Byron Chalidis

Surgical stress response

Recent advances in molecular medicine have allowed the characterization and quantification of inflammatory cascades following surgery and trauma. Activation of immune cells is followed by the release of various cytokines as well as by migration of leukocytes into inflamed tissues. Various methods have been developed in order to modulate the immune-inflammatory system and at the same time to prevent overreaction and unexpected complications. In this context, the magnitude of surgical stress exerted on the patient is of paramount importance. Several factors, either controllable or not, are known to contribute to the development and amplification of the surgical stress response. Therefore, they should be taken into consideration by both surgical practitioners and other medical specialties involved in the management of the traumatised patient.

Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature

Treatment of complex distal humeral fractures in older patients with osteopenic bone remains a major surgical challenge. We report the results of 11 patients over 75 years of age who underwent semiconstrained sloppy-hinge total elbow arthroplasty (TEA) due to comminuted intraarticular fractures of the distal humerus. There were 9 women and 2 men with a mean age of 79.6 years. The mean duration of follow up was 2.8 years. According to AO classification, there were 8 type C3 and 3 type C2 fractures. The mean time from injury to operation was 4.3 days and the mean length of hospital stay was 9.8 days. The elbow flexion/extension and forearm pronation/supination arc of motion averaged 107(0) and 121(0) respectively. The mean Mayo Elbow Performance Score (MEPS) was 90 points, equivalent to excellent result. One patient sustained a periprosthetic humeral fracture and signs of non-progressive radiolucency were found in 8 out of the 11 elbows. Our search in the English and International literature revealed 9 other clinical studies describing the results of TEA in 167 patients with 168 distal humeral fractures. The mean age of patients varied from 69 to 84.6 years and the mean follow up from 17.8 months to 7 years. The mean MEPS among the studies was between 85 and 95 points. Wound infection was diagnosed in 9 cases (5.4%) but component removal and subsequent reimplantation was only applied in 3 elbows (1.8%). Partial ulnar nerve lesions were reported in 11 patients (6.5%) and reflex sympathetic dystrophy was developed in 5 patients (3%). In 3 elbows (1.8%) a periprosthetic fracture after a fall was recorded. Radiolucent lines between the cement mantle and bone interface were described in 24 cases (14.3%) but the majority of them (17 cases) were stable and asymptomatic. In conclusion, TEA constitutes a viable treatment option for the complex distal humeral fractures in elderly and medically compromised patients. Careful patient selection and regular follow up evaluation are mandatory for achieving an optimal result and eliminating the risks of mismanagement and early implant failure.

Internal fixation of traumatic diastasis of pubic symphysis: is plate removal essential?

IntroductionInternal fixation of the traumatic diastasis of symphysis pubis is an integral part of the definitive management of pelvic ring injuries. Both functional outcome and long term physiological effects of plate retention have not been clearly addressed and no specific indications regarding implant removal have been proposed in the literature.Materials and methodsWe reviewed 74 patients (18 females and 56 males), with an average age of 40.6 (16–75) years, who underwent open reduction and internal fixation (ORIF) of the pubic symphysis. Except from the demographic data many other parameters like suprapubic pain, sexual disturbance, impotence and dyspareunia were taken under consideration. Furthermore, any correlation between implant failure and functional impairment was recorded and the subject of implant removal in pregnant women was examined. Health outcome was assessed according to EuroQol 5-D (EQ-5D) questionnaire. Mean follow up: 41.7 (28–89) months.ResultsSuprapubic pain was present in ten patients. Three men developed neurogenic impotence and one woman had deep dyspareunia. None of these symptoms were related to implant status. Three of the four females who had uncomplicated pregnancy in the post-stabilization period had the plate in situ. Implant failure was seen in four patients but they remained asymptomatic. EQ-5D questionnaire revealed high satisfaction scores among young women and men of all age groups.ConclusionThis study supports the view that routine removal of the plate is not essential. The issue of whether the implant needs to be removed in women of childbearing age requires further investigation.

Is the lateral sacral fluoroscopic view essential for accurate percutaneous sacroiliac screw insertion? An experimental study.

