Ioannis Gkiatas

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.

Use of recombinant human bone morphogenetic protein-2 in spine surgery

Bone morphogenetic proteins are osteoinductive factors which have gained popularity in orthopaedic surgery and especially in spine surgery. The use of recombinant human bone morphogenetic protein-2 has been officially approved by the United States Food and Drug Administration only for single level anterior lumbar interbody fusion, nevertheless it is widely used by many surgeons with off-label indications. Despite advantages in bone formation, its use still remains a controversial issue and several complications have been described by authors who oppose their wide use.

The Multifactorial Role of Peripheral Nervous System in Bone Growth

Bone alters its metabolic and anabolic activities in response to the variety of systemic and local factors such as hormones and growth factors. Classical observations describing abundance of the nerve fibers in bone also predict a paradigm that the nervous system influences bone metabolism and anabolism. Since 1916 several investigators tried to analyze the effect of peripheral nervous system in bone growth and most of them advocated for the positive effect of innervation in the bones of growing organisms. Moreover, neuronal tissue controls bone formation and remodeling. The purpose of this mini-review is to present the most recent data concerning the influence of innervation on bone growth, the current understanding of the skeletal innervation and their proposed physiological effects on bone metabolism as well as the implication of denervation in human skeletal biology in the developing organism since the peripheral neural trauma as well as peripheral neuropathies are common and they have impact on the growing skeleton.

Modeling of blood flow through sutured micro-vascular anastomoses

Microanastomosis is a surgical procedure used to reconnect two blood vessels using sutures. The optimal microanastomosis may be predicted by assessing the factors that influence this invasive procedure. Blood flow and hemodynamics following microanastomosis are important factors for the successful longevity of this operation. How is the blood flow affected by the presence of sutures? Computational Fluid Dynamics (CFD) is a powerful tool that permits the estimation of specific quantities, such as fluid stresses, that are hardly measurable in vivo. In this study, we propose a methodology which evaluates the alterations in the hemodynamic status due to microanastomosis. A CFD model of a reconstructed artery has been developed, based on anatomical information provided by intravascular ultrasound and angiography, and was used to simulate blood flow after microanastomosis. The 3D reconstructed arterial segments are modeled as non-compliant 1.24 - 1.47 mm diameter ducts, with approximately 0.1 mm arterial thickness. The blood flow is considered laminar and the no-slip condition is imposed on the boundary wall, which is assumed to be rigid. In analyzing the results, the distribution of the wall shear stress (WSS) is presented in the region of interest, near the sutures. The results indicate that high values of WSS appear in the vicinity of sutures. Such regions may promote thrombus formation and subsequently anastomotic failure, therefore their meticulous study is of high importance.

Calcific deposit needling in combination with extracorporeal shock wave therapy (ESWT): A proposed treatment for supraspinatus calcified tendinopathy

Background: Calcified tendinopathy of the rotator cuff is one of the most common conditions concerning the shoulder pathology. It is characterized by a reactive calcification that affects the tendons being part of the rotator cuff. The reported prevalence varies from 2.7% to 22%. Most of the patients can be treated effectively with non-operative measures such as anti-inflammatory drugs, subacromial injection of steroid, physiotherapy, extracorporeal shock wave therapy (ESWT) and needle aspiration irrigation. Results of a treatment combining some of these methods have not been reported. Objectives: The purpose of this study is to present the radiological as well as the clinical results of our proposed protocol which combines drilling of the calcium deposits with xylocaine under ultrasound guidance, with a specific program of physiotherapy for 1 month without the use of NSAIDs. Methods: Sixty-six consecutive patients (68 shoulders) were treated for calcified tendinitis of supraspinatus, which was diagnosed clinically and radiologically, with needle drilling using xylocaine under ultrasound guidance. After the drilling the patient followed a physiotherapy protocol with ESWT which included five visits within a month. After the end of the physiotherapy, the patients were evaluated clinically and radiologically. The Visual Analogue Scale (VAS) for pain and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were measured before and after the end of the therapy. Results: All the patients showed clinical improvement of the symptoms at the follow-up. The mean VAS score showed improvement from 8.1 to 3.3 whereas the mean DASH score was 27 and after the end of the therapy 5. Radiologically all but one calcific deposits were disappeared. Conclusions: The ultrasound-guided drilling of the calcific deposit using xylocaine, in combination with physiotherapy using ESWT provides a reliable alternative treatment for the calcific tendinitis of the supraspinatus

Surgical Considerations and Treatment Algorithm for ACL Tear

Anterior cruciate ligament (ACL) reconstruction surgeries in skeletally immature patients have increased during the last two decades. Operative treatment has gained popularity since poor results have been reported after conservative treatment of complete ACL tears. Management of ACL tears in skeletally immature patients remains controversial secondary to a lack in the basic science literature on physeal growth and response to injury. Clinical studies published on the treatment of this condition have contributed to the confusion by having poor methodology and low level of evidence and combining patients with different levels of skeletal maturity and methods of treatment. Several techniques of ACL reconstruction in skeletally immature patients using different graft types and graft stabilization techniques have been described. In this section, a treatment algorithm and basic surgical techniques of ACL reconstruction are presented.

Predicting Risk of Recurrent Patellar Dislocation

Purpose of ReviewLateral patellar dislocation (LPD) is one of the most common injuries of the knee, especially in a young patient. It is multifactorial with several underlying risk factors. The purpose of this review is to present the most recent data concerning risk factors and their predictive value to estimate recurrent LPD risk.Recent FindingsSeveral demographic risk factors (age, skeletal immaturity, sex, bilaterality), mechanism of injury, and anatomic risk factors (trochlear dysplasia, patella alta, excessive tibial tubercle lateralization, increased patellar tilt) have been recognized. The combination of different risk factors, their relative contribution to instability, weightage of each factor, and multivariate analysis have led to the development of a prediction model and instability scoring system.SummaryIf recurrent instability and poor outcomes could be predicted based on these prediction tools, then alternative treatment or early surgical intervention after first-time LPD could be considered. This information can also be used to predict contralateral LPD and failure of surgical treatment. Current prediction tools are mainly based on retrospective studies. In the future, prospective validation of these prognostic factors would be beneficial.

Fluid-structure interaction analysis of anastomosis in patient specific arterial segment

Although micro-anastomosis is the most commonly performed procedure for reconnecting two blood vessels through sutures, thrombus formation and subsequently anastomotic failure remains one of the most serious clinical complications. An important stimulus to thrombus formation is the altered hemodynamics with abnormal Wall Shear Stress (WSS) distribution on endothelial cells generated by the presence of sutures. Computational simulation is a valid tool to examine the local hemodynamics of micro-anastomosed vessels, allowing for the calculation of the WSS, a factor that could otherwise not directly possible to be measured in vivo. The aim of this study is to perform Fluid-Structure Interaction (FSI) analysis of micro-anastomosis in order to examine the effects of the wall compliance on the hemodynamic quantities.

Subtalar dislocation without associated fractures: Case report and review of literature

Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed.