Should We Routinely Exclude Retroperitoneal Abscess in Cases of Hip Periprosthetic Joint Infections?

Hip periprosthetic joint infections (PJIs) with concomitant retroperitoneal abscesses may not be common clinical situations but they can be easily misdiagnosed affecting the effectiveness of infection control and eradication interventions. We present the case of a 75-year-old female patient with a late hip PJI complicated with iliopsoas abscess that was barely discovered intraoperatively. Literature review supports our recommendation of a high index of suspicion in cases of hip PJI and even routinely imaging examination of pelvis and abdomen for retroperitoneal involvement exclusion.

Treatment outcomes for infected juxta-articular knee nonunions

PURPOSE

This retrospective case series assessed the results of a treatment protocol for patients with infected para-articular knee nonunions. The aim was to demonstrate that knee function and quality-of-life (QoL) can be improved.

CASE SERIES

Between January 2001 and December 2011, eleven patients with septic proximal tibial nonunion and seven with septic distal femoral nonunion were managed at our institution. The treatment protocol included extensive debridement, skeletal stabilization, culture-specific antibiotic administration, and soft-tissue and bone-deficit reconstruction. Knee function was evaluated with the Knee Society Score (KSS) while the Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-12 were used for QoL assessment at a mean follow-up of 37.2 (range: 12-149) months. Seventeen nonunions healed at a mean of 21.9 weeks. One patient needed above knee amputation. Knee Society function and knee scores were improved significantly, from 16.7 and 33.8, to 75.0 and 84.9 respectively (p <0.001). KOOS outcome and SF-12 physical and mental components scores confirmed the QoL improvement.

CONCLUSIONS

Staged management can improve QoL and functional knee outcome. HIPPOKRATIA 2018, 22(4): 183-187.

An Experimental Model on the Biomechanical Behaviour of the Flexor Tendons in New Zealand Rabbits

BACKGROUND

In order to introduce new pharmacological agents with the intent to inhibit the adhesion formation, it is important to test such products on laboratory animals under a protocol that can evaluate the quantitative and qualitative aspects of healing of the tendons. Most experimental models focus on the tensile strength and histological analysis of the tendons, failing to sufficiently quantify the degree of the adhesion formation.

METHODS

The experiment included six male New Zealand rabbits that underwent surgery of their right forepaws. The deep flexor tendon of the middle finger was transected and repaired and after six weeks the rabbits were killed. In order to assess the extent of adhesions, the functional stiffness of the tendons and the range of motion of the specimens' fingers was studied using a tensile testing machine. The setup used allowed the simultaneous recording of the specimens' motion and the pulling force values.

RESULTS

The mean values of the left and right forepaws were expressed in the same chart showing a clear difference between the operated and non operated forepaws.

CONCLUSIONS

Using a relatively simple set up in the laboratory we had the chance to focus on a more elaborate analysis of the data with the help of low cost and accessible software.

An 11- to 15-year clinical outcome study of the Advance Medial Pivot total knee arthroplasty

Aims

The Advance Medial-Pivot total knee arthroplasty (TKA) was designed to reflect contemporary data regarding the kinematics of the knee. We wished to examine the long-term results obtained with this prosthesis by extending a previous evaluation.

Patients and Methods

We retrospectively evaluated prospectively collected data from 225 consecutive patients (41 men and 184 women; mean age at surgery 71 years, 52 to 84) who underwent 284 TKAs with a mean follow-up of 13.4 years (11 to 15). Implant failure, complication rate, clinical (both subjective and objective) and radiological outcome were assessed. Pre- and post-operative clinical and radiographic data were available at regular intervals for all patients. A total of ten patients (4.4%; ten TKAs) were lost to follow-up.

Results

Survival analysis at 15 years showed a cumulative success rate of 97.3% (95% confidence interval (CI) 96.7 to 97.9) for revision for any reason, of 96.4% (95% CI 95.2 to 97.6) for all operations, and 98.8% (95% CI 98.2 to 99.4) for aseptic loosening as an end point. Three TKAs (1.06%) were revised due to aseptic loosening, two (0.7%) due to infection, one (0.35%) due to instability and one (0.35%) due to a traumatic dislocation. All patients showed a statistically significant improvement on the Knee Society Score (p = 0.001), Western Ontario and McMaster University Osteoarthritis Index (p = 0.001), Short Form-12 (p = 0.01), and Oxford Knee Score (p = 0.01). A total of 207 patients (92%) were able to perform age appropriate activities with a mean flexion of the knee of 117° (85° to 135°) at final follow-up.

Conclusion

This study demonstrates satisfactory functional and radiographic long-term results for this implant. Cite this article: Bone Joint J 2016;98-B:1050–5.

RhBMP-7 for the treatment of nonunion of fractures of long bones

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients' quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.

