Christos G. Dimitriou

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.

Aspiration alone versus aspiration and bupivacaine injection in the treatment of undisplaced radial head fractures: a prospective randomized study.

HYPOTHESIS Some physicians advocate that aspiration of elbow joint hematoma in radial head fractures is helpful not only for determining a mechanical block to motion from a fracture fragment but also for improving the elbow motion and pain. However, the supplementary role of intra-articular anaesthetic injection is unclear. MATERIALS AND METHODS In this prospective randomized study, 40 patients with undisplaced radial head fractures (Mason I) were treated with elbow joint aspiration alone (20 patients) or aspiration plus intra-articular injection of 3 mL of bupivacaine 0.5% (20 patients). Active elbow exercises were immediately commenced. The patients were evaluated at 1 day, 1, 3, and 6 weeks, 3 and 6 months, and 1 year. RESULTS No difference was found in terms of range of motion, pain and elbow function between the 2 groups in all the examined time points. The improvement in the above parameters achieved a plateau at 3 weeks in both groups. DISCUSSION Intra-articular use of local anaesthetic after joint aspiration does not offer any benefit over aspiration alone in the treatment of undisplaced radial head fractures and its routine application is not supported by the clinical data.

Rotaglide total knee arthroplasty: a long-term follow-up study.

BACKGROUND Mobile-bearing knee designs represent an alternative to conventional fixed-bearing implants in total knee arthroplasty. The purpose of this study was to determine the clinical results of a mobile-bearing knee implant. METHODS From 1990 to 1998, 326 primary consecutive mobile-bearing total knee prostheses were implanted in 260 patients who had a mean age and standard deviation of 66.7 ± 6.9 years. Femoral and tibial components were cemented in all knees, and the patella was resurfaced in 199 knees (61%). Patients were evaluated with the use of the Knee Society clinical rating system and radiographic examinations. Complications were noted, and survivorship of the prostheses was determined. RESULTS The mean follow-up period was 156 ± 27.3 months, with maximum follow-up at eighteen years. The mean Knee Society knee score improved from 32.4 ± 21.2 preoperatively to 92.6 ± 10.0 at the time of the last follow-up (p = 0.00), and the mean Knee Society functional score improved from 39.3 ± 18.7 preoperatively to 66.7 ± 18.6 at the time of the last follow-up (p = 0.00). Mean knee flexion improved from 92.3° ± 14.5° preoperatively to 112.1° ± 13.4° at the time of the last follow-up (p = 0.00). There were twenty-four (7.4%) knees that required revision. In eighteen (5.5%) knees, worn out or broken polyethylene was found and a polyethylene-only exchange was done. Six knees (1.8%) were fully revised. The survival rate was 0.96 (95% confidence interval, 0.93 to 0.98) at ten years and 0.87 (95% confidence interval, 0.79 to 0.93) at eighteen years. CONCLUSIONS A fully congruent, mobile-bearing total knee prosthesis had excellent survivorship during the ten to eighteen-year follow-up interval.

Modified ulnar translocation technique for the reconstruction of giant cell tumor of the distal radius.

Giant cell tumors of the distal radius have been frequently described as difficult to treat, chiefly because of their close proximity to multiple tendons, median nerve, radial artery and carpus.The aim of treatment is to remove the tumor completely and preserve the radiocarpal and radioulnar joints.However, this is not always feasible as giant cell tumors seem to behave more aggressively and have a higher recurrence rate in the distal radius, even if local adjuvant treatment with phenolmethylmethacrylate or liquid nitrogen is applied. The above incidence is increased in Campanacci grade III lesions, which are characterized by fuzzy borders, loss of cortical continuity, and extension into soft tissues. In these cases, wide excision instead of intralesional excision may be advocated, particularly when the tumor breaks through the cortex, violates the articular surface, and destroys >50% of the surrounding metaphysis. Several reconstructive options (e.g., resection arthroplasty, prosthetic replacement, arthrodesis, ulnar translocation, centralization of the carpus over the remaining ulna, use of a nonvascularized, or vascularized fibular graft [with or without arthrodesis], and allograft replacement) have been described for the treatment of either recurrent or primary grade III giant cell tumor with destruction of the bone cortex and associated soft tissue mass. Ulnar translocation has been mentioned rarely in the literature, and, according to our knowledge, only 10 cases have been previously reported. This article presents a case of a woman with a grade III giant cell tumor of the distal radius. Wide excision of the tumor followed by reconstruction of the distal forearm with a modified ulnar translocation technique and wrist arthrodesis led to optimum results and no mass recurrence at 13 years postoperatively.

Reconstruction of a missed posterior locked shoulder fracture-dislocation with bone graft and lesser tuberosity transfer: a case report

IntroductionPosterior shoulder fracture-dislocation is a rare emergency condition with poor prognosis when there is a delay in diagnosis and presence of associated injuries.Case presentationWe present a case of a neglected four-part fracture-dislocation of the proximal humerus in a 34-year-old Greek woman. Except from the substantially displaced and comminuted tuberosity fractures, an anterolateral defect of approximately 50% of the articular surface was apparent. Open reduction of the humeral head was followed by reconstruction of the proximal humerus with allograft impaction, transfer of lesser tuberosity to the humeral defect and anatomic fixation of the greater tuberosity and humeral neck fractures. At two and a half years postoperatively, the humeral head was revascularised and properly articulated with the glenoid fossa.ConclusionThe presented case underlines the variability of injury pattern, the potential of missed diagnosis and the need for preserving the humeral head in young patients regardless of the amount of articular surface defect and disruption of soft tissue attachments.

