neoformed surfaces in the knee joint (with or without a hydrogel implant) and on adjacent articular cartilage in order to assess the mechanical properties of the newly formed surface. Kruskal-Wallis analysis indicated that the mechanical behavior of the neoformed surfaces was significantly different from that of normal cartilage. Histological analysis of the repaired defects showed that the hydrogel implant filled the defect with no signs of inflammation as it was well anchored to the surrounding tissues, resulting in a newly formed articular surface. In the case of empty control defects, osseous tissue grew inside the defects and fibrous tissue formed on the articular surface of the defects. The repaired surface of the hydrogel implant was more compliant than normal articular cartilage throughout the 16 weeks following the operation, whereas the fibrous tissue that formed postoperatively over the empty defect was stiffer than normal articular cartilage after 5 weeks. This stiffness started to decrease 16 weeks after the operation, probably due to tissue degeneration. Thus, from the biomechanical and histological point of view, the hydrogel implant improved the articular surface repair.

Inflammatory reaction of rat striated muscle to particles of carbon fiber reinforced carbon

1. Carbon fiber reinforced carbon (CFRC) was implanted in rats as particles measuring 30 microns or 11 microns, denoted as CFRC-A and CFRC-B, respectively. Titanium (Ti) and vitreous carbon (VC) were used as controls. Ti was used with the same particle size as CFRC (Ti-A or Ti-B). The VC particles measured 11 microns. All materials were separately sterilized on ethylene oxide before use. 2. One hundred and ten female Wistar rats, weighing 180 to 220 g, were divided into six groups of 4 to 5 animals each, according the time of the observation (1, 2, 4, 8, 16 and 52 weeks). 3. Under aseptic conditions, one 3-0 curette full of CFRC-A or CFRC-B was implanted into the right triceps surae muscle in each animal and the same quantity of Ti-A (paired with CFRC-A) or Ti-B or VC (paired with CFRC-B) was implanted into the left muscle. 4. Histological analysis did not show necrosis of muscular tissue nor exudative reaction during the acute phase. 5. During the chronic phase the particles induced a chronic inflammatory infiltration containing fibroblasts, macrophages and giant cells. VC and CFRC-B induced the lowest inflammatory infiltration and CFRC-A induced the highest one. 6. We suggest that the longer carbon fiber fragments contained in CFRC-A may be responsible for this more intensive reaction, which may restrict the medical use of the preparation

Cintilografia óssea trifásica para guiar a retirada de implantes metálicos em fraturas: estudo preliminar / Three-phase bone scintigraphy as a guide to metallic implant removal

O objetivo deste estudo foi avaliar o papel da cintilografia óssea trifásica na indicação da retirada do material de síntese de pacientes com fratura diafisária do fêmur, submetidos à fixação com haste intramedular bloqueada (HIB) ou com placa em ponte (PP), já que, atualmente, a indicação da retirada é feita por critérios não totalmente confiáveis. Foram estudados 13 pacientes, seis com colocação de HIB e sete com PP. Todos os pacientes foram submetidos a cintilografia óssea trifásica com 740MBq de MDP-99mTc em uma câmara de cintilação computadorizada. Em quatro pacientes (dois com HIB e dois com PP) houve retirada do material de síntese, em média, 42,2 meses após a fratura. Os pacientes com HIB apresentaram alterações discretas na fase tardia da cintilografia óssea e formação discreta do calo ósseo, enquanto os com PP mostraram alterações cintilográficas moderadas e formação anormal do calo ósseo. As discretas alterações descritas na cintilografia óssea nos pacientes com HlB indicam que este tipo de fixação leva a menor exigência mecânica do calo ósseo com remodelação mais fisiológica, comprovada pelo estudo tomográfico em dois pacientes, mostrando sua anatomia semelhante à do fêmur contralateral. Isto não ocorreu nos pacientes com PP, talvez devido a uma maior movimentação dos fragmentos ósseos permitida por este material. Esta movimentação sugere que este tipo de fixação talvez não seja o mais fisiológico, não proporcionando à fratura condições adequadas para se consolidar.