Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases.

In this article, we report using free vascularized medial femoral condyle (MFC) flaps for reconstruction of bone defects and nonunion of the hindfoot and ankle in two patients. One patient had an open calcaneal fracture and hindfoot bone defect with impaired gait due to Achilles tendon functional loss. The second patient had nonunion with a chondral defect of the talus after a fall. Following uneventful recoveries, good objective and subjective results were achieved in terms of pain reduction and improved gait in both patients. No further operative intervention was needed during a 3-year follow-up period. The versatility of the corticoperiosteal graft from the MFC makes it an important reconstructive tool for addressing several major surgical problems of bony nonunion in the extremities, including posttraumatic reconstruction of hindfoot and ankle disorders.

Delta III reverse shoulder arthroplasty in the treatment of complex 3- and 4-part fractures of the proximal humerus: 6 to 42 months of follow up.

BACKGROUND: There is a growing tendency for complex proximal humerus fractures (PHF) in osteoporotic patients to be treated with reverse shoulder arthroplasty (RSA). It has been proposed that RSA has more benefits than other treatment options. The aim of our study was to investigate preoperative characteristics as well as clinical and radiological outcomes in patients with complex 3- or 4-part PHF who had undergone primary RSA. METHODS: Patients with a minimum follow-up of 6 months who had undergone a primary RSA after 3- or 4-part PHF in the period between 2008 and 2011 were eligible for the study. Clinical records, X-rays and CT-scans were investigated and a clinical examination was performed. Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant-Murley score (CMS) were calculated. Sixteen patients were examined as part of the study. The mean follow-up was 20 months (range 6-42 months). According to Codman-Hertel classification we encountered 15 Hertel "12" and 1 Hertel "8" type fractures. RESULTS: Thirty-two patients (27 female - 84.4%) with a mean age of 72 years underwent operations to treat complex 3- and 4-part fractures of the proximal humerus. Sixteen patients were reexamined. In 14 cases the dominant upper extremity was on the right, in 2 cases it was on the left, in 6 cases the right side was affected and in 10 cases the left side was affected. The mean CMS was 54.8 (range 18-95) and the mean DASH was 37.5 (range 2.9-81). A trend was established between the CMS and dominance of the affected shoulder. The CMS was better if the affected shoulder was on the non-dominant side (p-value 0.051). No statistical difference was noted between age and clinical outcome. CONCLUSIONS: Our mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. RSA can provide immediate relief and good shoulder function in elderly patients. Nevertheless, the question of longevity of these implants remains to be observed.

Urine toxicology screening in Austrian trauma patients: a prospective study.

INTRODUCTION: The question as to whether the patient consumed drugs prior to the trauma and which drugs were consumed, is of prime importance for the anesthesia required during surgery. However, many patients are unwilling or unable (including those with multiple trauma or impaired consciousness, or unconscious patients) to answer this question. The purpose of our prospective multicenter study was to collect data about drug consumption in Austria to determine whether drugs are identifiable in the urine of recently injured individuals and to establish the types of drugs consumed. MATERIALS AND METHODS: This prospective study included severely and moderately injured patients admitted to the Lorenz Boehler Trauma Hospital (Vienna, Austria), the Trauma Hospital Linz (Linz, Austria) and the Department of Trauma Surgery of the General Hospital Horn (Horn, Austria) during an 18-month period (October 2003-March 2005). All patients were suffering from injuries urgently requiring surgery. Urine samples were gained from all patients immediately after admission. Urinary samples were tested by Immuno-Assay (Triage 8 Immuno-Assay, Biosite, San Diego, USA). Urine samples were screened simultaneously for opiates, methadone, cocaine, barbiturates, amphetamines, cannabinoids, benzodiazepines and tricyclic antidepressants. RESULTS: Our prospective study included a total of 664 patients (320 from Vienna, 193 from the city of Linz, and 151 from Horn). Six hundred and forty-two patients were moderately injured (ISS < 16), suffering mostly from injuries to the extremities (504 patients) and 22 patients were severely injured (ISS > 16). Of the 664 patients, 178 (26.8%) tested positive for one or more drugs. The drugs most commonly detected were benzodiazepines (111 patients, 16.7%), cannabinoides (39 patients, 6%), tricyclic antidepressants (28, 4.2%) and opiates (26, 3.9%). CONCLUSION: Drug use is widespread in patients presenting to urban trauma centers in Austria. Physicians should maintain a high index of suspicion that their patients may be intoxicated and should perform drug testing routinely.

Assessment of bone union/nonunion in an experimental model using microcomputed technology.

