Elias Lambiris

Double-Loop Suture Repair for Acute Acromioclavicular Joint Disruption

Background Although it has been established that surgical treatment for acromioclavicular joint disruption (types IV-VI and type III in overhead throwing athletes and heavy laborers) is preferred, the literature is inconclusive about the best type of surgery. Purpose With the goal of avoiding the potential complications of hardware use, the authors present a coracoclavicular functional stabilization technique with the intention to restore the anteroposterior and superior displacement of the clavicle. Study Design Case series; Level of evidence, 4. Methods From 1999 to 2003, 38 patients with an acute, complete acromioclavicular joint separation (34 men, 4 women; mean age, 33.5 years) underwent surgical reconstruction with the described coracoclavicular loop stabilization technique. With this technique, the superior and anteroposterior displacement of the clavicle can be easily controlled using 2 pairs of Ethibond No. 5 nonabsorbable sutures—one passed in front and the other behind the clavicle, through a central drill hole, 2 cm from its lateral end, directly above the base of the coracoid process (at the corresponded attachment of coracoclavicular ligaments). Passive shoulder motion was encouraged by the second postoperative day. Results Thirty-four patients were available for the last clinical and radiologic evaluation. At a mean follow-up of 33.2 months (range, 18-59 months), the mean Constant-Murley score was 93.5 points (range, 73-100 points), and 2 cases with slight loss of reduction (less than half of the width of the clavicle) were detected. Complications included 1 case with superficial infection and 1 patient (basketball player) with persistent tenderness in the acromioclavicular joint without signs of secondary arthritis. The incidence of periarticular ossification was 17.6% and did not affect the final outcome. Secondary degenerative changes were not detected. Conclusion Considering the nearly anatomical reconstruction, the avoidance of hardware complications, and the low rate of recurrence, this technique may be an attractive alternative to the management of acute acromioclavicular joint separations.

Midterm results of treatment with a retrograde nail for supracondylar periprosthetic fractures of the femur following total knee arthroplasty

Objectives: Although the short-term results of supracondylar periprosthetic fractures treated with retrograde nailing have been satisfactory, there is always a concern about the long-term survival of the prosthesis. The aim of the study was to evaluate fracture healing and knee functional outcome with a follow-up time of at least 2 years in periprosthetic fractures of the knee treated with a supracondylar nail. Design: Cohort study. Patients: There were 9 patients with 10 periprosthetic fractures. In 1 patient, the fracture occurred intraoperatively. In the others, the time between the total knee arthroplasty and the periprosthetic fracture ranged between 2 weeks and 7 years (average time: 2.78 years). The mean follow-up was 34.5 months (25-52 months). Main Outcome Measurements: The Western Ontario and McMaster Universities index was used to evaluate the functional result postoperatively using the paired t test as the statistical test. Fracture union was assessed with plain x-rays. Results: All the fractures united within 3 months. One fracture united in extreme valgus (35°) and was revised to a stemmed total knee replacement. There were no infections and no prosthesis loosening. The paired t test before the fracture and after the operation demonstrated no statistically significant differences; however, there was a trend toward lower functional score postoperatively. Conclusions: It appears that retrograde nailing is a reliable technique to treat periprosthetic supracondylar fractures. It provides adequate stability until fracture union. The morbidity of the operation is minimal, and the complication rate is low. The midterm results in our study showed that none of the prostheses required revision. In our opinion, it is the treatment of choice for a periprosthetic fracture when the prosthesis is stable.

Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus.

