Serafim Tsitsilonis

Periprosthetic Fractures in Total Ankle Replacement: Classification System and Treatment Algorithm

BACKGROUND Despite progress in implant design and surgical technique, the reported number of periprosthetic ankle fractures following total ankle joint replacement continues to increase. A treatment-oriented classification of these fractures has not yet been reported. The purpose of this study was to evaluate the prevalence, cause, and location of periprosthetic fractures and the stability of the associated prosthetic components after total ankle replacement and to develop a method of classification. METHODS Data regarding 503 total ankle replacements with a mean follow-up of 14.7 months were reviewed. The prevalence, location, and possible cause of the fractures as well as prosthesis stability were analyzed and a systematic method of classification based on these factors was developed. RESULTS Twenty-one patients (4.2%) with a periprosthetic fracture were identified. The fracture was intraoperative (Type 1) in eleven patients (2.2%) and postoperative in the remaining ten (2.0%). Two of the latter fractures were traumatic (Type 2) and eight were stress fractures (Type 3). Two-thirds (fourteen) of the twenty-one fractures occurred in the medial malleolus. CONCLUSIONS The prevalence of periprosthetic fractures following primary total ankle replacement was relatively low. We propose a classification system for these fractures that is based on more than 500 cases. We believe that this classification can facilitate therapeutic decision-making, as it allows for differential analysis of the cause and guides the choice among operative and nonoperative treatment options.

Surgical management of thoracolumbar spinal sarcoma

Primary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewings sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.ZusammenfassungPrimäre maligne Tumoren der thorakolumbalen Wirbelsäule sind sehr selten. Die häufigsten Entitäten sind das Chordom, gefolgt vom Osteo-, Ewing- und Chondrosarkom. Eine detaillierte Bildgebung gefolgt von einer Biopsie sind die entscheidenden diagnostischen Schritte. Das chirurgische Stagingsystem von Weinstein und Boriani erlaubt eine genaue Analyse der Tumorausbreitung. Die Therapie in einem multimodalen Konzept besteht aus (neo-)adjuvanter Polychemotherapie und wahlweise Radiatio. Die chirurgische Therapie sollte in einer En-bloc-Exzision mit suffizienten Resektionsgrenzen erfolgen. Die Defektrekonstruktion muss über Wirbelkörperersatzverfahren und langstreckige Instrumentierungen vorgenommen werden. Die En-bloc-Spondylektomie ist ein sehr anspruchsvolles Verfahren und erfordert eine strenge Indikationsstellung, eine enge Kooperation mit benachbarten Fachabteilungen und exakte Operationsplanung. Nur so ist der Eingriff realisierbar und stellt die einzige suffiziente Resektionsform dar. Die Durchführung der En-bloc-Spondylektomie an sich sollte Wirbelsäulenzentren mit großer Erfahrung vorbehalten bleiben, die dann auch ein entsprechendes Komplikationsmanagement sicherstellen können.AbstractPrimary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewing’s sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.

Closed reduction of distal radius fractures: does instability mean irreducibility?

IntroductionThe belief that not all distal radius fractures can be initially anatomically reduced with conservative means is rising. The aim of this study was to examine whether adequate reduction with a closed reduction technique is possible and to assess the importance of each step.Materials and methodsWe prospectively enrolled 63 distal radius fractures (62 patients). A standardized reduction technique was implemented. Reduction was radiologically evaluated in hanging traction, after reduction, and in plaster. Subgroup analysis was performed for fracture-dependent and fracture-independent factors on their influence on reduction.ResultsThe mean radiological values (radial inclination, dorsal tilt, ulnar variance) showed near anatomic reduction of all fractures in plaster. Fracture severity according to AO classification, initial displacement, number of instability criteria and patient age did not affect the reduction outcome.ConclusionsAll types of enrolled fractures were nearly anatomically reduced. This contradicts the opinion that some “severe” fractures are too unstable to be initially reduced by closed means.

