Loading rate patterns in scoliotic children during gait: the impact of the schoolbag carriage and the importance of its position.

PURPOSE: Concerns have been raised regarding the effects of schoolbag carriage on adolescent schoolchildren and particularly those with a pre-existing spinal deformity. The purpose of this study was to determine the effect of school backpack loads in scoliotic and healthy school-age children during walking, in terms of peak vertical ground reaction forces and loading rates. We hypothesized that walking with a loaded backpack would have a greater effect on gait kinetics of scoliotic compared to healthy. METHODS: Eight children with idiopathic scoliosis and eight healthy children were assessed. Kinetic data were collected using two AMTI OR6-7 force-plates, while the subjects walked freely along a 6-m walkway under three walking conditions: (1) without a schoolbag, (2) carrying a schoolbag bilaterally (over both shoulders-symmetrical load) and (3) carrying a schoolbag unilaterally (over each shoulder-asymmetrical load). Kinetic data were collected and four parameters were calculated; peak ground reaction force at the first maximum force peak (F1), time needed to reach F1 (T1), loading rate of F1 (LRF1) and total contact time (T2). RESULTS: We found no significant differences between the scoliotic and healthy children for any of the kinetic variables examined. In addition, the position of the bag did not seem to have any effect on loading rate. CONCLUSIONS: The results of this study indicate that in terms of kinetic parameters during normal gait, the schoolbag load (symmetrical or asymmetrical) does not have a different effect on children with mild adolescent idiopathic scoliosis compared to normal controls.

The role of radiation dose in a combined therapeutic protocol for the prevention of heterotopic ossification after total hip replacement.

PURPOSE: To present the results of a prospective study which aimed to evaluate the efficacy of radiation dose in a combined protocol using postoperative radiotherapy (RT) and indomethacin for the prevention of heterotopic ossification (HO) in patients undergoing total hip arthroplasty (THA) and are at high risk for HO development. METHODS: Seventy-one patients with a mean age of 63 years received either a single dose of 7 Gy or a fractionated dose of 10 Gy in 5 fractions of 2 Gy within the 3 postoperative days. Concurrently all patients received 75 mg of indomethacin for 15 days. Patients were analysed for radiographical evidence of HO development and clinically with the Merle d'Aubigné score at 1 year. RESULTS: At 12 months combined RT and indomethacin achieved excellent prophylaxis of HO. The overall radiographical incidence of HO was 7.04% (95% CI 2.33-15.67), while no patient with clinically significant HO (Brooker III-IV) was seen. There was no statistically significant difference between the two RT protocols. In a subgroup of 12 patients with bilateral THA the incidence of HO in the non-irradiated hips was statistically significantly higher compared with the irradiated hips. All patients had improved joint mobility and function during follow up compared with the preoperative period. No statistically significant differences regarding the Merle d'Aubigné score was documented between the 2 RT groups. No acute or late side effects related to RT were noted. CONCLUSION: This study demonstrated the efficacy of combined RT and indomethacin in preventing heterotopic ossification after total hip arthroplasty. Fractionated total dose of 10 Gy seems to offer no further benefit compared to a single dose of 7.0 Gy.

Reliability and validity of the Hartofilakidis classification system of congenital hip disease in adults.

The reliability and validity of the Hartofilakidis et al. classification system in adults with congenital hip disease (CHD) were examined. The radiographs of 102 adult patients (158 hips) with CHD were independently assessed by three senior surgeons. Interobserver variability was assessed by examining the agreement between the three raters while validity of the classification system was assessed by examining the agreement between the assessment by either one of the three raters and the intraoperative finding (reference standard). The interobserver agreement between the three observers was high ranging from 0.720 to 0.854 (substantial to excellent) while the agreement of the preoperative prediction with the intraoperative findings was 87.4% (K = 0.823, excellent agreement). The Hartofilakidis et al. classification system reliably predicts from preoperative pelvis radiographs the bone deficiencies encountered during the operation.

