Stamatios A. Papadakis

Greek versions of the Oswestry and Roland-Morris Disability Questionnaires

Disability questionnaires are increasingly used for clinical assessment, outcome measurement of treatment and research methodology of low back pain. Their use in different countries and cultural groups must follow certain guidelines for translation and cross-cultural adaptation. The translation of such an instrument must be tested for its reliability and validity to be applied and to allow comparability of data. The Oswestry Disability Index and the Roland-Morris Disability Questionnaire are two disability questionnaires most commonly used as outcome measures in patients with low back pain. The two questionnaires were translated for use with the Greek population, were back translated and tested, and became available in a final version. The Greek versions of the Oswestry Disability Index and the Roland-Morris Disability Questionnaire were tested in 697 patients with low back pain. Internal consistency reliability for the Greek translation of the Oswestry Disability Index and the Roland-Morris Disability Questionnaire reached a Cronbach’s alpha coefficient of 0.833 and 0.885 respectively. Face validity and content validity were ensured. Concurrent validity was assessed using a six-point pain scale as a criterion. The correlation of both scales was significant. The Greek translation of these disability questionnaires provided reliable and valid instruments for the evaluation of Greek-speaking patients with low back pain.

Lateral Mass Screw Complications: Analysis of 1662 Screws

Study Design Retrospective, consecutive patient series. Objective To quantify the risks and the complications associated with screw fixation devices of the cervical spine. Summary of Background Data The usefulness of lateral mass internal fixation has been well documented in the clinical setting. However, there is a paucity of studies examining the complications associated with these devices in a degenerative clinical setting. Methods From 1999 to 2007, 225 consecutive patients underwent posterior cervical fixation using a screw-plate and polyaxial screw-rod implant systems. There were 105 women and 120 men (age range: 45 to 84 y; mean, 68 y). In all patients, the surgical indication was cervical spondylosis with myelopathy. Mean follow-up interval was 18 months (range: 12 to 72 mo). Screw position was evaluated by computed tomography scanning postoperatively in all patients. Clinical and radiographic outcome was assessed at each visit after surgery. Results Intraoperative complications include fracture of lateral mass in 27 screws placement and nerve irritation in 3 bicortical screws. Early complications include hematoma formation in 2 cases and C5 root palsy in 5 cases after spinal canal decompression. Late complications include pseudarthrosis in 6 cases and screw pull-out in 3 cases. There were no cases of spinal cord or vertebral artery injury, infections, deaths, or adjacent segment disease. All patients had radiographic union, and no patient developed mechanical implant failure requiring removal of instrumentation. Reoperation was required in 14 (6.2%) cases because of nerve injury, hematoma formation, pseudarthrosis, and screw pull-out. Conclusions Our clinical findings indicate that lateral mass fixation can be used safely with minimal complications and low rate of morbidity for cervical myelopathy treatment.

Halo pin intracranial penetration and epidural abscess in a patient with a previous cranioplasty: case report and review of the literature.

Study Design. Report of a patient with an epidural abscess after halo pin intracranial penetration at the site of a previous cranioplasty. Objectives. To report a rare case of intracranial penetration at the site of a previous cranioplasty associated with epidural abscess, and to discuss the diagnostic and therapeutic approach to its management. Summary of Background Data. The most serious complications associated with use of halo device occur when pins penetrate the inner table of the skull, resulting in cerebrospinal fluid leak and rarely in an intracranial abscess. However, no mention of intracranial halo pin penetration at the site of a previous cranioplasty was found in the literature. Methods. A 64-year-old man with ankylosing spondylitis had a halo vest placed for management of a fracture dislocation through the C5–C6 intervertebral disc space associated with left C6 radiculopathy. One week later, the patient experienced fever and headache associated with pain, redness, and drainage at the site of the insertion of the left posterior pin. Computed tomography of the brain showed a 1.5-cm intracranial penetration of the halo pin through a previous cranioplasty of the temporal bone, associated with epidural abscess and cerebral edema in the left temporoparietal lobe. The pins and the halo vest were removed, the pin site was cleaned, and a Philadelphia cervical collar was applied. Staphylococcus epidermidis grew on the culture of drainage from the pin site. The patient started immediate intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 2 additional weeks. Results. The patient had gradual improvement of his symptoms within the first 48 hours. At the latest follow-up visit, he had fully recovered and his fracture had healed. Conclusions. The halo device should not be used for patients with a previous cranioplasty, especially if the pins cannot be inserted at other safe areas of the skull. A thorough medical history and physical examination of the skull are important before the application of a halo device. Computed tomography of the skull may be necessary before elective halo application for patients with concomitant head trauma, confusion, or intoxication and for patients with a previous cranioplasty to ascertain the safest pin sites.

