Ofir Chechik

An international survey on anterior cruciate ligament reconstruction practices

PurposeBone-patellar-tendon-bone (BPTB) autografting fixed with metal interference screws (IS) is the gold standard for anterior cruciate ligament (ACL) reconstruction. Advances in surgical technology provide a wide choice of grafts, fixation devices and surgical approaches.MethodsTwo-hundred and sixty-one orthopedic surgeons of ten subspecialties from 57 countries were surveyed on their choice of graft and fixation device, the number of reconstructed bundles, and arthroscopic portal. Their preferences were analyzed according to country of origin, field of expertise and seniority, and compared to current publications.ResultsHamstring autografting was the most popular choice (63xa0%), then BPTB (26xa0%) and allograft (11xa0%). The anteromedial portal was preferred over the traditional transtibial portal (68xa0% versus 31xa0%). Two-thirds reported routinely performing a single-bundle graft reconstruction, compared to one-third who used the double-bundle technique. The Endo-button was the most common graft fixation method (40xa0%), followed by the bioabsorbable IS (34xa0%), metallic IS (12xa0%), rigidfix (10xa0%) and others (4xa0%). The preferences of hamstring tendon grafting and the anteromedial portal are not supported in the literature. Responses from North American and European surgeons were different from all the others.ConclusionsSurgeon preferences in ACL reconstruction differ considerably worldwide. Common practice is not always supported by evidence-based publications.

Carbon fiber reinforced PEEK Optima--a composite material biomechanical properties and wear/debris characteristics of CF-PEEK composites for orthopedic trauma implants.

BACKGROUNDnThe advantageous properties of carbon fiber reinforced polyetheretherketone (CF-PEEK) composites for use as orthopedic implants include similar modulus to bone and ability to withstand prolonged fatigue strain.nnnMETHODSnThe CF-PEEK tibial nail, dynamic compression plate, proximal humeral plate and distal radius volar plate were compared biomechanically (by four-point bending, static torsion of the nail, and bending fatigue) and for wear/debris (by amount of the debris generated at the connection between the CF-PEEK plate and titanium alloy screws) to commercially available devices.nnnRESULTSnFour-point bending stress of the tibial nail and dynamic and distal radius plates yielded characteristics similar to other commercially available devices. The distal volar plate bending structural stiffness of the CF-PEEK distal volar plate was 0.542 Nm2 versus 0.376 Nm2 for the DePuys DVR anatomic volar plate. The PHILOS proximal humeral internal locking system stainless steel plate was much stronger (6.48 Nm2) than the CF-PEEK proximal humeral plate (1.1 Nm2). Tibial nail static torsion testing showed similar properties to other tested nails (Fixion, Zimmer and Synthes). All tested CF-PEEK devices underwent one million fatigue cycles without failure. Wear test showed a lower volume of generated particles in comparison to the common implants in use today.nnnINTERPRETATIONnThus, these tested implants were similar to commercially used devices and can be recommended for use as implants in orthopedic surgery.

The effect of clopidogrel and aspirin on blood loss in hip fracture surgery

INTRODUCTIONnAnti-platelet drugs are commonly used for primary and secondary prevention of thrombo-embolic events and following invasive coronary interventions. Their effect on surgery-related blood loss and perioperative complications is unclear, and the management of trauma patients treated by anti-platelets is controversial. The anti-platelet effect is over in nearly 10 days. Notably, delay of surgical intervention for hip fracture repair for >48 h has been reported to increase perioperative complications and mortality.nnnPATIENTS AND METHODSnIntra-operative and perioperative blood loss, the amount of transfused blood and surgery-related complications of 44 patients on uninterrupted clopidogrel treatment were compared with 44 matched controls not on clopidogrel (either on aspirin alone or not on any anti-platelets).nnnRESULTSnThe mean perioperative blood loss was 899±496 ml for patients not on clopidogrel, 1091±654 ml for patients on clopidogrel (p=0.005) and 1312±686 ml for those on combined clopidogrel and aspirin (p=0.0003 vs. all others). Increased blood loss was also associated with a shorter time to operation (p=0.0012) and prolonged surgical time (p=0.0002). There were no cases of mortality in the early postoperative period.nnnCONCLUSIONSnPatients receiving anti-platelet drugs can safely undergo hip fracture surgery without delay, regardless of greater perioperative blood loss and possible thrombo-embolic/postoperative bleeding events.

