Antibacterial Bioactive Glass, S53P4, for Chronic Bone Infections - A Multinational Study.

Osteomyelitis is an infectious process in bone that occasionally leads to bone destruction. Traditionally, the surgical treatment procedure is performed in combination with systemic and local antibiotics as a two-stage procedure that uses autograft or allograft bone for filling of the cavitary defect. Bioactive glass (BAG-S53P4) is a bone substitute with proven antibacterial and bone bonding properties.One hundred and sixteen patients who had verified chronic osteomyelitis was treated using BAG-S53P4 as part of the treatment. Most of the patients had previously undergone numerous procedures, sometimes for decades. A register of patient data obtained from 11 centers from Finland, Italy, the Netherlands, Germany, Azerbaijan and Poland was set-up and continuously maintained at Helsinki University Central Hospital.The location of the osteomyelitis was mainly in the tibia followed by the femur and then the calcaneus. The median age of the patients was 48 years (15-87). The patients were either treated according to a one-stage procedure without local antibiotics (85 %) or by a two-stage procedure using antibiotic beads in the first procedure (15 %). The minimum follow-up was 1 year (12-95 months, median 31).The cure rate was 104/116, the total success rate 90 % and most of the patients showed a rapid recovery.The study shows that (BAG-S53P4) can be used in a one-stage procedure in treatment of osteomyelitis with excellent results.

MRI-guidance in percutaneous core decompression of osteonecrosis of the femoral head.

OBJECTIVES: The purpose of this study was to evaluate the usefulness of MRI-guidance for core decompression of avascular necrosis of the femoral head. MATERIALS AND METHODS: Twelve MRI-guided core decompressions were performed on patients with different stages of avascular necrosis of the femoral head. The patients were asked to evaluate their pain and their ability to function before and after the procedure and imaging findings were reviewed respectively. RESULTS: Technical success in reaching the target was 100 % without complications. Mean duration of the procedure itself was 54 min. All patients with ARCO stage 1 osteonecrosis experienced clinical benefit and pathological MRI findings were seen to diminish. Patients with more advanced disease gained less, if any, benefit and total hip arthroplasty was eventually performed on four patients. CONCLUSIONS: MRI-guidance seems technically feasible, accurate and safe for core decompression of avascular necrosis of the femoral head. Patients with early stage osteonecrosis may benefit from the procedure. KEY POINTS: • MRI is a useful guidance method for minimally invasive musculoskeletal interventions. • Bone drilling seems beneficial at early stages of avascular necrosis. • MRI-guidance is safe and accurate for bone drilling.

MRI-guided percutaneous retrograde drilling of osteochondritis dissecans of the talus: a feasibility study.

OBJECTIVES: The purpose of this study was to evaluate the feasibility of MRI guidance for percutaneous retrograde drilling in the treatment of osteochondritis dissecans of the talus (OCDT). METHODS: Four patients, one juvenile and three adults, with one OCDT lesion each and persisting ankle pain after conservative treatment, were treated with MRI-guided retrograde drilling. All lesions were stable and located in the middle or posterior medial third of the talar dome. Pain relief and the ability to return to normal activities were assessed during clinical follow-up. MRI and plain film radiographs were used for imaging follow-up. RESULTS: Technical success was 100% with no complications and with no damage to the overlying cartilage. All patients experienced some clinical benefit, although only one had complete resolution of pain and one had a relapse leading to surgical treatment. Changes in the pathological imaging findings were mostly very slight during the follow-up period. CONCLUSIONS: MRI guidance seems accurate, safe and technically feasible for retrograde drilling of OCDT. Larger series are needed to reliably assess its clinical value. KEY POINTS: • MRI serves as a useful guidance method for numerous mini-invasive applications. • Retrograde drilling is a cartilage-sparing alternative in the treatment of osteochondritis dissecans. • MRI guidance seems feasible for treatment of osteochondritis dissecans of the talus.

MRI-guided biopsy and fine needle aspiration biopsy (FNAB) in the diagnosis of musculoskeletal lesions.

