Femoral neck fractures secondary to renal osteodystrophy. Literature review and treatment algorithm.

Pathological fractures after minor trauma in osteopenic patients are not uncommon, but fractures due to hypocalcemic convulsions in patients with renal insufficiency are relatively rare. Though similar cases have been reported in the literature, this type of fracture is still an unusual condition. The complex underlying pathophysiological mechanisms and the poor bone mineral density signify the employment of specific hardware and a different treatment approach, especially in young adults, where the salvage of the femoral head is of utmost importance. The aim of this review is to examine the specific features of the femoral neck fractures in young individuals who suffer from renal osteodystrophy and the treatment algorithm should be followed. The patient's age, the uremic condition, the skeletal maturity and the bone properties in renal osteodystrophy are examined in relation to the priorities in osteosynthesis methods. A conclusive treatment algorithm is proposed where all the relevant parameters are incorporated.

Vascularised fibular graft in the management of femoral head osteonecrosis: twenty years later.

The management of osteonecrosis of the femoral head ranges from symptomatic therapy to total hip replacement. Conservative treatment is effective only in small, early-stage lesions. Free vascularised fibular grafting has provided more consistently successful results than any other joint-preserving method. It supports the collapsing subchondral plate by primary callus formation, reduces intra-osseous pressure, removes and replaces the necrotic segment, and adds viable cortical bone graft plus fresh cancellous graft, which has osseoinductive and osseoconductive potential. Factors predisposing to success are the aetiology, stage and size of the lesion. Furthermore, it is a hip-salvaging procedure in early pre-collapse stages, and a time-buying one when the femoral head has collapsed.

Treatment of pink pulseless hand following supracondylar fractures of the humerus in children.

Although acute vascular injury is a common complication in children with severely displaced supracondylar humeral fractures, the management of patients with a pink pulseless hand still remains controversial. Between 1994 and 2006, 66 children with displaced supracondylar fractures of the humerus were treated. Five patients had an absence of the radial pulse with an otherwise well perfused hand. In one patient, radial pulse returned after closed reduction of the fracture. In four patients, open reduction and vascular exploration was required. Three patients had brachial artery occlusion because of thrombus formation. Thrombectomy was performed, which led to the restoration of a palpable radial pulse. In one patient with open fracture, brachial artery contusion and spasm were found, and treated by removal of adventitia. Surgical exploration for the restoration of brachial artery patency should be performed, even in the presence of viable pink hand after an attempt at closed reduction.

Functional outcome after excision of heterotopic ossification about the knee in ICU patients.

The objective of this study was to evaluate the degree of improvement in the range of movement in the knee joint, sitting ability, and overall ambulation in patients with heterotopic ossification of the knee joint who underwent surgical excision of ectopic bone. Between 1999 and 2006, 14 patients (23 joints) with significant heterotopic ossification of the knee joint that required surgery were evaluated. We compared the range of movement in the knee joint, sitting ability, and overall ambulation in the preoperative and postoperative periods using the Fuller and Keenan classification systems. Range of movement increased in 82% of cases (19 knee joints). Sitting ability improved in 13 patients (93%). Postoperatively, ambulation in eight patients (57%) was remarkably superior. In conclusion, resection of heterotopic ossification may significantly improve the range of movement in the knee joint, sitting ability, and overall ambulation.

Anatomic variations of the median nerve in carpal tunnel release.

Carpal tunnel syndrome (CTS) is a well-known clinical entity. Release of the transverse carpal ligament is considered to be the treatment of choice. Both open and endoscopic release of the transverse carpal ligament in CTS has yielded satisfactory results. Although these procedures are very common in surgical practice, inadequate release and intraoperative damage to neural elements are very frustrating complication for both the patient and the surgeon. The purpose of this study was to demonstrate incidental intraoperative findings of variations of the standard median nerve anatomy. We obtained incidental intraoperative identification of median nerve variations in 110 consecutive patients operated with open release of the transverse carpal ligament in CTS. Using the Amadio classification, we found intraoperatively variations of median nerve at the wrist in 11 patients. In three patients, there was an aberrant sensory branch arising from the ulnar side of the median nerve and piercing the ulnar margin of the transverse carpal ligament. Neural variations arising from the ulnar aspect of the median nerve were common and could be a cause of iatrogenic injury during endoscopic or open release. Surgeons should be aware of anomalous branches, which should be recognized and separately decompressed if needed.