Chirurgisches Management von Sarkomen der thorakolumbalen Wirbelsäule

Primary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewings sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.ZusammenfassungPrimäre maligne Tumoren der thorakolumbalen Wirbelsäule sind sehr selten. Die häufigsten Entitäten sind das Chordom, gefolgt vom Osteo-, Ewing- und Chondrosarkom. Eine detaillierte Bildgebung gefolgt von einer Biopsie sind die entscheidenden diagnostischen Schritte. Das chirurgische Stagingsystem von Weinstein und Boriani erlaubt eine genaue Analyse der Tumorausbreitung. Die Therapie in einem multimodalen Konzept besteht aus (neo-)adjuvanter Polychemotherapie und wahlweise Radiatio. Die chirurgische Therapie sollte in einer En-bloc-Exzision mit suffizienten Resektionsgrenzen erfolgen. Die Defektrekonstruktion muss über Wirbelkörperersatzverfahren und langstreckige Instrumentierungen vorgenommen werden. Die En-bloc-Spondylektomie ist ein sehr anspruchsvolles Verfahren und erfordert eine strenge Indikationsstellung, eine enge Kooperation mit benachbarten Fachabteilungen und exakte Operationsplanung. Nur so ist der Eingriff realisierbar und stellt die einzige suffiziente Resektionsform dar. Die Durchführung der En-bloc-Spondylektomie an sich sollte Wirbelsäulenzentren mit großer Erfahrung vorbehalten bleiben, die dann auch ein entsprechendes Komplikationsmanagement sicherstellen können.AbstractPrimary malignant tumors of the thoracolumbar spine are very rare. The most common entities are chordoma, followed by osteosarcoma, Ewing’s sarcoma and chondrosarcoma. Detailed imaging and a sequential biopsy are the most important diagnostic steps. The surgical staging system of Weinstein and Boriani permits a precise analysis of tumor expansion. Therapy under a multimodal concept consists of (neo-) adjuvant therapy and possible radiation. The surgical therapy should be performed as an en bloc excision with sufficient resection borders. The reconstruction of the defects must include methods of vertebral body replacement and long posterior instrumentation. En bloc spondylectomy is a very demanding technique and demands strict indications, close cooperation with adjacent specialties and exact planning of the operation. Only in this manner is the operation possible and offers the only sufficient form of resection. The execution of the en bloc spondylectomy should be left to spine centers with great experience, as they could also guarantee the respective complication management.

Operative therapy of fractures of the distal femur. Predictive factors for a complicated course

BACKGROUND Fractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high. OBJECTIVES This study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment. MATERIALS AND METHODS We retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed. RESULTS Open soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia. CONCLUSIONS The complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patients general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.ZusammenfassungHintergrundDistale Femurfrakturen sind seltene Verletzungen, die überwiegend operativ therapiert werden und relativ hohe Komplikationsraten aufweisen.Ziel der ArbeitZiel dieser Arbeit war es, Komplikationen nach operativer Versorgung von distalen Femurfrakturen zu analysieren sowie Einflussfaktoren zu identifizieren, welche potenziell einen komplikationsbehafteten Verlauf vorhersagen können.Material und MethodenAlle operativ stabilisierten distalen Femurfrakturen im Zeitraum von 2005 bis 2015 wurden retrospektiv analysiert. Neben patienten- und frakturspezifischen Daten wurden chirurgische Parameter der Therapie sowie die Art der Komplikationen erfasst und ausgewertet.ErgebnisseOffene Weichteilschäden, ein polytraumatisierter Patient und der Zeitpunkt der Operation (Versorgung als Notfall) sind signifikante Risikofaktoren für das Auftreten einer Pseudarthrose. Risikofaktoren für das Auftreten einer Infektion sind offene Weichteilschäden. Typ-C-Frakturen, die notfallmäßige Versorgung und ein begleitendes Polytrauma sind Risikofaktoren für eine postoperative Pneumonie.DiskussionDie Komplikationsrate wird signifikant durch chirurgische Einflussfaktoren bestimmt. Um die Rate an Pseudarthrosen, Infektionen und Pneumonien zu senken ist die Optimierung des Zustandes des Patienten präoperativ sowie die optimale Versorgung wichtiger als eine notfallmäßige unmittelbare Ausversorgung.AbstractBackgroundFractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high.ObjectivesThis study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment.Materials and methodsWe retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed.ResultsOpen soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia.ConclusionsThe complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patient’s general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.

