Gregory Mitsionis

Transtibial versus anteromedial portal of the femoral tunnel in ACL reconstruction: A cadaveric study

The aim of this cadaveric study was to compare the transtibial versus the anteromedial portal with respect to the anatomic femoral positioning of the ACL attachment. Ten fresh frozen cadaveric knees were included in our study. A standard arthroscopy was performed and the normal ACL was partially cut through with arthroscopic scissors leaving a small footprint of 2 mm at the anatomical insertion area on the lateral femoral condyle. The femoral tunnel was drilled through the tibial tunnel and subsequently through the anteromedial portal. Using a probe with standard magnification, we measured the distances of the two femoral tunnels from the margin of ACL footprint arthroscopically. The femurs were then dissected and we measured the distances of the two tunnels from the posterior part of the lateral femoral condyle. The median arthroscopically measured distance of the centers of transtibial femoral tunnel and of the femoral tunnel through the anteromedial portal from the margin of the femoral ACL footprint were 6.20 mm and 2.80 mm respectively. The difference was statistically significant. After femoral dissection the median distance of the centers of the transtibial femoral tunnel and the femoral tunnel performed through the anteromedial portal from the border of the articular surface at the lateral femoral condyle was 6.10 mm and 5.25 mm respectively (p<0.001). Both measurements showed that ACL reconstruction technique through the anteromedial portal is more accurate compared to the transtibial technique.

Surgical treatment of malleolar fractures. A review of 144 patients.

Malleolar fractures are one of the most common fractures faced in orthopaedic surgery. The results from a consecutive series of 144 malleolar fractures during a 10-year period that were classified and treated according to the AO system are presented. Assessment of outcome was done using the scoring system of Baird and Jackson, which is based on subjective, objective, and radiographic criteria. Excellent and good results were achieved in 107 of the 144 patients surgically treated. Overall, excellent and good results were obtained in almost all unimalleolar fractures, but were significantly less in bimalleolar fractures. There was no difference in outcome achieved between Weber C and Weber D fractures. The presence of a large bony fragment or dislocation also significantly affected the final outcome. Posttraumatic osteoarthritis was found to be associated significantly with poor clinical results, bimalleolar fractures, and unsatisfactory surgical reduction.

Normative data on hand grip strength in a Greek adult population.

The objectives of this study were to establish data concerning normal hand grip strength (GS) and to explore possible associations with anthropometric parameters. GS was measured in 232 individuals in a standard arm position using the Jamar dynamometer. We examined differences between right/left and dominant/nondominant hands. Possible correlations of GS with anthropometric values were evaluated. Right hand and dominant hand GS were found to be higher and statistically significant compared to left hand and nondominant hand GS, respectively. Men had higher values of GS compared to women. A negative association was observed between age and dominant hand GS. A positive association was documented between height and dominant hand GS, while the respective comparison for weight and dominant hand GS documented a statistically significant positive association only in the male group. A positive association between BMI and dominant hand GS was seen in female individuals. Additional factors associated with GS should be the goal of future investigations.RésuméEtablir des données concernant la force de serrage de la main (GS) et, explorer les possibles associations avec des paramètres anthropométriques. La force de la main: GS a été mesurée chez 232 individus en position standard du bras, utilisant le dynamomètre de Jamar. Nous avons examiné les différences entre les côtés droit et gauche et dominant/non-dominant. Les possibles corrélations de GS avec des valeurs anthropométriques ont été évaluées. Respectivement main droite et GS du côté dominant ont été retrouvées de manière significativement plus élevée que main gauche et GS non-dominant. Les hommes avaient des valeurs de GS plus élevées que les femmes. Une association négative a été retrouvée entre l’âge et la GS de la main dominante. Une association positive a été documentée entre la taille et la GS du côté dominant, tandis que la comparaison entre le poids et la GS du côté dominant montre une association positive de manière statistiquement significative, uniquement dans le groupe des hommes. Une association positive a été retrouvée entre le BMI et la GS du côté dominant dans le groupe des femmes. Des facteurs additionnels associés avec la GS devraient être le but d’une future investigation.

Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.

PURPOSE To evaluate the results of a modified Paneva-Holevich technique for flexor tendon reconstruction in zone II. METHODS Twenty patients (22 digits) with poor prognosis injuries (Boyes grade 2-5) were reconstructed. The technique included placing a silicone rod and creating a loop between the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) in the first stage and reflecting the latter as a pedicled graft through the pseudosheath created around the silicone rod in the second stage. RESULTS After a follow-up period of at least 1 year (mean, 50 mo) the rate of good and excellent results was 82% according to the Buck-Gramco scale and 73% using the modified Strickland scale. CONCLUSIONS These results compare favorably with those using the classic (Hunter) 2-stage reconstructions with a silicone rod and a free tendon graft. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity, and a low rate of postreconstruction tendon ruptures and tenolysis.

Axonal regeneration stimulated by erythropoietin : An experimental study in rats

The aim of the present study is to evaluate the effects of erythropoietin to the collateral sprouting by using systemically delivered erythropoietin in an end-to-side nerve repair model. Forty-five rats were evaluated in four groups: (A) end-to-side neurorrhaphy only, (B) end-to-side neurorrhaphy and erythropoietin administration, (C) end-to-end neurorrhaphy and (D) nerve stumps buried into neighboring muscles. In all animals, the contralateral healthy side served as control. Functional assessment of nerve regeneration was performed at intervals up to 5 months using the Peroneal Function Index. Evaluation 150 days after surgery included peroneal and tibial nerve morphometric examination, and wet weights of the tibialis anterior muscle. During the first three weeks after surgery, when erythropoietin was regularly administered, functional evaluation showed that erythropoietin may facilitate peripheral nerve regeneration. However, there was rapid deterioration in the functional recovery when erythropoietins administration was discontinued. As a consequence, at the end of this study, erythropoietin failed to maintain its initial stimulating effect in axonal regeneration. The results of wet muscle weights revealed statistically significant differences between Groups A and C, and Group B. Furthermore, data on axonal counting showed significant difference between Groups A and C, and Group B. Erythropoietin appears to facilitate peripheral nerve regeneration at the initial phase of its administration. Further investigation will be necessary to optimise the conditions (dose, mode of administration) in order to maintain its effects.

Pyomyositis in children: early diagnosis and treatment

PURPOSE This study was conducted to evaluate early diagnosis, clinical course, and treatment outcome in children with pyomyositis. METHODS Between 2001 and 2006, 6 children with a mean age of 7.2 years were diagnosed and treated for pyomyositis in our clinic. The most common site of involvement was the hip and thigh region. All patients underwent early magnetic resonance imaging (MRI) examination that played a significant role in the early diagnosis and management of the disease. RESULTS Staphylococcus aureus was the most common pathogen and was identified in 3 cases. Intravenous antibiotics were administered and were followed by oral agents for an additional period. The duration of therapy ranged from 3 to 6 weeks. No surgical intervention was needed. Magnetic resonance imaging was used to evaluate response to the therapy. CONCLUSIONS Although pyomyositis is a rare disease, it should be considered in the differential diagnosis of immediate onset of musculoskeletal pain in children. Early diagnosis and antibiotic treatment are important as major complications such as abscess formation and sepsis can be avoided. Having a high sensitivity to reactive inflammatory changes, MRI is a valuable tool in the armamentarium of the clinician in early diagnosis of pyomyositis.