OBJECTIVES: The purpose of this study was to evaluate the diagnostic performance of magnetic resonance imaging (MRI) guided musculoskeletal biopsy and the value of fine needle aspiration biopsy (FNAB) when combined with histologic biopsy. MATERIALS AND METHODS: A total of 172 biopsies were performed under MRI guidance, 170 were histologic biopsies. In 112 cases, a fine needle aspiration biopsy was also performed. In two cases, a stand-alone FNAB was performed. The diagnostic performance was evaluated retrospectively by comparing the histopathologic and cytologic diagnosis with the current or final diagnosis after at least one year of clinical and imaging follow-up. A 0.23 T open MRI scanner with an interventional stereotactic guidance system was used. RESULTS: The overall diagnostic accuracy of MRI guided biopsy was 0.95, sensitivity 0.91, specificity 0.98, positive predictive value (ppv) 0.97 and negative predictive value (npv) 0.93. The diagnostic accuracy of trephine biopsy alone was 0.93, sensitivity 0.89, specificity 0.98, ppv 0.97 and npv 0.91 and accuracy for FNAB alone was 0.85, sensitivity 0.80, specificity 0.90, ppv 0.89 and npv 0.82. CONCLUSIONS: MRI guidance is a feasible and accurate tool in percutaneous musculoskeletal biopsies. Fine needle biopsy is a useful low-cost supplement to histologic biopsy.

MRI-guided percutaneous retrograde drilling of osteochondritis dissecans of the knee.

OBJECTIVE: The purpose of this study was to evaluate the feasibility of a new method for osteochondritis dissecans (OCD) treatment. MATERIALS AND METHODS: Ten OCD lesions of the knee unresponsive to conservative management were treated with MRI-guided percutaneous retrograde drilling to reduce symptoms and promote ossification of the lesion. All lesions were located in distal femoral condyles. Only stable OCD lesions were included (preprocedural MRI grade I or II). Five lesions were of juvenile type and five lesions were of adult type OCD. All the patients had severe limitation of activity due to the OCD-related pain. By using a 0.23 T open MRI scanner and spinal anesthesia, percutaneous retrograde drilling of the OCD lesions was performed (3 mm cylindrical drill, one to three channels). Optical tracking and MRI imaging were used to guide instruments during the procedure. Mean postprocedural clinical follow-up time was 3 years. Eight patients had a post-procedural follow-up MRI within 1 year. RESULTS: All the OCD lesions were located and drilled using the 0.23 T open MRI scanner without procedural complications. All the patients had pain relief, mean visual analog score (VAS) declined from 6 to 2. Follow-up MRI showed ossification in all lesions. Eight patients could return to normal physical activity with no or minor effect on function (Hughston score 3-4). Treatment failed in two cases where the continuation of symptoms led to arthroscopy and transchondral fixation. CONCLUSION: [corrected] MR-guided retrograde OCD lesion drilling is an accurate, feasible, and effective cartilage-sparing techique in OCD management.

Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests.

BACKGROUND: This study was designed to assess the sensitivity, specificity, and interobserver reliability of the hook test and the stress test for the intraoperative diagnosis of instability of the distal tibiofibular joint following fixation of ankle fractures resulting from supination-external rotation forces. METHODS: We conducted a prospective study of 140 patients with an unstable unilateral ankle fracture resulting from a supination-external rotation mechanism (Lauge-Hansen SE). After internal fixation of the malleolar fracture, a hook test and an external rotation stress test under fluoroscopy were performed independently by the lead surgeon and assisting surgeon, followed by a standardized 7.5-Nm external rotation stress test of each ankle under fluoroscopy. A positive stress test result was defined as a side-to-side difference of >2 mm in the tibiotalar or the tibiofibular clear space on mortise radiographs. The sensitivity and specificity of each test were calculated with use of the standardized 7.5-Nm external rotation stress test as a reference. RESULTS: Twenty-four (17%) of the 140 patients had a positive standardized 7.5-Nm external rotation stress test after internal fixation of the malleolar fracture. The hook test had a sensitivity of 0.25 (95% confidence interval, 0.12 to 0.45) and a specificity of 0.98 (95% confidence interval, 0.94 to 1.0) for the detection of the same instabilities. The external rotation stress test had a sensitivity of 0.58 (95% confidence interval, 0.39 to 0.76) and a specificity of 0.96 (95% confidence interval, 0.90 to 0.98). Both tests had excellent interobserver reliability, with 99% agreement for the hook test and 98% for the stress test. CONCLUSIONS: Interobserver agreement for the hook test and the clinical stress test was excellent, but the sensitivity of these tests was insufficient to adequately detect instability of the syndesmosis intraoperatively.

Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study.

BACKGROUND: This study was designed to assess whether transfixion of an unstable syndesmosis is necessary in supination-external rotation (Lauge-Hansen SE/Weber B)-type ankle fractures. METHODS: A prospective study of 140 patients with unilateral Lauge-Hansen supination-external rotation type 4 ankle fractures was done. After bony fixation, the 7.5-Nm standardized external rotation (ER) stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. If the stress test was positive, the patient was randomized to either syndesmotic transfixion with 3.5-mm tricortical screws or no syndesmotic fixation. Clinical outcome was assessed using the Olerud-Molander scoring system, RAND 36-Item Health Survey, and Visual Analogue Scale (VAS) to measure pain and function after a minimum 1-year of followup. RESULTS: Twenty four (17%) of 140 patients had positive standardized 7.5-Nm ER stress tests after malleolar fixation. The stress view was positive three times on tibiotalar clear space, seven on tibiofibular clear space, and 14 times on both tibiotalar and tibiofibular clear spaces. There was no significant difference between the two randomization groups with regards to Olerud-Molander functional score, VAS scale measuring pain and function, or RAND 36-Item Health Survey pain or physical function at 1 year. CONCLUSION: Relevant syndesmotic injuries are rare in supination-external rotation ankle fractures, and syndesmotic transfixion with a screw did not influence the functional outcome or pain after the 1-year followup compared with no fixation.

Arthroscopic Bankart repair: results and risk factors of recurrence of instability.

The purpose of this study was to discover the recurrence rate of instability after arthroscopic Bankart repair and to assess risk factors for recurrence, with special interest in bone defects seen on preoperative plain radiographs. Consecutive unselected patients (182; 186 shoulders) with recurrent instability (redislocation or subluxation) after initial traumatic anteroinferior shoulder dislocation were operated on using arthroscopic suture-anchor repair at our institution during 2000-2005. Demographic data and details of the operation were retrospectively reviewed from case records, and glenoid and Hill-Sachs lesions were assessed from preoperative radiographs. The primary outcome measure was recurrence of instability (redislocation or subluxation). Functional results were assessed via Oxford instability scores and subjective shoulder values (SSVs), using postal questionnaires. One hundred and seventy-four shoulders (170 patients) were assessed after a median of 51 (range 24-95) months' follow-up. The recurrence rate of instability was 19% (redislocation 9% and subluxation 10%). Eighteen patients (10%) needed further surgery. The mean Oxford instability score was 21 and the mean SSV 84%. The recurrence rate among patients aged 20 or less was 44% and among patients over 20, 12%. Multivariate logistic regression analysis showed that age ≤20 (OR 8.8), Hill-Sachs lesion (OR 3.3), glenoid erosion (OR 2.7) and length of follow-up (OR 1.5) were the most important risk factors for recurrence. Young age is the most important risk factor for recurrence of instability after arthroscopic suture-anchor Bankart repair. Bone defects seen in preoperative plain radiographs are less important and more accurate imaging is needed to reveal their true role for recurrence of instability.

Acromial shape in asymptomatic subjects: a study of 305 shoulders in different age groups.

