George Papachristou

Treatment of tibial and femoral bone loss by distraction osteogenesis. Experience in 28 infected and 14 clean cases.

42 patients with diaphyseal bone defects (25 tibial and 17 femoral) who were treated by radical debridement and bone transport are reviewed. Their mean age was 35 (10-64) years and there were 29 men. 19 patients had active infections with drainage and 9 were previously infected. After resection of the infected and necrotic bone, the intercalate defect averaged 6 (3-12) cm. The mean duration of treatment was 10 (20-52) months. Regeneration of the distraction gap was achieved in all 42 patients. Union at the target zone was achieved in 38, and in the remaining 4 cases consolidation was achieved by application of autogenous bone grafts. The infection was eradicated in all 28 patients treated for bone defects associated with infection, without the need for a second operation. Complications were not severe and did not affect the final results. Residual malalignment remained in 2 patients, 1 femur and 1 tibia, with 10 degrees and 8 degrees of varus deformity, respectively. The final leg-length discrepancy never exceeded 1.5 cm. Residual fixed flexion of the knee was left in 5 cases, but never exceeded 10 degrees. Loss of 5 degrees to 10 degrees of dorsiflexion of the ankle joint remained in 7 patients. There were no intraoperative or postoperative neurovascular damage or compartment syndrome. Psychological intolerance was seen in 1 young patient. All patients, but 3 returned to their previous occupation. Bone transport is a simple and safe method for successful treatment of diaphyseal bone defects.

Total hip arthroplasty for developmental hip dysplasia

We reviewed 38 hip replacements in 33 female patients (mean age 55.3 years) with developmental hip dysplasia. One patient had died and the remaining 32 patients (36 hips) had a mean follow-up of 12.2 years (range 8–19 years). All hips were replaced using the Müller cemented implant, and in 32 hips bulk femoral head autograft was used. In 33 hips the socket was reconstructed at the level of the true acetabulum. Complications included one intra-operative femoral fracture and two early dislocations. Correction of leg length discrepancy was possible in 30 patients. The post-operative mean modified Merle d’Aubigne and Postel scores for pain, movement and walking were 5.9, 5, and 5.3 respectively. One cup was revised due to aseptic loosening at ten years. All grafts united, but minor graft resorption was noticed in 24 hips, moderate in 2 hips and major in 1 hip.RésuméNous avons examiné 38 remplacements prothétiques de la hanche chez 33 femmes (âge moyen 55,3 ans) avec une dysplasie de la hanche. Une patiente était décédée et les 32 autres (36 hanches) avaient un suivi moyen de 12,2 ans ( 8 à 19). Toutes les hanches ont eu un implant type Müller cimenté et pour 32 une autogreffe massive de tête fémorale a été utilisé. Pour 33 hanches la cavité a été reconstruite au niveau du paléo-cotyle. Les complications comprenaient une fracture fémorale opératoire et deux luxations précoces. La correction de l’inégalité de longueur des membres inférieurs était obtenue chez 30 malades. Le score postopératoire modifié de Merle d’Aubigné et Postel pour la douleur, la mobilité et la marche étaient en moyenne de 5,9, 5 et 5,3 respectivement. Une cupule a été révisée pour un descellement aseptique à 10 ans. Toutes les greffes ont consolidé, mais une résorption mineure de la greffe a été remarquée dans 24 hanches, une résorption modéré dans deux hanches et majeure dans une.

