J. Degreif

Pathogenesis and clinical relevance of bone marrow embolism in medullary nailing — demonstrated by intraoperative echocardiography

For the clarification of pulmonary impairment after medullary nailing of femoral fractures, the intramedullary pressure in the femoral cavity during the operative procedure was investigated. In addition, an intraoperative transoesophageal echocardiography was performed which revealed two phenomena occurring once the intramedullary pressure had increased: snow-flurry and configured emboli. An experimental study in sheep was performed in order to define the substrata of the sonographic echoes. The level of intrafemoral pressure which would result in bone marrow intravasation and the substrata of the echocardiographic echoes were studied in sheep by applying pressure to the femoral cavity. Sonography of the distal vena cava by laparotomy and macroscopic and histological investigation of the venous blood received throughout a proximal subdiaphragmal venotomy were undertaken. The intrafemoral pressure peaks correlated with the appearance of sonographic echoes in both patients and sheep. Snow-flurry is an indication of small amounts of bone marrow and already appears at an intramedullary pressure of 50 mmHg, which can easily occur during movement of non-stabilised fractures (values up to 90 mmHg were observed)--configured emboli consist of a core of bone marrow surrounded by thrombotic aggregate and only appeared at pressure increases of over 200 mmHg in the animal experiments. During medullary nailing in patients the intrafemoral pressure increases up to 200-600 mmHg in all reaming procedures. Configured emboli were seen in 8 of 20 patients being treated with reamed nailing. In five nailing procedures performed using the unreamed technique, no pressure increases greater than 70 mmHg and no configured emboli were observed. I.v. injected bone marrow results in pulmonary impairment.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimally invasive plate fixation in femoral shaft fractures

Bridge-plating with its advantages in terms of vascularity and bone healing is a well established procedure today in the treatment of comminuted femoral fractures. Bridge-plating means that the fracture site is not interfered with during the operative procedure. This paper introduces a surgical technique in which the plate is inserted through isolated proximal and distal incisions only, behind the vastus lateralis. Alignment is secured by the plates, the fracture site remains untouched, fixation and screw insertion is restricted to the proximal and distal main fragments. Longitudinal femoral fractures extending right into the trochanteric and or condylar areas are the main indication for minimally invasive plate fixations with angled blade plates or condylar screws since fractures which are restricted to the diaphyseal area are mostly treated by nailing today. The surgical trauma resulting from plating by proximal and distal incisions only is less than that associated with conventional techniques. Indirect reduction of femoral fragments is much easier since the integrity of the surrounding muscles and soft tissue is preserved, the fragments often being reduced simply by traction. Adjustment of rotation is an essential aspect requiring careful attention. For special indications, namely comminuted fractures affecting a large part of the femur and extending into the trochanteric or condylar areas, insertion of the plate via proximal and distal incisions only is a further development in bridge-plating which minimizes surgical trauma and operation time.

Pathogenesis and prophylaxis of circulatory reactions during total hip replacement

SummaryCirculatory reactions such as a drop in blood pressure, bradycardia, cardiac arrest, and even intraoperative death after insertion of the stem are well known events during total hip replacement. The present paper reports bone marrow intravasation after rise of intramedullary pressure in the femoral cavity during insertion of hip protheses, demonstrated by intraoperative transesophageal echocardiography. In an animal study, the ultrasound echoes were identified as “mixed emboli” consisting of a core of bone marrow surrounded by thrombus. These results suggested the use of an intramedullary plug to restrict the intravasation of bone marrow. A trial was undertaken in 60 total hip replacement operations. The first 30 were performed using the conventional technique without an intramedullary plug. In a second series of 30 operations, an intramedullary plug made of cancellous bone taken from the resected femoral head was placed 2 cm below the expected location of the tip of the stem. The cement was applied from distal to proximal by syringe. After implantation of the prosthesis using the conventional technique, a significant drop in blood pressure was observed. In the second series, the drop in blood pressure did not occur. In conclusion, it was demonstrated that effective venting of the bone marrow cavity by a bore hole, and avoidance of compression of the bonemarrow-filled distal femoral cavity by using a plug, results in effective prevention of circulatory reactions: no drop in blood pressure occurred. The use of an intramedullary plug is discussed and recommended.