Thirty-eight patients with four-part proximal humerus fractures and fracture dislocations were treated with humeral head replacement between 1989 and 1995. At followup (mean, 37 months; range, 12–48 months) the patients were evaluated for postoperative pain, active range of motion, muscular strength, overall function in every day activities, and patient satisfaction. Complications developed in five patients and consisted of humeral component malposition (one shoulder), rotator cuff insufficiency (two shoulders), and heterotopic ossification (two shoulders). According to the Neer criteria, the overall results were: 32 (84%) patients had no pain and improved motion (active forward elevation averaged 130°, external rotation 45°, and average internal rotation to the first lumbar vertebra); in this group strength and function 6 months postoperatively was 80% of the normal side and reached 90% of the normal side at 1 year postoperatively under continuous stretching and strengthening exercises; and 34 patients (90%) were satisfied with their treatment. The results of the study indicate that humeral head replacement is a dependable method to restore comfort and function to patients with acute or old four-part fractures of the proximal humerus. However, recovery of function and range of motion are much less predictable in patients with an old injury.

Interlocking Intramedullary Nailing in Distal Tibial Fractures

This retrospective study examined the results of non-pilon fractures of the distal part of the tibia treated with interlocking intramedullary nailing. Seventy-three patients with equal numbers of fractures treated surgically between 1990 and 1998 were reviewed. Mean patient age was 39.8 years, and follow-up averaged 34.2 months. The AO fracture classification system was used. Concomitant fractures of the lateral malleolus were fixed. All but three fractures achieved union within 4.2 months on average. Satisfactory or excellent results were obtained in 86.3% of patients. These results indicate interlocking intramedullary nailing is a reliable method of treatment for these fractures and is characterized by high rates of union and a low incidence of complications.

The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paleys grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies.

BACKGROUND Spinal cord injury without radiographic abnormalities (SCIWORA) is thought to represent mostly a pediatric entity and its incidence in adults is rather underreported. Some authors have also proposed the term spinal cord injury without radiologic evidence of trauma, as more precisely describing the condition of adult SCIWORA in the setting of cervical spondylosis. The purpose of the present study was to evaluate adult patients with cervical spine injuries and radiological-clinical examination discrepancy, and to discuss their characteristics and current management. METHODS During a 16-year period, 166 patients with a cervical spine injury were admitted in our institution (Level I trauma center). Upper cervical spine injuries (occiput to C2, 54 patients) were treated mainly by a Halo vest, whereas lower cervical spine injuries (C3-T1, 112 patients) were treated surgically either with an anterior, or posterior procedure, or both. RESULTS Seven of these 166 patients (4.2%) had a radiologic-clinical mismatch, i.e., they presented with frank spinal cord injury with no signs of trauma, and were included in the study. Magnetic resonance imaging was available for 6 of 7 patients, showing intramedullary signal changes in 5 of 6 patients with varying degrees of compression from the disc and/or the ligamentum flavum, whereas the remaining patient had only traumatic herniation of the intervertebral disc and ligamentum flavum bulging. Follow-up period was 6.4 years on average (1-10 years). CONCLUSION This retrospective chart review provides information on adult patients with cervical spinal cord injuries whose radiographs and computed tomography studies were normal. It furthers reinforces the pathologic background of SCIWORA in an adult population, when evaluated by magnetic resonance imaging. Particularly for patients with cervical spondylosis, special attention should be paid with regard to vascular compromise by predisposing factors such as smoking or vascular disease, since they probably contribute in the development of SCIWORA.

Antibiotic prophylaxis in primary hip and knee arthroplasty: comparison between cefuroxime and two specific antistaphylococcal agents.

This is a prospective randomized study comparing cefuroxime to 2 antistaphylococal agents (fusidic acid and vancomycin), for prophylaxis in total hip arthroplasty (THA) and total knee arthroplasty (TKA) in an institute, where methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE) prevalence exceeds 25% of orthopedic infections. There were 3 patient groups. Group A included the patients who received cefuroxime, group B those who received fusidic acid, and group C those who received vancomycin. Patients were evaluated for the presence of superficial and/or deep infection at the surgical site. Statistical analysis did not reveal any substantial difference between the 3 groups. We do not recommend the use of specific antistaphylococcal agents for prophylactic use in primary THA and TKA, even in institution where MRSA and MRSE exceed 25% of orthopedic infections.

Minimal internal fixation augmented by small wire transfixion frames for high-energy tibial plateau fractures.