Management of acute acromioclavicular joint dislocation with a double-button fixation system

INTRODUCTION Numerous static and dynamic techniques have been described for the management of acute acromioclavicular (AC) joint dislocation. To date, no standard technique has been established and several complications have been described for each of these techniques. The purpose of the present study was to evaluate the functional and radiographic outcomes of acute AC joint reconstruction after a mini-open technique using the double-button fixation system. PATIENTS AND METHODS Twelve patients with acute AC joint dislocation treated with the double-button fixation system by one surgeon were retrospectively reviewed. Functional assessment was performed by an independent reviewer using the DASH, Constant and the VAS scores. The coracoclavicular (CC) distance of the affected shoulder was assessed on a standard radiograph and compared with the contralateral normal one. RESULTS Eight patients were operated on for grade III AC joint dislocation and 4 for grade IV. The mean age of the patients at the time of surgery was 27.5 years. The mean follow-up was 18.25 months (range: 12-30 months). At the most recent follow-up, the mean Constant score was 94.8 (range: 84-100) showing a significant increase compared with the mean pre-operative value of 34.4 (range: 25-52) (p<0.001). The mean DASH score was significantly decreased from 19.6 (range: 14-28) preoperatively to 0.25 (range: 0-3) at the last follow-up (p<0.001). The mean VAS score showed a significant decrease from 5.75 (range: 4-7) to 0.2 (range: 0-2) (p<0.001). The mean CC distance on the operated shoulder was found to have no significant difference from the CC distance on the contralateral normal side (10.5 vs. 10mm) (p>0.05). There was no evidence of AC joint osteoarthrosis, CC calcification or osteolysis of the distal clavicle or the coracoid process. CONCLUSIONS The proposed mini-open technique provides adequate exposure of the base of the coracoid with minimal damage to the soft tissues surrounding the CC ligaments while ensures an excellent cosmetic result. We recommend this fast and relatively simple technique for all type IV injuries and for type III injuries in heavy manual workers and high-demand upper extremities athletes.

Shoulder abduction and external rotation restoration with nerve transfer.

INTRODUCTION In upper brachial plexus palsy patients, loss of shoulder function and elbow flexion is obvious as the result of paralysed muscles innervated by the suprascapular, axillary and musculocutaneus nerve. Shoulder stabilisation, restoration of abduction and external rotation are important as more distal functions will be affected by the shoulder situation. PATIENTS AND METHODS Between 2005 and 2011, eleven patients with upper type brachial plexus palsy were operated on with triceps nerve branch transfer to anterior axillary nerve branch and spinal accessory nerve transfer to the suprascapular nerve for shoulder abduction and external rotation restoration. Nine patients met the inclusion criteria for the study. All patients were men with ages ranged from 21 to 35 years (average, 27.4 years). The interval between injury and surgery ranged from 4 to 11 months (average, 7.2 months). Atrophy of the supraspinatus, infraspinatus and deltoid muscle and subluxation at the glenohumeral joint was obvious in all patients preoperatively. During the pre-op examination all patients had at least muscle grading 4 on the triceps muscle. RESULTS The mean post-operative value of shoulder abduction was 112.2° (range: 60-170°) while preoperatively none of the patients was able for abduction (p<0.001). The mean post-operative value of shoulder external rotation was 66° (range: 35-110°) while preoperatively none of them was able for external rotation (p<0.001). Postoperative values of shoulder abduction were significantly better that those of external rotation (p=0.0004). The postoperative average muscle grading for shoulder abduction according the MRC scale was 3.6±0.5 and for the shoulder external rotation was 3.2±0.4. CONCLUSIONS Combined nerve transfer by using the spinal accessory nerve for suprascapular nerve neurotisation and one of the triceps nerve branches for axillary nerve and teres minor branch neurotisation is an excellent choice for shoulder abduction and external rotation restoration.

