Antonis Kouzelis

The treatment of infected nonunion of the tibia following intramedullary nailing by the Ilizarov method

The purpose of this study was to demonstrate the effectiveness of the Ilizarov method and circular external fixator in order to eradicate the infection and restore bone union, limb anatomy and functionality in cases with infected nonunion of the tibia following intramedullary nailing. During 7 years nine patients suffering from infected nonunion of the tibia after intramedullary nailing were treated in our department. The series comprised seven men and two women with an average age of 39.7 years (range 21-75 years). The patients had previously undergone an average of 4.8 operations (range 3-6 operations). Active purulent bone infection occurred in all nine patients. Bone defect was present in all patients with a mean size of 5 cm (range 2-12 cm). In three cases with bone defect less than 2 cm, monofocal compression osteosynthesis technique was used. In the rest cases where bone defect exceeded 2 cm, bifocal consecutive distraction-compression osteosynthesis technique was applied. Three patients required a local gastrocnemius flap. The mean follow-up period was 26.6 months (range 13-42 months). Results were evaluated using Paleys functional and radiological scoring system. Bone union was achieved in all nine patients without recurrence of infection during the follow-up period. Bone results were graded as excellent in five cases and good in the rest four cases. Functional results were graded as excellent in three cases, good in four and fare in two cases. Mean external fixation time was 187.4 days (range 89-412 days) and mean lengthening index was 32 days/cm (range 27-39 days/cm). Complications observed included eight grade II pin tract infections, axial deformity at the lengthening site in two cases and at the nonunion site in another two cases. Ankle joint stiffness was detected in five cases. The Ilizarov method may be an effective method in infected nonunions of the tibia following intramedullary nailing.

Does graded reaming affect the composition of reaming products in intramedullary nailing of long bones

Reaming products taken during intramedullary nailing were examined to identify possible differences in their composition depending on the reaming percentage. Reaming products were taken from 39 fresh closed tibial and femoral diaphyseal fractures in patients with an average age of 29 years. According to histology, reaming products mainly consisted of bone trabeculae, viable or nonviable, and bone marrow stroma. A statistically significant reverse correlation exists between viable bone mass percentage and reaming progress. Reaming 1 mm less than the minimum canal diameter provides a higher viable bone mass percentage, which might be an important factor in the bone healing process.

Treatment of unstable distal radius fractures with Ilizarov circular, nonbridging external fixator

Unstable distal radius fractures remain a challenge for the treating orthopaedic surgeon. We present a retrospective follow-up study (mean follow-up 12.5 months) of 20 patients with 21 unstable distal radius fractures that were reduced in a closed manner and stabilized with a nonbridging Ilizarov external fixator. Subsequent insertion of olive wires for interfragmentary compression was performed in cases with intra-articular fractures. According to the overall evaluation proposed by Gartland and Werley scoring system 12 wrists were classified as excellent, 6 as good, 2 as fair and 1 as poor. Grade II pin-tract infection in distal fracture fragment was detected in 3 wires from a total of 78 (3.8%) and in 4 half pins out of a total of 9 (44.4%). Pronation was the most frequently impaired movement. This was restricted in 4 patients (19%) in whom a radioulnar transfixing wire was applied. Symptoms of irritation of superficial sensory branch of the radial nerve occurred in 3 patients with an olive wire applied in a closed manner in the distal fragment. Ilizarov method yields functional results comparable to that of other methods whilst it avoids wrist immobilization, open reduction and reoperation for implant removal. The method is associated with a low rate of major complication and satisfactory functional outcome.

Least possible fixation techniques of 4-part valgus impacted fractures of the proximal humerus: a systematic review

The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. Level of evidence: systematic review of literature (level IV) as most of the studies were level IV.

Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients

Background: The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. Objectives: The present study reports the midterm clinical and radiological results of a large series of consecutive patients with 4-part VI fractures treated with a minimal invasive technique of internal fixation. Methods: Over a ten-year period (2004-2014), we treated 56 patients with a true 4-part valgus impacted fracture of the proximal part of the humerus. Four patients were lost to follow-up and three died, leaving 49 patients (33 female, 16 males, average age 60,1 years) available for the study. Fracture fixation was achieved through the lateral transdeltoid approach with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding gross disimpaction of the humeral head from the valgus position. Functional outcome assessment was performed using the parameters of the Constant-Murley score within a mean follow up period of 43,8 months (range, 24 to 115 months). Results: All fractures were united within the first 3 months except one that showed late displacement and finally nonunion. The median Constant score was 81,7 points and the functional score in comparison with the unaffected shoulder was 86.2%. There were three patients with total Avascular Necrosis (AVN) of the head revised to hemiarthroplasty. The nonunion case was revised to reverse shoulder arthroplasty 12 months after surgery. In five cases, absorption of the greater tuberosity was noted in the last radiographic control without any serious consequences to the shoulder function. Conclusion: Advantages of this minimally invasive technique can be summarized as shorter operative time, no use of hardware, minimal soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with “tension band effect” and adequate rotator cuff repair allowing for early joint motion.

