Anastasios V. Korompilias

Bone marrow edema syndrome

Bone marrow edema syndrome (BMES) refers to transient clinical conditions with unknown pathogenic mechanism, such as transient osteoporosis of the hip (TOH), regional migratory osteoporosis (RMO), and reflex sympathetic dystrophy (RSD). BMES is primarily characterized by bone marrow edema (BME) pattern. The disease mainly affects the hip, the knee, and the ankle of middle-aged males. Many hypotheses have been proposed to explain the pathogenesis of the disease. Unfortunately, the etiology of BMES remains obscure. The hallmark that separates BMES from other conditions presented with BME pattern is its self-limited nature. Laboratory tests usually do not contribute to the diagnosis. Histological examination of the lesion is unnecessary. Plain radiographs may reveal regional osseous demineralization. Magnetic resonance imaging is mainly used for the early diagnosis and monitoring the progression of the disease. Early differentiation from other aggressive conditions with long-term sequelae is essential in order to avoid unnecessary treatment. Clinical entities, such as TOH, RMO, and RSD are spontaneously resolving, and surgical treatment is not needed. On the other hand, early differential diagnosis and surgical treatment in case of osteonecrosis is of crucial importance.

Restoration of elbow function in severe brachial plexus paralysis via muscle transfers

SUMMARY Reconstruction of elbow function in severe or late brachial plexus injuries represents a challenge to the reconstructive microsurgeons. The current sophisticated techniques of nerve reconstruction in combination with secondary local or free functional muscle transfers, may offer satisfactory outcome. Latissimus dorsi can be transferred as a pedicled or free muscle to restore elbow function. We present our experience with elbow reanimation in late cases of brachial plexus paralysis utilising latissimus dorsi muscle transfer. From 1998 to 2006 we operated 103 patients with brachial plexus paralysis. Amongst these patients, 21 were late cases and underwent latissimus dorsi muscle transfer for elbow reanimation. Ten patients had free latissimus dorsi transfer for elbow flexion. Free latissimus dorsi muscle was neurotised either directly via three intercostals in three patients or with a nerve transfer procedure using the contralateral seventh cervical nerve root in seven patients. Care was taken to maintain the proper tension to the muscle, which must hold the elbow in static flexion of about 120 degrees at the end of the procedure. Powerful elbow flexion (M4-M4+) or extension (M4) was obtained after the first 3 months in all patients who had an ipsilateral pedicled latissimus dorsi transfer. In the group of free muscle transfers, elbow flexion was seen after 6-8 months. After the initiation of muscle contraction, eight of the patients regained elbow flexion of M3-M4+. Latissimus dorsi muscle transfer is a reliable method for elbow reanimation. Appropriate postoperative management is also an important factor to obtain better outcome.

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.

Anticardiolipin antibodies and osteonecrosis of the femoral head.

The current study evaluated the prevalence of anticardiolipin antibodies, which have been associated with thrombotic phenomena, in patients with nontraumatic osteonecrosis of the hip and assessed whether the presence of such antibodies is associated with an increased risk for the development of bone necrosis. Forty consecutive patients (25 men and 15 women) with nontraumatic osteonecrosis of the hip were studied. Their ages ranged from 19 to 56 years (average, 34.3 years). Anticardiolipin antibodies were present in 37.5% (15 of 40) of the tested patients, a significantly higher rate than is seen in healthy subjects, of whom only one of 100 had low titer anticardiolipin antibodies (1%). Six of 40 patients tested positive for immunoglobulin M alone, and six of 40 patients tested positive for immunoglobulin A alone. Three of 40 patients tested positive for immunoglobulin M and immunoglobulin A isotype. The results of the current study indicate an increased incidence of anticardiolipin antibodies in patients with nontraumatic osteonecrosis of the femoral head, which may reflect that anticardiolipin antibodies play a role in the pathogenesis of bone necrosis by predisposing to thrombotic phenomena.

Diagnostic and treatment modalities in nonunions of the femoral shaft. A review

Nonunions of the femoral shaft represent a treatment challenge for the orthopaedic surgeon and a serious socioeconomic problem for the patient. Inadequate fracture stability, insufficient blood supply, bone loss or presence of infection are the main reasons for the development of a nonunion. Careful classification and exclusion of infection are crucial for the choice of the proper treatment alternative. Nail dynamization, primary intramedullary nailing or nail exchange, plate osteosynthesis and external fixation along with bone grafting, usage of bone substitutes and electrical stimulation can stimulate osseous union. A review of the aetiology, classification and treatment should prove helpful managing this serious complication.