Combined Radiotherapy and Indomethacin for the Prevention of Heterotopic Ossification after Total Hip Arthroplasty

Background and Purpose:Heterotopic ossification (HO) is a frequent complication following total hip arthroplasty. The aim of this study was to evaluate the efficacy of combined radiotherapy and indomethacin as compared to indomethacin alone for the prevention of HO after hip arthroplasty.Patients and Methods:96 patients were prospectively enrolled to receive either a single dose of postoperative radiotherapy of 7.0 Gy and indomethacin for the first 15 postoperative days or indomethacin alone for the same period. A historical group of 50 patients that received indomethacin alone served as control. Primary endpoint was the radiographic evidence of HO at 6 months. Secondary endpoints were the evaluation of factors related to HO development, side effects from each treatment, and group differences in the clinical assessment with the Merle d’Aubigné Score.Results:Four patients in the combined-therapy group developed HO compared to 13 patients in the indomethacin group (p < 0.05) and 13 patients in the historical group (p < 0.05). One patient each in the combined group and the historical group developed Brooker III HO (nonsignificant difference). Duration of surgery and congenital hip disease were associated with HO development in the indomethacin groups, while age and congenital hip disease showed such an association in the combined-therapy group. The side effects and mean Merle d’Aubigné Score did not differ significantly between the three groups.Conclusion:Combined radiotherapy and indomethacin was more efficacious in preventing HO after total hip arthroplasty compared to indomethacin alone and should be considered for future investigation.Hintergrund und Ziel:Heterotope Ossifikationen (HO) sind eine häufige Komplikation nach Implantation einer Hüfttotalendoprothese. In dieser Studie wurde die Wirksamkeit der Kombination von Radiotherapie und Indometacin im Vergleich mit alleinigem Indometacin zur HO-Prävention nach endoprothetischem Hüftgelenkersatz evaluiert.Patienten und Methodik:96 Patienten wurden prospektiv eingeschlossen und erhielten in den ersten 15 Tagen nach dem Eingriff entweder eine postoperative Radiotherapie mit einer Einzeldosis von 7,0 Gy und Indometacin oder nur Indometacin. Eine historische Gruppe von 50 nur mit Indometacin behandelten Patienten diente als Kontrolle. Primärer Endpunkt war die radiologische Evidenz von HO nach 6 Monaten. Sekundäre Endpunkte umfassten die Evaluierung von die HO-Entwicklung begünstigenden Faktoren, von Nebenwirkungen der jeweiligen Behandlung und von Gruppenunterschieden in der klinischen Beurteilung mit dem Score nach Merle d’Aubigné.Ergebnisse:Vier Patienten in der kombinierten Therapiegruppe entwickelten HO im Vergleich zu 13 Patienten in der Indometacingruppe (p < 0,05) und 13 Patienten in der historischen Gruppe (p < 0,05). Je ein Patient in der kombinierter und der historischen Gruppe entwickelte HO Brooker III (nichtsignifikanter Unterschied). Operationsdauer und kongenitale Hüftdysplasie waren in den Indometacingruppen mit der Entwicklung von HO assoziiert, während Alter und kongenitale Hüftdysplasie in der kombinierten Therapiegruppe eine solche Assoziation zeigte. Die Nebenwirkungen und der durchschnittliche Score nach Merle d’Aubigné zeigten keine signifikanten Unterschiede zwischen den drei Gruppen.Schlussfolgerung:Die Kombination von Radiotherapie und Indometacin war zur HO-Prävention nach Implantation einer Hüfttotalendoprothese effektiver als alleiniges Indometacin und erfordert weitere Untersuchungen.

Two-stage flexor tendon reconstruction in zone 2 of the hand in children.

Two-stage flexor tendon reconstruction (Hunter) is indicated in children with extensive adhesions in zone 2 of the hand, with some reservations concerning the patients age and cooperation. Nine children (mean age 6.9 years) were treated with the modified Paneva-Holevich technique, which has advantages over the classic Hunter reconstructions. It involves an intrasynovial graft (FDS of the injured finger) that is anatomically stable and morphologically more appropriate compared with free grafts. The size of the silicone rod is precisely assessed in the first stage, the proximal tenorrhaphy has healed by the time the second stage is performed, and donor site morbidity is minimized. After a mean follow-up of 40.1 months, the mean total active motion was 196 degrees, and eight patients achieved a good or excellent result according to the Buck-Gramcko and the revised Strickland scale. Staged flexor tendon reconstruction is technically feasible even in very young children. Results in children are comparable to those achieved in adults.