Translation, cultural adaptation, validity and reliability of the Greek version of the modified Constant Score

Aim The purpose of this study was to produce a modified Greek translation of the CS and to test this version in terms of reliability and validity. Materials and methods Translation of the modified Constant score testing protocol was done according to established international guidelines. Sixty-three patients with shoulder pain caused by degenerative or inflammatory disorders completed the Greek version of CS along with the Greek versions of SF-12 and Quick Dash Scores and the ASES Rating Scale and were included into the validation process. To assess test–retest reliability, 58 individuals completed the subjective part of the test again after 24–36 hours, while abstaining from all forms of treatment; internal consistency was measured using Cronbachs alpha (α); reliability was assessed with test–retest procedure and the use of Interclass Correlation Coefficient (ICC), whereas the validity of the reference questionnaire was evaluated using Pearsons correlation coefficient in relation to control questionnaires. Results There were no major problems during the forward–backward translation of the CS into Greek. The internal consistency was high (Cronbachs alpha 0.92) while the test–retest reliability for the overall questionnaire was also high (intra-class coefficient 0.95). Construct validity was confirmed with high values of Pearsons correlation between CS and Q-DASH (0.84), SF-12 (0.80) and ASES score (0.86) in respect. Conclusion A translation and cultural adaptation of CS into Greek was successfully contacted. The Greek version of the modified Constant Score can be a useful modality in the evaluation of shoulder disorders among Greek patients and doctors.

Successful treatment of infected femoral shaft nonunion with teriparatide after eradication of infection

B one healing requires a multitude of cell types, inflammatory cytokines, growth factors, prostaglandins, and other substances to restore biomechanical properties. The biologic process of fracture healing is complex, and several factors may impede or enhance this process. Delayed or nonunion of long-bone fractures continues to have a high incidence despite modern treatment options, often leaving patients with residual physical disability. Femoral nonunion presents a difficult treatment challenge and a formidable personal and economic hardship for the patient. A number of techniques have been proposed for treating nonunion of the femoral shaft, including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, and various surgical options such as nail dynamization, exchange nailing, external fixators, augmented or wave-plate osteosynthesis, and other complex reconstructive techniques. Plating is the treatment of choice for femoral nonunion if an intramedullary nail is in situ, and reamed intramedullary nailing is the treatment of choice for failed plate fixation. Enhancement of the biologic environment at the nonunion site can be achieved with bone grafting, bone graft substitutes, or new bioactive factors. Pharmacological agents that modulate bone formation and bone remodeling are in broad use for treatment of osteoporosis and bone fragility, but interest in their use in fracture repair has recently emerged. Teriparatide is a synthetic polypeptide hormone that contains the 1-34 amino acid fragment of recombinant human parathyroid hormone (PTH 1-34). It has been approved for the treatment of postmenopausal women with osteoporosis who are at high risk for sustaining a fragility fracture, with demonstrated increases in bone mineral density. Recent animal studies have suggested that PTH (1-34) may be effective in enhancing fracture healing, showing that callus forms earlier and has superior biomechanical properties than those without PTH (1-34) treament. Although studies suggest a potential clinical role for PTH (1-34), one study in postmenopausal women showed no benefit of teriparatide use in distal radial fracture healing. Anecdotal literature on the use of teriparatide in promoting bone healing suggests its efficacy, and reports of successful treatment of nonunions are rapidly increasing. Teriparatide seems useful in the treatment of atypical femoral fractures after long-term administration of bisphosphonates. The effect of teriparatide in nonunions range from an acceleration of the healing process to its reactivation in atrophic nonunions, but these cases refer to fractures in various sites, both in cancellous and cortical bone, often in patients with risk factors for nonunion, and some after initial conservative treatment of fractures. A systematic literature review on the use of recombinant PTH in human fracture healing yielded only 16 publications on the subject, including 13 case reports or series and two randomized controlled trials. In eight case reports, treatment was initiated for delayed union or chronic nonunion, resulting in callus formation at 1--3 mo with a decrease in fracture gap. Complete resolution of pain and final healing of the nonunions was seen in 5--21 mo. We present a patient with an atrophic femoral nonunion after plate fixation, complicated by low-grade infection. The patient was treated successfully with off-label use of teriparatide for 3 mo, confirming a possible benefit in using teriparatide in long-bone nonunions. To the best of our knowledge, we believe this is the first case report in the literature of an infected nonunion of a long-bone diaphyseal fracture treated with teriparatide. According to Greek law, ethical approval for this study was not required; however, written informed consent was obtained from the patient for surgical treatment, off-label use of teriparatide, and publication of her information.