Panagiotis Givissis

Meniscal Tear Characteristics in Young Athletes with a Stable Knee: Arthroscopic Evaluation

Background There has been great interest in the literature regarding meniscal tears in unstable knees, but there is not as much information available on stable knees. Purpose To report the characteristics of isolated meniscal tears (type and location) in athletes with intact cruciate ligaments. Study Design Case series; Level of evidence, 4. Methods Arthroscopic surgery was performed on 314 (83.1%) knees in the acute phase (<6 weeks) of injury and on 64 (16.9%) knees more than 6 weeks after injury for a total of 364 athletes (378 knees). Coopers classification was used to classify the meniscal tears according to the type and location. Results Overall, 262 of 378 tears (69.3%) were located in the medial meniscus and 116 (30.7%) in the lateral meniscus. Vertical tears (77.5%) were significantly more frequent than were horizontal tears (22.5%; ϰ2 test, P < .001). A total of 23.2% of tears involved the peripheral zones (zone 0 or 1), and tears that extended into the posterior horn accounted for 75.7%. Regarding the tear shape between male and female athletes, on both sides there were no statistically significant differences in the percentage of horizontal, bucket-handle, longitudinal, or radial tears. Conclusion The characteristics of isolated meniscal tears differ with regard to the sport, sex, and tear location and type from those seen in unstable knees. This knowledge is useful in knee injury management.

Treatment of tuberculous spondylitis with anterior stabilization and titanium cage

We retrospectively reviewed 12 patients with spinal tuberculosis of the thoracic and lumbar spine who had radical débridement, anterior decompression, interbody arthrodesis with an anterior interbody titanium cage, and autologous bone grafts, combined with a standardized perioperative antituberculous regimen. Their mean age was 55.1 years and they were observed for a mean of 65.3 months. Indications for surgery included epidural abscess, structural destruction with instability, progressive kyphosis, and/or neurologic deterioration. Kyphotic deformity was corrected from a mean of 24.6° (range, 15°-32°) to a mean of 10° (range, 4°-18°). Tuberculous infection was controlled and bony fusion was achieved in all patients. No recurrence of infection or construct failure was recorded. All patients were safely mobilized within the first postoperative week; back pain fully resolved in eight patients and improved in the remaining four. We conclude that radical débridement followed by anterior stabilization with a titanium cage and bone grafting is a reasonable alternative for tuberculous spondylitis requiring surgical treatment. It enables accurate and lasting deformity correction and provides adequate stability to allow early mobilization. The presence of a titanium cage in an area of mycobacterial infection did not preclude infection control or lead to recurrence.Level of Evidence: Therapeutic study. Level IV (case series). Please see Guidelines for Authors for a complete description of levels of evidence.

Reduction of postoperative spinal infections based on an etiologic protocol.

Acute postoperative spinal infections are serious complications. We saw a sudden increase in the infection rate in our unit during a 6-month period. This led us to construct an assessment protocol combining risk factors into a mnemonic we named the “Nine Ps Protocol” (patient-related factors, personnel, place, preoperative length of stay, procedure, prosthetics, prophylaxis, packed red blood cells, and pus cultures). We reviewed 102 consecutive patients having spine surgery in three sequential 6 month periods: Group A included 34 patients before the outbreak of infection and Group B included 26 patients during the outbreak of infection. We prospectively applied the protocol in 26 patients (Group C) after the outbreak. After the implementation of the protocol the infection rate dropped from 16.7% (Group B) to 3.6% (Group C). Increased risk factors for postoperative infection included advanced age, posterior instrumented fusion, high allogenic blood transfusion rates, and suboptimal sheet and dressing changing conditions. We propose the Nine Ps Protocol as a useful clinical tool for the etiologic assessment and prevention of spinal infections.Level of Evidence: Prognostic study, Level II (Lesser quality prospective study [eg, patients enrolled at different points in their disease or < 80% followup]). Please see Guidelines for Authors for a complete description of levels of evidence.