The aim of this study was to evaluate the role of the lateral fluoroscopic view in optimising percutaneous sacroiliac screw insertion. Plastic pelvic models (n=26) were used for the introduction of 104 cannulated screws into the first and second sacral (S1 and S2) vertebral bodies, controlled with an image intensifier using either two views (inlet/outlet) for the right side (group A, n=52) or three views (inlet/outlet/lateral) for the left side (group B, n=52). The mean radiation exposure times for S1 were 18.6s and 14s, in groups A and B, respectively, and for S2 were 16.1s and 12.2s, respectively; 13 cortex perforations were noted in group A and 20 in group B. After insertion into S1, in both groups there were three cases of foraminal and none of central canal perforation, but after S2 insertion in both groups there were ten foraminal and five canal perforations. A higher incidence of misplacement of S1 screws was found in group A in comparison with group B (p=0.001), with sufficient data to support percutaneous screw fixation using inlet, outlet and lateral views rather than only inlet and outlet acquisition images.

Primary malignant clavicular tumours: a clinicopathological analysis of six cases and evaluation of surgical management

Primary malignant tumours of the clavicle are extremely rare and little is known regarding their clinicopathological characteristics and outcomes of surgical management. The aim of the study is to analyse the clinical, imaging, and histological features of six patients with malignant tumours of the clavicle and present the outcome of cleidectomy in four of them. A review of the literature is also provided. Six cases were included in this series: two plasmocytomas; three PNETs, one non-Hodgkin lymphoma, one high-grade chondrosarcoma and one post-irradiation fibrosarcoma. Apart from one patient with plasmocytoma and another one with non-Hodgkin lymphoma, the remaining four patients underwent partial or complete cleidectomy according to tumour location. At the time of latest follow-up all patients were alive. Neither local recurrence nor metastases were observed in patients that underwent cleidectomy. In this group, the average score was 86.6% of the expected normal function according to the Musculoskeletal Tumour Society (MSTS) evaluation form. The mean Constant–Murley score of the affected side was 80. Patients after cleidectomy were pain free, they had almost full shoulder range of motion and no significant functional deficit was reported. Primary malignant clavicular tumours may be easily undiagnosed due to their insidious clinical onset. Partial or total cleidectomy is associated with adequate shoulder mobility and mild functional deficit. Therefore, the extent of clavicle excision during tumour removal does not seem to determine the functional outcome of the affected shoulder.

Management of Pelvic Instability Secondary to Chronic Pyogenic Sacroiliitis: Case Report

BACKGROUNDnPyogenic sacroiliitis is a rare musculoskeletal infection that is difficult to diagnose and treat. The consequences of delayed diagnosis or inadequate treatment are often the formation of abscesses and sinuses, destructive osteomyelitis, and sequestration.nnnMETHODSnCase report and literature review.nnnRESULTSnA 26-year-old woman developed chronic destructive pyogenic sacroiliitis and gross pelvic instability. Over a two-month hospitalization, she required six extensive surgical debridements with application of cement spacer, negative-pressure closure, intravenous antibiotics, and complex definitive fixation of the pelvic ring with autografting and application of bone morphogenetic protein-7. Radiologic union of her symphysis pubis fusion was verified during the fifth postoperative month. Thirteen months postoperatively, the patient was walking freely without aids and reported pain-free function for most of her daily activities.nnnCONCLUSIONnChronic destructive pyogenic sacroiliitis is one of the most demanding infections of the musculoskeletal system. A successful outcome depends on prompt referral, appropriate antibiotic treatment, correct timing of surgical intervention, surgical expertise, and multidisciplinary follow up.

Management and reconstruction of pelvic instability after emergency symphysiotomy

dissection of the tissues, causing a collection in the perivascular area, which subsequently distended into the uterine cavity. There was then rupture, with sudden intractable blood loss. Diagnosis is difficult, requiring color Doppler ultrasound, CT scan, or angiography. Being a rare cause of secondary postpartum hemorrhage, a high degree of suspicion is required to anticipate this diagnosis. Uterine artery embolization is a safe and effective method to control hemorrhage under these circumstances. References

Safety and efficacy of albumin administration in trauma

Albumin is one of the oldest known and studied human proteins. It is characterised by diverse physiological and biochemical properties that render it relevant to many aspects of the disordered vascular and cellular functions after trauma. Apart from the ability to maintain the colloid oncotic pressure, human serum albumin has multiple effects, including antioxidant activity and binding affinity for drugs and toxic substances, inhibition of apoptosis and modulation of trauma-induced inflammatory response. According to the current state of knowledge, there are conflicting results regarding the benefits of albumin administration in critically ill patients. Further investigations are warranted to resolve the continued uncertainty about the safety and efficacy of human serum albumin in specific clinical circumstances and selected populations of severely injured patients.