Internal fixation of patellar apex fractures with the basket plate: 25 years of experience.

INTRODUCTION: Comminution of the patellar apex is amenable to internal fixation by standard techniques and usually requires partial patellectomy. In our institution, multifragmentary fractures of the distal pole are treated with the basket plate, which is shaped to fit the geometry of the patellar apex. This implant has been used in our institution for over 25 years. The aim of this study was to evaluate long-term results of internal fixation of comminuted fractures of the patellar apex with the basket plate. MATERIALS AND METHODS: A total of 142 patients with fracture of the distal pole of the patella were treated with the basket plate between 1988 and 2013. Functional evaluation was conducted using the modified Cincinnati knee rating system. A total of 98 patients were available for late functional evaluation. RESULTS: There were no infections or implant-related problems during the follow-up period. All fractures healed within 8 to 10 weeks. There were three cases of early revision because of improper use of the implant and incorrect indication. Functional outcome following internal fixation with the basket plate was excellent in 80 patients and good in 18; there were no poor results. CONCLUSION: Internal fixation with the basket plate is recommended for management of multifragmentary fractures of the patellar apex because this method enables early, unrestricted knee motion, and provides reliable healing and good functional outcome. This method is an alternative to partial patellectomy and is considered a patella-saving procedure; therefore, the use of the basket plate is strongly recommended for the treatment of distal pole fractures.

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

INTRODUCTION: Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. MATERIALS AND METHODS: A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. RESULTS: Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. CONCLUSION: MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.

Soluble type III TGFß receptor in diagnosis and follow-up of patients with breast cancer.

Type III transforming growth factor (TGFß) receptor (TGFßrIII) modulates TGFß superfamily signaling. Its tumor tissue expression is downregulated in human breast cancer. We determined (indirect ELISA) plasma levels of the soluble receptor (sTGFßrIII) in 47 women with breast cancer (AJCC stages 0-IIB) (cases) pre-surgery and over two months after the surgery, and in 36 healthy women (controls). Plasma sTBFßrIII was lower in cases than in the controls (age-adjusted difference -29.7 ng/mL, p < 0.001), and discriminated between disease and health (sensitivity and specificity 100% at 16.6 ng/mL). With adjustment for age, AJCC stage, lymph node involvement, HER2 and hormone receptor status, higher pre-surgery sTBFßrIII was associated with better progression-free survival (HR = 0.68, 95%CI 0.49-0.89, p = 0.004). An increasing trend in plasma sTBFßrIII was observed over 2 months after the surgery (0.6% increase/day, p < 0.001), consistently across the patient subsets. Data suggest a high potential of plasma sTBFßrIII as a novel diagnostic and prognostic biomarker in breast cancer.

A correlation of peak height velocity and olecranon apophysis ossification assessed by ultrasound.

Peak height velocity (PHV) is defined as the period of the fastest growth during puberty. An ability to predict annual growth and the timing of PHV may provide an opportunity to modify treatment of many diseases and conditions of the skeletal system such as scoliosis and kyphosis, slipped capital femoral epiphysis, leg length inequality and adolescent Blount's disease. There is a good correlation of peak height velocity and skeletal age determined from the radiographic assessment ofolecranon. To avoid radiation, we tested value of olecranon ultrasound in prediction of annual growth and peak height velocity. In present study, using ultrasound, we made a classification of olecranon apophysis in 7 levels (0-6) according to the amount of cartilage left unossified. In 134 healthy children, aged from 10 to 15, evaluation of olecranon sonographs and staging was done by two observers in two spaced time intervals. Calculation of intra-examiner and inter-examiner agreement presented satisfactory reliability (intraclass correlation coefficient for Rater 1 = 0.967 and Rater 2 = 0.836) and very good reproduciblity (Cohen's Kappa 0.85). We measured increase in height, during six month period, for 54 children, who were classified by ultrasound in levels from 0 to 6. The greatest growth was noted in children classified as level 4. Olecranon apophysis maturity level 4, assessed by ultrasound could correspodent to peak height velocity.