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.

Heterotopic ossification after total hip arthroplasty (THA) in congenital hip disease: comparison of two different prophylactic protocols.

INTRODUCTION: We aimed to evaluate retrospectively the efficacy of combined postoperative radiotherapy and indomethacin compared to indomethacin alone for the prevention of heterotopic ossification (HO) in high-risk patients with congenital disease of hip (CDH) undergoing total hip arthroplasty (THA). MATERIALS AND METHODS: Fifty-five patients received indomethacin alone (Group A), while 44 patients received the combined protocol (Group B). Patients >or=55 years were enrolled in Group B and those younger than 55 years in Group A. Patients were evaluated radiologically for the presence of HO 6 months after the operation. RESULTS: The incidence of HO in Group A was 34.5% (95% confidence interval 22.2-48.6%), while the respective incidence in Group B patients was 27.3% (95% CI 15.0- 42.8%). The difference was not statistically significant (p=0.5). No significant treatment-related side effects were reported. CONCLUSIONS: This is the first study evaluating the impact of HO prophylaxis in an immiscible population of patients with secondary arthritis due to CDH undergoing THA. Further future randomised evidence is required in order to ascertain the observed trend towards improved efficacy of the combined protocol for HO development.

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.

Use of (99m)Tc-sulesomab for the diagnosis of prosthesis infection after total joint arthroplasty.

This study aimed to evaluate the diagnostic efficacy of antigranulocyte scintigraphy using the antibody fragment (99m)Tc-sulesomab (LeukoScan) for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty. The results from 19 patients with suspected total joint arthroplasty infection who had undergone a three-phase bone scan and a subsequent examination with (99m)Tc-sulesomab during a 1-year period were reviewed. Twelve patients were shown to have prosthesis infection on culture of aspirated synovial fluid or intra-operative samples. The overall sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for (99m)Tc-sulesomab were 75%, 86%, 90%, 66% and 79%, respectively, compared with 54%, 83%, 88%, 45% and 63%, respectively, for the three-phase bone scan. This study showed that (99m)Tc-sulesomab had good diagnostic value for the detection of prosthesis infection. The combination of (99m)Tc-sulesomab with other laboratory or imaging examinations may improve diagnostic performance in prosthesis infection and should be investigated further.

Concomitant ipsilateral traumatic dislocation of the hip and knee following high-energy trauma: a case report.

Traumatic dislocation of the hip or knee can occur after high-energy trauma and is often associated with concomitant injuries and secondary complications. Concomitant traumatic dislocation of both hip and knee is rare. We describe a case of combined ipsilateral posterior hip dislocation with a posterior acetabular fracture and a complete open knee dislocation with disruption of the popliteal artery that resulted in amputation.

Puberty in girls: correlation of serum levels of gonadotropins, prolactin, androgens, estrogens, and progestins with physical changes.

Twenty-seven girls aged 8 to 18 were studied in a longitudinal prospective fashion. Serum samples were collected at 6 month intervals up to 4 years and radioassayed for hormones of pituitary, ovarian, and adrenal origin. A progressive elevation of luteinizing hormone (LH), follicle-stimulating hormone/FSH), estradiol (E2), dehydroepiandrosterone (DHA), and androstenedione (delta4) occurred during puberty and continued until menarche. The onset of puberty occurred concomitantly with an elevation of estrone (E1) dehydroepiandrosterone (DHA), dehydroepiandrosterone sulfate (DHAS), and 17-hydroxyprogesterone (17-OH-P). Prolactin (Prol) and progesterone (Prog) concentrations did not change during puberty until after menarche. After menarche, levels of LH and FSH were comparable with menstruating adult females. Concentrations of E2 and Prog were lower during the second half of the cycle among most regularly menstruating subjects than expected during the luteal phase. LH and Prog levels indirectly suggest that ovulation occurs in a few girls within months after menarche.