Analysis of kidney dysfunction in orthopaedic patients.

BackroundThis retrospective study was undertaken to determine the incidence of kidney dysfunction (KD) and to identify potential risk factors contributing to development of KD in orthopaedic population following an elective or emergency surgery.MethodsA total of 1025 patients were admitted in our institution over a period of one year with various indications. Eight hundred and ninety-three patients (87.1%) had a surgical procedure. There were 42 (52.5%) male and 38 (47.5%) female with a mean age of 72 years (range: 47 to 87 years). We evaluated the following potential risk factors: age, comorbidities, shock, hypotension, heart failure, medications (antibiotics, NSAIDs, opiates), rhabdomyolysis, imaging contrast agents and pre-existing KD.ResultsThe overall incidence of KD was 8.9%. Sixty-eight patients developed acute renal injury (AKI) and 12 patients developed acute on chronic kidney disease (CKD). In sixty-six (82.5%) patients renal function was reversed to initial preoperative status. Perioperative dehydration (p = 0.002), history of diabetes mellitus (p = 0.003), pre-existing KD (p = 0.004), perioperative shock (p = 0.021) and administration of non-steroid anti-inflammatory drugs (NSAIDs) (p = 0.028) or nephrotoxic antibiotics (p = 0.037) were statistically significantly correlated with the development of postoperative KD and failure to gain the preoperative renal function.ConclusionWe conclude that every patient with risk factor for postoperative KD should be under closed evaluation and monitoring.

Piriform and trochanteric fossae. A drawing mismatch or a terminology error? A review.

The current literature indicates that the standard starting point for intramedullary nailing is the piriform fossa. The accuracy of the entry point for anterograde femoral intramedullary nailing between published texts and relevant illustrations was recorded. The piriform fossa is the site of insertion of the piriform tendon and represents a small, shallow depression located on the tip of the greater trochanter. The trochanteric fossa is a deep depression on the inner surface of the greater trochanter, and in the vast majority of the published data is indicated incorrectly as “piriform fossa”. As a result of either a recurrent drawing mismatch or a terminology error, the correct entry point for anterograde femoral intramedullary nailing is confusing and should be indicated in the current literature. The trochanteric fossa appears to be the standard entry point that most surgeons recommend.

Treatment of unstable thoracolumbar burst fractures by indirect reduction and posterior stabilization: short-segment versus long-segment stabilization.

In order to compare short-segment stabilization with long-segment stabilization for treating unstable thoracolumbar fractures, we studied fifty patients suffered from unstable thoracolumbar burst fractures. Thirty of them were managed with long-segment posterior transpedicular instrumentation and twenty patients with short-segment stabilization. The mean follow up period was 5.2 years. Pre-operative and post-operative radiological parameters, like the Cobb angle, the kyphotic deformation and the Beck index were evaluated. A statistically significant difference between the two under study groups was noted for the Cobb angle and the kyphotic deformation, while, as far as the Beck index is concerned, no significant difference was noted. In conclusion, either the long-segment or the short-segment stabilization is able for reducing the segmental kyphosis and the vertebral body deformation postoperatively. However, as time goes by, the long-segment stabilization is associated with better results as far as the radiological parameters, the indexes and the patient’s satisfaction are concerned.

