Multiple small intestinal perforations in a patient with Hepatitis B Virus-associated Polyarteritis Nodosa.

We present the case of a 38-year-old patient with a history of Hepatitis B Virus-associated Polyarteritis Nodosa, who presented with acute abdomen and septic shock. The patient initially had three perforations of the small intestine that were treated with segmental enterectomy and anastomosis at two sites. During his postoperative course he continued to develop new perforations and necrotic lesions along the whole length of the small intestine, that mandated repetitive laparotomies and the technique of the open abdomen was employed. Despite the aggressive surgical treatment and the medical treatment with corticosteroids, cyclophosphamide and plasma exchanges, the patient died 15 days after the first operation due to septic shock and multiple organ failure.

Colocutaneous Fistula after Open Inguinal Hernia Repair.

The plug-and-patch technique is frequently used for the open repair of inguinal hernias; however, serious complications may arise on rare occasions. We present the case of a 69-year-old patient who presented with a colocutaneous fistula with the sigmoid colon 9 years after the repair of a left sliding inguinal hernia with the plug-and-patch technique. The patient underwent sigmoidectomy and excision of the fistulous track. He was discharged on postoperative day 5 and had an uneventful recovery. Although such complications are reported rarely, the surgeon must be aware of them when deciding upon the method of hernia repair.

Melanoma of the gallbladder: appropriate surgical management and review of the literature.

KEY CLINICAL MESSAGE: Melanomas of the gallbladder (GB) are extremely rare with a very poor prognosis. They feature in the literature as a few case reports and the method of their management is not clear. We report a case of patient with metastatic cutaneous melanoma to the GB, and our treatment suggestion.

Comparative analysis of the microstructure of the hamstring tendons: an electron microscopic, histologic, and morphologic study.

Semitendinosus and gracilis tendons taken from 25 cadaveric knees were investigated using light and electron microscopy, immunohistochemistry, and morphometry. Thickness of the collagen fibrils, fibril/interstitium ratio, density of blood vessels, density of fibroblasts, and distribution of the collagen fibrils (types I, III, and V collagen and elastic fibers) were analyzed. It was hypothesized that the difference in biomechanical stability between the gracilis and semitendinosus tendons could be reflected by different morphologic features. The results of this study showed that the gracilis tendon, in comparison with the semitendinosus tendon, provides a significantly higher fibril/interstitium ratio and a higher density of collagen III fibers. Conversely, the semitendinosus tendon provides a higher density of blood vessels and collagen I fibers. No differences regarding the density of fibroblasts, thickness of collagen fibrils, and elastic and type V collagen fibers were found. In conclusion, the gracilis tendon graft can provide approximately 15% more collagen than the semitendinosus tendon graft with the same thickness. This fact can play an important role for better biomechanical stability of the gracilis tendon.

Comparative and morphological analysis of commonly used autografts for anterior cruciate ligament reconstruction with the native ACL: an electron, microscopic and morphologic study.

Ligaments and tendons are similar in composition but differ in proportion and arrangement. Tendons are being used as grafts for the ACL reconstruction. Their microscopic structure has not been sufficiently studied and compared to the native ACL. A null hypothesis was declared stating that the anterior cruciate ligament should be histological, morphologically and functionally different from the tendon grafts used for ACL reconstruction. We investigated similarities and differences of the structure of ACL and tendons used as a graft tissue for ACL reconstruction. In this study, standardized samples of quadriceps, hamstrings (semitendinosus and gracilis) and patellar tendons, and the ACL were harvested from 26 autopsies (average age 36.4) and were investigated using light and electron microscopy, immunohistochemistry and morphometry. The thickness of the collagen fibrils, collagen organization and diameter, the fibril/interstitium ratio, density of fibroblasts and blood vessels, and distribution of the collagen type I, III and V fibrils were analyzed. The semitendinosus showed the highest density of fibroblasts and blood vessels, while the gracilis the highest fibril/interstitium ratio. No differences regarding the thickness of collagen fibrils and distribution of fibrils were found. The ACL had the highest concentration of type III and V collagen fibrils as well as elastic fibers. The histological and ultrastructural appearance of the ACL differs from those of the tendons used as graft, for ACL reconstruction. Its ultrastructure is varied and complex, with its collagen fibers bundles lying in many directions.