A new technique of autogenous conduits for bridging short nerve defects. An experimental study in the rabbit.

BACKGROUND: [corrected] Nerve grafting is the most reliable used procedure to bridge a neural defect, but it is associated with donor site morbidity. In experimental surgery the search for an optimal nerve conduit led to the use of biological and artificial material. Nerve regeneration through epineural conduits for bridging short nerve defect was examined. METHODS: Four groups including 126 New Zealand rabbits were used. There were 3 study groups (A, B and C) and 1 control group (D). A 10-mm long sciatic nerve defect was bridged either with 3 variations of an epineural flap (Groups A, B and C) or with a nerve graft (Group D). Animals from all groups were examined 21, 42 and 91 days postoperatively to evaluate nerve regeneration employing light microscopy and immunocytochemistry. Nerve regeneration was studied in transverse sections at 3, 6 and 9 mm from the proximal stump. Using muscle stimulator the gastrocnemius contractility was examined at 91 days post surgery in all groups. FINDINGS: Immunohistochemical and functional evaluation showed nerve regeneration resembling the control group, especially in group A, were an advancement epineural flap was used. CONCLUSION: An epineurial flap can be used to bridge a nerve defect with success.

Complications in limb-lengthening procedures: a review of 49 cases.

The purpose of this study was to examine the nature and number of complications relative to magnitude of limb lengthening. Results and complications of 50 limb-lengthening procedures were analyzed. There were 49 patients. Mean age was 21 years (range, 7-48 years). Lengthening was performed in 24 femora, 18 tibiae, 4 humerii, 3 radii, and 1 ulna. Average length gained was 5 cm (range, 3-15 cm) at average follow-up of 48 months (range, 12-76 months). Desired length was accomplished in all but 1 patient. The 69 complications varied in severity, but only 5 of these significantly impaired end results. The most serious complications occurred in patients with >30% bone lengthening. Patients with <15% lengthening had a significantly decreased complication rate. The healing index was lower in children. We conclude that incidence and severity of complications after limb-lengthening procedures are significantly influenced by relative lengthening of bone.

Reinnervation after end-to-side nerve coaptation in a rat model.

We assessed the effectiveness of end-to-side nerve coaptation by evaluating the extent of reinnervation and the integrity of the donor nerve in the rat. Fifty-six Sprague-Dawley rats were randomly divided into "fresh" and "predegenerated" (delayed) repair groups with or without a window in the perineurium. The right peroneal nerve was cut and sutured to the tibial nerve in an end-to-side fashion. Two and 3 months postoperatively, we measured the nerve conduction velocity (NCV) of the peroneal and tibial nerves, took dry muscle weights, and performed histologic studies. Peroneal NCV recovered up to 71% (2 mo) and 79% (3 mo), and tibial NCV recovered up to 88% (2 mo) and 91% (3 mo). The latter results indicate that this procedure had a slightly negative effect on donor tibial NCV. Dry weight of the tibialis anterior muscle returned to 60% (2 mo) and 82% (3 mo) of that of the contralateral side. Histologic results showed that there were numerous regenerating axons in the distal end of the peroneal nerve. Presence of a window in the perineurium improved the histologic profile significantly.

Treatment of avascular necrosis of the femoral head with vascularized fibular transplant.

