Amos Peyser

Engineered human mesenchymal stem cells: a novel platform for skeletal cell mediated gene therapy

Human mesenchymal stem cells (hMSCs) are pluripotent cells that can differentiate to various mesenchymal cell types. Recently, a method to isolate hMSCs from bone marrow and expand them in culture was described. Here we report on the use of hMSCs as a platform for gene therapy aimed at bone lesions.

Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia.

Background Perioperative myocardial ischemia occurs in 35% of unselected elderly patients undergoing hip fracture surgery. Perioperative epidural analgesia may reduce the incidence of adverse cardiac events. Methods The effect of early administration of epidural analgesia during the stressful presurgical period, on preoperative cardiac events was evaluated in a prospective randomized study in 68 patients with hip fractures who either had known coronary artery disease or were at high risk for coronary artery disease. On admission to the emergency room, patients were assigned to receive a usual care analgesic regimen (intramuscular meperidine, control group, n = 34) or continuous epidural infusion of local anesthetic and opioid (epidural group, n = 34). Monitoring in the preoperative period included a preoperative history and physical examination, daily assessment of cardiac adverse events, serial electrocardiograms, cardiac enzymes, and pain scores. Results Preoperative adverse cardiac events were significantly more prevalent in the control group compared with the epidural group (7 of 34 vs. 0 of 34;P = 0.01). Adverse cardiac events included fatal myocardial infarction in three, fatal congestive heart failure in one, nonfatal congestive heart failure in one, and new onset atrial fibrillation in two. The incidence of intraoperative and postoperative adverse cardiac events was similar for the two groups. The significant difference between groups in the incidence of preoperative cardiac events prompted interruption of the study after the planned interim analysis. Conclusions The authors’ data indicate that compared with conventional analgesia, early administration of continuous epidural analgesia is associated with a lower incidence of preoperative adverse cardiac events in elderly patients with hip fracture who have or are at risk for coronary artery disease. Preoperative epidural analgesia may be advantageous for this surgical population.

Talc sclerodhesis of persistent Morel-Lavallée lesions (posttraumatic pseudocysts): case report of 4 patients.

Large posttraumatic pseudocysts are infamous for their tendency to recur despite repeated aspiration. The standard practice has been repeated extensive surgical debridement. To avoid the need for such treatment, talc was used to sclerose the lesion in 4 patients treated between 2000 and 2003. The patients were between the ages of 20 and 73 and had thigh and buttock pseudocysts that persisted for an average of 3 months. Talc was administered under fluoroscopic guidance and suction drainage (wall suction followed by a bulb vacuum drainage system) was applied for an average of 12 days. The patients were followed for an average period of 27 months after talc sclerodhesis. All persistent pseudocysts showed an immediate cessation of fluid accumulation in the treated space without reccurence. One case which was complicated by infection, had to be treated twice with talc to cease the accumulation. In this case, the infection recurred, although fluid accumulation did not recur. Talc sclerodhesis proved to be a simple and rapid method of treatment in posttraumatic cases classically treated by repeated and aggressive surgical methods.

The floating hip injury: patterns of injury.

OBJECTIVE To evaluate the relationship between mechanism of injury, type of femoral fracture and type of acetabular fracture in floating hip injury. DESIGN Historical retrospective. PATIENTS Twenty consecutive patients who sustained a floating hip injury, i.e. simultaneous ipsilateral fracture of the acetabulum and the femur. INTERVENTION Statistical analysis of the correlation between the mechanism of injury and fracture type. RESULTS Two main patterns of floating hip injury were observed. The first is the posterior type, which occurs due to a longitudinal force along the femur that causes first, a posterior type fracture of the acetabulum and thereafter, a midshaft femoral fracture. The second pattern is the central type, caused by a lateral blow to the greater trochanter, which then causes a central fracture-dislocation of the acetabulum and a proximal fracture of the femur. CONCLUSIONS This observation explains the biomechanical nature of this injury and has treatment related implications.