Tumors and tumor-like lesions mimicking carpal tunnel syndrome

INTRODUCTION

Tumors and tumor-like lesions in or around the median nerve are uncommon causes of carpal tunnel syndrome (CTS). The purpose of the present study is to highlight the diagnostic approach and point out the profile of patients with CTS and potential underlying pathology.

MATERIALS AND METHODS

Twenty-eight patients with 32 affected hands had CTS correlated to a mass in or around the nerve. In 20 hands a palpable mass was present. Diagnostic workup included nerve conduction studies, ultrasound and/or MRI. Pre- and postoperative examination included two-point discrimination (2PD), grip strength, visual analogue scale (for pain) (VAS) and disabilities of the arm, shoulder and hand (DASH) scores.

RESULTS

Twelve of 28 patients were young (range 9-38 years) and 10 were male. Nerve compression was due to 27 extraneural lesions (8 abnormal muscles, 5 lipomas, 7 tenosynovitis, 4 vascular tumors, 2 ganglia, 1 Dupuytren's fibromatosis) and five intraneural tumors (three schwannomas, one neurofibroma, one sarcoma). Nerve decompression and excision of extraneural lesions were performed in all cases whereas in intraneural tumors, decompression was followed by excision in most cases and nerve grafting in one. Mean follow-up was 22 months (12-105 months). Extraneural masses were associated with a better outcome than nerve tumors. The mean postoperative VAS/DASH scores were 0.3/16.2 in extraneural lesions and 2.5/22 in intraneural lesions. The 2PD improved gradually in all patients (mean pre- and postoperative 12 and 5 mm). The mean grip strength increased from 28 to 31.3 kg postoperatively.

CONCLUSIONS

Although rare, the surgeon should include in the differential diagnosis of CTS the unusual cause of tumors and tumor-like lesions, especially when the patients' profile is not typical (young, male, no repetitive stress or manual labor). In addition, the presence of a palpable mass at the distal forearm or palm dictates the need for imaging studies. The extent, location and aggressiveness of the mass will determine the approach and type of procedure.

Surgical treatment of hip fractures: factors influencing mortality

BACKGROUND

Data for osteoporotic hip fractures in Greece is limited and little is known upon the meaning of family support during the postoperative/rehabilitation period.

OBJECTIVE

To identify the factors influencing the mortality after hip fractures in the elderly, the effect of rehabilitation and family support in the post-fracture course, and the impact of these fractures on the family of the injured elderly.

METHODS

We conducted an observational study of 218 consecutive patients older than 60 years of age, who underwent surgical management of a unilateral hip fracture at a tertiary hospital of Central Greece, with follow-up contacts at 30 days, 3 months and one year. Demographic characteristics, pre- and post-fracture residential and functional status, assessment of basic activities of daily living (ADL), co-morbidities, type and mechanism of fracture and hospitalization data as well as the modification of activities of the patients' relatives were recorded.

RESULTS

Fifteen patients (6.9%) died during hospitalization; thirty-nine (17.9%) died within one year of fracture. The factors that were predictive of in-hospital, 30-days and one-year mortality, based on multivariate analysis, were male sex, advanced age >85 and Charson index >3. There was a significant association between delayed surgery (>48 hours) and increased in-hospital mortality. The percentage of patients assessed as ADL A or B at baseline, decreased form 84% preoperatively to 50.4% one year postoperatively. Only one-third of patients walking without aid before the fracture returned to the previous state. Family members modified their activities in 48% of cases to assist their relatives with a hip fracture.

CONCLUSIONS

One-year mortality in patients with hip fractures was 17.9%. Surgical delay (>48 hours) increased in-hospital mortality. Comorbidities >3, male sex, and advanced age increased the risk of in-hospital and post-discharge mortality during the 1st year. Twelve months postoperatively, half of patients walking without aid before the fracture returned to the previous state. Despite the beneficial effect of family support, the lack of organized rehabilitation programs and geriatric units are potential negative factors for patients' functional outcome. In addition, 48% of patients' relatives changed their daily activities to assist their relatives.

Smoking affects mRNA expression of bone morphogenetic proteins in human periosteum

