Georgios Petsatodis

Multiple trauma: An ongoing evolution of treatment modalities?

The management of casualties with multiple injuries has changed considerably in recent years. This is in keeping with the developments that have occurred in the fields of molecular biology, genetics, resuscitation, intensive care management and pharmacological agents, and with the better understanding of the host inflammatory response to trauma. In addition, improved rescue times have allowed resuscitation measures to be applied early, facilitating the practice of clinical and diagnostic procedures according to established trauma protocols. The prompt recognition of life-threatening injuries, the setting up of correct priorities and application of appropriate surgical procedures characterise good emergency department management. Individually adjusted surgical ‘damage control’ and ‘immune control’ are important interactive concepts in polytrauma management. Improvements have been made in every step of the treatment pathway of these trauma victims, from safety measures in terms of vehicle design to timing and types of surgical interventions, supportive care in the intensive care unit, early rehabilitation and late reconstruction procedures relating to fracture malunion or non-union. After completion of the overall treatment course, some individuals may have functional deficits associated with variable degrees of disability that may not allow them to return to their previous occupation. An appropriate social infrastructure is then required so that these persons can be successfully absorbed into suitable occupations. This article examines some of the advances that have been made during the past few years in the management of people with multiple trauma.

The effect of steroid-abuse on anatomic reinsertion of ruptured distal biceps brachii tendon

INTRODUCTION There is an increase in the number of anabolic-steroid (AS)-abusing trainees, who suffer from sports injuries, needing reconstruction surgery. Rupture of the distal biceps brachii tendon is a common injury in this group. PURPOSE The study aimed to investigate the effect of AS abuse in the anatomic reconstruction of the ruptured distal biceps brachii tendon along with an immediate range-of-motion postoperative protocol. METHODS We conducted an observation study of 17 male athletes suffering from distal biceps tendon ruptures. Six of them reported that they abused AS (group A), whereas the non-users comprised group B (n=11). Both groups were treated with the modified single-incision technique with two suture anchors and an immediate active range-of-motion protocol postoperatively. Follow-up was at 4, 16 and 52 weeks postoperatively, with a final follow-up at 24 months. RESULTS Follow-up at 4, 16 and 52 weeks postoperatively showed a statistical significance in favour of group A for therapeutic outcomes concerning flexion, supination, pronation, Disabilities of the Arm, Shoulder and Hand (DASH) Disability Symptom Scores, Mayo Elbow Performance Elbow Scores and isometric muscle strength tests for both flexion and supination. Twenty-four months postoperatively, statistical significance in favour of group A was recorded in isometric muscle strength tests for both flexion and supination and also in DASH Disability Symptom Score. DISCUSSION The results of our study suggest that there is a correlation between the effect of AS and the quicker and better recuperation and rehabilitation observed in group A. Nonetheless, these results must be interpreted with caution, and further in vivo research is needed to confirm these findings.

Does aprotinin reduce blood loss in total hip arthroplasty

This prospective randomized study examined the effects of aprotinin during total hip arthroplasty (THA). Fifty patients who were enrolled in the study received aprotinin or normal saline. Mean intraoperative blood loss was reduced from 1496 mL in the control group to 1073 mL in the aprotinin group. The mean transfusion unit was 1.56 in the aprotinin group and 3.8 in the control group.

Distraction osteogenesis as a salvage method in infected knee megaprostheses.

Infection of total knee replacement represents a severe complication. Especially in cases of infected megaprostheses, treatment options are limited and even amputation may become unavoidable. We present two cases of infected knee hinged megaprostheses. Both were treated by prosthesis removal and debridement of all surrounding infected bone and soft tissue, followed by distraction osteogenesis for the bridging of the large bone defect which had resulted. Implant removal and surgical debridement were combined with Ilizarov frame application and femoral and tibial osteotomies in a one-stage procedure, for commencing distraction osteogenesis. After bone transportation was completed, arthrodesis of the knee in both cases was successful. Two years after completion of the treatment, both patients demonstrate a stable knee arthrodesis and a satisfactory clinical result. The described treatment plan represents an effective salvage method in cases of infected knee megaprostheses that can successfully address both the need for a stable arthrodesis and the avoidance of a severe leg-length discrepancy by bridging the extensive bone defect.

Osteonecrosis in children with acute lymphoblastic leukemia: A 10-year study from northern Greece

To the Editor: We read with great interest the report from Burger et al. regarding incidence and characteristics of osteonecrosis (ON) in children with ALL and we would like to report our 10-year experience in the two Pediatric Oncology Units of Northern Greece [1]. We retrospectively analyzed 276 patients who were treated according to trial ALL-BFM 95 (240 children) and UKALL XI (36 children) from January 1996 to December 2005. Standard and median risk patients treated with ALL-BFM 95 protocol received prednisone at a cumulative dose of 1,837 mg/m (induction) and dexamethasone at 236 mg/m (reintensification). High-risk patients received a shortened induction with 1,417mg/m of prednisone and an intensive interim consolidation with 600 mg/ m of dexamethasone. Diagnosis of ON was based on clinical symptoms and was confirmed by MRI scan of the affected site. Among 276 patients with ALL, 7 patients developed symptomatic ON (2.5%). Sex distribution demonstrated that 3 of 149 (2%) male and 4 of 127 (3.1%) female patients developed ON. Mean age of patients with ALL and thosewith ONwas 4.3 (range: 1–13) and 8.7 (range: 6–13) years, respectively. The mean time between the diagnosis of ALL and the diagnosis of ON was 27.7 months (range: 2–78 months). The most frequently affected site was the hip (5/7 patients). Regarding treatment of ON, all patients were initially managedwith physical therapy, non-weight bearing, and analgesics. Finally, in three patients were administered biphosphonates (Alendronate 70 mg once a week) for a mean of 11 months (range: 10–12 months) with an excellent outcome in all. These data demonstrate that symptomatic ON is a rare but disabling complication in children with ALL. The incidence of ON in our study is higher in comparison to recent reports from Europe [1,2]. Adolescents during consolidation treatment seem to have a significant higher risk of developing ON. Recent reports indicate that pharmacogenetic risk factors for the development of ON include thevitaminD receptor Fok ICCand theTYMS2/2 genotype who have a sensitivity for predicting the development of ON in children with ALL of 96% [3]. This suggests that screening of patients with ALL might identify those at highest risk to develop ON.

