Free corticoperiosteal flap in the treatment of an infected bone defect of the tibia. A case report.

The treatment of septic bone defects represents a significant challenge in orthopaedic surgery. Non-vascularised cancellous bone grafts are very commonly used. In contrast, thin and malleable periosteal grafts have generally only been investigated in animal models. The free corticoperiosteal flap is used only in exceptional cases in traumatology. This case report describes the treatment of an infected and non-reactive bone defect in the shaft of the tibia. This case involves a septic non-union over two years old with evidence of methicillin-resistant Staph. aureus. A vascularised corticoperiosteal flap was used to bridge this defect. The procedure was supplemented by rigid internal fixation. There were no postoperative complications. Bone healing was documented eleven months after the described treatment. No further invasive procedures were required. The patient was able to return to his original occupation as a store manager. Stable internal fixation is an important precondition for successful treatment. The method described in this article can be considered for short defects when a conventional cancellous bone graft appears to be contraindicated.

Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity?

Five patients with atrophic or septic non-union of long bones were treated with free vascularised corticoperiosteal bone flaps. The patients had undergone an average of nine prior operations (range, 2-29). The treatment was combined with repeat internal fixation in four patients,. Treatment took place an average of 25.5 months (range 5-83 months) after the initial injury. The thin corticoperiosteal grafts were harvested from the supracondylar region of the femur. One patient died from unrelated causes 2.5 months postoperatively. In the other four patients, bone healing was documented after an average of 7.7 months (range 6-11 months). No further operations were necessary during the follow-up period of 13.7 months on average (range 10-17 months). There were no complications associated with the procedure. The treatment presented here is complex but was successful in this small population. The procedure has the potential to become established as a treatment option for problematic bone defects.

Mini-open percutaneous transarticular screw fixation for acute and late atlantoaxial instability.

The treatment of atlantoaxial instability by means of posterior transarticular screw fixation combined with a Gallie fusion is an established method when direct anterior odontoid screw fixation is not indicated or has failed. In this retrospective study, the results of a modified percutaneous mini-open transarticular C1-C2 screw fixation are presented. Between February 1998 and March 2006, 47 patients with acute or late (after failed conservative treatment) atlantoaxial instability were treated with the modified technique. Their average age was 74.9 years. There were no intraoperative injuries to neural structures or blood vessels; 96.8% of the screws were placed correctly. A revision operation was necessary in one patient because of infection at the graft donor site. No patient experienced a neurological complication. Three patients died during hospitalisation, 6 others later on; 6 could not be traced, leaving thirty-two patients or 68% available for follow-up. The average clinical follow-up was 42 months (range: 12 to 91). The results with respect to the pain and activity status were good or excellent in more than 90% of cases. The radiographic follow-up averaged 25 months (range: 12 to 75). Bony fusion was documented in all cases. The modified technique of transarticular screw fixation presented here is a safe and functionally satisfactory method of achieving stabilisation of the atlantoaxial complex. Special cannulated instruments are not required. This mini-open transcutaneous technique is an alternative to the conventional open procedure, and reduces operation time as well as blood loss.

Proximal humeral fractures in geriatric patients. Is the angle-stable plate osteosynthesis really a breakthrough?

This is a retrospective study of the results of angle-stable plating of displaced 3- or 4- part fractures of the proximal humerus in 92 geriatric patients treated between 2/2000 and 2/2004. At final follow-up patients were clinically evaluated using the Constant-Murley score and were examined radiologically. The mean non-age-related Constant-Murley score was 69.8 points. A clear correlation was found between the final score and the quality of reposition of the tuberosities and/or plate position. Accurate reduction and plate positioning led to a significantly better functional result. For 28 patients (30.4%), sinkage of the humeral head into the shaft occurred despite angle-stable anchoring. The currently celebrated angle-stabilising plates did not lead to a significant improvement in functional outcome, compared with other established osteosynthesis procedures.