School-screening for scoliosis. A prospective epidemiological study in northwestern and central Greece.

A two-year prospective study was done to assess the prevalence and distribution of various parameters associated with scoliosis in schoolchildren in northwestern and central Greece. A total of 82,901 children (41,939 boys and 40,962 girls) who were nine to fourteen years old were screened for scoliosis. Five thousand eight hundred and three children had clinical signs of scoliosis and, of these, 4185 were referred for posteroanterior radiographs (to be made with the patient standing) because they had a positive result on the forward-bending test (a difference of more than five millimeters between the two sides of the torso as measured in the thoracic or thoracolumbar region with use of a ruler and a level plane) at the time of a second screening. The prevalence of scoliosis (defined as a curve of 10 degrees or more) was 1.7 per cent (1436 of 82,901 children), and most of the curves (1255; prevalence, 1.5 per cent) were small (10 to 19 degrees). The ratio of boys to girls was 1:2.1 over-all but varied according to the magnitude of the curve (1:1.5 for curves of less than 10 degrees, 1:2.7 for curves of 10 to 19 degrees, 1:7.5 for curves of 20 to 29 degrees, 1:5.5 for curves of 30 to 39 degrees, and 1:1.2 for curves of 40 degrees or more). Thoracolumbar curves were the most common type of curve identified, followed by lumbar curves; specifically, of the 1436 children who had a curve of at least 10 degrees, 493 (34.3 per cent) had a thoracolumbar curve, 475 (33.1 per cent) had a lumbar curve, 261 (18.2 per cent) had a thoracic curve, and 207 (14.4 per cent) had a double curve. Although most (753) of these curves were to the left, the left:right ratio varied according to the location of the apex of the curve (1:3.1 for thoracic curves, 2.0:1 for thoracolumbar curves, and 3.2:1 for lumbar curves). The cost of the screening process was negligible (estimated at thirty cents per child); however, the decreased number of operative procedures performed in children from the geographical area of our University Hospital, the identification of a large number of previously undiagnosed curves (eleven of which were treated operatively and 170 of which were treated with a brace), and the identification of children who were at high risk for progression were considered important benefits of the school-screening program.

The role of MRI in the evaluation of hip joint disease in clinical subtypes of juvenile idiopathic arthritis.

The purpose of this study was to evaluate the role of MRI in the assessment of hip joint involvement in clinical subtypes of juvenile idiopathic arthritis (JIA). 28 patients (mean age 12.5 years) with JIA (oligoarthritis 8, polyarthritis 13, systemic arthritis 7) were examined with T(2) weighted turbo spin echo and T(1) weighted spin echo (plain and contrast enhanced) sequences. The severity of joint involvement was evaluated using an MR grading score: grade 1=no contrast enhancement; grade 2=focal synovial contrast enhancement; grade 3=diffuse synovial contrast enhancement; grade 4=grade 3+diffuse synovial thickening; grade 5=grade 4+villonodular synovial thickening; and grade 6=grade 5+cartilage and subchondral bone erosions. MRI was abnormal in 57.1% of cases (25% of oligoarthritis, 53.8% of polyarthritis and 100% of systemic arthritis). Clinical examination was positive in 32.1% of cases and was associated with higher MR grades (mean 4.6, SD 1.34) compared with a negative clinical examination, which was associated with lower MR grades (mean 1.78, SD 1.13) (p<0.001). Patients with active disease (mean grade 3.9, SD 2) had higher MR grades than those with inactive disease (mean grade 2.1, SD 1.4) (p<0.01). The MR grades were different in the three clinical subtypes: oligoarticular (mean 1.5, SD 1.06); polyarticular (mean 2.38, SD 1.55); and systemic (mean 4.85, SD 1.21) (F:12.3, p<0.001), with a significant difference between systemic arthritis and oligoarthritis, and between systemic arthritis and polyarthritis (p<0.001). MRI of the hip might be considered for inclusion in the study protocol of patients with JIA since it reveals joint involvement at early stages and provides a detailed evaluation of the extent of joint disease.

