George M. Kontakis

Early management of proximal humeral fractures with hemiarthroplasty: A SYSTEMATIC REVIEW

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7 degrees (10 degrees to 180 degrees) and the mean abduction to 92.4 degrees (15 degrees to 170 degrees). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.

Application of BMP-7 to tibial non-unions: A 3-year multicenter experience

SUMMARY The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9-317 mo). Patients had undergone a median of 2 (range 0-11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3-15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute.

The influence of osteoporosis in femoral fracture healing time

AIM In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed. PATIENTS AND METHODS Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis. RESULTS In all group A patients Singh score < or =4 and CBR>0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score > or =5 and CBR<0.48. Fractures of group A healed in 19.38+/-5.9 weeks (12-30) and in group B 16.19+/-5.07 weeks (10-28), P=0.02. CONCLUSIONS Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process.

Sympathetic and sensory neural elements in the tendon of the long head of the biceps.

BACKGROUND Although the tendon of the long head of the biceps is a well-known source of shoulder pain, the pathophysiological basis of this pain has yet to be explained. The aim of this study was to detect and characterize any nervous element of the tendon and to determine a possible explanation for pain originating from this structure. METHODS The nature of the neuronal innervation of the tendon of the long head of the biceps was studied immunohistochemically, in four tendons from different human cadavers, with use of neurofilament antibody 2H3, neurofilament-like antibody 3A10, calcitonin gene-related peptide, substance P, and tyrosine hydroxylase. RESULTS A large neuronal network, asymmetrically distributed along the length of the tendon with a higher degree of innervation at the tendon origin, was identified by the neurofilament and neurofilament-like antibodies 2H3 and 3A10. This innervation was found to be positive for calcitonin gene-related peptide and substance P, suggesting the presence of thinly myelinated or unmyelinated sensory neurons. It was also positive for tyrosine hydroxylase, suggesting a post-ganglionic sympathetic origin. CONCLUSIONS AND CLINICAL RELEVANCE These findings demonstrate that the tendon of the long head of the biceps is innervated by a network of sensory sympathetic fibers, which may play a role in the pathogenesis of shoulder pain.

Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation.

STUDY DESIGN In this prospective study, the results of treating unstable thoracolumbar and lumbar injuries with Cotrel-Dubousset instrumentation were investigated. OBJECTIVE To determine the pain and work status of the patients, to evaluate neurologic status, and to assess the efficacy of instrumentation in the short term. SUMMARY OF BACKGROUND DATA Short-segment pedicle screw construct is the method of choice for reduction and stabilization of unstable thoracolumbar spinal injuries. Many investigators have recently reported a high rate of instrument failure. In this study, the use of segmental transpedicular fixation two levels above the kyphosis decreased instrument failure and sagittal collapse. METHODS Thirty patients, who had unstable thoracolumbar and lumbar spinal injuries, underwent application from a posterior approach of Cotrel-Dubousset instrumentation two levels above and one below at the thoracolumbar junction and short segment fixation in the lumbar area. Radiologic parameters were evaluated before and after surgery. RESULTS The mean follow up was 31 months (range, 25-49) months. There were statistically significant differences between the pre- and postoperative values in all radiologic parameters. Neurologic status improved in 70% of the patients, with a mean Frankel grade of 1.3 grades. CONCLUSIONS Cotrel-Dubousset instrumentation provided spinal stability in unstable injuries, forming a rigid construct and restoring physiologic thoracolumbar and lumbar postural contours because of its highly corrective effect in the sagittal profile with no loss of correction.

Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation)

AIMS AND OBJECTIVES To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury. METHODS One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover. RESULTS Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p<0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response. CONCLUSIONS These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible.