Early weight bearing after posterior malleolar fractures: An experimental and prospective clinical study

The distribution of axial load to the lower end of the tibia at different positions of the ankle joint for the anterior, middle, and posterior part of the joint was studied in both photoelastic models and fractured ankle joints in cadaveric specimens. Synthetic models were used to simulate both normal ankle joints and ankles with fractures of the posterior lip of the tibia. Tests were performed with the ankle at dorsiflexed, neutral-flexed, and plantarflexed positions of the ankle joint. The clinical portion of the study evaluated 15 patients with fracture of the posterior malleolus that comprised 0% to 33% of the articular surface. All patients had open reduction and internal fixation through a posterolateral or posteromedial approach, and were allowed full weight bearing in a cast within 7 days of surgery. In the simulated models, the posterior one fourth of the ankle joint remains unloaded in the majority of the cases. The stresses are greatly increased when the load is doubled and are mainly distributed to the 2 central quadrants. With additional axial load, the fourth quadrant sustained little increase in the load bearing. All patients have had an uneventful recovery. By the second postoperative month, they were able to walk normally and had a painless range of motion of the ankle. By the third month, all patients were able to undertake their daily activities, and all fractures were consolidated. The clinical relevance of this study is early weight bearing, after open reduction internal fixation of posterior malleolar fracture of the ankle joint, facilitates recovery, promotes fracture union, and allows the patient to assume normal activity by the third month after surgery.

Reconstruction of anterior cruciate ligament using the doubled tendon graft technique: an experimental study in rabbits

Abstract In an attempt to assess reconstruction of the anterior cruciate ligament (ACL) by a new method, 18 New Zealand white rabbits underwent ACL replacement using the medial one-third of the patellar tendon and the semitendinosus tendon, thus partly reproducing the anatomical configuration of the ACL, with the semitendinosus tendon replacing the posterolateral bundle of the ACL and the patellar tendon replacing the anteromedial bundle. The Noulis-Trillat-Lachman test was performed before and after transection of the ACL, after reconstruction and before sacrifice. The animals were divided into four groups and were killed at 3, 6, 12 and 22 weeks after surgery. Femur-ligament-tibia complexes were evaluated postoperatively for gross morphology and histological appearance. The tendons of the first group showed compact parallel fibres with no definitive separation of their bundles and areas of disorganized collagen matrix. Tendons were surrounded by trabecular lamellar bone haphazardly arranged. The tendons of the second, third and fourth groups looked more like normal tendon. The trabecular bone surrounding the tendons formed a tunnel. The Noulis-Trillat-Lachman test result was negative before the procedure, 6.5±0.5 mm on average after transection of the ACL, 1.5±0.6 mm after the procedure, and negative again before sacrifice. The joints of the animals killed at 12 and 22 weeks showed signs of osteoarthritic lesions.

Comparison of fixation methods of double-bundle double-tibial tunnel ACL reconstruction and double-bundle single-tunnel technique

An experimental study was conducted in order to evaluate biomechanical methods of single-bundle reconstruction in ACL and compare it with a new double-bundle double-tibial tunnel technique. Twenty-four porcine cadaver knees, divided into 4 groups of 6 knees each and 48 proper extensors of the fourth toe tendons, were used for the fixation techniques. In groups A and B, a double-bundle technique with a single femoral and tibial tunnel was used, fixed to a femoral and tibial post with screws and with buttons, respectively. In groups C and D, a double-bundle technique (technique Δ) with two separate tibial tunnels was used, fixed to a femoral and tibial post with screws and with buttons, respectively. A material testing system (Instron) was used for anteriorly translating the tibia until failure. The femoral and tibial post as a fixation method is superior to the conventional buttons technique. The more anatomical double-bundle reconstruction technique provided significantly higher structural properties and smaller loss of fixation compared with the single-bundle reconstruction technique. The comparison of the two techniques gave superior results to the femoral and tibial screws over the buttons. The double-bundle technique attempts to restore the anterior stability of the knee joint.RésuméUne étude expérimentale a été réalisée de façon à évaluer en biomécanique, la reconstruction du ligament croisé antérieur avec un faisceau en comparant celle-ci avec une reconstruction avec deux faisceaux et un double tunnel tibial. Vingt quatre cadavres de porcs ont été répartis en 4 groupes de 6 genoux chacun. Dans le groupe A et B une technique à double faisceaux a été réalisée avec un simple tunnel fémoral et tibial, par vis sur rondelle. Pour les groupes C et D, un double faisceau (technique A) a été réalisé avec deux tunnels tibiaux séparés, fixé au fémur et au tibia avec également une vis et un bouton. Le montage a été testé grâce au système Instron utilisant jusqu’à la rupture une translation antérieure du tibia. La fixation postérieure fémorale tibiale est supérieure à la fixation conventionnelle par une vis avec rondelle. La reconstruction par double faisceaux est supérieure à la reconstruction par simple faisceau. En conclusion, la comparaison de ces deux techniques montre des résultats supérieurs pour une fixation fémorale et tibiale par vis avec rondelles. La technique de double faisceaux permet de restaurer une anatomie et une stabilité antérieure de l’articulation du genou.