A single dose of platelet-rich plasma improves the organization and strength of a surgically repaired rotator cuff tendon in rats

IntroductionRotator cuff tear (RCT) is a common cause of pain and disability among adults. Platelet-rich plasma (PRP) is a fraction of whole blood containing concentrated growth factors and proteins important for tissue healing. This study aimed at investigating the effects of local autologous PRP injection on repaired rotator cuff (RC) tendon repair in rats.MethodsFollowing experimental RCT and suturing, 44 Wistar rats were randomly allocated into two groups: (1) RC repair only (controls); (2) RC repairxa0+xa0PRP administration-shoulders were treated with intra-articular PRP immediately after the repair. Animals were killed after 3xa0weeks and tendon, were tested biomechanically in tension (12 rats/group). The remaining tendons (10 rats/group) were stained using hematoxylin and eosin and Picro-sirius Red. Histological analysis evaluated the cellular aspects of the repair tissue.ResultsPRP administration following experimental RC tear and suture resulted in a significantly higher maximal load (pxa0<xa00.001) and stiffness (pxa0<xa00.005) as compared to non-treated animals. Bonar score of PRP-treated tendons was significantly better (pxa0=xa00.018) than the control group. Collagen birefringence was significantly higher in PRP shoulders (pxa0=xa00.002), indicating improved organization. Vascularity scores were similar in both groups.ConclusionApplication of a single dose autologous PRP in adjunct to surgical repair resultes in improved tendon-to-bone healing, assessed by histological and biomechanical testing in a rat model of acute RCT, when tested at 3xa0weeks compared to controls. Further studies will be essential to determine the role of PRP in clinical practice.

Superior outcome of strut allograft-augmented plate fixation for the treatment of periprosthetic fractures around a stable femoral stem

PURPOSEnThis study was designed to compare the outcome of two surgical approaches for treating femoral periprosthetic fractures around a stable femoral stem. The hypothesis was that plate fixation alone might be associated with a higher complication rate due to insufficient mechanical stability. We also considered that the addition of a strut allograft would contribute to fracture healing by means of osteoconduction.nnnMETHODSnWe retrospectively assessed the outcome of 21 patients who sustained periprosthetic fractures around a total hip replacement system (Vancouver type B1 and type C fractures) and who were treated in our department (January 2006 and August 2011) either by plate fixation alone or by plate fixation and a strut allograft. The mean postoperative follow-up was 23 months (range 9-69 months). Eleven patients were treated by plate fixation alone (Plate Group), and 10 patients were treated by plate fixation and a deep frozen cortical strut allograft (AG Group). Functional outcome was rated by the Harris Hip scoring system. Postoperative radiographs were assessed for evidence of fracture union. Surgical failure was defined as any complication requiring surgical revision.nnnRESULTSnThe 21 patients included 17 females and 4 males. The average age was 79 years (range, 73-88) for the Plate Group and 82 years (range, 53-94) for the AG Group, and the average time to fracture union was 12 weeks (range, 2.5-6 months) and 12.95 weeks (range, 1.5-3) respectively. The overall failure rate was significantly higher in the Plate Group: 5 of them required revision surgery compared to none in the AG Group (p=0.014).nnnCONCLUSIONnThe results of this analysis indicate that a strut allograft augmentation approach to Vancouver type B1 and type C periprosthetic fractures results in a better outcome than plate fixation alone by apparently adding mechanical stability and enhancing the biological healing process.

Arthroscopic rotator interval closure in shoulder instability repair: A retrospective study

BACKGROUNDnArthroscopic Bankart repair (ABR) is a standard treatment for recurrent anterior shoulder instability. Young age, hyperlaxity, loss of bone stock and multidirectional or voluntary type of instability are all associated with failure of this procedure. Rotator interval laxity is associated with shoulder instability, whereas rotator interval closure increases humeral head stability and reduces shoulder range of motion.nnnMETHODSnThe records of patients with recurrent anterior shoulder dislocations who underwent ABR with or without arthroscopic rotator interval closure (ARIC) in our department between 1999 and 2007 were reviewed. Rates of recurrent dislocation or symptomatic subluxation as well as functional outcome were evaluated using Walch-Dupley score.nnnRESULTSnThree (8.1%) of the 37 ABR+ARIC patients (age 19-44 years, 32 males) had re-dislocated their shoulder at 42±16 months following the procedure, all of which had systemic joint hyperlaxity. Six (13%) of the 46 ABR patients (age 19-39 years, 42 males) had re-dislocated their shoulder at 13±14 months, three of which had systemic joint hyperlaxity and dislocated their shoulder within 1 year following the operation. Systemic joint hyperlaxity (28% of ABR and 41% of ABR+ARIC patients) was significantly associated with recurrent dislocation and poor functional outcome. ABR+ARIC patients had slightly more limited range of motion with similar good and excellent functional results (75%) at final follow up time.nnnCONCLUSIONSnSystemic joint hyperlaxity is a risk factor for failure of ABR. When ARIC is performed in combination with ABR, it may have an additive effect on shoulder stability.