Distal Locking Screws for Intramedullary Nailing of Tibial Fractures.

Recently introduced tibial intramedullary nails allow a number of distal screws to be used to reduce the incidence of malalignment and loss of fixation of distal metaphyseal fractures. However, the number of screws and the type of screw configuration to be used remains obscure. This biomechanical study was performed to address this question. Thirty-six Expert tibial nails (Synthes, Oberdorf, Switzerland) were introduced in composite bone models. The models were divided into 4 groups with different distal locking configurations ranging from 2 to 4 screws. A 7-mm gap osteotomy was performed 72 mm from the tibial plafond to simulate a 42-C3 unstable distal tibial fracture. Each group was divided in 3 subgroups and underwent nondestructive biomechanical testing in axial compression, coronal bending, and axial torsion. The passive construct stiffness was measured and statistically analyzed with one-way analysis of variance. Although some differences were noted between the stiffness of each group, these were not statistically significant in compression (P=.105), bending (P=.801), external rotation (P=.246), and internal rotation (P=.370). This in vitro study showed that, when using the Expert tibial nail for unstable distal tibial fractures, the classic configuration of 2 parallel distal screws could provide the necessary stability under partial weight-bearing conditions.

Outcome of Surgical Treatment for Complicated Humeral Shaft Fractures in Elderly Adults with Osteoporosis

ments, as illustrated by the decrease in 25OHD concentration during follow-up (Table 1). With this design, the effect of receiving vs not receiving vitamin D supplements and, indirectly, the effect of increasing vs decreasing 25OHD concentrations was captured. Finally, an improvement was also found in executive functions after vitamin D3 supplementation. This is concordant with previous studies suggesting that brain structures underlying executive functions are the target of neuroprotective and vasculoprotective properties of vitamin D. Nevertheless, the pre–post design of the current study without randomization limits the exploration of the cognitive effect of vitamin D repletion. Placebo-controlled randomized clinical trials are needed to corroborate these results with higher levels of evidence.

Knee Joint Effusion following Ipsilateral Hip Surgery

Purpose. To correlate patellar reflex inhibition with sympathetic knee joint effusion. Methods. 65 women and 40 men aged 45 to 75 (mean, 65) years underwent hip surgery. The surgery entailed dynamic hip screw fixation using the lateral approach with reflection of the vastus lateralis for pertrochantric fractures (n=49), and hip hemiarthroplasty or total hip replacement using the Watson-Jones approach (n=38) or hip hemiarthroplasty using the posterior approach (n=18) for subcapital femoral fractures (n=28) or osteoarthritis (n=28). Knee joint effusion, patellar reflex, and thigh circumference were assessed in both legs before and after surgery (at day 0.5, 2, 7, 14, 30, and 45). Time-sequence plots were used for chronological analysis, and correlation between patellar reflex inhibition and knee joint effusion was tested. Results. In the time-sequence plot, the peak frequency of patellar reflex inhibition (on day 0.5) preceded that of the knee joint effusion and the thigh circumference increase (on day 2). Patellar reflex inhibition correlated positively with the knee joint effusion (r=0.843, p=0.035). These 2 factors correlated significantly for all 3 surgical approaches (p<0.0005). All 3 approaches were associated with patellar reflex inhibition on day 0.5 (p=0.033) and knee joint effusion on day 2 (p=0.051). Conclusion. Surgical trauma of the thigh may cause patellar reflex inhibition and subsequently knee joint effusion.

Severe skeletal complications in a child with acute lymphoblastic leukemia.

We have read the interesting report by Dr. Goldbloom et al. regarding osteoporosis at presentation of childhood ALL. We would like to present the case of an adolescent girl with ALL who developed osteoporosis-related complications after chemotherapy and was successfully treated with alendronate. A 10-year-old girl was admitted to our department with a history of pain and swelling in the left knee for 1 month. Diagnosis of T-lineage ALL was confirmed by bone marrow aspirate. The girl was treated with high-risk ALL BFM’95 protocol. Bone marrow examination at 33 days confirmed a complete remission. Evaluation of bone metabolism with bone mineral density (BMD; g/cm2) of lumbar spine (LS) and femoral neck (FN) at diagnosis was normal (z scoreLS = −0.25, z scoreFN = −0.1) but after induction chemotherapy revealed severe osteopenia (z scoreLS = −1.95, z scoreFN = −2.33) and she was started treatment with calcium carbonate and alfacalcidol. Two months later, while on consolidation treatment, she complained of severe pain in the right ankle joint, only during walking. Radiographs of the right foot revealed diffuse osteoporosis and diagnosis of astragalus osteonecrosis was posed after magnetic resonance images (Figure 1). She was temporarily started on a conservative medical treatment consisting of physical inactivity and use of a pair of crutches for pain reduction. She was evaluated after 1 month, and MRI images indicated

Reinforcement Rings and Cages

Rings and cages are implants used in revision THA when the remaining bone stock is deficient. They span the bone defect and act as a scaffold while protecting morcellized or structural allograft during the bone remodeling phase [1]. The use of cages has been reduced over time following mechanical failure of cages and the introduction of newer techniques of trabecular metal components [1].