Two hundred twenty-eight hips in 187 patients with avascular necrosis of the femoral head were treated with vascularized fibular transplant from March 1989 to March 2000. The etiologic factors associated with the disease included corticosteroids in 84 patients (44%; 101 hips, trauma in 25 patients (13%; 29 hips), alcohol abuse in 24 patients (12%; 28 hips), and 41 hips (18%) were classified as idiopathic. Systemic disorders, including systemic lupus erythematosus, sickle cell anemia, inflammatory bowel disease, pregnancy, and dysbaric disease were observed in 12, nine, four, three, and one hip(s), respectively. Of the 228 hips operated on, 184 hips (152 patients) were assessed postoperatively with followup ranging from 1 to 10 years (mean, 4.7 years). Using the Steinberg classification system, 39 hips (21%) were in Stage II; 45 hips (25%) were in Stage II; 77 hips (42%) were in Stage IV; and 23 hips (12%) were in Stage V. Of the 184 hips treated, 101 (54%) remained stable postoperatively, whereas 69 (38%) had progression, and 14 hips (8%) were converted to total hip arthroplasty. Of the 69 hips that had progression, 44 (64%) did not progress until 6 to 10 years after the procedure, whereas 25 (36%) progressed within the first 5 years postoperatively. The best results were obtained in patients with Stage II osteonecrosis in whom 95% of the hips did not progress postoperatively. In contrast, only 39% of the hips in patients with Stage V osteonecrosis remained stable. Preoperative and postoperative clinical evaluation using the Harris hip score showed an increase from 85 to 96 points in hips with Stage II disease; from 74 to 91 points in hips with Stage III disease; from 69 to 85 points in hips with Stage IV disease; and from 61 to 76 in hips with Stage V disease. The current results show that the vascularized fibular graft is an excellent procedure for the precollapse stages and a valuable alternative for patients with Stages III, IV, and V of the disease.

Multimodal imaging quantitation of the lesion size in osteonecrosis of the femoral head.

Early diagnosis of osteonecrosis of the femoral head is important for initiating early treatment, which is associated with a more favorable outcome for patients. Confusion in evaluating the severity of the disease, and the clinical outcome after treatment partially is attributed to the use of various staging systems that are based on qualitative rather than quantitative criteria. At the authors' institution, 45 patients (77 hips) with osteonecrosis of the femoral head were evaluated using a multimodal imaging approach that included conventional radiography, bone scintigraphy, and magnetic resonance imaging. A computerized image analysis program that allowed quantification of the lesion size on radiographs and magnetic resonance images was used. Measurements of the extent of involvement on radiographs and selected serial magnetic resonance images were compared in 33 hips (42.9%) before collapse versus 44 hips (57.1%) after collapse. The size of the necrotic lesion varied significantly according to the specific stage of disease. Quantification of the lesion during the course of the disease provided a record of the progression of osteonecrosis, despite a spurious stability in staging. In general, conventional radiography closely approximated measurements of the lesion size obtained by magnetic resonance imaging. Bone scintigraphy and magnetic resonance imaging were well suited for detection of osteonecrosis at an early stage. Finally, precise quantification of the lesion size was an optimal preoperative means for evaluating the extent of involvement of the femoral head in the early and advanced stages of osteonecrosis.

Optimizing free fibular grafting in femoral head osteonecrosis: the Ioannina aiming device.

The extracapsular placement of a vascularized fibular graft in the subchondral region of the femoral head now is a widely accepted method for treating patients with osteonecrosis of the femoral head. The effectiveness of the fibular graft seems to be dependent on precise placement in a biologically and anatomically relevant site within the femoral head. The current authors present the Ioannina technique for application of a new computer-aided design and computer-aided manufacturing process in the treatment of osteonecrosis of the femoral head using free vascularized fibular transplantation. The objective was to develop a computer-assisted design and manufacturing system for an accurate and easier approach to the necrotic area in the femoral head. The Ioannina technique uses serial computed tomography scans of the proximal femur to identify the configuration of the proximal femur, and the size, location, and configuration of the lesion using a computer-aided design and computer-aided manufacturing process. Optimal graft placement is determined and a guide wire canal is drilled into an patient-specific aiming device. In this process, identification of the optimal graft location is related to achieving that location surgically. The more arbitrary placement of the graft during conventional fibular graft surgery leads to accurate graft placement in only 55% of the patients, whereas the use of the patient-specific Ioannina aiming device resulted in optimal graft placement in 89% of the patients.

Back pain caused by benign tumors and tumor-like lesions of the thoracolumbar spine.

