Stavros I. Stavridis

New trends in fixation of proximal humeral fractures: A review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Mid-term results of internal fixation of proximal humeral fractures with the Philos plate

OBJECTIVE To report our experience from the use of the Philos plate for the treatment of three- and four-part proximal humeral fractures and to investigate factors influencing the final outcome. MATERIALS AND METHODS Between April 2005 and September 2007, 29 Philos plates were implanted in 17 women and 12 men, with a mean age of 62.3 years (range: 28-80 years). Positioning of the plate was performed under fluoroscopic control, through a deltopectoral approach and with the patient in the beach chair position. 27 patients were available for follow-up (mean: 17.9 months; range: 12-39). Follow-up included plain shoulder radiographs and functional assessment with Constant-Murley score. RESULTS Healing of the fracture occurred uneventfully within 6 months. In three patients, humeral head collapsed due to aseptic necrosis after fracture healing and the plate had to be removed in two cases. In one patient, fracture healing occurred in >10 degrees varus displacement. The clinical result according to the Constant-Murley score was 86 points (range: 58-112). CONCLUSIONS Internal fixation with the Philos plate seems to be a reliable option in the operative treatment of upper end humeral fractures, especially in osteoporotic bone. It allows secure fracture fixation and quick shoulder mobilisation, while quick and uneventful fracture healing and very satisfactory clinical results are achieved.

Implant removal after posterior stabilization of the thoraco-lumbar spine

IntroductionImplant removal because of pain after posterior fusion in the thoracic and lumbar spine is a widely performed operation. We conducted a retrospective study to examine whether patients benefit from implant removal.Patients and methods57 patients (29 males, 28 females, mean age 46.5 years) who have undergone removal of pedicle screws because of pain and discomfort were interviewed 6–24 months postoperatively. Fracture was the initial diagnosis in 40% of the patients and degenerative spine disease in 58%. The following factors were evaluated: patient satisfaction and postoperative outcome, patients’ native language and psychological background, operative data, hospital stay and complications.ResultsPain decreased significantly from 62 to 48 on visual analogue scale postoperatively. Complications occurred in five patients (8.8%). 36 patients (61%) stated they had some benefit from the operation, but only seven patients (12%) were free of pain completely. 36 patients (63%) would undergo the same procedure again. Outcome in the subgroup of foreigners was significantly worse, though the psychological background did not affect the outcome. Preoperative diagnostic infiltration was helpful in 9 of 13 patients.ConclusionRemoval of pedicle screws because of back pain may be effective, but complete remission of symptoms could be achieved in only 12% of patients. However, 63% of patients would undergo hardware removal again. Preoperative diagnostic infiltration can help to predict the outcome but results are inconsistent. Communication difficulties may worsen the outcome. Surgeons should consider these results when planning implant removal and patients should be informed thoroughly to avoid too high expectations.

The effect of haematoma aspiration on intra-articular pressure and pain relief following Mason I radial head fractures

BACKGROUND The aspiration of the accompanying haematoma by Mason type I radial head fractures is advocated by several authors to achieve an analgesic effect. The purpose of this study was to investigate the effect of haematoma aspiration on intra-articular pressure and on pain relief after Mason I radial head fractures. MATERIALS AND METHODS A total of 16 patients (10 men and six women, age 23-47 years) with an isolated Mason I radial head fracture were subjected to haematoma paracentesis. Initially, intra-articular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. After haematoma aspiration, a new pressure measurement without moving the needle was performed. Pain before and after haematoma aspiration was evaluated by using an analogue 10-point pain scale. RESULTS Intra-articular elbow pressure prior to haematoma aspiration varied from 49 to 120 mmHg (median, 76.5 mmHg), while following aspiration, it ranged from 9 to 25 mmHg (median, 17 mmHg). The median quantity of the aspired blood was 2.75 ml (range, 0.5-8.5 ml). Patients reported a decrease in the visual analogue score (VAS) for pain from 5.5 (4-8) before to 2.5 (1-4) after aspiration. Decrease for both pressure and pain was statistically significant (p=0.005). CONCLUSION The formation of an intra-articular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intra-articular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief.