Operative Therapie von distalen Femurfrakturen

BACKGROUND Fractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high. OBJECTIVES This study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment. MATERIALS AND METHODS We retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed. RESULTS Open soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia. CONCLUSIONS The complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patients general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.ZusammenfassungHintergrundDistale Femurfrakturen sind seltene Verletzungen, die überwiegend operativ therapiert werden und relativ hohe Komplikationsraten aufweisen.Ziel der ArbeitZiel dieser Arbeit war es, Komplikationen nach operativer Versorgung von distalen Femurfrakturen zu analysieren sowie Einflussfaktoren zu identifizieren, welche potenziell einen komplikationsbehafteten Verlauf vorhersagen können.Material und MethodenAlle operativ stabilisierten distalen Femurfrakturen im Zeitraum von 2005 bis 2015 wurden retrospektiv analysiert. Neben patienten- und frakturspezifischen Daten wurden chirurgische Parameter der Therapie sowie die Art der Komplikationen erfasst und ausgewertet.ErgebnisseOffene Weichteilschäden, ein polytraumatisierter Patient und der Zeitpunkt der Operation (Versorgung als Notfall) sind signifikante Risikofaktoren für das Auftreten einer Pseudarthrose. Risikofaktoren für das Auftreten einer Infektion sind offene Weichteilschäden. Typ-C-Frakturen, die notfallmäßige Versorgung und ein begleitendes Polytrauma sind Risikofaktoren für eine postoperative Pneumonie.DiskussionDie Komplikationsrate wird signifikant durch chirurgische Einflussfaktoren bestimmt. Um die Rate an Pseudarthrosen, Infektionen und Pneumonien zu senken ist die Optimierung des Zustandes des Patienten präoperativ sowie die optimale Versorgung wichtiger als eine notfallmäßige unmittelbare Ausversorgung.AbstractBackgroundFractures of the distal femur are rare injuries that are mainly treated operatively. Complication rates remain high.ObjectivesThis study aimed to analyse complications following the operative treatment of these fractures and to identify predictive factors that have the potential to identify patients who are at risk for a complicated course of treatment.Materials and methodsWe retrospectively analysed all fractures of the distal femur that were treated operatively at our institution between 2005 and 2015. Besides patient and fracture-specific data, surgical details and the types of complications that occurred were recorded and analysed.ResultsOpen soft tissue damage, the polytraumatised patient and the timing of surgery (i.e. emergency surgery) are significant risk factors for the development of a nonunion. A risk factor that predicts a postoperative infection is open soft tissue damage. Type C fractures, stabilisation as emergency surgery and an accompanying polytrauma are risk factors for a postoperative pneumonia.ConclusionsThe complication rate is significantly determined by surgical factors. To reduce the rate of nonunion, infection and pneumonia, the optimisation of the patient’s general condition before surgery and optimal surgical care is more important than an immediate emergency surgery.

Fracture severity of distal radius fractures treated with locking plating correlates with limitations in ulnar abduction and inferior health-related quality of life