Twenty-two patients with benign tumors or tumor-like lesions of the spine (vertebral echinococcal cysts, eosinophilic granuloma) presented with back pain and deformity. The duration of pain ranged from 1 to 6 years. Five patients had incomplete paraplegia at admission. Spine deformity was observed in patients with osteoid osteoma, osteoblastoma, hemangioma, and vertebral echinococcal involvement. All patients underwent clinical evaluation, laboratory studies, and histologic studies. Electromyogram studies were performed in patients who had a neurologic deficit or nerve root irritation. Imaging evaluation consisted of plain films, bone scans, computed tomography scans, and magnetic resonance imaging scans. Fifteen patients had lumbar involvement; 7 had thoracic involvement. For 18 patients, management included tumor excision and thorough debridement of the lesion. Spinal instrumentation and fusion were used to correct the deformity and treat the instability in 5 patients. Patients were followed for 1 to 8 years. Of the 5 patients with incomplete paraplegia, 4 recovered completely, and the fifth (who had spinal cord hemangioma) improved 2 grades on Frankel's scale. The remaining patients were disease free and returned to routine daily activities. Benign tumors or tumor-like lesions of the thoracolumbar or lumbar spine are very rare and easily misdiagnosed in patients with persistent back pain. Patients whose symptoms progress or fail to respond over an appropriate period of time should be evaluated further. Complete excision of the tumor followed by spinal instrumentation in the presence of deformity or instability is the treatment of choice.

Risk factors for idiopathic scoliosis: review of a 6-year prospective study.

This study identified factors associated with the prevalence of idiopathic scoliosis and curve evolution in schoolchildren from northwestern and central Greece. A total of 85,627 children aged 9-15 years were screened for scoliosis. A subset of children with curves of at least 10 degrees underwent clinical and radiographic follow-up. The total population screened and the cohort followed for curve progression were evaluated according to factors associated with curve evolution. The prevalence of scoliosis was 1.7%, with most cases appearing at ages 13 and 14 years and small scoliotic curves (10 degrees-19 degrees) being most prevalent (prevalence 1.5%). Prevalence was associated with gender; age; and magnitude, apex, and direction of the curve. Progression of the curve occurred in 14.7% of 839 children, while 27.4% demonstrated spontaneous improvement of at least 5 degrees. A high risk of curve progression was associated with the following: sex--girls, curve pattern--right thoracic and double curves in girls and right lumbar in boys, maturity--girls before the onset of menses, age--time of pubertal growth spurt, and curve magnitude--curves > or = 30 degrees. Although only a small percentage of scoliotic curves undergo progression, the pattern of the curve according to curve direction and the sex of the child plays a significant role in the ability to identify which curves will progress.

Long-term evaluation of rat peripheral nerve repair with end-to-side neurorrhaphy.

This study was designed to assess long-term reinnervation of end-to-side neurorrhaphy in the rat. The cut right peroneal nerve was repaired and sutured to the side of the intact tibial nerve. Both the extent of reinnervation and the integrity of the intact donor nerve were evaluated in 48 Sprague-Dawley rats randomly treated with fresh or delayed nerve repair with or without perineurotomy. Evaluations included nerve conduction velocity (NCV) of both the peroneal and tibial nerves, dry muscle weight, and histologic examination (neurofilament stain and morphometric assessment) at 8 and 12 months postoperatively. Although animals treated with perineurotomy tended to have better NCV and dry muscle weight recovery than those without, the difference was not statistically significant. No difference was observed between fresh and predegenerated nerve repair. The mean total (all four subgroups) NCV recovery rates were 87 percent and 94 percent for the peroneal nerve, and 93 percent and 95 percent for the tibial nerve, compared to the contralateral intact nerves, at 8 and 12 months, respectively. Tibialis anterior muscle mass measurements revealed a recovery in dry muscle weight of about 85 percent and 89 percent at 8 and 12 months, respectively, compared to the intact contralateral tibialis anterior muscles. Histologic studies with neurofilament staining revealed numerous axons at the distal end of the peroneal nerve in all groups, indicative of myelinated axonal regeneration. Morphometric analysis demonstrated that the presence of a window in the perioneurium improved the histologic picture. The mean number of myelinated fibers at 12 months postoperatively was significantly higher in animals with a perineurotomy window (compared to without) in both fresh and predegenerated nerve repair subgroups, respectively (p <0.05). These results indicated that end-to-side neurorrhaphy permits axonal regeneration from the intact donor nerve and is associated with satisfactory recovery. The effect of the procedure on the donor nerve was negligible.

