Alexandros N. Mavrodontidis

Low-Intensity Transosseous Ultrasound Accelerates Osteotomy Healing in a Sheep Fracture Model

BACKGROUND Low-intensity transcutaneous ultrasound can accelerate and augment the fracture-healing process. The aim of this study was to investigate the effect of transosseous application of low-intensity ultrasound on fracture-healing in an animal model. METHODS A midshaft osteotomy of the left tibia was performed in forty sheep. An external fixator was used to stabilize the osteotomy site. A thin stainless-steel pin was inserted into the bone, 1.0 cm proximal to the osteotomy site. Ultrasound was transmitted through the free end of this pin, with a PZT-4D transducer. In twenty animals, the treated limb received a 200-microsec burst of 1-MHz sine waves repeated at 1 kHz with an average intensity of 30 mW/cm(2) for twenty minutes daily. Twenty other animals underwent the same surgery but did not receive the ultrasound (controls). Animals were killed at seventy-five and 120 days postoperatively. Radiographic evaluation was performed every fifteen days. Mechanical testing and quantitative computed tomography were performed after death. RESULTS Fractures treated with ultrasound healed significantly more rapidly, as assessed radiographically, than did the controls (seventy-nine compared with 103 days, p = 0.027). On day 75, the mean cortical bone mineral density (and standard deviation) was 781 +/- 52 mg/mL in the treated limbs compared with 543 +/- 44 mg/mL in the control group (p = 0.014), and the average ultimate strength (as assessed with a lateral bending test) was 1928 +/- 167 N in the treated limbs compared with 1493 +/- 112 N in the control group (p = 0.012). No significant differences were noted on day 120. CONCLUSIONS This study demonstrated that low-intensity transosseous ultrasound can significantly accelerate the fracture-healing process, increase the cortical bone mineral density, and improve lateral bending strength of the healing fracture in a sheep osteotomy model.

Femoral Periprosthetic Fracture in Osteoporotic Bone after a Total Knee Replacement: Treatment with Ilizarov External Fixation

We report 3 cases of periprosthetic fractures after total knee replacement treated with Ilizarov external fixator (Smith and Nephew plc, Memphis, Tenn) and a follow-up of at least 3 years. We used 2 rings in the supracondylar area distal to the fracture and 3 half pins proximally in all our cases leaving the knee free to move. In one patient apart from the 2-ring frame placed distal to the fracture site the fixator included another ring frame placed proximally just below the 3 half pins. Uncomplicated fracture healing with lower extremity excellent alignment was achieved in 12 weeks after surgery. In periprosthetic femoral fractures, especially in elderly patients, Ilizarov external fixator is a treatment option which provides stable fixation, prompt postoperative mobilization, and has no major complications.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques

BackgroundTo compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator.MethodsSeventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel.ResultsAll fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant.ConclusionProximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Free vascularized fibular graft for treatment of pathological femoral neck fracture and osteonecrosis of the femoral head: A case report with a long-term follow-up

We present a case of a 34‐year‐old white female patient who, 13 years ago, sustained a pathological intracapsular femoral neck fracture on a pre‐existing aneurysmal bone cyst. Three months later radiographic and magnetic resonance imaging evaluation revealed both femoral neck fracture and stage IV osteonecrosis of the femoral head according to Steinberg classification system. Management was accomplished with combined free vascularized fibular grafting and internal osteosynthesis with a 130° blade plate. Union was achieved in 7 months. Progression of osteonecrosis was arrested. Hip salvage and a satisfactory subjective and clinical outcome were achieved. At the last follow‐up, 13 years postoperatively, the patient had satisfactory functional outcome.

Percutaneous repair of acute Achilles tendon rupture: a functional evaluation study with a minimum 10-year follow-up

OBJECTIVE The purpose of this study was to present the functional outcomes of percutaneous tenorrhaphy of the Achilles tendon with a minimum follow-up of 10 years. METHODS The medical records of patients who underwent percutaneous surgery for acute unilateral Achilles tendon rupture between 2000 and 2004 were retrospectively reviewed. RESULTS A total of 11 male patients met the inclusion criteria and were followed for a mean of 12.6 years (range: 10-13 years). The average age at the time of surgery was 39.3 years (range: 29-53 years). Patients returned to work at an average of 2.7 months (range: 1-4 months) after surgery and to normal daily activities (NDA) at an average of 4.1 months (range: 3-6 months) postoperatively. The mean strength ratio between the injured and normal sides was 90%. Compared with the contralateral normal side, the thickness of the operated tendon increased by a mean of 0.7 cm, while the circumference of the affected calf diminished by a mean of 1.1 cm. No difference in active and passive range of motion (ROM) was recorded between the affected and the contralateral normal ankle joints. Isometric plantar flexion was 87% of normal. Sensory impairment in the territory of the sural nerve was identified in 1 patient immediately after surgery. The sensory defect had completely resolved by 6 months postoperatively. CONCLUSION Long-term outcomes of our series support the effectiveness of percutaneous tenorrhaphy in Achilles function rehabilitation of patients with acute ruptures.