BACKGROUND: It has been reported that acromial morphology and age have an independent association with rotator cuff pathology. In a recent study, we found the acromial angle of patients with stage III impingement syndrome (tear in the rotator cuff, according to the Neer classification of shoulder impingement syndrome) to be significantly greater than the acromial angle of their age-matched healthy controls. PURPOSE: To find out if acromial shape also changes, i.e., becomes more curved with age, in shoulders without any rotator cuff problems or previous shoulder surgery. MATERIAL AND METHODS: Standard supraspinatus outlet view (SOV) was obtained from both shoulders of healthy persons with no shoulder-related problems or previous shoulder surgery (n = 305; 36 SOVs for subjects aged 21-30 years, 60 for 31-40 years, 67 for 41-50 years, 52 for 51-60 years, 48 for 61-70 years, and 42 for over 71 years of age). Acromial angle, tilt, and the type of the acromion were evaluated. RESULTS: There were no statistically significant differences in the evaluated morphological parameters between the different age groups. CONCLUSION: Our results suggest that the shape of the acromion does not change with age in individuals who do not have any rotator cuff pathology. According to our results, the changes in acromial morphology seem to be similar in each age group.

Two-ring hybrid external fixation of distal tibial fractures: a review of 47 cases.

BACKGROUND: The healing of a metaphyseal fracture line is a major problem in cases of distal tibial fracture treated with external fixation. METHODS: Forty-seven distal tibial fractures treated with two-ring Ilizarov hybrid external fixation (16 AO/OTA type A and 31 type C, 10 open) were followed up. Fracture reduction and union time was evaluated and IOWA and RAND 36-Item Health Survey scores were used to assess functional outcome. RESULTS: Thirty-five fractures united uneventfully in a median time of 20 weeks, but 12 fractures needed additional procedures because of delayed union. According to univariate analysis, the risk factors for a longer time needed for fracture union were translational displacement and current smoking, and the risk factors for reoperation because of delayed union translational displacement fibular fracture fixation, and the number of cigarettes smoked per day. In multivariate analysis, translational displacement was a risk factor for both longer time to fracture union and reoperation and fibular fracture fixation was a risk factor for reoperation. If the translational displacement was less than 3 mm, the reoperation rate was 6%, whereas if the displacement was more than 3 mm, it was 83%. Reoperation was performed on 50% of the patients who underwent fibular fixation and on 15% of the patients who did not undergo fibular fixation. There were only marginal decreases in the range of motion and arthritis scores in the AO/OTA fracture types other than type C3. There were no significant differences in RAND 36 scores between the general Finnish population aged 18 to 64 years and our patients. CONCLUSIONS: Hybrid external fixation of distal tibial fractures is associated with delayed union, which is closely related to the degree of residual translational displacement after reduction. Fixation of an associated fibular fracture does not help to achieve better contact in the tibial fracture and increases the risk of delayed union.

Hook-plate fixation of unstable lateral clavicle fractures: a report on 63 patients.

BACKGROUND: Hook-plate fixation of unstable lateral clavicle fractures has given promising results in previous reports, but numbers of patients have been small. We assessed the results of this technique in 63 patients. PATIENTS AND METHODS: 63 patients with unstable lateral clavicle fractures were operated on at Oulu University Hospital during 1997-2004, using a clavicle hook-plate. Fracture union and complications were assessed retrospectively from case records and radiographs. The subjective part of the Constant score, Oxford shoulder questionnaire data and subjective shoulder value (SSV) were assessed after an average of 3.6 years in 58 patients. 31 patients were reviewed at the outpatient clinic, using complete Constant scores and radiographs of both acromioclavicular joints. RESULTS: 59 fractures united uneventfully. There was 1 case of delayed union and 3 nonunions, but only 1 of these required surgery. Additional complications involved 1 case of infection, 1 frozen shoulder and 3 cases of late fracture medial to the plate. The mean Oxford score was 15, the mean for the subjective part of the Constant score was 32, and the SSV was 86%. INTERPRETATION: Clavicle hook-plate fixation of unstable lateral clavicle fractures results in a good union rate and good shoulder function.