Periosteum is important for bone homoeostasis through the release of bone morphogenetic proteins (BMPs) and their effect on osteoprogenitor cells. Smoking has an adverse effect on fracture healing and bone regeneration. The aim of this study was to evaluate the effect of smoking on the expression of the BMPs of human periosteum. Real-time polymerase chain reaction was performed for BMP-2,-4,-6,-7 gene expression in periosteal samples obtained from 45 fractured bones (19 smokers, 26 non-smokers) and 60 non-fractured bones (21 smokers, 39 non-smokers). A hierarchical model of BMP gene expression (BMP-2 > BMP-6 > BMP-4 > BMP-7) was demonstrated in all samples. When smokers and non-smokers were compared, a remarkable reduction in the gene expression of BMP-2, -4 and -6 was noticed in smokers. The comparison of fracture and non-fracture groups demonstrated a higher gene expression of BMP-2, -4 and -7 in the non-fracture samples. Within the subgroups (fracture and non-fracture), BMP gene expression in smokers was either lower but without statistical significance in the majority of BMPs, or similar to that in non-smokers with regard to BMP-4 in fracture and BMP-7 in non-fracture samples. In smokers, BMP gene expression of human periosteum was reduced, demonstrating the effect of smoking at the molecular level by reduction of mRNA transcription of periosteal BMPs. Among the BMPs studied, BMP-2 gene expression was significantly higher, highlighting its role in bone homoeostasis.

Use of a mini-external fixator for the treatment of hand fractures

PURPOSE

To evaluate the outcome of hand fractures managed with mini-external fixators (MEFs) in order to assess their usefulness in different fracture types and to make recommendations regarding potential applications.

METHODS

Fifty-one patients with 59 metacarpal and phalangeal fractures were treated with MEFs. Fixators were used to reduce the fracture or to achieve volar plate arthroplasty when anatomical joint reconstruction was impossible. The mean period from injury to MEF application was 4.5 days.

RESULTS

The procedure was performed using regional anesthesia and fluoroscopic control, and it lasted 20 to 45 minutes. MEFs were removed in a mean period of 6 weeks, and follow-up was 18 to 55 months. Forty-nine patients with 57 fractures remained in the follow-up group. In all cases the skeleton was successfully reconstructed, whereas the clinical outcome varied according to the type of the original injury: intra-articular fractures had worse outcome than extra-articular (p=.035 for grip strength and p=.0005 for total active motion), and open fractures had worse outcome than closed (p=.06 for grip strength and p=.001 for total active motion). In all cases, patients' satisfaction was high; the Disabilities of the Arm, Shoulder, and Hand score was <7.9 and the visual analog scale score was <0.5.

CONCLUSIONS

The findings of this series demonstrate the efficacy of versatile MEFs to establish union and correct alignment of hand skeleton with minimal tissue trauma while retaining a good clinical outcome even in the most complex injuries. MEFs can be considered for all hand fractures requiring surgical treatment, and especially for the intra-articular and comminuted fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Purulent flexor tenosynovitis: factors influencing the functional outcome

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

Injection injuries: seemingly minor injuries with major consequences

BACKGROUND

High-pressure injection injuries are rare injuries, characterized by a small puncture wound that is often underestimated by physicians and patients. The injected substance leads to extensive tissue damage and sometimes to loss of the limb.

AIM

To underline the severity of these injuries and to alert physicians to recognize them and treat them appropriately.

METHODS

Eight patients with injection injuries from lubricants (6) or solvents (2) were treated in a University Orthopaedic Department in a 5-year period. In all patients the mild initial symptoms were aggravated over the next 4-6 hours leading to a severe compartment syndrome of the hand. Five patients were referred with a mean delay of 3.8 days and 3 were treated immediately; all with debridement and compartment release.

RESULTS

The total number of procedures per patient was 2 to 5. In 3 patients a heterodigital flap was necessary whereas in one the second ray was amputated. Results were excellent in 5 cases and good in 3.

CONCLUSIONS

In injection injuries, prompt diagnosis and immediate aggressive surgical intervention are necessary to save the patients' digit/limb. Patients should be informed about the severity of their injury, its potential complications and the multiple surgical procedures that may be required for a satisfactory functional result.

Scaphoid Nonunions: Management with Vascularized Bone Grafts from the Distal Radius: A Clinical and Functional Outcome Study

BACKGROUND

Scaphoid nonunions remain controversial with regard to optimal management, especially for those located at the proximal third. In this study, the authors aim to assess the union rate, avascular proximal pole revascularization, and functional outcome of scaphoid nonunions managed with distal radius vascularized bone grafts.

METHODS

Thirty patients were treated with vascularized bone grafts between 1999 and 2003 and prospectively followed up. The average nonunion chronicity was 3.3 years. Nine patients (30 percent) had avascular necrosis of the proximal pole, five had unsuccessful previous surgical procedures, and four had radioscaphoid arthritis (Lichtman type III). Twenty proximal third nonunions were managed with dorsal radius bone graft, whereas 10 waist nonunions had palmar grafts. Union was assessed clinically and radiologically and, in 67 percent of the patients, by means of magnetic resonance imaging.

