Nikolaos Lasanianos

Application of bone morphogenetic proteins to femoral non-unions: a 4-year multicentre experience

Fracture non-unions often complicate orthopaedic trauma. BMPs (bone morphogenetic proteins) are currently considered the most appealing osteoinductive agents. Applications of BMP-7 since January 2004 were prospectively recorded in a multicentre registry of aseptic femoral non-unions. The study included 30 patients who had undergone a median of 1 revision operation before BMP-7 application and who were followed up for a median 24 months. In 23/30 cases the application of BMP-7 was combined with revision of the fixation, and in 12 it was combined also with autograft. Non-union healing was verified in 26/30 cases in a median period of 6 months. No adverse events were associated with BMP-7 application. Our case series supports the safety and efficacy of BMP-7 in femoral non-unions. Multicentre networks and systematic, long-term follow-up of patients may improve understanding of this promising osteoinductive bone substitute.

Intramedullary Nailing of Combined/Extended Fractures of the Humeral Head and Shaft

Objectives: To evaluate the use of intramedullary nailing in the management of both “combined” and “extended” fractures of the humeral head and shaft. Design: Retrospective case series study. Setting: Level I trauma center. Patients and Intervention: Twenty-one consecutive patients who underwent intramedullary nail insertion for “extended” or “combined,” closed, nonpathologic fractures of the humeral head and shaft between October 1999 and December 2006 were included in the study. Two patients were lost to follow up and one died before fracture healing. Main Outcome Measurements: Evaluation of outcomes was assessed with the use of the Constant score. Results: There were no neurovascular problems or infections. Eighteen fractures united from 4 to 7 months postoperatively. One case of avascular necrosis of the humeral head, one case of acromion impingement, and one case of unacceptable loss of reduction occurred. Shoulder range of motion was not regained fully in any case and mild shoulder discomfort remained in eight patients. The mean Constant score for all 18 patients was 74.4 (range, 20-95) for the affected side and 89.17 points for the uninjured side. The percentage created from the mean affected/unaffected side scores was 83.4%. Conclusions: Intramedullary nailing for proximal humeral fractures associated with shaft extension or segmental involvement appears to offer a reliable treatment option.

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts

BACKGROUND Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised. METHOD This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing. RESULTS The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points. CONCLUSIONS The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.

New Classification System for Long-bone Fractures Supplementing the AO/OTA Classification

This article describes a novel, clinically oriented classification system for long-bone fractures that is simple, reliable, and useful to predict treatment method, complications, and outcome. The reliability and memorability of the new classification were statistically tested and compared with the AO-Müller/Orthopaedic Trauma Association (AO/OTA) long-bone fracture classification. The proposed classification system was also clinically validated with a targeted pilot study designed for content and clinical outcome retrospectively reviewing 122 closed tibial shaft fractures, which were used as a representative paradigm of long-bone fractures. Statistical evaluation showed that the proposed classification system had improved inter- and intraobserver variation agreement and easier memorability compared with the AO/OTA classification system. The clinical validation study showed its predictive value regarding selection of treatment method, complication rate, and injury outcome.The proposed classification system proved simple, reliable, and memorable. Its clinical value appeared strong enough to justify the organization of larger studies for a complete assessment of its clinical usefulness for all long-bone fractures.

Compartment Syndrome Following Lower Limb Arthroplasty: A Review

Compartment syndrome is an urgent clinical entity characterised by an increase in the interstitial pressure within a closed osseofascial compartment. Although well recognised as a potential complication after orthopaedic trauma, it is very rarely presented after elective orthopaedic surgery and especially joint arthroplasty. In these rare cases a number of variables are associated with it (positioning, coagulopathy, extensive soft tissue dissection, previous scarring, and epidural analgesia). In this study we present the current evidence with regard to incidence and causation of compartment syndrome after lower limb joint arthroplasty and make recommendations on how to avoid the development of this devastating complication.

