Ioannis P. Kostas-Agnantis

Treatment of Full-Thickness Chondral Defects of the Knee With Autologous Chondrocyte Implantation: A Functional Evaluation With Long-Term Follow-up

Background: Autologous chondrocyte implantation (ACI) has been proven an effective method in treating large articular cartilage defects in short- or medium-term follow-up clinical studies. Hypothesis: First generation ACI of patients with large full-thickness chondral defects of the knee could yield reliable functional outcomes after a minimum follow-up of 5 years. Study Design: Case series; Level of evidence, 4. Methods: Between 1997 and 2005, 42 patients (45 knees) underwent first generation ACI for symptomatic chondral defects of the knee. All patients had moderate to large (mean, 5.33 cm2) full-thickness chondral defects. Patients were evaluated using the International Cartilage Repair Society (ICRS) score, the International Knee Documentation Committee (IKDC) Knee Examination Form, the Tegner activity score, the Lysholm score, the Stanmore functional rating score, and a visual analog scale (VAS) for pain. Results: The mean follow-up was 96 months (range, 62-144 months). At the final follow-up, a significant increase in all scores was recorded. Compared with preoperative findings, the median Lysholm score significantly improved, increasing from 56.0 to 89.0 (P < .05). The IKDC and the Tegner activity score showed significant improvement postoperatively, increasing from 45 and 5.5 to 69 and 6.5, respectively (P < .05). The mean ICRS improved from grade 3.8 preoperatively to grade 2.8 postoperatively (P < .05). The Stanmore functional rating score and the VAS pain score were decreased from 3.06 and 7.33 to 0.94 and 2, respectively (P < .05). Reoperation was required in 5 patients. In 2 of them graft failure was recorded due to degeneration or partial detachment, respectively. Conclusion: The long-term outcomes of our series support the effectiveness of first generation ACI in both pain relief and functional rehabilitation of patients with large full-thickness osteochondral defects of the knee.

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.

Approach to radial nerve palsy caused by humerus shaft fracture: Is primary exploration necessary?

INTRODUCTION While recommendations for early exploration and nerve repair in cases of open fractures of the humeral shaft associated with radial nerve palsy are clear, the therapeutic algorithm for the management of closed humeral shaft fractures complicated by radial nerve palsy is still uncertain. The purpose of this study was to determine whether patients with complete sensory and motor radial nerve palsy following a closed fracture of the humeral shaft should be surgically explored. PATIENTS AND METHODS Twenty-five patients with closed humeral shaft fractures complicated by complete radial nerve palsy were retrospectively reviewed during a 12-year period. Surgical intervention was indicated if functional recovery of the radial nerve was not present after 16 weeks of expectant management. RESULTS Surgical exploration was performed in 12 patients (48%) after a mean period of expectant management of 16.8 weeks (range: 16-18 weeks). In 2 of them (10%) total nerve transection was found. In the rest 10 patients underwent surgical exploration the radial nerve was found to be macroscopically intact. All intact nerves were fully recovered after a mean time of 21.6 weeks (range: 20-24 weeks) post-injury. In 13 patients (52%) in whom surgical exploration was not performed the mean time to full nerve recovery was 12 weeks (range: 7-14 weeks) post-injury. CONCLUSIONS We proposed immediate exploration of the radial nerve in case of open fractures of the humeral shaft, irreducible fractures or unacceptable reduction, associated vascular injuries, radial nerve palsy after manipulation or intractable neurogenic pain. Due to high rate of spontaneous recovery of the radial nerve after closed humeral shaft fractures we recommend 16-18 weeks of expectant management followed by surgical intervention.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction.

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.

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.

The role of hypercoagulability in the development of osteonecrosis of the femoral head.