Additional anterior plating enhances fusion in anteroposteriorly stabilized thoracolumbar fractures

INTRODUCTION To prospectively evaluate the potential radiological and clinical effect of the additional application of an anterior plate in anteroposteriorly stabilized thoracolumbar fractures. PATIENTS AND METHODS 75 consecutive patients with unstable thoracolumbar fractures underwent posterior (internal fixator) and anterior stabilization (corpectomy cage with local autologous bone grafting). 40 (53.3%) patients received an additional anterior plate (Group A), while 35 (46.6%) (Group B) did not. Plain X-rays and CT-scans were obtained pre- and postoperatively, after 12 months and at the last follow-up (mean 32 months, range 22-72). Loss of reduction, cage subsidence to adjacent vertebrae, fusion rates and clinical results were evaluated. RESULTS 66 (87%) patients (36 Group A; 30 Group B) were available for follow-up. Patients in both groups were comparable regarding age, gender, comorbidities, localization and classification of fracture. Average loss of reduction was 2.4° in Group A, and 3.1° in Group B (not significant). Cage subsidence did not differ significantly between both groups, too. However, after 12 months the rate of continuous osseous bridging between endplates was significantly higher in Group A (63% vs. 25%) (p<0.05). After 32 months this difference was even higher (81% vs. 33%) (p<0.001). The bony fusion mass was located beneath or around the anterior plate in 94% of patients. There was no significant difference in clinical outcome. CONCLUSIONS Additional anterior plating in anteroposteriorly stabilized thoracolumbar fractures leads to significant faster fusion but does neither influence reduction loss nor cage subsidence. The anterior plate serves as a pathway for bone growth and increases biomechanical stability, resulting in a higher fusion rate.

Distraction osteogenesis as a salvage method in infected knee megaprostheses.

Infection of total knee replacement represents a severe complication. Especially in cases of infected megaprostheses, treatment options are limited and even amputation may become unavoidable. We present two cases of infected knee hinged megaprostheses. Both were treated by prosthesis removal and debridement of all surrounding infected bone and soft tissue, followed by distraction osteogenesis for the bridging of the large bone defect which had resulted. Implant removal and surgical debridement were combined with Ilizarov frame application and femoral and tibial osteotomies in a one-stage procedure, for commencing distraction osteogenesis. After bone transportation was completed, arthrodesis of the knee in both cases was successful. Two years after completion of the treatment, both patients demonstrate a stable knee arthrodesis and a satisfactory clinical result. The described treatment plan represents an effective salvage method in cases of infected knee megaprostheses that can successfully address both the need for a stable arthrodesis and the avoidance of a severe leg-length discrepancy by bridging the extensive bone defect.

Isolated injury of the posterior interosseous nerve complicating a deep laceration of the proximal forearm dorsolateral muscles: a case report.

