Sokratis E. Varitimidis

Vascularized Compared with Nonvascularized Fibular Grafting for the Treatment of Osteonecrosis of the Femoral Head

Background: We are not aware of any clinical studies in the literature comparing the results of vascularized and nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purpose of this study was to compare the clinical results of free vascularized fibular grafting with those of nonvascularized fibular grafting.Methods: Two hundred patients (220 hips) with osteonecrosis of the femoral head were treated with free vascularized fibular grafting at the University of Pittsburgh Medical Center, and ninety-nine patients (123 hips) were treated with nonvascularized fibular grafting at the Kyungpook National University Hospital in Korea. From these populations, two groups of fifty hips each, followed for a minimum of three years (average, five years), were matched by the stage, size, and etiology of the lesion and by the mean preoperative Harris hip score. A retrospective case-control study of these groups was then performed to compare the postoperative Harris hip scores as well as the prevalences of radiographic progression and collapse of the femoral head following free vascularized fibular grafting with those measures following nonvascularized fibular grafting.Results: The mean Harris hip score improved for 70% of the hips treated with free vascularized fibular grafting: seventeen hips (34%) were rated excellent, fourteen (28%) were rated good, nine (18%) were rated fair, and ten (20%) were rated poor. The mean Harris hip score improved for 36% of the hips treated with nonvascularized fibular grafting: five hips (10%) were rated excellent; nine (18%), good; sixteen (32%), fair; and twenty (40%), poor. The rate of survival at seven years for the Stage-I and II hips (precollapse) was 86% after treatment with free vascularized fibular grafting compared with 30% after nonvascularized fibular grafting.Conclusions: The results of this study strongly suggest that vascularized fibular grafting is associated with better clinical and radiographic results.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon

Fifty-eight patients (62 joints) with arthritis of the thumb carpometacarpal joint were treated with resection arthroplasty, ligament reconstruction, and tendon interposition with the entire flexor carpi radialis tendon. The mean age of the patients at the time of surgery was 58.4 years (range, 28-80 years), and the average followup was 42.5 months (range, 21-86 months). The entire flexor carpi radialis tendon was used for reconstruction and interposition. In 32 of the 62 joints, a partial trapezoidectomy was performed for scaphotrapezoidal arthritis. Fingertip pinch improved by 88%, key pinch improved by 86%, and grip strength improved by 69%. Palmar and radial abduction also improved by 8% and 10%, respectively. Fifty-five (95%) patients reported excellent pain relief, whereas three patients reported only mild pain. No patients experienced an increase in pain. All thumbs were stable radiographically. This study indicated ligament reconstruction with tendon interposition, accompanied by partial trapezoidectomy when indicated, provides excellent pain relief and restoration of function. No morbidity was observed with use of the entire flexor carpi radialis tendon.

Classification of osteonecrosis of the femoral head. Reliability, reproducibility, and prognostic value.

The purpose of the current investigation was to determine interobserver and intraobserver reliability of the classification system of Steinberg et al for osteonecrosis of the femoral head. Sixty-five anteroposterior and lateral radiographs of hips were selected randomly from a pool of patients with confirmed osteonecrosis of the femoral head. Six fellowship-trained observers viewed the radiographs (Reading 1). The observers used six main stages of the classification excluding A, B, and C subgroups. The same observers viewed the radiographs 4 months later in reverse order (Reading 2). Reading 1 was used to calculate interobserver kappa values. Reading 2 was used to calculate intraobserver kappa values. Stage-specific kappa values for interobserver variation between all viewers were as follows: Stage I, k = 0.64; Stage II, k = 0.51; Stage III, k = 0.21; Stage IV, k = 0.49; Stage V, k = 0.36; and Stage VI, k = 0.80. Stage-specific kappa values for intraobserver variation between all viewers were as follows: Stage I, k = 0.74; Stage II, k = 0.60; Stage III, k = 0.46; Stage IV, k = 0.59; Stage V, k = 0.27; and Stage VI, k = 0.78. An average of 10 of 21 (48%) of these errors involved Stage III. An average of 6.3 of 21 (30%) intraobserver errors involved Stage V. The presence of the crescent sign in Stage III and joint space narrowing in Stage V markedly diminished the overall reliability of any four-to six-stage classification system. Based on the authors’ experience and analysis of the current classifications of osteonecrosis of the femoral head, an easy and reproducible Pittsburgh classification system is proposed.

RECURRENT COMPRESSIVE NEUROPATHY OF THE MEDIAN NERVE AT THE WRIST: TREATMENT WITH AUTOGENOUS SAPHENOUS VEIN WRAPPING

Recurrence of symptoms occurs in a significant number of patients after surgical decompression for carpal tunnel syndrome, and its management is both challenging and difficult. Fifteen patients with recurrent carpal tunnel syndrome were treated with a vein wrapping technique using the autologous saphenous vein. A total of 48 operations had been performed on these patients before wrapping the median nerve with a saphenous vein graft. At a mean follow-up of 43 months all patients reported significant pain relief and improvement in their sensory disturbances. Two-point discrimination and the findings of nerve conduction studies also improved.