An Unusual Case of Elbow Dislocation

The annual incidence of elbow dislocation is 6 to 8 cases per 100,000 in the United States; these dislocations represent 11% to 28% of all elbow injuries. The frequency of elbow dislocation is second to that of shoulder dislocation. Adult elbow dislocations are classified by the direction of displacement and associated fractures. They can be anterior, posterior, lateral, or divergent, with the most common type being posterior displacement of both the radius and ulna in relation to the distal humerus. This case report presents a rare case of a twisting dislocation of the elbow joint without any accompanying fracture. A 55-year-old woman presented with a swollen and painful right elbow joint and a pronated forearm after falling on her outstretched right arm. Closed reduction was performed under local anesthetic. No neurovascular deficit was recorded before or after reduction, and no ectopic calcification was observed at 1 year follow-up. Early mobilization of the elbow resulted in a stable joint with full range of motion. The rehabilitation of elbow dislocation ranges from aggressive immediate active motion to traditional plaster of Paris immobilization for several days. Forceful passive mobilization in the rehabilitation period must be avoided, since the elbow joint has a natural tendency to develop myositis ossificans following passive manipulation.

An occult acetabular fracture preceding a femoral neck fracture.

This article describes the case of a 69-year-old patient with an occult acetabular fracture complicated by an ipsilateral femoral neck fracture occurring within 2 months. The acetabular fracture remained undiagnosed at examination due to insufficient clinical and radiographic data interpretation. The patient was assured of early mobilization that led to a fall and subsequent hip fracture. We focus on the potential reasons for the nondiagnosis of the acetabular fracture. Acetabular fractures in the elderly may occur after low-energy injuries. The lack of history of violent injury may lead to an incorrect diagnosis. Plain anteroposterior (AP) pelvis radiographs alone may prove an insufficient tool, especially in the hands of inexperienced personnel. As is characteristic, a retrospective review of the AP pelvis radiograph obtained after the first fall in our case revealed the undisplaced fracture of the anterior column that was missed initially. Combined fractures of the hip and the acetabulum are rarely described in the literature and are usually addressed by total hip arthroplasty (THA) alone. Similar fracture patterns that develop in 2 stages (2 injuries), as the 1 presented herein, are even more rare. The uniqueness of this combined fracture required a unique surgical treatment. The senior surgeon (P.V.G.) addressed the acetabular fracture separately to graft the anterior column fracture and facilitate union, as it was already 8 weeks old and the second fall had generated a further gap between the fragments. Stable fixation was felt appropriate prior to the THA. Thus, a double surgical approach was used. Six weeks postoperatively, the patient was able to perform full weight-bearing mobilization without an antalgic gait pattern. At 6-month follow-up, radiographs showed the metalwork to be in place with no displacement, and the fracture had progressed to union.

Ipsilateral Floating Second Metatarsal and Ankle Fracture Dislocation: Complications and Outcome of a Rare Type of Injury

Lisfranc fracture dislocations are complex lesions which, when combined with additional trauma of the ankle and foot region, create a difficult to treat injury pattern. This article presents a case of a patient with Lisfranc fracture dislocation combined with metatarsophalangeal dislocation of the second toe and ankle fracture-dislocation. The sequence of medical acts and complications included: reduction of dislocations, cast immobilization, compartment syndrome and fasciotomies, external fixator application, fasciotomies closure, and final internal fixations. The following examinations were performed: radiography, computed tomography (CT), and intracompartmental pressure measurement. Despite the compartment syndrome incidence, which was effectively managed, the patient regained an ankle- and foot-pain-free full range of motion. Although this is an isolated case of a rare injury, several recommendations can be made. Early CT scan should be used for injuries of the Lisfranc joints to fully assess the distorted anatomy of the midfoot and forefoot, which is essential for preoperative planning, medicolegal issues, and prognosis of the injury. The use of a spanning external fixator, especially in complex injuries as the one described, should be preferred to cast immobilization and should be performed as a priority surgical procedure early on in the patients admission. The development of compartment syndrome should be monitored and intracompartmental pressures measured especially in unconscious patients. There should be a high degree of suspicion for early complications in complex fracture patterns, even if the initial clinical assessment is reassuring.