Isolated injuries of the posterior interosseous nerve (PIN) or its branches without additional damage of the superficial radial nerve are rare and are usually caused by penetrating injuries.1–3 Injuries of the PIN caused by extensive proximal forearm lacerations without damage of the superficial sensory branch of the radial nerve have not been yet reported to the best of our knowledge. Although 12 cases of PIN palsies caused by forearm lacerations are mentioned in several articles in the English literature,4–6 in none of them the above combination is described. In such a case, the intact sensation could mask the underlying motor neuronal damage, because the loss of both carpal and finger extension can be satisfactorily explained by the extensor muscles laceration. The radial nerve divides into the PIN and the superficial radial nerve within an area 3 cm proximal or distal to the elbow joint. The PIN enters the radial tunnel and rests directly superficial and anterior to the radiocapitellar joint, before entering the supinator muscle through the Arcade of Frohse.7 As the PIN exits the supinator, it divides into two major branches: the recurrent branch, supplying the superficial layer of extensor muscles (extensor digitorum communis, extensor digiti minimi, and extensor carpi ulnaris), and the descending branch for the deep extensors (abductor pollicis longus, extensor pollicis longus and brevis, and extensor indicis proprius).8 We report a case of wrist and all five fingers drop caused by an extensive forearm laceration at the level of the radial neck without any sensory loss of the hand. The main feature of the injury was the PIN damage before its division to its major branches, which was diagnosed by careful clinical examination on musculoskeletal and neurologic basis and treated immediately postinjury. CASE REPORT A 55-year-old man who was carrying a 2 m 2.5 m large, 4-mm thick glass plate, sustained an injury, while loading the plate on a truck and holding it above his head. The plate was cracked and a large fragment fell on the dorsolateral side of his right forearm, just below the elbow joint, causing an extensive laceration wound of 10 cm in length (Fig. 1). At admission, the patient was unable to extend the wrist and all five fingers, while sensation over the whole area of the radial nerve distribution was unaffected. The clinical manifestation was primarily attributed to the muscle injury, and the patient was referred to the orthopaedic team for further treatment. Although the loss of carpal and finger extension could be explained by the extensor muscles laceration, it was the observed lack of thumb extension, which raised the suspicion of a possible neuronal involvement, because both extensor pollicis longus and extensor pollicis brevis muscles originate at the middle third of the dorsal side of the forearm, hence more distally to the injury site.9 The surgical exploration was performed by one (P.K.G.) of our two qualified upper limb surgeons trained in microvascular surgery. One of them is always available and in charge of dealing with such complicated neurovascular upper limb injuries. Intraoperatively, the wound was extended proximally and distally, and the extensor muscles of the posterior compartment (extensor digitorum, supinator, extensor digiti minimi, and extensor carpi ulnaris) as well as the muscles of the mobile wad (brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis), were found to be totally severed through the muscle belly. The PIN was also identified to be completely crosscut, in contrast to the intact superficial, sensory branch of the radial nerve (Fig. 2, A). After a thorough surgical preparation, the proximal and distal nerve endings were mobilized. The nerve injury was a “clear-cut” injury without significant neuronal tissue loss, and the nerve endings could be reapproximated without tension. Furthermore, the fascicular orientation could be easily identified. Taken these facts into consideration, epineurial suturing was chosen and was performed under 3.5 magnification without tension, using microsurgery instruments with 8-0 blue, monofilament, nonabsorbable polypropylene sutures (Medipac, Kilkis, Greece). The epineurial suturing consisted Submitted for publication May 10, 2007. Accepted for publication July 20, 2007. Copyright

Surgical treatment of a twice recurrent chondrosarcoma of the pubic symphysis: a case report and review of the literature

The case of a patient with a second recurrence of a chondrosarcoma of the pelvis and pubic symphysis is presented, in order to show the difficulties of the surgical treatment and the long course of the tumor.A 56-year-old woman having already been operated upon twice within two decades, presented with a large, mass of the pubic symphysis, extending into the left proximal thigh.Preoperative imaging revealed a large tumor occupying the pubic symphysis and the pubic bones up to the ischial tuberosities, extending into the soft tissues of the inner surface of the left thigh and displacing the urinary bladder, the urethra and the vagina.Intraoperatively, a radical excision of the tumor was performed, including removal of the osseous substrate of the anterior pelvis. The anterior abdominal wall was supported with a special synthetic mesh secured on the osseous stumps in order to prevent visceral herniation. Histological examination showed grade I to II chondrosarcoma, while the patients postoperative course was uncomplicated.At the latest follow-up two years postoperatively, the patient is pain-free and ambulatory with no signs of tumor recurrence, genitourinary complications or visceral herniation.

The “Pillow” Technique for Thumb Carpometacarpal Joint Arthritis: Cohort Study With 10- to 15-Year Follow-Up

PURPOSE Arthritis of the carpometacarpal joint of the thumb is common, and there are many studies regarding its treatment. We investigated the long-term outcome of interposition arthroplasty with a fascia lata allograft (pillow technique), without ligament reconstruction, to treat thumb carpometacarpal arthritis. The technique consisted of complete trapeziectomy, use of alloplastic tensor fascia lata, and K-wire immobilization for 5 weeks. METHODS The outcomes of 31 thumbs in 24 female patients were measured at a mean follow-up of 12.5 years (range, 10-15 years). RESULTS Grip strength, key pinch, pulp-to-pulp pinch, tripod pinch, and range of motion were all improved. The Disabilities of the Arm, Shoulder, and Hand median score, which was only measured postoperatively, was an average of 5 (range, 0-52.6). No extrusion of the graft material was noted, and no revisions were performed. CONCLUSIONS Our results indicate that a fascia lata allograft can be used as an interposition material in thumb carpometacarpal arthroplasty. This technique provides pain relief and satisfactory function at an average of 12.5 years after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.