Posttraumatic Painful Hip Sonography as a Screening Test for Occult Hip Fractures

Objective. Nondisplaced hip fractures may be radiographically occult and require magnetic resonance imaging (MRI) or bone scintigraphy for diagnosis. Both examinations are expensive and are not readily available in many hospitals. Our objective was to evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. Methods. We prospectively evaluated 30 patients (mean age, 73 years), who were admitted for painful hips after having low‐energy trauma with nondiagnostic hip radiographs. After inclusion, patients underwent sonography of both hips for signs of injury. After completion of the sonographic examination and analysis of the results, patients underwent MRI of both hips. The sonographic findings were compared with the MRI findings, which served as the reference standard for accurate detection of a hip fracture. Results. Ten hip fractures were diagnosed by MRI. Sonography showed trauma‐related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. Conclusions. Sonography for posttraumatic hip pain with negative radiographic findings did not result in a single missed hip fracture. Therefore, sonography may serve as an effective screening tool, mandating MRI only for cases with positive findings, whereas patients with negative sonographic findings need no further investigation. Sonography may therefore be very useful in hospitals around the world, where MRI may not be readily affordable or available.

Lateral malleolar reconstruction after distal fibular resection. A case report.

T umors of the distal part of the fibula necessitating resection pose a problem because of the need to reconstruct a stable ankle joint and to obtain coverage of this area. Standard textbook solutions include simple resection of the distal aspect of the fibula including the lateral malleolus, as described by Carnesale1 and later by Norman-Taylor et al.2, and resection of the distal part of the fibula with reconstruction of the lateral malleolus with use of the fibular head, as described by Carrell3, Herring et al.4, and de Gauzy et al.5. An allograft reconstruction has also been described6, as has reconstruction with an iliac crest bone graft7. Other possible techniques, albeit less desirable, are ankle arthrodesis and amputation. Although the textbook techniques are considered to be classics, not many reports have detailed their use and results2-5,8-12. These methods, at least theoretically, have a number of drawbacks. In distal fibular resection without reconstruction, the stabilizing effect of the lateral malleolus is lost. Soft-tissue reinforcement, even when it is possible, cannot fully compensate for the loss of stability13. Thus, the ankle may collapse into valgus and may be unstable in varus. Conversely, when the mortise is reconstructed with use of a proximal fibular (head) graft, the lateral collateral ligament of the knee is affected and the peroneal nerve is endangered14,15. Additionally, the fibular head is not totally congruent with the lateral articular surface of the talus and provides no stabilizing ligament attachments. Ankle arthrodesis might solve the problems of instability, but it limits the ability to walk. Amputation is reserved as a last resort for patients in whom limb-sparing is not feasible. We describe a …

Percutaneous compression plating for intertrochanteric fractures. Surgical technique, tips for surgery, and results.