Purpose: To evaluate the outcome of bicondylar tibial plateau fractures treated with minimal internal fixation augmented by small wire external fixation frames and to assess the necessity of bridging the knee joint by extending the external fixation to the distal femur. Methods: This is a retrospective study of 48 tibial plateau fractures. There were 40 (83.5%) Schatzker type VI fractures, 8 Schatzker type V fractures, and 18 (37.5%) fractures were open. A complex injury according to the Tscherne-Lobenhoffer classification was recorded in 30 (62.5%) patients. All fractures were treated with combined minimally invasive internal and external fixation. Closed reduction was achieved in 32 (66.6%) of the fractures. Extension of the external fixation to the distal femur was done in 30 (62.5%) fractures. Results were assessed according to the criteria of Honkonen-Jarvinen. Results: Follow-up ranged from 28 to 60 months with an average of 38 months. All fractures but 1 united at an average of 13.5 weeks (range 11-18 weeks). One patient developed an infected nonunion of the diaphyseal segment of his fracture. Thirty-nine (81%) patients achieved an excellent or good radiologic result. An excellent or good final clinical result was recorded in 36 patients (76%). Bridging the knee joint did not affect significantly the result (P < 0.418). No significant correlation was found between the type of fracture and the final score (P < 0.458). Conclusions: Hybrid internal and external fixation combined with tibiofemoral extension of the fixation is an attractive treatment option for complex tibial plateau fractures.

Sexual function in females with severe cervical spinal cord injuries: a controlled study with the Female Sexual Function Index.

The objective of this study was to identify the sexual adjustment of females with severe cervical spinal cord injuries (SCI) using the Female Sexual Function Index (FSFI). The 19-item questionnaire of the FSFI concerns sexual function and satisfaction in sex life. This study, conducted by the Orthopaedic and Psychiatry Departments of Patras University, used a sample of a series of 39 consecutive female patients with severe traumatic SCI. We compared these female patients with an age–economic–educational level- and marital status-matched control group of the general population. Sexual activity was lower among females with SCI, but the desire, the emotional quality of sex life and overall sexual satisfaction did not differ from the controls. These results demonstrate that sexual life in females with SCI remains almost unaffected.

Anterior Traumatic Shoulder Dislocation Associated With Displaced Greater Tuberosity Fracture : The Necessity of Operative Treatment

Objective: To evaluate the radiographic and clinical outcome, including the incidence of recurrence, in patients with displaced greater tuberosity (GT) fractures associated with a traumatic anterior shoulder dislocation. Design: Retrospective study. Setting: University Hospital (Level 1 trauma center). Patients: There were 34 completely evaluated patients (19 male, 15 female) seen between 1993 and 2002 with a displaced GT fracture associated with a traumatic anterior shoulder dislocation. Average age was 52.8 years and the mean follow-up period was 4.8 years (range, 2.0 to 10 years). Intervention: All GT fractures were internally fixed solely with heavy non-absorbable sutures and any associate rotator cuff tear was repaired at the same time. A special rehabilitation protocol was administered in all patients. Main Outcome Measurements: Functional assessment was obtained using the parameters of the Constant score which grades outcomes as excellent, very good, good and poor. Results: Overall, there were 25 (73.5%) excellent, 6 (17.6%) very good, 2 (5.8%) good and 1 (3.1%) poor results, and the average Constant score was 88.4 (range 45.0 to 100.0). All fractures healed radiographically, without evidence of secondary displacement, except in one patient. No case of recurrence of dislocation was noted in any patient. Partial absorption or “lysis” of the GT without significant clinical relevance was detected in 4 cases. Conclusions: Displaced fractures of the GT after traumatic anterior shoulder dislocation may result in limitation of motion and functional disability if they are not treated promptly by surgery. Open reduction and stable fixation of the GT along with rotator cuff repair when present, allows for early passive motion of the joint, and yields excellent final results in approximately three quarters of the patients and restores their ability to return to full activities of daily living. A compliant patient is also necessary for a successful result.