Complications arising from a misdiagnosed giant lipoma of the hand and palm: a case report

IntroductionLipomas are benign tumors which may appear in almost any human organ. Their diagnosis rate in the hand region is not known.Case PresentationWe present the case of a 63-year-old Greek Caucasian woman with a giant lipoma of the hand and palm which was not initially diagnosed. After repeated surgical decompression of the carpal tunnel the patient was referred with persisting symptoms of median and ulnar nerve compression and a prominent mass of her left palm and thenar eminence. Clinical examination, magnetic resonance imaging, nerve conduction study and biopsy, revealed a giant lipoma in the deep palmar space (8.0 × 4.0 × 3.75 cm), which was also infiltrating the carpal tunnel. She had already undergone two operations for carpal tunnel syndrome with no relief of her symptoms and she also ended up with a severed flexor pollicis longus tendon. Definitive treatment was performed by marginal resection of the lipoma and restoration of the flexor pollicis longus with an intercalated graft harvested from the palmaris longus. Thirty months after surgery the patient had a fully functional hand without any neurological deficit.ConclusionNot all lipomas of the wrist and hand are diagnosed. Our report tries to emphasize the hidden danger of lipomas in cases with carpal tunnel symptoms. The need for a high index of suspicion in conjunction with good clinical evaluation and the use of appropriate investigative studies is mandatory in order to avoid unnecessary operations and complications. Marginal excision of these tumors is restorative.

Condylar Buttress Plate versus Fixed Angle Condylar Blade Plate versus Dynamic Condylar Screw for Supracondylar Intra-Articular Distal Femoral Fractures

Purpose. To compare outcomes of 3 fixation techniques for intra-articular distal femoral fractures. Methods. Records of 59 men and 49 women aged 16 to 80 (mean, 47) years who underwent internal fixation for 116 type-C (complete intra-articular) distal femoral fractures were retrospectively reviewed. According to the AO classification, 25 fractures were type C1 (23 closed and 2 open), 71 type C2 (69 closed and 2 open), and 20 type C3 (16 closed and 4 open). Based on implant availability at the time, all surgeries were performed by a single surgeon using a condylar buttress plate (n=38), a fixed angle (95°) condylar blade plate (n=24), or a dynamic condylar screw (n=54). The mean follow-up period was 11 (range, 4–19) years. At the latest follow-up, functional outcome was classified according to Schatzker and Lambert criteria. Results. Functional outcomes were excellent in 64 (55%) of the fractures, good in 37 (32%), moderate in 9 (8%), and poor in 6 (5%). Outcomes in patients treated by the dynamic condylar screw were significantly superior to those treated by the condylar buttress plate (p=0.016) or condylar blade plate (p=0.001). Good-to-excellent results were achieved in 96% vs 84% vs 71% of these patients, respectively. Complication rates were lower in the dynamic condylar screw group than the other 2 groups (pseudarthrosis, 5% vs 11% vs 25%; varus deformity, 4% vs 26% vs 25%; knee stiffness, 0% vs 5% vs 8%, respectively). No implant failure was encountered. Conclusion. Dynamic condylar screw fixation for distal femoral fractures achieves better functional outcomes and lower complication rates.

Somatosensory Evoked Potentials suppression due to remifentanil during spinal operations; a prospective clinical study

BackgroundSomatosensory evoked potentials (SSEP) are being used for the investigation and monitoring of the integrity of neural pathways during surgical procedures. Intraoperative neurophysiologic monitoring is affected by the type of anesthetic agents. Remifentanil is supposed to produce minimal or no changes in SSEP amplitude and latency. This study aims to investigate whether high doses of remifentanil influence the SSEP during spinal surgery under total intravenous anesthesia.MethodsTen patients underwent spinal surgery. Anesthesia was induced with propofol (2 mg/Kg), fentanyl (2 mcg/Kg) and a single dose of cis-atracurium (0.15 mg/Kg), followed by infusion of 0.8 mcg/kg/min of remifentanil and propofol (30-50 mcg/kg/min). The depth of anesthesia was monitored by Bispectral Index (BIS) and an adequate level (40-50) of anesthesia was maintained. Somatosensory evoked potentials (SSEPs) were recorded intraoperatively from the tibial nerve (P37) 15 min before initiation of remifentanil infusion. Data were analysed over that period.ResultsRemifentanil induced prolongation of the tibial SSEP latency which however was not significant (p > 0.05). The suppression of the amplitude was significant (p < 0.001), varying from 20-80% with this decrease being time related.ConclusionRemifentanil in high doses induces significant changes in SSEP components that should be taken under consideration during intraoperative neuromonitoring.