A relationship between serum gentamicin concentrations and minimal inhibitory concentration.

Since there are few widely accepted guidelines upon which to base therapeutic decisions and adjust for the many variables which may influence the ultimate therapeutic outcome, and few studies have evaluated what the optimal peak concentration-to-MIC ratio should be, pharmacokinetic parameters were estimated from pre- and post-dose concentrations measured in 30 orthopaedic patients, receiving gentamicin. The fluorescence polarization method was used, and simultaneous determination of the MIC (minimal inhibitory concentration) has been made. When Gram(-) microorganisms were incriminated for the infection, the optimal peak concentration exceeded the MIC by more than 3-fold in our serum samples. In Gram(+) bacteria, the peak antibacterial activity usually obtained tended to be lower (between 1.5 and 2). No correlation was found for the nadir bacteriostatic level. Our investigations showed that the peak bacteriostatic activity correlated well with response to therapy. Based on these findings, the peak antibacterial activity should therefore be between 1.5 and 2 for Gram(+) and greater than 3-fold for Gram(-) microorganisms, and these values seem to be effective for eradication of the infection.

Vascular complications in orthopaedic patients treated by orthopaedic microsurgeons.

Over a 20 year period, five patients experienced serious vascular complications involving major arterial insult during various routine orthopaedic procedures. The nature of the vascular damage necessitated immediate surgical repair which was performed successfully by an orthopaedic microsurgeon who was either a member of the initial surgical team or the hospital's Orthopaedic Unit. The purpose of this study is to illustrate not only the severity of these limb and/or life-threatening complications, but also to focus attention on the importance of the orthopaedic surgeon's ability to manage these serious injuries promptly. This suggests the need for Orthopaedic Units to have surgeons with adequate training in microvascular techniques, so as to be able to successfully manage these unexpected and serious complications. We conclude that the presence of a vascular surgeon or an orthopaedic surgeon trained in microvascular surgery represents an invaluable attribute to the orthopaedic team, and minimizes, if not eliminates the potentially disastrous outcome from these serious intraoperative vascular complications.

Bone grafting in total hip arthroplasty for insufficient acetabulum.

We assessed the effectiveness of total hip arthroplasty (THA) supplemented with autologous bone grafts in patients with congenital disease of the hip (CDH). 2 groups of patients were evaluated: In Group A, 33 patients with a mean age of 54 years underwent arthroplasties using a threaded ceramic conical acetabular cup without cement (Autophor). In Group B, 85 patients with a mean age of 55 years underwent arthroplasties using a threaded, noncemented, titanium cup (CST). Bone grafts were supplemented the THA in 3 ways: 1) intrapelvic application using the cotyloplasty technique, 2) as bone chips in order to cover small defects around the upper and lateral part of the cup, and 3) as a bulky corticocancellous graft which was secured with screws. Follow-up averaged 11 and 9 years for patients in Groups A and B, respectively. All the grafts in Group A had consolidated by the end of 6th month. Only 2 partial absorptions were observed, 1 intrapelvic graft and 1 corticocancellous graft. 2 revisions were performed in this group of patients, but neither were related to bone graft absorption. By the end of 6 month, 63 of 85 in Group B had consolidated bone grafts. In 16 patients with intrapelvic cotyloplasty, 3 demonstrated complete and 1 partial absorption of the grafts. 3 cup revisions were performed in this group of patients, all with complete graft absorption. Our findings indicate that autologous bone grafts are strong adjunct for satisfactory fixation of THA in patients with CDH, a particularly demanding group of patients to manage. In addition, the ceramic threaded cup was found to be superior to the titanium threaded cup in terms of both bone graft consolidation and the number of revisions required.

Surgical management of tibial plateau fractures.