ZusammenfassungOperationszielAnatomische Reposition und minimalinvasive Stabilisierung pertrochantärer Frakturen mit der perkutanen Kompressionsplatte (PCCP™). Sofortige postoperative Vollbelastung.IndikationenPertrochantäre Frakturen.KontraindikationenPertrochantäre Frakturen, die nicht geschlossen reponiert werden können, subtrochantäre Frakturen und „reverse oblique fractures“ (AO/OTA 31-A3).OperationstechnikDer Patient wird auf einem Extensionstisch gelagert. Das Femur distal der Fraktur wird durch eine dorsale Repositionshilfe (PORD™ [„posterior reduction device“]) unterstützt. Reposition der Fraktur durch geschlossene Manipulation. Perkutanes Einführen der Platte über eine proximale laterale Inzision. Die Platte wird mit Hilfe einer Zange über eine zweite, mehr distal gelegene Inzision an den proximalen Femurschaft angelegt. Einbringen der Gleitschrauben durch die Platte in den Schenkelhals und Sicherung der Platte am Femurschaft mit drei zusätzlichen Schrauben. Abschließend Vervollständigung der Frakturstabilisierung mit einer zweiten Schenkelhalsschraube.ErgebnisseVon 130 Patienten mit einer pertrochantären Fraktur, die zwischen Mai 2000 und Dezember 2001 mit der beschriebenen Technik in der Hadassah-Universitätsklinik für Orthopädische Chirurgie, Jerusalem, Israel, behandelt wurden, konnten 108 in diese Studie eingeschlossen werden. Das Patientenalter lag bei durchschnittlich 81 Jahren (± 8 Jahre). Die durchschnittliche Operationszeit betrug 67 min, der Krankenhausaufenthalt lag bei 11,5 Tagen. 40% der Patienten benötigten während des Krankenhausaufenthalts keine Bluttransfusion, wohingegen 8,3% mehr als drei Erythrozytenkonzentrate erhielten. Komplikationen traten bei vier Patienten auf: in zwei Fällen Implantatversagen, das erfolgreich mit Kompressionshüftschrauben (CHS) behandelt wurde, und eine Pseudarthrose, die mit einer Arthroplastie behandelt wurde. Der vierte Patient hatte eine Beinverkürzung von 3 cm, die mit einer Schuherhöhung ausglichen wurde. Drei Patienten entwickelten eine Infektion, wovon eine ein chirurgisches Débridement erforderte.AbstractObjectiveFixation of intertrochanteric fractures by a minimally invasive technique using the Percutaneous Compression Plate (PCCP™) allowing anatomic reduction and immediate postoperative weight bearing.IndicationsIntertrochanteric fractures.ContraindicationsIntertrochanteric fractures that cannot be reduced by closed manipulation, subtrochanteric and reverse oblique fractures (AO/OTA 31-A3).Surgical TechniquePlacement of patient on a fracture table with a posterior reduction device (PORD™) supporting the fracture. Reduction of the fracture by closed manipulation. Percutaneous insertion of the plate through a lateral proximal incision. Adaptation of the plate to the lateral aspect of the proximal femoral shaft with a bone clamp inserted through a second, more distal incision. Insertion of telescoping compression neck screw through the plate into the neck and securing of plate to the femoral shaft with three additional screws. Finally, completion of fracture fixation with second neck screw.ResultsOf 130 patients with intertrochanteric fractures treated using the described technique at the Orthopedic Surgery Department Hadassah University Hospital, Jerusalem, Israel, between May 2000 and December 2001, 108 were available for this study. Patients’ age averaged 81 years (± 8 years). Mean surgical time was 67 min and mean hospital stay 11.5 days. 40% of patients did not require a transfusion during hospitalization, while 8.3% needed more than three units of packed cells. Complications occurred in four patients: two implant failures that were successfully revised with a Compression Hip Screw, one nonunion treated with hip arthroplasty; the fourth patient had a shortening of 3 cm needing a heel lift. Three patients developed an infection, one requiring surgical debridement.

Retrograde nailing of femoral fractures distal to previous osteosynthesis.

As the proportion of elderly in the population grows, the incidence of femoral fractures distal to previous proximal osteosynthesis is increasing. When the gap between two rigid load-bearing fixations consists of osteopenic bone, the risk of further fractures increases. Herein the authors describe a load-sharing device that stabilizes the fracture and eliminates the osteopenic gap, allowing early mobilization and rapid return to the preinjury level of activity.