Traumatic dislocation of the knee

SummarySixteen patients with traumatic dislocation of the knee were treated during the period 1977–1995. The average period of follow up was 7 years. The mean age was 39.07 years for men and 45.6 years for women. One patient sustained a rupture of the popliteal artery and peroneal nerve at the same time, while two others sustained peroneal nerve neurapraxia. Fourteen out of 16 patients underwent surgical treatment for various combinations of ligamentous injuries, and the following techniques were used: suturing, pullout, reconstruction by using the semitendinosus tendon or the iliotibial band or the patellar tendon, and finally reattachment. Simple peripheral menisceal tears were sutured, while partial meniscectomy was performed only in extensive tears of the posterior horn of the meniscus. Postoperatively all the patients had a long backslab applied for 3 weeks and from the first postoperative day commenced isometric quadricep exercises and mobilised on elbow crutches non weight bearing on the injured side. After the backslab was removed, all started active knee exercises. The postoperative results were satisfactory regarding the knee stability, the pain and the patients level of activity despite the seriousness of the injury.

The modified Bosworth technique for the treatment of acute traumatic Achilles tendon rupture

Between 1983 and 1994, 15 patients (range 18 to 62 years) with acute traumatic Achilles tendon rupture, were treated surgically in our Department. We employed a modified Bosworth technique. The modifications were the use of a shorter strip of tendon and more secure fixation of the proximal and distal stump, than the original Bosworth technique. Postoperatively an above - knee plaster cast was applied with the knee flexed 30°–40° and the foot in a relaxed equinus position. The plaster cast was changed to a below - knee after 4 weeks and the foot gradually dorsiflexed to a neutral position until the 8th week, and then the plaster cast was removed. No patient had wound separation, infection or skin sloughs. After an average follow-up of 9 years, no rerupture has been reported and all the patients have returned to their pre injury activities.RésuméQuinze malades présentant une rupture traumatique fermée du tendon d’Achille ont été traités selon la technique de Bosworth modifiée entre 1983 et 1994. Les ruptures sont survenues dans 9 cas à la suite d’une extension dorsale forcée du pied lors de la pratique sportive et dans 6 cas lors d’une activité courante. Le diagnostic fut posé dès l’examen clinique et confirmé par le Squeeze test. Le traitement chirurgical a été effectué dans un délai 1 à 8 jours après le traumatisme. La technique de Brosworth fut modifiée par l’utilisation d’une bandelette tendineuse moins longue (8 à 10 cm) et moins large (1 cm). Une contention rigide fut associée. L’immobilisation post-opératoire fut confiée à un plâtre cruro-pédieux, le genou en flexion à 30°, le pied en équin. Ce plâtre fut relayé à la 5ème semaine par une botte plâtrée avec diminution de la flexion plantaire, la marche avec appui fut autorisée à la 7ème semaine sous couvert d’une botte plâtrée pendant 2 semaines, la cheville étant maintenue à angle droit. L’immobilisation fut suivie de kinésithérapie active. Au contrôle (9 ans en moyenne), les mouvements de la cheville étaient indolores mais avec un déficit de 5° en flexion dorsale par rapport au côté sain. Tous les malades ont repris leur activité pré-opératoire et aucune rupture itérative n’ a été observée.