Primary malignant melanoma of gallbladder.

Gallbladder primary malignant melanoma (GPMM) is a rare and controversial entity. The existing controversy on the subject appears mainly because of the lack of definitive objective criteria of primitivity. Objective criteria proposed by the specific literature for distinguishing GPMM from secondary gallbladder melanoma include the exclusion of previous primitive melanoma, absence of synchronous involment of other sites, the unicity of lesion, its polipoid or papilary shape and the presence of a junctional melanocitary component. After laparoscopic cholecystectomy in one of our patients, dark polypus inside the gallbladder was found. A malignant melanoma was diagnosed according to all five criteria for GPMM.

Detecting Baker's cyst: venous duplex scanning in ambulatory setting.

Popliteal cyst, also called Baker's cyst, is a popliteal fossa enlargement filled with synovial fluid. Baker's cysts can be symptomatic and cause considerable pathologies such as thrombophlebitis, compartment syndrome and even nerve entrapment. It is the most common nonvascular pathology seen in the popliteal fossa but clinically indistinguishable from deep vein thrombosis. The aim of the present study was to evaluate venous duplex scanning in detecting and distinguishing complicated Baker's cyst and deep vein thrombosis in outpatient setting. Medical records of all patients undergoing venous duplex scanning during 2008 and 2009 to rule out deep vein thrombosis were reviewed. Ten patients having undergone ultrasonography examination were found to have complicated Baker's cyst. Baker's cysts are a rather common condition. When presenting with swollen and painful calf, it is impossible to differentiate it from deep vein thrombosis by simple clinical examination. Venous duplex scanning of lower extremity was found to be a useful imaging modality for detection of Baker's cysts, deep vein thrombosis and associated pathology.

Local recurrence of primary non-ampullary adenocarcinoma of duodenum after surgical treatment--a case report and a literature review.

Worldwide there is no general attitude on optimal surgical procedure in treatment of primary non-ampullary adenocarcinoma of duodenum, especially for early stage of duodenal cancer. Some authors prefer local excision and segmental resection while others rather perform duodenopancreatic resection, even in the case of early stage of duodenal cancer with aim to avoid tumor recurrence. In this paper we present a rare clinical course of a 60-year-old male patient with an endoscopically and pathohistologically proven early stage duodenal cancer that was treated by wide local excision. Three years after operation, control endoscopy showed "flat" polyp in the duodenum and radical duodenopancreatic resection was performed. Pathohistological examination of resected specimen showed cancer that had spread throughout the duodenal wall with metastases in the regional lymph nodes. According to our findings and literature review we gave some direction concerning the optimal diagnostic and surgical procedure for this rare tumor.

Endoscopic extraperitoneal inguinal hernia repair with double mesh: indications, technique, complications, and results.

Although totally extraperitoneal laparoscopic hernia repair has the same benefits attributed to the traditional preperitoneal prosthetic surgical repair, this procedure is not used widely because of perceived difficulty in dissection. Since one of the most common causes of hernia recurrence in this procedure is inadequate lateral inferior and medial inferior mesh fixation, we have introduced a double-mesh technique in an effort to reduce the rate of recurrence. Our procedure is a variation of the totally extraperitoneal laparoscopic inguinal hernia repair and provides a more secure inguinal floor by adjusting the second mesh to the area of weakness. We describe the laparoscopic inguinal hernia repair by the extraperitoneal double-mesh technique performed in 53 selected patients with very large indirect hernias and extremely large bilateral or recurrent hernias. The mean operative time was 74 minutes for unilateral hernias and 110 minutes for bilateral hernias. The median follow-up time was 65 months (range, 9-97 months) with no recurrences, neuralgia, or bleeding complications. We believe that this technique offers perfect positioning of the meshes and provides the most secure inguinal floor. Therefore, the method is presented for consideration in the laparoscopic repair of large indirect, direct, or recurrent hernias.