Hypothenar hammer syndrome in sports

Repetitive blunt trauma or single severe trauma to the hypothenar region may lead to traumatic thrombosis of the distal ulnar artery (hypothenar hammer syndrome, HHS). In the sports-related literature we found and analysed isolated cases attributed to injuries sustained during sporting activities such as baseball, badminton, handball, football, frisbee, softball, karate, weight-lifting and hockey. Further, we report the case of an amateur golf player with ischaemic symptoms of his left hand, where angiography revealed filling defects in the digital arteries associated with a corkscrew-like configuration of the distal ulnar artery. Magnetic resonance imaging (MRI) scan demonstrated, at the level of the hamulus ossis hamati, accessory fibres of m. palmaris brevis forming a sling around the ulnar artery. Treatment by resection of the ulnar artery. Treatment by resection of the thrombosed a. ulnaris segment and replacement with an autologous vein graft resulted in complete relief of symptoms. Histological sections revealed partially organized thrombi adherent to the intimal surface with fragmentation of the internal elastic membrane, indicating a traumatic genesis. As the mechanism of injury, we suspected intensive golf playing with the grip style and subsequent motions leading to pressure injury of the hypothenar area and the underlying ulnar artery. Contraction of the anomalous muscle belly may have additionally compressed the artery, slowing down the arterial flow and promoting thrombosis. In most reported cases including our own, it took a relatively long time until the cause of the disease as traumatic was found and accepted. The initial repetitive blunt or single severe trauma initiaing the HHS can easily be overlloked or ignored. After intimal damage of a. ulnaris, the beginning of symptoms may be prolonged and mislead one into thinking the cause is a collagen or vasospastic disease.

Dynamic angular three-dimensional measurement of multisegmental thoracolumbar motion in vivo.

Study Design. Method validation and in vivo motion segment study. Objective. To determine in healthy subjects in vivo intervertebral segmental kinematics and coupled motion behavior in all 3 planes simultaneously for 3 segments and to evaluate whether these results differ from those in the normal population according to the literature. Summary of Background Data. Few studies have provided a direct invasive approach to investigate segmental kinematics in vivo. Dynamic recordings of 3-dimensional segmental motion patterns of adjacent segments have rarely been reported. To date, no studies have examined the 3-dimensional segmental movements of the thoracolumbar junction in vivo in detail. Methods. K-wires were inserted into the Th11, Th12, L1, and L2 spinous processes of 21 healthy subjects. Ultrasound markers and sensors were attached to the k-wires. Real-time motion data were recorded during standardized ranging exercises. Errors caused by the k-wires, and the static and dynamic accuracy of the system, were considered. Results. Large intersubject variation was found in all of the exercises. The average ranges of motion from Th11 to L2 were 18.7° for flexion-extension, 13.5° for one-sided lateral bending, and 1.8° for one-sided axial rotation. Coupled-motion patterns among the subjects showed a coupled flexion in active lateral bending and a coupled extension in active rotation, but the results were inconsistent for active extension and flexion. Conclusion. This method offered accurate multisegmental dynamic-recording facilities. The dynamic exercises showed high reproducibility. The ranges of motion for extension/flexion and lateral bending differed from those reported in previous studies. The coupling patterns were only partly consistent because of large interindividual variation. The measurement error was comparable with that of other invasive methods.

Pigmented villonodular synovitis of the shoulder: review and case report.

Abstract Pigmented villonodular synovitis (PVNS) as reviewed in detail elsewhere most frequently involves the knee and finger synovial structures; shoulder involvement is rare: A search through the English literature yielded 18 publications describing 25 cases of PVNS affecting the shoulder joint. Analyzing these reports we found the clinical and radiological findings generally to be nonspecific, often mimicking a malignancy, as in the case presented here of a 16-year-old boy with painful swelling in the area of the left proximal humerus. Magnetic resonance imaging showed a suspected malignant soft tissue mass involving the shoulder capsule and measuring 7.5 × 6 × 4 cm. Preoperatively the patient could recall no trauma; however, postoperatively he did report a distorsion trauma of the affected shoulder following a bicycle accident. Intraoperatively, two tumors were found infiltrating the axillary vessels and nerve and tendon structures originating in the capsule of the shoulder joint. Rapid sections of the tissue revealed no signs of malignancy; further pathohistological examination revealed localized PVNS. Preoperatively, the shoulder joint was not suspected as the primary site of origin of the tumor because the patient had no complaints or functional deficits of the shoulder. The clinical presentation of such a PVNS lesion over the proximal humerus is unusual and to date has only twice been described in the literature.