BACKGROUND: High-resolution microcomputed tomography (microCT) is one of the most recent technical developments to visualize and quantify primarily cancellous bone. Regarding bone formation, microCT is becoming increasingly important, although its reliability has not yet been evaluated. Our study had two goals: to develop a reproducible nonunion model and to determine the efficacy of microCT for the assessment of bone healing in this model. METHODS: The designed fracture model in the rat simulates secondary fracture healing. After plate fixation to the femur, diaphysis transverse middiaphyseal osteotomy was performed with a reciprocating saw, resulting in a 0.38-mm gap with a defect of bone and periosteum corresponding to the thickness of the blade. Proximally and distally to this gap, the periosteum was preserved. Thus, three separate zones were defined: proximal femur diaphysis with periosteum, gap, and distal femur diaphysis with periosteum. In the nonunion group (NM group), a model of impaired bone healing (nonunion), silicone foil was wrapped around the femur diaphysis to block any influence from surrounding tissue. Coverage of the bone repair site by thigh muscles was designed for a model of bone union (M group). Four weeks postoperatively, callus formation was determined by conventional anterior-posterior and lateral plain radiographs. Ten weeks later, a second x-ray series was done as the clinical standard evaluation method. Afterward, specimens were harvested for microCT examination (two-dimensional and three-dimensional [3D]). Biomechanical testing was carried out to determine fracture healing. RESULTS: Our model is highly reproducible and results in bone nonunion in five out of six cases (83.3%). In determining fracture site, plain radiographs the least reliable method in comparison to the biomechanical testing which is the most accurate reference method. In contrast, microCT (the 3D reconstruction) showed significant correlation (r = 1) to the results assessed by biomechanical testing, whereas microCT was correct in 100%. We found bone healing in five out of six animals in the M group verified by microCT (in accordance to biomechanical data). In the M group, significantly enhanced bone formation (50%) (p = 0.008) was observed within the osteotomy site (i.e. within the gap), but there was no difference in periosteal bone formation between the groups proximally and distally to the gap. Interestingly, we did not find statistically significant differences in mineralization. CONCLUSION: We conclude that microCT with 3D reconstruction is the optimal method diagnostic tool in fracture healing, especially in nonunion. Furthermore, direct coverage of the fracture site by muscle flaps results in a mineralized enhanced bone formation within the osteotomy site (i.e. within the gap). Skeletal muscle coverage hypothetically might have osteogenic augmentation potential, thus being able to prevent pseudoarthrosis.

Bilateral lower leg replantation versus prosthetic replacement: long-term outcome of amputation after an occupational railroad accident.

BACKGROUND: This retrospective study investigated three very similar cases of bilateral lower leg amputation. The aim was to determine which of two therapeutical procedures is associated with better long-term outcome: replantation or primary treatment of the stumps and subsequent prosthetic replacement. METHODS: Evaluation included clinical examination, gait analysis, and a workup of the psychosocial background. Health problems were documented using the Nottingham Health Profile. Follow-up assessments were performed 6, 7, and 18 years after the trauma. RESULTS: One patient underwent successful bilateral lower leg replantation and continued to work for the same employer. Two patients underwent prosthetic replacement. One became a social outcast confined to a wheelchair. The other patient had a good psychosocial background, similar to that of the patient who underwent replantation. He showed a better gait analysis on even ground than the replantation patient, but the findings were vice versa for uneven ground. CONCLUSIONS: The decision between replantation and prosthetic replacement after bilateral lower leg amputation is case related and cannot be generalized. Patients who have undergone these procedures require long-term psychological and physiotherapeutic care to achieve a good long-term surgical outcome.

Alleviated tension at the repair site enhances functional regeneration: the effect of full range of motion mobilization on the regeneration of peripheral nerves--histologic, electrophysiologic, and functional results in a rat model.

BACKGROUND: In the clinical management of combined tendon and nerve injuries, competing treatment strategies are well known. The effect of mobilization on the functional regeneration of peripheral nerves remains controversial. This study sought to determine the effect of full range of motion mobilization on nerve repair by using tubular segmental nerve splinting to block movement, and thereby variable tension, at the nerve repair site. METHODS: In 96 rats, the right sciatic nerve was transected midthigh and coapted immediately microsurgically. The groups used in the study were as follows: group N, epineural nerve repair; group T, segmental tubular nerve splinting with fixed in situ tension at the nerve suture site,allowing segmental movement only; group TN, segmental tubular nerve splinting with alleviated in situ tension at the nerve suture site, allowing segmental movement only; and group TM, segmental tubular nerve splinting without fixed in situ tension at the nerve suture site, allowing movement of the nerve suture site. Full range of motion of the lower limbs was ensured by passive motion of hind limbs once a week after functional testing. Blinded histologic, immunohistochemical, and electrophysiologic assessment and 12 postoperative weekly function tests were carried out. RESULTS: Functional and electrophysiologic results were significantly better in group TN, by segmental tubular nerve splinting with alleviated in situ tension at the nerve repair site, mainly because of less scar formation and enhanced endoneural angiogenesis at the nerve suture segment. CONCLUSION: Full range of motion mobilization may impede functional nerve recovery by significant endoneural collagenization and decreased angiogenesis at the nerve suture segment. Complete alleviation of in situ (pathophysiologic) tension at the nerve suture site seems to improve functional peripheral nerve regeneration.