Efficacy of dietary hempseed oil in patients with atopic dermatitis.

BACKGROUND: Hempseed oil is a rich and balanced source of omega-6 and omega-3 polyunsaturated fatty acids (PUFAs). Anecdotal evidence indicated that dietary hempseed oil might be useful in treating symptoms of atopic dermatitis. PATIENTS AND METHODS: Dietary hempseed oil and olive oil were compared in a 20-week randomized, single-blind crossover study with atopic patients. Fatty acid profiles were measured in plasma triglyceride, cholesteryl and phospholipid fractions. A patient questionnaire provided additional information on skin dryness, itchiness and usage of dermal medications. Skin transepidermal water loss (TEWL) was also measured. RESULTS: Levels of both essential fatty acids (EFAs), linoleic acid (18:2n6) and alpha-linolenic acid (18:3n3), and gamma-linolenic acid (GLA; 18:3n6) increased in all lipid fractions after hempseed oil, with no significant increases of arachidonic acid (20:4n6) in any lipid fractions after either oil. Intra-group TEWL values decreased (p=0.074), qualities of both skin dryness and itchiness improved (p=0.027) and dermal medication usage decreased (p=0.024) after hempseed oil intervention. CONCLUSIONS: Dietary hempseed oil caused significant changes in plasma fatty acid profiles and improved clinical symptoms of atopic dermatitis. It is suggested that these improvements resulted from the balanced and abundant supply of PUFAs in this hempseed oil.

Recovery of shoulder joint function after humeral shaft fracture: a comparative study between antegrade intramedullary nailing and plate fixation.

INTRODUCTION: Antegrade intramedullary (IM) nailing of humeral shaft fractures is reported to cause shoulder joint impairment. This retrospective study compared shoulder joint symptoms, range of motion (ROM), and isometric strength after antegrade IM nailing and dynamic compression (DC) plating of humeral shaft fractures. MATERIALS AND METHODS: We compared 29 patients with DC plating and 44 with antegrade IM nailing of their humeral shaft fractures. Shoulder pain, L'Insalata and Constant scores, shoulder joint ROM and isometric shoulder strengths were measured after mean follow-up of 6.2 (1-15) years (DC plating) and 5.5 (2-10) years (IM nailing). RESULTS: Patients had nonsignificantly more shoulder pain after IM nailing than after DC plating. Shoulder scores and isometric strength measurements showed no difference between the groups. Flexion was significantly better after DC plating, but none of the other ROM parameters differed between the groups. The shoulder scores and all ROM and strength parameters of the injured side were significantly lower than on the uninjured side in both groups. CONCLUSIONS: Shoulder joint ROM and strength does not recover to normal after humeral shaft fracture. Antegrade IM nailing if performed properly is not responsible for shoulder joint impairment.

Early revision after hemiarthroplasty and osteosynthesis of cervical hip fracture: short-term function mortality unchanged in 102 patients.

BACKGROUND: There is no consensus on whether osteosynthesis or hemiarthroplasty is preferable in the treatment of cervical hip fractures. Osteosynthesis is associated with more reoperations than hemiarthroplasty but there is little information available on the consequences of these reoperations. PATIENTS AND METHODS: We studied the effect on mortality, hospital stay and functional outcome of revision performed within 4 months of primary surgery with hemiarthroplasty or osteosynthesis for cervical hip fracture. 50 (6%) of 792 patients treated with uncemented Austin-Moore hemiarthroplasty and 52 (13%) of 411 patients with osteosynthesis (86 with two hook pins and 325 with three cannulated screws) had had revision surgery. Control groups matched for age, sex, residential status, walking ability at fracture, type of primary operation and fracture type consisted of patients who had not had a reoperation. RESULTS: Reoperation impaired walking ability and was associated with increased use of walking aids at 4 months in the hemiarthroplasty group and the osteosynthesis group as compared to controls, but did not have any statistically significant effect on residential status. In the hemiarthroplasty group, 4-month mortality was 12% among the reoperated patients and 18% among the controls, while mortality at 1 year was 24% in both groups. The corresponding figures in the osteosynthesis group and controls were 6% and 6% at 4 months, respectively, and 17% and 13% at 1 year. INTERPRETATION: To some extent, reoperation impairs early functional outcome after cervical hip fracture treated by either osteosynthesis or hemiarthroplasty, but does not increase mortality to any significant degree.