Hypothenar hammer syndrome caused by recreational sports activities and muscle anomaly in the wrist

A 34-year-old man with digital ischemia is reported. Angiography revealed thromboembolic occlusions of the proper digital arteries of the index, middle, and ring fingers and a tortuous ulnar artery in Guyons canal. Though hypothenar hammer syndrome was suspected, there was no relevant occupational history. Magnetic resonance imaging and magnetic resonance angiography demonstrated an anomalous muscular sling around the ulnar artery immediately adjacent to the hook of the hamate. The ulnar artery showed mural thrombi in its tortuous segment. These findings were confirmed during operative exploration. After thrombectomy and embolectomy the involved segment of the ulnar artery was replaced by an autologous vein graft. Postoperatively there was complete resolution of the symptoms. Only during convalescence did it become clear that the patient was a passionate golfer.

Kernspintomographische Untersuchung thorakolumbaler Wirbelfrakturen nach Fixateur-interne-Stabilisierung

ZusammenfassungZur Analyse möglicher Unfallfolgen an vertebralen Bewegungssegmenten und insbesondere der Bandscheiben nach instabilen, mittels Fixateur interne versorgten thorakolumbalen Wirbelfrakturen führten wir bei 33 Patienten eine Magnetresonanztomographie (MRT) der Verletzungsregion nach der Implantatentfernung durch. Bei der Bandscheibendegeneration nach instabilen thorakolumbalen Wirbelfrakturen sind strukturelle von biochemischen Veränderungen zu unterscheiden. Die mittels MRT bestimmbare biochemische Degeneration findet sich deutlich seltener als ein morphologischer Schaden des Nucleus pulposus. Verletzungen des Anulus fibrosus, der eigentlich stabilisierenden Struktur der vertebralen Bewegungssegmente, wurden bei keinem Patienten beobachtet. Im Vergleich zur frakturbenachbarten oberen Bandscheibe ist der untere Diskus nach Ausheilung der Fraktur zwar weniger von Veränderungen der Form, jedoch häufiger von biochemischer Abnutzung und etwa gleich stark von Höhenverlust betroffen. Die Befürworter einer Resektion der oberen Bandscheibe bei der operativen Behandlung thorakolumbaler Wirbelfrakturen begründen ihr Procedere u. a. mit dem strukturellen Bandscheibenschaden, wie z. B. Höhenverlust und Impaktierung von Bandscheibengewebe in den Wirbelkörper, die in der Summe häufiger bei dem frakturbenachbarten oberen Diskus beobachtet werden. Unsere Beobachtungen, wonach eine Bandscheibe trotz morphologischer Schädigung des Gallertkerns einen dennoch biochemisch intakten Nucleus pulposus und strukturell unversehrten Anulus fibrosus aufweisen kann, sprechen eher für den Erhalt des betreffenden Diskus. Für die frakturbenachbarte obere Zwischenwirbelscheibe (seltener biochemisch degeneriert) bedeutet dies, daß die weitverbreitete Ansicht von der regelmäßigen Zerstörung und demzufolge obligaten Resektion zu überdenken ist. Die Frage, ob die untere Bandscheibe bei nachgewiesenermaßen ausgeprägter biochemischer Degeneration entsprechend häufiger reseziert werden sollte, kann durch die vorliegende Studie allein nicht beantwortet werden. Neben der statischen Beurteilbarkeit sämtlicher anatomischer Strukturen der Wirbelsäule in der MRT liefert die Wiederholung der Untersuchung in Bauchlage eine dynamische Information über das Verhalten des Rückenmarkes bei Verdacht auf dorsale Adhäsion.SummaryTo analyse the possible injuries of vertebral segments, especially the disc, after unstable thoracolumbar fractures stabilised with AO internal fixator, we performed magnetic resonance imaging (MRI) of the traumatised region after implant removal. There were two aspects of disc degeneration (DD): (1) biochemical changes and (2) structural damage. MRI detects biochemical processes as one aspect of DD that is often small even in the presence of greater structural damage of the nucleus pulposus caused by fracture. None of the patients presented with structural failure of the anulus fibrosus, which is the essential structural component of the vertebral segments with regard to stability. We observed biochemical changes more often in the lower of the two fracture-adjacent discs and alterations of discal shape more often in the upper of the two, whereas loss of height concerned both discs to approximately the same degree. The supporters of upper-disc resection in thoracolumbar fractures justify their procedure among other things with the structural disc damage, such as alteration of shape and loss of height (altogether more frequent in the upper disc). Our observations that a disc with a structurally altered nucleus pulposus can be biochemically intact and can show an intact anulus fibrosus are arguments in favour of disc preservation. With regard to the upper disc, the widespread opinion that complete and regular disc damage requires a resection has to be revised. The question of whether the lower disc should be resected more often because of its greater biochemical changes cannot be answered by the present study alone. Besides the excellent static information in all anatomical structures of the vertebral column available by MRI, a repeat examination in a prone position yields dynamic information on the spinal cord in the case of suspected dorsal adhesions.