From 1992 to 1996, 49 patients with 49 tibial plateau fractures underwent operative treatment at the First Orthopaedic Department of the General Hospital of Athens. There were 3 type I fractures, 12 type II, 5 type III, 9 type IV, 5 type V and 15 type VI according to Schatzker's classification. 7 of the type VI fractures were open (5 grade II and 2 grade IIIA). All fractures were managed with open reduction and internal fixation and were followed to complete healing which averaged 4 months. 28 patients had excellent results, 13 good, 6 fair and 2 poor results. The fair and poor results were in polytrauma patients and in patients with open (grade II and grade IIIA) type VI fractures. Open reduction and internal fixation, when not strongly contraindicated, was found to be the preferred treatment in displaced tibial plateau fractures.

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.

Two-stage treatment of flexor tendon ruptures. Silicon rod complications analyzed in 109 digits.

Complications during two-stage flexor tendon reconstruction may jeopardize the function of the repaired tendons. We reviewed complications encountered in 89 patients (109 digits) treated with a two-stage flexor tendon reconstruction using either silicone or Hunter rods. The complications could be distinguished according to the stage of reconstruction in which they occurred. Complications during stage I included rod buckling, rupture of the distal end of the rod, rod migration, synovitis and infection, and during stage II included distal rupture of the graft juncture, loose graft, tight graft, bowstringing, and flexion deformity of the PIP and DIP joints. The commonest complication was a flexion deformity of the PIP and/or DIP joint which was related to the surgical procedure. These deformities could easily be corrected in all cases with night splints.

Bridge plating osteosynthesis of 20 comminuted fractures of the femur.

We retrospectively studied the outcome of 20 comminuted fractures (20 patients, 15 men) of the femur treated in accordance with the principles of indirect reduction and biological osteosynthesis technique. The patients were followed for mean 1.5 (1-4.5) years. 11 fractures were subtrochanteric (type C), 6 complex diaphyseal and the remaining 3 were supracondylar (2 type C3 and 1 type A3); 3 fractures were open (type I, II, IIIA). Subtrochanteric fractures were treated with either 95 degrees dynamic condylar screw (DCS; 5 fractures) or with 135 degrees dynamic hip screw (DHS; 6 fractures). Autocompression plates (ACP) implants were chosen for diaphyseal fractures in 4 fractures, and a limited contact dynamic compression plate (LC/DCP) implant in 2. The 3 supracondylar fractures were treated with a 95 degrees DCS implant (1 fracture) and the Condylar Buttress Plate (2 fractures). 11 fractures were bone grafted. There were no immediate postoperative complications. All fractures united on an average of 5 months, irrespective of use of bone grafts. Late complications consisted of mild knee stiffness (4 patients) and 1-2 cm shortening (4 patients).

Knee dislocations and their management. A report of 16 cases.

We retrospectively studied the outcome of 16 knee dislocations. 11 patients had surgical treatment, 4 were managed nonoperatively and 1 patient died. In the elderly the outcome was poor, regardless of the type of treatment. Only 3 adolescents obtained excellent results and 2 young adults had good results after surgical repair of the knee. Concurrent arterial and nerve damage increased the morbidity.

Latissimus dorsi free tissue transfer for coverage of extensive soft tissue defects.

15 latissimus dorsi free flap transfers were performed at the University of Ioannina Medical School during a 3-year period. Soft tissue defects in the upper (3) and lower (12) extremities resulting from trauma, septic pseudoarthrosis, osteomyelitis, open type IIIb fractures, incomplete amputations and tumor or unstable scar resection were covered by myocutaneous flaps in 6 cases and muscle flaps with split thickness skin grafts in 9 cases. Complications included pressure ulcer, infection hematoma and massive lung embolism. The results of the present study in which 13 of the 15 flaps were successful, suggest that an "orthoplastic" approach in covering soft tissue defects is beneficial.