Evaluation of collateral sprouting after end-to-side nerve coaptation using a fluorescent double-labeling technique.

The mechanism of end-to-side neurorrhaphy is believed to be by collateral sprouting, although evidence for this is lacking. This study validates whether axonal sprouting originates from the donor intact nerve by collateral sprouting with the use of a fluorescent double-labeling technique. End-to-side neurorrhaphy was performed on adult female Sprague-Dawley rats. Eight and 12 months postoperatively, animals were injected with true blue and diamidino yellow into the tibialis anterior and/or gastrocnemius muscles and were transcardially perfused with fixative after 7 days of retrograde transport. The lumbar enlargement and the dorsal root ganglia from L3 to L6 were harvested and serial sectioning and fluorescent microscopy were performed. No double-labeling neurons were observed in control animals, but a group of neurons that were greenish or yellowish in color were seen with single labeling. Double-labeling neurons, however, were seen in animals treated with end-to-side neurorrhaphy whether or not perineurotomy was performed. These results demonstrate that one parent nerve fiber can emanate another axon by collateral sprouting following end-to-side neurorrhaphy. We hypothesize that the causes of collateral sprouting might result from "switching signals" and/or "switching factors."

Posterior traumatic dislocation of a Thompson prosthesis: report of a case.

A case of posterior traumatic dislocation of a Thompson prosthesis with fracture of the posterior wall of the acetabulum is presented. Nine years after the reduction and fixation of the posterior acetabular wall and 10 years after the initial neck fracture, the patient was free of pain, and the hip range of motion was within normal limits. To the best of our knowledge, no such case has ever been described in the English literature.

Clinical criteria and treatment of segmental versus upper extremity reflex sympathetic dystrophy.

The effectiveness of a multimodal treatment protocol in the long-term management of upper extremity reflex sympathetic dystrophy (RSD), as well as of isolated finger involvement, was analyzed. In the present series, 62 patients diagnosed with RSD were treated and followed for a mean of 22.2 +/- 1.5 months. The findings in the present study indicate that: 1) RSD occurs predominantly in females (female:male, 3:1); 2) regional dystrophy is twice as common as segmental dystrophy; 3) segmental dystrophy is most often associated with minor traumatic dystrophy, whereas regional dystrophy is more evenly distributed among the various clinical types; 4) patients with regional dystrophy score their pain significantly higher; and 5) segmental and regional dystrophy respond with equal satisfaction to the multimodal treatment regimen. In conclusion, the weight of the available evidence strongly suggests that RSD is a complex multifaceted disease entity which responds well when managed with a multimodal treatment program aimed at the various interacting components of the disorder. Furthermore, the finding that segmental dystrophy did not behave differently from the treatment protocol compared to extensive upper extremity RSD, suggests that the anatomic location of the syndrome may not significantly alter the course of the disease during treatment.

Versatility of TSRH spinal instrumentation system. Experience in 67 patients with trauma and spinal deformities.

We evaluated the effectiveness of the TSRH (Texas Scottish Rite Hospital) spinal instrumentation system in treating patients with spinal deformities and trauma to the spine. 38 patients (29 women) with spinal deformities and 29 (13 women) with trauma to the spine underwent fusion using the TSRH implant system. In patients with idiopathic scoliosis, the amount of curve correction achieved varied depending on the curve pattern, where patients with single thoracic (type III) or single extended thoracic (type IV) curves showed an improvement of 54% and 63%, respectively, compared to patients with King type II curves in which correction averaged only 45%. We found the TSRH spinal system to be effective for correcting the scoliotic curve. The fact that no neurologic complications were observed and that patients demonstrated a rapid ability to stand and walk as compared to the lengthy immobilization required with more traditional methods, suggests that the TSRH system is superior for scoliotic curve correction.