Efficacy of autologous iliac crest bone graft and bone morphogenetic proteins for posterolateral fusion of lumbar spine: a meta-analysis of the results

Study Design. Meta analysis of randomized control trials. Objective. To evaluate the radiographic and clinical effectiveness of bone morphogenetic proteins (BMPs) within the context of posterolateral fusion of the lumbar spine (LS). Summary of Background Data. Various bone graft substitutes have been used in the setting of posterolateral lumbar fusions. Recently, great interest has been shown in BMPs. Clinical trials have tested the efficacy of BMPs to iliac crest bone graft (ICBG) in posterolateral fusion procedures of the LS. A cumulative result of these studies would give more credit to the final conclusions. Methods. A systematic search of electronic databases, and references from eligible articles was conducted. Comparative studies reporting on the results of posterolateral fusion for treatment of degenerative disease of LS and including 2 treatment groups either ICBG (control group) or BMP (experimental group) for achievement of fusion were regarded eligible. A pooled estimate of effect size was produced using both random and fixed effect model. Results. Seven randomized control trials (n = 331 patients) and 1 prospective comparative study (n = 52 patients) were included in the present study. BMPs appeared more efficacious to ICBG in achieving solid fusion [relative risk (RR) = 0.42, 95% confidence interval (CI) = 0.28–0.61, P < 0.00001], but with significant heterogeneity (I2 = 42.5%). rBMP-2 was more efficacious to ICBG in promoting fusion (RR = 0.29, 95% CI = 0.18–0.47, P < 0.00001), whereas rhBMP-7 (osteogenic protein-1) appeared equivalent to ICBG in that respect (RR = 1.17, 95% CI = 0.54–2.54, P = 0.70). Patients treated with BMPs had a shorter hospitalization (by 1.03 days, 95% CI = 0.61–1.45 days) compared with those that were treated with ICBG. BMPs appeared more efficient in instrumented than noninstrumented posterolateral fusions. Conclusion. Although the radiographic results appeared better in the group of BMPs, the exact role of type, dose and carrier of BMPs and the cost-effectiveness of their use need further clinical delineation.

External fixation devices in the treatment of fractures of the tibial plafond: A SYSTEMATIC REVIEW OF THE LITERATURE

We have compared the outcomes of the use of external fixation devices for spanning or sparing the ankle joint in the treatment of fractures of the tibial plafond, focusing on the complications and the rates of healing. We have devised a scoring system for the quality of reporting of clinical outcomes, to determine the reliability of the results. We conducted a search of publications in English between 1990 and 2006 using the Pubmed search engine. The key words used were pilon, pylon, plafond fractures, external fixation. A total of 15 articles, which included 465 fractures, were eligible for final evaluation. There were no statistically significant differences between spanning and sparing fixation systems regarding the rates of infection, nonunion, and the time to union. Patients treated with spanning frames had significantly greater incidence of malunion compared with patients treated with sparing frames. In both groups, the outcome reporting score was very low; 60% of reports involving infection, nonunion or malunion scored 0 points.

Fractures of the hip and osteoporosis: THE ROLE OF BONE SUBSTITUTES

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised. Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.

Prosthetic replacement for proximal humeral fractures

The ideal management of complex proximal humeral fractures continues to be debatable. Evolution of proximal humeral fracture management, during the past decade, led to the implementation of many innovations in surgical treatment. Even though the pendulum of treatment seems to swing towards new trends such as locked plating, hemiarthroplasty remains a valid and reliable option that serves the patients needs well. Hemiarthroplasty is indicated for complex proximal humeral fractures in elderly patients with poor bone stock and when internal fixation is difficult or unreliable. Hemiarthroplasty provides a better result when it is performed early post-injury. Stem height, retroversion and tuberosity positioning are technical aspects of utmost importance. Additionally reverse total shoulder arthroplasty is an alternative new modality that can be used as a primary solution in selected patients with proximal humeral fracture treatment. Failed hemiarthroplasty and fracture sequelae can be successfully managed with reverse total shoulder arthroplasty. Individual decision-making and tailored treatment that takes into consideration the personality of the fracture and the patients characteristics should be used.