Nonbridging external fixation in the treatment of unstable fractures of the distal forearm.

INTRODUCTION: Unstable fractures of the distal forearm often require surgical treatment to restore the normal anatomy and function. We have used a relatively new technique, nonbridging external fixation, in the treatment of these fractures in our hospital during the past few years. Our results are presented here. MATERIALS AND METHODS: Fifty-two patients (41 female, 11 male) with an unstable fracture of the distal forearm were treated using nonbridging external fixation at Oulu University Hospital during 1996-1999. The patients' mean age was 57 years. There were 45 Colles-type fractures, and 7 distal radius fractures had a concomitant distal ulna fracture. Forty-three patients were reviewed after a mean of 16 months of follow-up to assess radiological, functional, and subjective results. RESULTS: The fixation device maintained reduction well during healing, and the final radiological result was good. Range-of-motion and grip strength were restored to levels of 87-98% compared with the uninjured forearm. The subjective result was rated as 8 (mean) on a scale of 0-10. Pin-tract infection was a common complication (19%), but such cases were easily treated with antibiotics. CONCLUSION: Nonbridging external fixation offers an easy, minimally invasive, and reliable technique in the treatment of unstable fractures of the distal forearm.

MR imaging-guided laser ablation of osteoid osteomas with use of optical instrument guidance at 0.23 T.

The purpose of this study was to determine the feasibility and features of low-field MR imaging in performing interstitial laser ablation of osteoid osteomas. Between September 2001 and April 2002, five consecutive patients with clinical and imaging findings suggesting osteoid osteoma and referred for removal of osteoid osteoma were treated with interstitial laser treatment. A low-field open-configuration MRI scanner (0.23 T, Outlook Proview, Philips Medical Systems, Finland) with optical instrument guidance hardware and software was used. Laser device used was of ND-Yag type (Fibertom medilas, Dornier Medizin Technik, Germany). A bare laser fiber (Dornier Medizin Technik, Germany) with a diameter of 400 microm was used. Completely balanced steady-state (CBASS; true fast imaging with steady precession) imaging was used for lesion localization, instrument guidance, and thermal monitoring. A 14-G (Cook Medical, USA) bone biopsy drill was used for initial approach. Laser treatment was conducted through the biopsy canal. All the lesions were successfully localized, targeted, and treated under MRI guidance. All the patients were symptom free 3 weeks and 3 months after the treatment. There was one recurrence reported during follow-up (6 months). The MRI-guided percutaneous interstitial laser ablation of osteoid osteomas seems to be a feasible treatment mode.

Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation.

During 1988-1999 39 unstable fractures of the distal clavicle (Neer 2) were operated on in Oulu University Hospital. Kirschner wire (K-wire) fixation was used in 22 cases and a clavicular hook plate in 17. Shoulder symptoms and function were assessed using self-administered questionnaires devised by L'Insalata et al. (1997), and Constant scoring. Mean follow-up was 6.2 years in the K-wire fixation group and 2.0 years in the clavicular hook plate one. The mean L'Insalata scores were 91 in both groups (92% and 93% of the contralateral side) and the mean Constant scores 84 (95% and 90 (96%) for K-wire fixation and the clavicular hook plate, respectively. Complications commonly occurred with K-wires, which migrated in 12 cases, resulting in loss of reduction in 7 and infection in 3, and 2 cases of non-union. In the clavicular hook plate group, there was 1 complication, a fracture of the clavicle, and 2 cases of non-union. We conclude that shoulder symptoms were reduced and function restored to an adequate level by both methods, but complications were unacceptably frequent when K-wires were used. The clavicular hook plate was better in this respect and it is therefore recommended.