Die perkutane Kompressionsplatte zur Behandlung pertrochantärer Frakturen

ZusammenfassungOperationszielAnatomische Reposition und minimalinvasive Stabilisierung pertrochantärer Frakturen mit der perkutanen Kompressionsplatte (PCCP™). Sofortige postoperative Vollbelastung.IndikationenPertrochantäre Frakturen.KontraindikationenPertrochantäre Frakturen, die nicht geschlossen reponiert werden können, subtrochantäre Frakturen und „reverse oblique fractures“ (AO/OTA 31-A3).OperationstechnikDer Patient wird auf einem Extensionstisch gelagert. Das Femur distal der Fraktur wird durch eine dorsale Repositionshilfe (PORD™ [„posterior reduction device“]) unterstützt. Reposition der Fraktur durch geschlossene Manipulation. Perkutanes Einführen der Platte über eine proximale laterale Inzision. Die Platte wird mit Hilfe einer Zange über eine zweite, mehr distal gelegene Inzision an den proximalen Femurschaft angelegt. Einbringen der Gleitschrauben durch die Platte in den Schenkelhals und Sicherung der Platte am Femurschaft mit drei zusätzlichen Schrauben. Abschließend Vervollständigung der Frakturstabilisierung mit einer zweiten Schenkelhalsschraube.ErgebnisseVon 130 Patienten mit einer pertrochantären Fraktur, die zwischen Mai 2000 und Dezember 2001 mit der beschriebenen Technik in der Hadassah-Universitätsklinik für Orthopädische Chirurgie, Jerusalem, Israel, behandelt wurden, konnten 108 in diese Studie eingeschlossen werden. Das Patientenalter lag bei durchschnittlich 81 Jahren (± 8 Jahre). Die durchschnittliche Operationszeit betrug 67 min, der Krankenhausaufenthalt lag bei 11,5 Tagen. 40% der Patienten benötigten während des Krankenhausaufenthalts keine Bluttransfusion, wohingegen 8,3% mehr als drei Erythrozytenkonzentrate erhielten. Komplikationen traten bei vier Patienten auf: in zwei Fällen Implantatversagen, das erfolgreich mit Kompressionshüftschrauben (CHS) behandelt wurde, und eine Pseudarthrose, die mit einer Arthroplastie behandelt wurde. Der vierte Patient hatte eine Beinverkürzung von 3 cm, die mit einer Schuherhöhung ausglichen wurde. Drei Patienten entwickelten eine Infektion, wovon eine ein chirurgisches Débridement erforderte.AbstractObjectiveFixation of intertrochanteric fractures by a minimally invasive technique using the Percutaneous Compression Plate (PCCP™) allowing anatomic reduction and immediate postoperative weight bearing.IndicationsIntertrochanteric fractures.ContraindicationsIntertrochanteric fractures that cannot be reduced by closed manipulation, subtrochanteric and reverse oblique fractures (AO/OTA 31-A3).Surgical TechniquePlacement of patient on a fracture table with a posterior reduction device (PORD™) supporting the fracture. Reduction of the fracture by closed manipulation. Percutaneous insertion of the plate through a lateral proximal incision. Adaptation of the plate to the lateral aspect of the proximal femoral shaft with a bone clamp inserted through a second, more distal incision. Insertion of telescoping compression neck screw through the plate into the neck and securing of plate to the femoral shaft with three additional screws. Finally, completion of fracture fixation with second neck screw.ResultsOf 130 patients with intertrochanteric fractures treated using the described technique at the Orthopedic Surgery Department Hadassah University Hospital, Jerusalem, Israel, between May 2000 and December 2001, 108 were available for this study. Patients’ age averaged 81 years (± 8 years). Mean surgical time was 67 min and mean hospital stay 11.5 days. 40% of patients did not require a transfusion during hospitalization, while 8.3% needed more than three units of packed cells. Complications occurred in four patients: two implant failures that were successfully revised with a Compression Hip Screw, one nonunion treated with hip arthroplasty; the fourth patient had a shortening of 3 cm needing a heel lift. Three patients developed an infection, one requiring surgical debridement.

Combined injuries to the lower limbs

Several patterns of severe lower limb injuries are presented. They all indicate high energy trauma and affect the immediate care of the patient. The improvement of evacuation systems and resuscitating methods in intensive care create many reconstruction challenges for the orthopaedic surgeon. Awareness of the different combinations which are presented can serve as a tool that may be helpful in these demanding injuries. Guidelines for management of combined injuries are essential to improve the outcome of these life-threatening situations.