Improved Corticosteroid Treatment of Recalcitrant de Quervain Tenosynovitis With a Novel 4-Point Injection Technique:

Background: Previously described corticosteroid injection techniques for de Quervain tenosynovitis (DQT) refer to either 1-point or 2-point injection techniques, showing superiority of the latter. Hypothesis: The authors’ novel 4-point injection technique (point 4 technique) yields more favorable results than do the older techniques. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: The authors treated 2 groups (A and B), each including 24 high-resistance training individuals (randomly allocated to each group) with persistent DQT. Group A received the point 4 technique, and group B, the 2-point injection technique. Follow-up was in 2, 4, 8, and 52 weeks after the first treatment. Results: After 2 weeks of treatment, 7 group A patients were symptom-free, whereas the rest scored better than their group B counterparts on the DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure, of whom only 1 was symptom-free. Ten group A patients received repeated injections, in contrast to 19 from group B. Four weeks after the first treatment, 13 group A patients were symptom-free, in contrast to 4 from group B. In group A, 2 patients received repeated injections, in contrast to 20 in group B. Eight weeks after the first treatment, 1 group A patient received repeated injection. One group B patient relapsed, whereas 4 opted for surgical decompression and 16 received repeated injections. Fifty-two weeks after the first treatment, 21 patients in group A were symptom-free, 1 was operated on, and 2 relapsed; in group B, 12 were symptom-free, 9 were operated on, 3 relapsed, and 3 received repeated injections. Conclusion: In high-resistance training athletes, recalcitrant DQT responds more favorably to the novel point 4 technique than to the standard 2-point injection technique.

Interposition arthroplasty of the first metatarsophalangeal joint with a fascia lata allograft.

A new technique for interposition arthroplasty of the first metatarsoplalangeal joint is described. It involves minimal resection of the base of the proximal phalanx and the use of a fascia lata allograft. The method is simple, safe, and easily reproducible. In selected cases it can offer restoration of pain-free motion in a nonsalvable joint.

The effect of steroid-abuse on anatomic reinsertion of ruptured distal biceps brachii tendon

INTRODUCTION There is an increase in the number of anabolic-steroid (AS)-abusing trainees, who suffer from sports injuries, needing reconstruction surgery. Rupture of the distal biceps brachii tendon is a common injury in this group. PURPOSE The study aimed to investigate the effect of AS abuse in the anatomic reconstruction of the ruptured distal biceps brachii tendon along with an immediate range-of-motion postoperative protocol. METHODS We conducted an observation study of 17 male athletes suffering from distal biceps tendon ruptures. Six of them reported that they abused AS (group A), whereas the non-users comprised group B (n=11). Both groups were treated with the modified single-incision technique with two suture anchors and an immediate active range-of-motion protocol postoperatively. Follow-up was at 4, 16 and 52 weeks postoperatively, with a final follow-up at 24 months. RESULTS Follow-up at 4, 16 and 52 weeks postoperatively showed a statistical significance in favour of group A for therapeutic outcomes concerning flexion, supination, pronation, Disabilities of the Arm, Shoulder and Hand (DASH) Disability Symptom Scores, Mayo Elbow Performance Elbow Scores and isometric muscle strength tests for both flexion and supination. Twenty-four months postoperatively, statistical significance in favour of group A was recorded in isometric muscle strength tests for both flexion and supination and also in DASH Disability Symptom Score. DISCUSSION The results of our study suggest that there is a correlation between the effect of AS and the quicker and better recuperation and rehabilitation observed in group A. Nonetheless, these results must be interpreted with caution, and further in vivo research is needed to confirm these findings.

Management of posttraumatic arthritis of the wrist with radiolunate fusion enhanced with a sliding autograft: a case report and description of a novel technique.

Although in rheumatoid cases radiolunate fusion presents with satisfying results, in cases with posttraumatic carpal distortion, the variability of injury pattern can influence the type of fixation and the rate of bony union. In this case report, we present an alternative technique of radiolunate fusion for the management of posttraumatic arthritis, which combines the traditional procedure with a corticocancellous autograft, created from the dorsal side of the radius that slides over the bones to be fused. That procedure provides the best environment for the bones to heal and an additional stabilizing effect on the radiolunate construct, thus better preserving the normal intercarpal relationships and wrist height. Patients clinical and radiological outcome was very satisfactory until the last follow-up.