Despite the large number of the outstanding researches, pathogenesis of osteonecrosis remains unknown. During the last decades the hypothesis that increased intravascular coagulation may be the pathogenetic mechanism which leads to osteonecrosis is gaining constantly support. Both primary factors of hyper-coagulability, such as resistance to activated protein C, protein C and protein S deficiency, low levels of tissue plasminogen activator, high levels of plasminogen activator inhibitor, von Willebrand factor, lipoprotein (a), and secondary factors of hypercoagulability with factors potentially activating intravascular coagulation, such as pregnancy, antiphospholipid antibodies, systemic lupus erythematosus, hemoglobinopathies and sickle cell disease, and hemato-oncologic diseases are discussed in this article. Although coagulation abnormalities in patients with hip osteonecrosis might represent increased risk factors for the development of bone necrosis by predisposing the patient to thromboembolic phenomena, further investigation is needed to indicate the definite correlation between factors leading to increased intravascular coagulation and pathogenesis of osteonecrosis.

Distal Radioulnar Joint Instability (Galeazzi Type Injury) After Internal Fixation in Relation to the Radius Fracture Pattern

PURPOSE The purpose of this study was to classify Galeazzi type injuries and determine the association of residual instability after rigid fixation with the fracture pattern of the shaft of the radius, using a system that is based on anatomic landmarks of the radial shaft. METHODS The clinical records of 95 patients (72 men and 23 women) with Galeazzi type injuries requiring open reduction and internal fixation of the fractures were retrospectively reviewed. The mean follow-up was 6.8 years (range, 18 mo to 11 y) after injury. Sixty-nine fractures occurred in the distal third of the radial shaft (type I), 17 fractures were in the middle third (type II), and 9 fractures were in the proximal third of the shaft of the radius (type III). Gross instability of the distal radioulnar joint (DRUJ) was determined intraoperatively by manipulation after radial fixation as compared to the uninjured side. RESULTS Forty patients had DRUJ instability after internal fixation and were treated with temporary pinning with a K-wire placed transversely proximal to the sigmoid notch. Distal radioulnar joint instability after internal fixation was recorded in 37 type I fractures, 2 type II fractures, and 1 type III fracture. CONCLUSIONS Distal radioulnar joint instability following radial shaft fracture fixation is significantly higher in patients with type I fractures than in patients with type II or type III fractures. The location of the radius fracture can be sufficiently used for preoperative estimation of percentage chance of potential DRUJ instability after fracture fixation.

Proximal screws placement in intertrochanteric fractures treated with external fixation: comparison of two different techniques

BackgroundTo compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator.MethodsSeventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel.ResultsAll fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant.ConclusionProximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement.

Use of intercostal nerves for different target neurotization in brachial plexus reconstruction

Intercostal nerve transfer is a valuable procedure in devastating plexopathies. Intercostal nerves are a very good choice for elbow flexion or extension and shoulder abduction when the intraplexus donor nerves are not available. The best results are obtained in obstetric brachial plexus palsy patients, when direct nerve transfer is performed within six months from the injury. Unlike the adult posttraumatic patients after median and ulnar nerve neurotization with intercostal nerves, almost all obstetric brachial plexus palsy patients achieve protective sensation in the hand and some of them achieve active wrist and finger flexion. Use in combination with proper muscles, intercostal nerve transfer can yield adequate power to the paretic upper limb. Reinnervation of native muscles (i.e., latissimus dorsi) should always be sought as they can successfully be transferred later on for further functional restoration.

Congenital Pseudarthrosis of the Radius Treated With Gradual Distraction and Free Vascularized Fibular Graft: Case Report

Only 18 cases of congenital radial pseudarthrosis have been reported in the English literature; of these, 4 have been treated with free vascularized fibular graft. We present a case of a 9-year-old female patient with neurofibromatosis type 1 who underwent gradual distraction through the pseudarthrosis site and subsequent vascularized fibular grafting for isolated congenital pseudarthrosis of her left radius and concomitant longitudinal and angular deformity of the wrist joint. At the last follow-up, 10 years postoperatively, the patient has maintained bony union, with full wrist flexion-extension and forearm pronation-supination.