RESULTS

All cases were united by 12 weeks, and magnetic resonance imaging confirmed that all necrotic proximal poles were revascularized. On at least 24 months' follow-up, 90 percent of patients achieved complete pain relief. Wrist flexion-extension and radial-ulnar deviation arcs did not change. The postoperative grip strength was 82 percent of the contralateral side. The Mayo Modified Wrist Score increased significantly from 58 to 85 points and, overall, 77 percent of patients had an excellent or good outcome. No risk factors for compromised wrist function were identified. The scapholunate angle, the scaphoid length, and the Nattrass index improved significantly.

CONCLUSIONS

This series demonstrates the efficacy of distal radius vascularized bone grafts in union enhancement, proximal pole revascularization, pain relief, improved wrist function, and carpal alignment. Vascularized bone grafts are a reliable therapeutic alternative for scaphoid nonunions.

Scaphoid nonunions treated with vascularised bone grafts: MRI assessment

PURPOSE

To assess the value of MR imaging (MRI) with regard to union, graft viability and proximal pole bone marrow status, after use of vascularized bone grafts for treating scaphoid nonunions.

MATERIALS AND METHODS

Vascularized bone grafts from the distal radius were used to treat 47 scaphoid nonunions resulting from fractures or enchondromas. Clinical and imaging evaluation was used for the pre- and postoperative assessment of all patients. Apart of conventional radiographs obtained in all cases, 15 patients were also assessed postoperatively with MRI at 3 months. From these 15 patients, eight were assessed preoperatively with MRI whereas nine had serial MRI evaluations at 6 and 12 months. The clinical follow-up time of this subgroup of 15 patients ranged from 6 to 27 months.

RESULTS

All patients showed clinical signs of union within 12 weeks form the procedure and at the latest follow-up they experienced complete (10 cases) or almost complete (five cases) relief from pain. Both plain and contrast-enhanced MRI obtained at 3 months showed viability of the bone graft in all cases. At 3 months union was established with plain radiographs in 12 patients at both sides of the graft and in three patients between the graft and proximal pole. At 3 months plain MRI showed nonunion in four patients (two between graft and proximal pole, two between graft and distal pole and one at both sides of the graft) whereas contrast-enhanced MRI revealed only one case of nonunion between graft and proximal pole. Four patients were considered to have osteonecrosis of the proximal pole intraoperatively. Two of them showed necrosis of the proximal pole with preoperative and postoperative plain radiographs and three of them with plain postoperative MRI. Contrast-enhanced MRI at 3 months showed postoperative reversal of necrotic changes in all four scaphoids. MRI also revealed bone marrow oedema of the carpal bones surrounding the scaphoid in 14 cases. Serial MRI at 6 and 12 months, obtained in nine patients, revealed resolution of the bone marrow oedema of the surrounding bones and full graft incorporation in all cases.

CONCLUSION

Contrast-enhanced MRI is able to demonstrate the early union after treatment of scaphoid nonunions with vascularised bone grafts allowing thus earlier mobilisation. In addition, MRI can assess the viability of the proximal pole and the graft as well as the postoperative bone marrow oedema-like lesions of the surrounding bones.

Scaphoid nonunion treated with bone graft and Herbert screw. 23 of 28 fractures healed

We retrospectively reviewed 28 patients with symptomatic, established nonunion of the waist of the scaphoid who were treated with bone grafting and Herbert screw fixation. A volar approach was used in 20 patients, and a dorsal in 8. Grafting was performed with cancellous bone from the radius in 16 patients and a iliac wedge graft in 12 patients. At a mean follow-up of 3 (1-6) years. 5 of the 28 patients had not united. The surgical approach, the type of graft applied, and the duration of postoperative immobilization played a role for the final outcome. The volar approach appeared to be associated with a better outcome which may be attributed, in part, to the relatively better view of the nonunion achieved with this incision compared to the dorsal approach. The iliac wedge graft was more effective for reduction of the deformity and initial stabilization. We believe that the relatively long period, 3 months, of postoperative immobilization negatively effected the postoperative function because of stiffness.

Current indications for single digit replantation

The functional outcome of 67 successfully replanted single digits (excluding the thumb) involving 31 complete and 36 incomplete nonviable amputations was found to be strictly related to the level of the amputation. While the survival rate was higher in patients with incomplete nonviable amputations (89 percent), compared to those with complete amputations (81 percent), the ability of the patient to use their digit was almost uniform among both groups of patients. All except 2 of the 9 digits with complete amputations at the level of the proximal phalanx or at the proximal interphalangeal joint (PIP) resulted in limited motion (less than 20 degrees-30 degrees) at the PIP and distal interphalangeal (DIP) joints. Only 9 from the group of patients with incomplete nonviable amputations at the proximal phalanx exceeded flexion greater than 40 degrees at the PIP joint. From these results, we conclude that the indications for replantation of a single digit amputation should be as follows: 1) amputation distal to the insertion of the flexor digitorum sublimis; 2) ring injuries type II and IIIa; and 3) amputations at the level of or distal to the DIP joint.