A two stage re-implantation protocol for the treatment of deep periprosthetic hip infection. Mid to long-term results

Deep periprosthetic hip infection is a devastating complication. Goal of treatment is infection eradication and durable functional reconstruction. Two-stage re-implantation is the standard of treatment. From January 1998 to December 2004 we treated 38 patients with an infected THA. There were 24 females and 14 males, with a mean age of 67 years (61–75). The infection occurred 13 months to 15 years (mean: 7.2 years) after the index operation. The mean follow-up was 11.6 years (7 to 14). 35 patients were available for review. Almost one third of the patients had been treated before with antibiotics. In 5 cases more than one pathogen were present. In 3 cases, it was not possible to isolate a causative organism. In 15 cases (43%), a resistant pathogen was isolated. We used a two stage reimplantation protocol. Spacer was not used in any of the cases. Femoral revision was performed with uncemented implants, 21 of distal (wagner type) fixation and 14 of modular type with proximal fixation. 24 press fit shells (17 oTMT cups) and 11 Muller rings were used. In 33 cases (94%) eradication of infection was achieved. The mean HHS improved from a mean of 38.2 preoperatively to a mean of 88.6 at final follow-up (p<0.001). There was no case of implant loosening or migration. Chronic late infection can be managed successfully with a two stage re-implantation protocol, without interim spacer, including neglected cases, previous long term antibiotics and cases with resistant pathogens.

Computed tomography study of radial head morphology

Computed tomography scans of 22 cadaveric adult elbows were obtained in 3 forearm positions: full supination, neutral, and full pronation. The radial head dimensions, the radiocapitellar joints, and the proximal radioulnar joints were measured. Multivariate analysis of variance was used to determine which portions of each articulation were the most congruent. The results showed that the radial head tended to become uncovered at the radial lip (P < .001). The radiocapitellar joint was tighter in pronation than in supination (P = .001). The proximal radioulnar joint was most congruent at the middle proximal radioulnar joint, at the midportion and posterior aspects rather than the anterior aspect (P < .001). The proximal radioulnar joint coverage was between 69 degrees and 79 degrees . Prosthesis trial sizing should be judged by the articulations providing the most congruency: (1) the ulnar lip or trough of the radiocapitellar joint in pronation and (2) the posterior or midportion of the middle proximal radioulnar joint.

Anti-personnel Landmine Injuries during Peace: Experience in a European Country

INTRODUCTION The purpose of this study is to report the incidence of landmine injuries during peacetime in a European country. METHODS Forty victims of landmine explosions were admitted to Didimoticho General Hospital in Greece, from December 1988 to March 2003. A total of 19 people survived (47.5%) these events; all of the others were dead upon admission to the hospital. All of the victims were men, either suspected smugglers or migrants entering the country illegally, with an average of 30 years (range: 15-56 years). RESULTS Most victims presented in groups, with multiple traumatic injuries, including lower extremity wounds. The mortality rate in the minefield prior to hospital admission was 52.5%, and the amputation rate for the survivors was 37%. There were no deaths of the patients admitted to the hospital. CONCLUSIONS Landmines cause high-energy injuries with high mortality and amputation rates. Illegal migrants are the main victims of landmine explosions in Greece.

The development of bone metastases as the first sign of metastatic spread in patients with primary solid tumours

The purpose of this retrospective study was to investigate the incidence of bone metastases as the first sign of metastatic spread in patients with primary solid malignant tumours. Between January 1987 and December 1998, we treated 867 patients suffering from primary solid malignant tumours. Their average age was 67 (range: 30–96) years and all were thoroughly investigated with a complete physical examination and laboratory tests as well as imaging studies and bone scans. No bone metastases were found at the time of the initial diagnosis, and the patients were then re-assessed every 6 months for the first 5 years and then once a year. We found that, regardless of treatment, bone metastases appeared in a certain number of patients and that after excluding patients with prostate cancer a bone metastasis was the first sign of “recurrence” in 1.3% of the patients with a known primary solid malignant tumour.RésuméLe but de cette é tude r é trospective é tait de rapporter la fr é quence des m é tastases osseuses comme premier signe m é tastatique, chez des patients ayant une tumeur solide primitive connue. De janvier 1987 à décembre 1998 nous avons traité 867 malades souffrant de tumeurs solides primitives. Leur âge moyen était de 67 (30–96) ans. Tous les malades ont eu un examen complet y compris les études d’imagerie et la scintigraphie osseuse. Aucune métastase osseuse n’a été trouvé au diagnostic initial. Les malades ont été évalués tous les 6 mois pendant les 5 premières années et ensuite une fois par an. Sans tenir compte du traitement, nous avons constaté que les métastases osseuses apparaissaient chez un certain nombre de malades. En excluant les malades avec un cancer prostatique, les métastases osseuses étaient le premier signe de récidive chez 1,3% des malades avec une tumeur solide primitive connue.