Arthroscopic fixation with a minimally invasive axillary approach for latissimus dorsi transfer using an endobutton in massive and irreparable postero-superior cuff tears.

Arthroscopically assisted latissimus dorsi transfer is a viable option for treatment of patients in their 50s to 70s, without arthritis of the glenohumeral joint, who suffer from massive rotator cuff tears that are not amendable to primary repair due to fatty changes in the muscle tissue, or that have failed previous repair attempts. This procedure offers immediate and dramatic pain relief and is not as technically demanding as one might think. Understanding and respecting the principles of tendon transfer is a key to the success of this procedure.

Sesamoid and Accessory Bones of the Hand—An Epidemiologic Survey in a Mediterranean Population

The prevalence and distribution of sesamoid and accessory bones in the hands is quite variable between different populations and ethnic groups. However, there are no published data on their distribution in Mediterranean populations. Studies on the validity of radiographic assessment for the presence of these bones are also lacking. A retrospective review of 442 radiographs of adult patients was performed in order to assess the incidence of sesamoid and accessory bones in the hands of a Mediterranean population. Additionally, two independent observers reviewed 174 radiographs and used the Kappa parameter in order to assess the validity of radiographic interpretation of radiographs for the presence of those bones. There was an incidence of 99.5% sesamoid bones (n = 440) in the 1st metacarpophalangeal (MCP) joint, 42.3% in the 2nd MCP joint (n = 187), and 41.1% (n = 182) in the 5th MCP joint. The incidence in the 1st interphalangeal joints was 26.2% (n = 116). The incidence of sesamoid bones in the 1st, 2nd, and 5th metacarpophalangeal joints in a Mediterranean population was found to be similar to that of Arab and Caucasian populations, whereas their prevalence in the 1st interphalageal joint coincided more with Arab populations. Interobserver reliability of the interpretation of radiographs for the presence of sesamoid bones in the hand was good (Kappa > 0.68) in all locations, except for the 1st MCP joint. Further research is warranted to further elucidate the genetic and/or environmental reasons for the differences between those populations. Clin. Anat. 24:183–187, 2011.

Sequelae of Underdiagnosed Foot Compartment Syndrome after Calcaneal Fractures

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49xa0± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52xa0± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (pxa0= .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

The effects of ‘old’ red blood cell transfusion on mortality and morbidity in elderly patients with hip fractures – A retrospective study

BACKGROUNDnElderly patients admitted with hip fractures often receive allogenic blood transfusion (ABT) in the perioperative period. We examined the effect of the shelf life of the ABT on mortality and morbidity.nnnMETHODSnA total of 1381 patients with hip fractures were retrospectively analysed. Two groups were compared, group A (new), with an ABT shelf life≤14 days, and group B (old), with an ABT shelf life>14 days. Data collected for both groups included general demographic data, data regarding postoperative infections and other complications rates and data regarding mortality. Kaplan-Meier curves were used to assess difference in survival between the groups. Cox regression was performed to analyse the survival after controlling for age, sex, pre-surgical haemoglobin concentration, pre-surgical creatinine, American Society of Anesthesiologists (ASA) score, surgery type and number of blood units given.nnnRESULTSnHigher mortality was seen in hip fracture patients who received old blood unit compared to new blood unit but the difference was not statistically significant (P=0.5). Cox regression model demonstrated that designation into either young or old groups was not associated with mortality (hazard ratio: 1.14 (confidence interval: 0.85-1.53)). No differences were noted between the groups with regard to infection and other postoperative complication rates.nnnCONCLUSIONnPatients undergoing surgery for hip fractures who received old units of blood did not differ from those receiving new units with regard to mortality and morbidity. Large-scale clinical trials are needed to further investigate this association.