Ergebnisse nach primärer ungebohrter Tibianagelung von Unterschenkelfrakturen mit schwerem offenem oder geschlossenem Weichteilschaden

Primary stabilization was performed in 72 tibial fractures with severe open (n = 37) or closed (n = 35) soft tissue injury using unreamed interlocking nails. In 60 (83%) cases the fractures healed without additional procedures. There were 2 cases of osteitis, but both these fractures healed after removal of the nail or after reamed nailing. In 9 patients with delayed union reamed nailing (n = 8) or bone grafting (n = 1) led to healing. In 1 patient with hypertrophic pseudarthrosis, union was achieved after substitution of a reamed nail for the anreamed nail. The infection rate was similar to that observed with external fixation. More secondary procedures, such as bone grafting or a change of the osteosynthesis technique, are necessary with external fixation than with unreamed nailing. Further advantages of unreamed nailing are the internal treatment of the fracture and the patients greater comfort. Therefore, unreamed nailing can be recommended for the primary treatment of tibial fractures with severe open or closed soft tissue trauma.

Ultrasound-guided spinal fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar burst fractures.

Study Design. Computed tomography aided evaluation of spinal decompression by ultrasound-guided spinal fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar burst fractures. Objectives. To determine the necessity of spinal canal widening by ultrasound-guided fracture repositioning for fractures with and without neurologic deficit. Summary of Background Data. Ultrasound-guided spinal fracture repositioning is an alternative new approach. Reports have varied concerning ligamentotaxis and remodeling. Methods. Computed tomography aided planimetry of the spinal canal (64 consecutive burst fractures) and neurologic evaluation by Frankel grades. Results. Ultrasound-guided spinal fracture repositioning (n = 37) reduced the stenosis of the spinal canal area from 45% before surgery to 20% after surgery of the estimated original area. Fifteen patients had a primary neurologic deficit, which improved markedly in 11 cases after treatment. Patients with neurologic symptoms had a greater preoperative spinal stenosis than those without. No correlation was seen between the degree of pretreatment spinal stenosis, fracture type, and severity of the neurologic deficit. Ligamentotaxis (n = 27) reduced the stenosis from 30% before surgery to 18% after surgery and remodeling (n = 11) from 25% after surgery to 13% after metal removal. Conclusion. Ultrasound-guided fracture repositioning is an efficient method for spinal canal decompression of burst fractures with neurologic symptoms. The marked degree of widening of the spinal canal due to the effects of ligamentotaxis and remodeling may render the reposition of retropulsed fragments unnecessary in cases of fractures without a neurologic deficit.