Introduction/background: The operative treatment of distal radius fractures has significantly increased after the introduction of locking plates. The aim of the present study was the evaluation of health-related quality of life, functional and radiological outcome of patients with distal radius fractures treated with the locking compression plate (LCP). Materials and methods: In the present study 128 patients (130 fractures) that were operatively treated with the LCP (2.4 mm/3.5 mm, Synthes®) were retrospectively evaluated. Mean follow-up was 22.7 months (SD 10.6). The fractures were radiographically evaluated (radial inclination, palmar tilt, ulnar variance) pre-, postoperatively and at the last follow-up visit. Range of motion (ROM) was documented. Grip strength was assessed with the use of a JAMAR dynamometer. The score for disabilities of the arm, shoulder and hand (DASH) and the Gartland-Werley score (GWS) were evaluated. Health-associated quality of life was assessed with use of SF-36 Health Survey. Results: Postoperative reduction was excellent; at the last follow-up visit only minimal reduction loss was observed. Except for pronation, a statistically significant decrease of ROM was present; in most cases that was not disturbing for the patients. The injured side achieved 83.9% of grip strength of the intact side. Mean DASH was 18.9 and mean GWS was 3.5. Health-associated quality of life was generally not compromised. However, limitations in ulnar abduction correlated with inferior quality of life. Fracture severity correlated with inferior quality of life, despite the absence of correlation with the functional and radiological outcome. Complication rate was low. Conclusions: Fracture severity seems to affect ulnar abduction and therefore patient quality of life, despite almost anatomical reduction; the objective and subjective scores were in most cases excellent. Modern everyday activities, such as keyboard typing, could be associated with the present results.

Functional and radiological outcome of periprosthetic fractures of the ankle

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA). A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically. A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%. There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively. A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Long-term functional outcome and quality of life after successful surgical treatment of tibial nonunions.

PurposeOur aim was to evaluate quality of life (QoL) and functional outcome of patients with tibial nonunions after completion of surgical treatment with an average follow-up of five years.MethodsThe following data of 64 patients were retrospectively evaluated: fracture type, type and duration of surgical therapy, range of motion of the knee and ankle and American Orthopaedic Foot and Ankle Society (AOFAS) score. QoL was evaluated with the Short-Form Health Survey (SF-36) questionnaire; pain intensity, patient satisfaction and impairments of daily, professional and sport activities with a ten point visual analogue scale.ResultsQoL, even in cases with successfully completed treatment, was significantly reduced compared with the normal general population. Pain intensity and limited ankle dorsal extension, despite the absence of intra-articular fractures, were significantly correlated with inferior QoL.ConclusionsThis study emphasises the long-term negative impact of tibial nonunions on patient QoL, even after successful surgical treatment.

Biomechanical behavior of MRI-signal-inducing bone cements after vertebroplasty in osteoporotic vertebral bodies: An experimental cadaver study.

BACKGROUND Conventional water-free polymethylmethacrylate cements are not MRI visible due to the lack of free protons. A new MRI-visible bone cement was developed through the addition of a contrast agent and either a saline solution or a hydroxyapatite (Wichlas et al., 2010). The purposes of the study were to examine the influence of the two MRI-signal-inducing cements on the biomechanical behavior of cadaveric osteoporotic vertebral bodies after vertebroplasty and to compare the performance of the cements with conventional polymethylmethacrylate cement. METHODS Three different cements were used: standard polymethylmethacrylate cement and two modified MRI-signal-inducing cements that were mixed with either a 0.9% saline solution or a hydroxyapatite. The modulus of elasticity for the standard polymethylmethacrylate cement was 2040MPa, and the moduli for the MRI-signal-inducing cements that were mixed with a 0.9% saline solution and a hydroxyapatite were 1477 and 1225MPa, respectively. The lumbar vertebral bodies from nine osteoporotic spines (mean age=87 years, range=78-99 years) of female cadavers were examined. Three groups were formed: polymethylmethacrylate cement with saline solution (n=14), polymethylmethacrylate cement with hydroxyapatite (n=12) and polymethylmethacrylate cement (n=13). The vertebral bodies were biomechanically tested before and after vertebroplasty. Stiffness was chosen as the primary biomechanical parameter. FINDINGS The vertebral body stiffness was nearly two-fold greater after vertebroplasty, and this increase was statistically significant for every group. All the groups had similar vertebral body stiffness value before and after the vertebroplasty. The UNIANOVA test for multivariate analysis of variance showed no influence of lumbar level, injected cement volume and initial vertebral body stiffness. INTERPRETATION The elastic moduli of the cements appear to exert little influence on the biomechanical values when the cement is in the vertebral body. Based on the direct comparison with the classic polymethylmethacrylate cement, we believe that the implementation of such cements for MRI-guided vertebroplasties is feasible.