The use of split deltoid-flap in the treatment of massive rotator cuff defects: a retrospective study of 61 patients.

Massive and irreparable rotator cuff tears are a challenge for the orthopaedic surgeon. The purpose of this study was to report our experience with the treatment of massive and irreparable defects of the rotator cuff with a modified deltoid split transfer. Between 1996 and 2004, for all patients suffering from full-thickness tears of the rotator cuff (> 5 cm tears in diameter, involving two or more tendons) were operated with a modified deltoid split transfer. A total of 61 patients (39 females and 22 males; age 61.9: range 49-75 years) were operated. Duration of symptoms before surgery averaged 9.6 months (range 3.5-14 months). The patients were followed for an average of 46 months (range 24-64 months). The operation included an arthroscopic evaluation, acromioplasty with resection of the lateral clavicular end, resection of the acromioclavicular joint and where necessary biceps tenodesis. The cuff defect was repaired by transfer of half thickness anterior deltoid-flap (3 cm x 5 cm) into the defect. All patients were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily life, range of motion, strength and satisfaction. The patients subjectively rated their results--49 (80%) excellent or good outcome, seven moderate and five poor. Preoperatively, the Constant amounted 33.5 +/- 7.74 points. At follow-up, the score significantly increased to 77.57 +/- 19.74 points. The acromiohumeral distance increased from 5.1 +/- 1.4 mm to 9.1 +/- 1.5 mm. Pain free flexion improved from an average 90 degrees to an average 165 degrees (P < 0.01), and abduction improved from an average 110 degrees to an average 160 degrees (P < 0.01). The mean external rotation increased from 40 degrees to 65 degrees (P < 0.01), and internal rotation increased from 50 degrees to 70 degrees (P = 0.06). In the MRI and ultrasound examination, all patients had intact flap, except the three patients with flap necrosis. There were eight complications--three haematomas, two superficial wound infections which did not influence the outcome, and three fibrotic transformation after an early aseptic necrosis of the deltoid flap, which were re-operated. This technique is easy to perform, and it is possible to obtain a satisfactory outcome after repair of massive tears of the rotator cuff. A substantial decrease of pain, increased stability, an increase range of motion and strength can be achieved, with proper rehabilitation.

The use of trochanteric slide osteotomy in the treatment of displaced acetabular fractures.

From January 2003 and February 2006, 31 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a single approach, involving a straight lateral incision centered over the greater trochanter, trochanteric osteotomy and dislocation of the femoral head. The mean age of the patients was 48 (range 20-74 years) with a mean follow up 24 months (range from 20 to 42 months). Ten fractures were classified as simple, and 21 as complex fractures. The mean time to surgery was 4.5 days (range from 0 to 14 days). Mean operating time was 118 min (range 52-168). Five patients presented with posterior dislocation of the hip joint at the time of initial presentation. The trochanteric fragment was fixed with three 3.5mm cortical screws. Congruent reduction was achieved in all patients and all osteotomies healed within 5 months. Clinical evaluation was based on the modified Merle d'Aubigne and Postel scoring. Motor strength of abduction was evaluated according to the Medical Research Council grading. Clinical scoring was excellent to good in 24%. The strength of the abductors was grade 0/5 in a patient with Brooker's class IV heterotopic ossification, and 3/5 in the two patients with necrosis of the femoral head. There were five patients with grade 4/5 and the 5/5 in the rest. Complications included two segmental femoral head necrosis, one of them combined with necrosis of the weight bearing acetabular dome area. These patients required total hip replacement. Mild heterotopic ossification grade II was seen in one patient and significant (grade IV), in another patient. Two patients developed superficial wound infection over the trochanteric area and another two patients persistent pain due to irritation caused by the screws. One patient developed peroneal nerve palsy which resolved 3 months after the surgery. The trochanteric slide osteotomy can enhance the exposure of the whole acetabulum and the femoral head. This allows better evaluation of any osteochondral lesions, intra-articular bony fragments and fracture steps, providing a more accurate reduction and easier fixation of the acetabular fracture.

Degenerative changes of the interface membrane as a possible reason for prosthesis loosening.