Carpal tunnel syndrome due to an atypical deep soft tissue leiomyoma: The risk of misdiagnosis and mismanagement

BackgroundLeiomyomas of the deep soft tissue are quite uncommon and occur even more rarely in upper extremity.Case presentationA 32-year old manual laborer man presented with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed but the patient experienced only temporary relief of his symptoms. MRI examination revealed a deep palmary located mass with well-defined margins and ovoid shape. Intraoperatively, the tumor was in continuity with the flexor digitorum superficialis tendon of the middle finger causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with leiomyoma. After two years the patient was pain-free without signs of tumor recurrence.ConclusionDespite the fact that reports on deep soft tissue leiomyoma are exceptional, this tumor had to be considered as differential diagnosis in painful non-traumatic hand syndromes especially in young patients.

Intercalary Bone Grafting for the Reconstruction of Phalangeal Osteolysis in Disappearing Bone Disease: Case Report

Disappearing bone disease (DBD) is a rare condition of unknown etiology that may cause massive hand deformity due to severe osteolysis and soft-tissue atrophy. Bone grafting of the affected metacarpal bones or wrist has been described with moderate success in only 4 cases, but phalanx reconstruction has not been attempted. We report a case with multicentric DBD that was treated with staged intercalary iliac bone grafting of the phalanges of the dominant thumb and index finger. After 3 years, no graft resorption was noticed and the patient reported considerable functional improvement.

The effect of transverse carpal ligament lengthening on carpal tunnel volumetry: a comparison between four techniques.

Transverse carpal ligament (TCL) reconstruction after open carpal tunnel release has been advocated to restore wrist kinematics and grip strength. This study investigates the effect of TCL reconstruction in carpal tunnel volume (CTV). Thirty-eight cadaveric wrists were volarly approached and TCL was exposed to its proximal and distal edges. Carpal tunnel contents were removed and the CTV was measured considering that carpal tunnel resembled the shape of a truncated cone. TCL was then dissected and subsequently reconstructed by using 4 different surgical lengthening techniques. Three of these techniques were retrieved from the literature. The fourth was proposed and performed by the authors. Postreconstruction calculation of CTV was done with the same method. In 6 cadavers, a magnetic resonance imaging-based measurement of CTV was performed to assess the validity and reliability of simulation method. The average increase of CTV ranged from 31% to 44% (P < 0.001 for all techniques). However, no statistical significant difference was found between the 4 techniques (P = 0.097). Magnetic resonance imaging volumetric values were equal to simulation measured values before and after reconstruction of TCL (P = 0.224 and P = 0.674, respectively). Lengthening of TCL substantially increases the carpal tunnel capacity regardless the applied surgical technique. The simulation model method seems to be an accurate, precise, and cost-effective approach for the evaluation of CTV.

Brucella cervical spondylitis complicated by spinal cord compression: a case report

A case of 65-year-old farmer who presented with Brucella-related cervical spondylitis is described. Because of the advanced form of the infection resulted in neurological impairment, cervical vertebra corpectomy and debridement of the paravertebral granulomatous tissue deposits were performed followed by stabilization with anterior plating and bone grafting. In addition, double antimicrobial chemotherapy regimen was administered for 12 weeks. After one year, follow up evaluation demonstrated resolution of the infection. The authors recommend that brucellosis should be included in the differential diagnosis of cervical spondylitis, particularly in patients who reside in countries where the zoonosis is still endemic.

Cuff Width Increases the Serum Biochemical Markers of Tourniquet-induced Skeletal Muscle Ischemia in Rabbits

Tourniquet application is a widely accepted adjuvant technique in extremity surgery. The purpose of this prospective, randomized trial was to evaluate the effect of cuff width on skeletal muscle ischemia-reperfusion injury. A 2- or 4-cm wide curved tourniquet cuff was applied around the midthigh of 36 New Zealand White rabbits and inflated to a pressure of 200 or 400 mm Hg for 2 hours: group A=2 cm to 200 mm Hg; group B=2 cm to 400 mm Hg; group C=4 cm to 200 mm Hg; group D=4 cm to 400 mm Hg. Blood levels of potassium, lactic acid, urea, lactic dehydrogenase, and creatinine phosphokinase MM isoenzyme (CPK-MM) were measured as basic indicators for limb ischemia before tourniquet inflation and 1, 5, and 30 minutes after cuff release.Potassium values did not differ among the 4 groups. Lactic acid and urea concentrations were always higher in the 400 mm Hg groups (B and D) (P<.001). However, cuff width did not affect their levels (P>.16). Lactic dehydrogenase and CPK-MM values were also greater in the 400 mm Hg groups at all times (P<.001). Further subgroup analysis of 200 mm Hg pressure groups showed higher lactic dehydrogenase (P<.02) but not CPK-MM (P>.9) concentrations in group C than in group A during the 30-minute period. At 400 mm Hg, lactic dehydrogenase and CPK-MM values were higher in group D compared with group B only 30 minutes after cuff deflation (P<.001). Broad tourniquets are associated with significantly greater and prolonged elevation of serum biochemical markers of inducible skeletal muscle ischemia-reperfusion injury compared with narrow ones. This difference is more prominent when a wide cuff is inflated to a high pressure.