Meniscal fixation with an absorbable staple An experimental study in dogs

Abstract An absorbable staple for meniscal fixation was developed and evaluated in an in vivo canine study. The staple consisted of two rigid barbed legs, made of a copolymer of polyglycolic acid and polylactic acid, connected by a flexible suture made of the same absorbable material. The staple was developed for arthroscopic use, eliminating the risk of nerve or vascular injuries associated with suture fixation. Eighty-two mongrel dogs underwent meniscal repair in this study, which was performed in two sequential parts. An incision was made in the medial meniscus at the peripheral third and was fixed with either the staple or with a single 3-0 PDS suture. The animals from the first part of the study, in which the biocompatibility of a prototype staple design, was evaluated were sacrificed at 3 days, 2 weeks, 6 weeks, 3 months, and 9 months. Those from the second part of the study, in which an improved staple design of the same material, was evaluated were sacrificed at 6 weeks, 4 months, and 1 year. The operated menisci were either examined histologically or were mechanically tested for tensile strength. Absorption of the staple began by 3 months and was almost complete by 1 year. Mechanically, the staple provided greater tensile strength augmentation of the meniscus than suture fixation for up to 4 months. In the long term, there was no difference between the staple and suture in enhancement of healing.

Comparative study of surgical treatment of ulnar nerve compression at the elbow.

HYPOTHESIS The optimal surgical treatment for cubital tunnel syndrome remains unclear. We aim to evaluate the long-term outcome of surgical treatment by comparing the results of the different methods proposed. MATERIALS AND METHODS We retrospectively reviewed 113 patients in whom 3 different surgical methods were used for cubital tunnel syndrome treatment. In situ decompression, partial epicondylectomy, and anterior subcutaneous transposition were performed from 1997 to 2007. RESULTS Results were graded as excellent in 51 patients (45%), good in 34 (30%), fair in 8 (7%), and poor in 20 (18%). When we compared the results among the different surgical procedures, good and excellent results were achieved in 26 of 31 patients (84%) treated with in situ decompression, 36 of 45 (80%) treated with release and partial medial epicondylectomy, and 23 of 37 (62%) treated with release and anterior subcutaneous transposition of the nerve. CONCLUSIONS Our results indicate that in situ decompression and partial epicondylectomy both represent efficient and safe methods for cubital tunnel syndrome management. In patients in whom anterior subcutaneous transposition was performed, although they had a significant improvement of their clinical signs and symptoms, they had an inferior outcome when compared with patients treated with the other 2 methods.

Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.

PURPOSE To evaluate the results of a modified Paneva-Holevich technique for flexor tendon reconstruction in zone II. METHODS Twenty patients (22 digits) with poor prognosis injuries (Boyes grade 2-5) were reconstructed. The technique included placing a silicone rod and creating a loop between the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) in the first stage and reflecting the latter as a pedicled graft through the pseudosheath created around the silicone rod in the second stage. RESULTS After a follow-up period of at least 1 year (mean, 50 mo) the rate of good and excellent results was 82% according to the Buck-Gramco scale and 73% using the modified Strickland scale. CONCLUSIONS These results compare favorably with those using the classic (Hunter) 2-stage reconstructions with a silicone rod and a free tendon graft. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity, and a low rate of postreconstruction tendon ruptures and tenolysis.

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.RésuméAu cours d’une fracture supra condylienne du coude déplacée, les complications vasculaires sont relativement fréquentes. Le traitement, lui aussi, est largement controversé, notamment lorsqu’il existe une absence de pouls radial après la fracture. Entre 1994 et 2006, 66 enfants présentant une fracture supra condylienne du coude ont été traités. 5 présentaient une complication vasculaire avec absence de pouls radial. Chez un des patients, le pouls radial est réapparu après réduction à foyer fermé. Chez les 4 autres patients, il a été nécessaire de faire une réduction sanglante avec exploration vasculaire. 3 des patients avaient une occlusion de l’artère humérale. La thrombectomie a été réalisée avec restauration du pouls radial. Sur un patient, il s’agissait d’une contusion de l’artère brachiale avec spasme et une réapparition du pouls après endar térectomie. L’exploration vasculaire chirurgicale doit être réalisée même si la main se recolore après une réduction à foyer fermé.

The role of erythropoietin in central and peripheral nerve injury

Erythropoietin (Epo) is a cytokine which controls red cell production. Apart from the red cell surface, erythropoietins receptor (Epo-R) is also expressed in a large variety of normal tissues. Erythropoietin, as well as its receptor, is present in the central and peripheral nervous system. As erythropoietin having direct and indirect effect on nerve cells, enhances antioxidotic enzyme production, antagonizes glutamates cytotoxic action, metabolizes free radicals, normalizes cerebral blood flow, affects neurotransmitters release and stimulates neoangiogenesis. After injury of the central as well as the peripheral nervous system, Epo presents an anti-apoptotic action. In combination with its anti-apoptotic effect, Epo, by reducing the inflammatory response plays a crucial role in neuroprotection in many types of injury in the central and the peripheral nervous system. Epos administration contributes to the recovery of mechanical allodynia and may be effective in peripheral nerve regeneration after neurorrhaphy.