OBJECTIVE: The aim of the present study was to perform a comparative evaluation of septic and aseptic interface membranes, assessing histological features, inflammatory infiltrate, and expression of inflammatory cytokines. METHODS: Septic and aseptic interface membranes from 102 patients were examined by histology, histochemistry, and immunohistochemistry (tissue arrays). The cell subpopulations were characterized by quantification of CD3, CD4, CD8, CD20, and CD163 positive cells. Additionally, a semiquantitative evaluation of inflammatory cytokines (TNFalpha, TGF-beta1, IL-1, IL-6, CRP, MMP-1, MMP-6) was performed to complete the analysis of inflammatory infiltrates. RESULTS: The histological analysis revealed three different types of aseptic interface membranes: wear particle, degenerative, and mixed type. The expression of inflammatory molecules did not differ between septic and wear particle interface membranes. Significantly lower expression of cytokines, MMPs and CRP was observed, however, in degenerative interface membranes compared to other types. No expression of TNFalpha was observed in the degenerative interface membranes. Over 88% of patients with degenerative interface membranes had had a clinical record of osteoarthritis. CONCLUSION: Aseptic interface membranes were represented by wear particle, degenerative and mixed type. The expression of inflammatory factors in wear particle type is similar to this in septic membranes and can contribute to the bone destruction and prosthesis loosening. These factors seem not to play a major role in the degenerative membranes.

Computer-assisted surgery in revision total knee arthroplasty: early experience with 46 patients.

Use of the OrthoPilot navigation system (B. Braun Aesculap, Tuttlingen, Germany) in navigated revision surgery allows for precise alignment of components, restoration of the joint line, balance of the gaps, and filling of the bony defects by facilitating selection of appropriate implant sizes and wedges. Our study results confirm these benefits through clinical and radiologic evaluation of the first 46 cases in our series in which the system was used. Continuous feedback from the system during surgery confirms that the surgeon is using proper technique. The OrthoPilot navigation system simplifies revision surgery and helps produce successful patient outcomes.

Comparative analysis of the morphologic structure of quadriceps and patellar tendon: a descriptive laboratory study.

PURPOSE: The difference in ultimate strength between the quadriceps and patellar tendon could be reflected by different morphologic features. METHODS: Standardized samples of quadriceps and patellar tendons were harvested from 20 cadavers and were investigated via light and electron microscopy, immunohistochemistry, and morphometry. The thickness of collagen fibrils, fibril-interstitium ratio, density of blood vessels, density of fibroblasts, and distribution of collagen fibrils were analyzed. RESULTS: In comparison with the patellar tendon, the quadriceps tendon showed a significantly higher fibril-interstitium ratio (P = .0004) and a higher fibroblast density (P = .0011). No differences regarding the thickness of collagen fibrils, density of blood vessels, and distribution of fibrils were found. CONCLUSIONS: The quadriceps tendon graft can provide approximately 20% more collagen than the patellar tendon graft with the same thickness. This fact can play an important role in the better ultimate strength of the quadriceps tendon. CLINICAL RELEVANCE: The detailed anatomic description of the quadriceps tendon and patellar tendon explains the difference in their ultimate strength.

Morphologic and histologic comparison between the patella and hamstring tendons grafts: a descriptive and anatomic study.

PURPOSE: Morphologic and histologic comparison of patella and hamstring tendon grafts. METHODS: Hamstring tendons (semitendinosus and gracilis) and patellar tendons were taken from 20 cadaveric knees and were investigated by using light and electron microscopy, immunohistochemistry, and morphometry. The thickness of collagen fibrils, fibril/interstitum ratio, density of blood vessels, density of fibroblasts, and distribution of the collagen fibrils were analyzed. RESULTS: The semitendinosus and gracilis tendons provide 20% and 30% more fibril/interstitum ratio compared with the patella tendon (P = .0056 and .0028). Also, the density of fibroblasts was 50% and 35% more (P = .0061 and .0050). No differences regarding the thickness of the collagen fibrils, density of blood vessels, and distribution of the fibrils were found. CONCLUSIONS: Both semitendinous and gracilis tendons provide significantly more density of collagen fibrils as well as density of fibroblasts in comparison with patellar tendons. These findings provide a potential advantage of the hamstrings group on better remodelling and regeneration of the tissue. CLINICAL RELEVANCE: These grafts have been used as autografts for anterior cruciate ligament reconstruction. Despite the interest on these tendons, their microscopic structure has not been sufficiently investigated yet.