Autograft Contamination During Preparation for Anterior Cruciate Ligament Reconstruction

BACKGROUND The autograft preparation process for anterior cruciate ligament reconstruction has a potential for graft contamination. The purpose of this study was to evaluate the possibility of contamination of the bone-patellar tendon-bone and hamstring tendon autograft during preparation for anterior cruciate ligament reconstruction. METHODS A primary isolated reconstruction of the anterior cruciate ligament with use of bone-patellar tendon-bone autograft (thirty patients) and hamstring tendon autograft (thirty patients) was performed in a prospective, consecutive series of patients. Three tissue samples were obtained for culture from each graft at different time-intervals during the graft preparation. In addition, the erythrocyte sedimentation rate and the C-reactive protein level were evaluated preoperatively and on the third, seventh, and twentieth postoperative days, and the clinical course of all patients was monitored. RESULTS The time needed for graft preparation was significantly longer for hamstring autografts (nineteen minutes) than for bone-patellar tendon-bone autografts (ten minutes) (p = 0.032). In the hamstring group, cultures of graft tissue from four patients (13%) were positive for bacteria. In the bone-patellar tendon-bone group, cultures of graft tissue from three patients (10%) were positive for bacteria; the difference between groups was not significant (p = 0.923). No patient had development of a postoperative infection. There were no differences between patients with a contaminated graft and those with an uncontaminated graft with regard to postoperative changes in the erythrocyte sedimentation rate or the C-reactive protein level at all time-intervals. CONCLUSIONS A high rate (12%) of autograft contamination can be expected during autograft preparation for anterior cruciate ligament reconstruction. The contamination rate is almost equal for both bone-patellar tendon-bone and hamstring tendon autografts. We could not identify an association between contaminated grafts implanted in the knee and postoperative inflammatory markers such as the erythrocyte sedimentation rate and the C-reactive protein level.

Treatment of Chronic Injuries of the Ulnar Collateral Ligament of the Thumb Using a Free Tendon Graft and Bone Suture Anchors

We report the results of a simple technique, using bone suture anchors and free tendon graft, for the reconstruction of chronic injuries of the ulnar collateral ligament complex at the thumb metacarpophalangeal (MP) joint. Our series includes 20 patients, with a mean age of 29 years. The mean follow-up period was 42 months. Using the Glickel grading system, 14 patients had excellent results and six had good results. Seventeen patients had no pain and three complained of mild pain with weather changes. Fourteen patients regained full stability of the MP joint and six had mild laxity. The mean loss of pinch strength was 18% compared with the contralateral thumb. The mean loss of motion at the metacarpophalangeal joint was 21%.

PURULENT FLEXOR TENOSYNOVITIS : FACTORS INFLUENCING THE FUNCTIONAL OUTCOME

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

Anterior cruciate ligament reconstruction using the Bio-TransFix femoral fixation device and anteromedial portal technique

The cross-pin femoral fixation technique for soft tissue grafts is a popular option in anterior cruciate ligament (ACL) reconstruction. One of these devices is the Bio-TransFix (Arthrex Inc., Naples, FL, USA) which provides high fixation strength. According to the manufacturer, the femoral tunnel is created by placing the femoral aiming device through the tibial tunnel (transtibial technique). However, using this technique it is very difficult or even impossible to place the graft at the anatomical ACL attachment site at the “10 o’clock” position. In this report, we describe the use of the Bio-TransFix device with an anteromedial portal technique. Using this technique, the surgeon has more freedom to place the graft in an anatomical position, while combining the advantages of the excellent biomechanical properties of this device.

Outcome after tantalum rod implantation for treatment of femoral head osteonecrosis : 26 hips followed for an average of 3 years

Background and purpose Tantalum rod implantation has recently been proposed for treatment of early stages of femoral head osteonecrosis. The purpose of our study was to report the early results of its use in pre- and post-collapse stages of the disease. Methods We studied prospectively 27 patients who underwent tantalum rod implantation for treatment of nontraumatic femoral head osteonecrosis between December 2000 and September 2005. Patients were evaluated radiologically and clinically using the Steinberg classification and the Harris hip score (HHS). Disease stage varied between stages II and IV. Mean follow-up time was 38 (15–71) months. Results 1 patient (1 hip) died 15 months after surgery for reasons unrelated to it. 13 of 26 hips remained at the same radiographic stage, and 13 deteriorated. Mean HHS improved from 49 to 85. 6 patients required conversion to total hip arthroplasty. When the procedure was used for stages III and IV, both radiological outcome and revision rates were worse than for the stage II hips. There was, however, no difference in postoperative HHS between patients at pre- and post-collapse stages at the time of initial evaluation. Survivorship, with revision to THA as the endpoint, was 70% at 6 years. Interpretation The disease process does not appear to be interrupted, but there was a significant improvement in hip function initially in most hips. Tantalum rod implantation is a safe “buy-time” technique, especially when other joint salvage procedures are not an option. Appropriate patient selection and careful rod insertion are needed for favorable results.

Evaluating and treating the stiff elbow

The evaluation and treatment of the stiff elbow are described, as well as the lateral, medial, anterior, and posterior approaches for release of elbow contractures. The results after surgical release in 48 patients that failed nonoperative treatment for elbow contractures in our institution are reported. A literature review is provided.