Atraumatic Sacral Fracture in Late Pregnancy: A Case Report

Study Design Case report. Objective Sacral fractures, traumatic or atraumatic, are a rather rare cause of low back pain. The majority of the cases of pregnancy-related sacral fractures are reported as a postpartum complication, and only few cases of sacral atraumatic fractures have been reported in the last trimester of the pregnancy. The aim of this study is to report a rare case of atraumatic sacral fracture in the third trimester of pregnancy. Methods We report the case of a 30-year-old Caucasian European woman during her 37th week (36 weeks and 4 days) of gestation, who complained during her scheduled obstetric examination of continuous low back pain with no associated history of trauma. The patient performed activities of daily living with a normal level of fatigue and reported no running or walking long distances. She was examined in our department, and a magnetic resonance imaging scan was performed that showed a vertical nondisplaced fracture in her left sacrum. Results The patient was treated conservatively, and analgesics were administrated according to the consensus of the orthopedic and the anesthesiology departments. No further complications were recognized in the remaining period of her pregnancy, and a healthy child was born by caesarean section. Conclusions Atraumatic fractures of the sacrum should be included in the differentiated diagnosis of pregnant patients with low back pain.

Popliteal artery damage during total knee arthroplasty

Injury of popliteal artery during total knee arthroplasty is a relatively rare complication. We report on one case of transverse semi-dissection of the popliteal artery during the tibial cut and one case of popliteal pseudoaneurysm formation caused by Hohmann retractors. Diagnosis was made early in the first case but it was delayed in the second due to misdiagnosis of deep vein thrombosis. Both injuries were managed eventually by open surgery. Postoperative clinical examination and ultrasound imaging confirmed the successful restoration of the blood flow. This case report also describes the classification system of the type of vascular damage and describes the mechanism, the clinical presentation, diagnostic modalities and treatment options for these rare complications of total knee arthroplasty surgery.

Intraoperative measurement of limb lengthening during total hip arthroplasty

Background: Limb length discrepancy (LLD) after total hip arthroplasty (THA) is a common problem which cannot be completely resolved. Many techniques have been described in order to minimize postoperative LLD, but most of these techniques are difficult to apply. Ideal technique must be simple and accurate. The most simple technique using a suture tied on the skin has well-known limitations, but its accuracy has not been evaluated before. Materials and Methods: Sixty THAs in sixty patients (mean age 71 years, 1:1 male to female ratio) with hip osteoarthritis (37 cases in the right, and 23 cases in the left side) were studied in this prospective study. In all surgeries, the intraoperataive measurement of limb lengthening was performed using a suture tied on the skin of the lateral pelvis. The accuracy of this technique and correlation between intraoperative and postoperative radiological measurements of lengthening were evaluated. Results: The mean preoperative LLD was –7.5 mm while the mean postoperative LLD was 1.58 mm. The accuracy of this technique, defined as the mean difference between the intraoperative and postoperative measurements was 1.8 mm. A strong correlation between these two measurements was noticed (r = 0.86). Conclusion: The accuracy and correlation index of this simple technique were similar to those of other techniques. The studied technique is quite accurate when attention is given to certain details, such as the amount of tension applied on the suture, the position of the tied point on the skin, and the position of the leg during measurements.

Subtalar dislocation without associated fractures: Case report and review of literature

Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed.

Ilizarov treatment of humeral shaft nonunion in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity

Nonunion of the humeral shaft in patients with antiepileptic drug associated metabolic bone disorder constitute a challenging surgical problem difficult to treat due to seizure activity, osteoporosis, and poor stabilization options. We report a case of nonunion of the humeral shaft in an antiepileptic drug patient with uncontrolled generalized tonic-clonic seizure activity successfully treated with Ilizarov external fixator and a follow-up of 4 years.