Treatment concept in infected bone and soft-tissue defects

The first priority when treating infected bone and soft-tissue defects is the maintenance or reconstruction of vitality, vascularity and stability. This means that when signs of infection are apparent, this is an immediate indication for operative revision with protective preparations on the tissue and radical debridement. Treatment of the soft-tissue damage is carried out with local or microsurgically connected muscle flaps. As for stability, in early infection the retention of well-bonded implants is often possible. If not, it is often necessary to change over to external fixation. Reconstruction of bone damage is carried out after the infection recedes, and complete healing is finally achieved by further treatment changes to conservative means or further stabilizing treatment.     

AO external mini-fixateur for the hand bones. Surgical technique and initial experiences

Fractures of the hand and fingers showing comminution or associated soft-tissue lesions are best treated with external fixation. In contrast to other systems, the new AO mini-external fixator enables less bulky unilateral fixation facilitating early mobilisation and the special design of the double clamps allows preliminary intraoperative stabilisation with only one wire in each fragment. Modular fixation makes free placement of the wires possible with accommodation of bone and soft tissue lesions. Twenty patients with hand injuries showed uneventful soft tissue healing and there were no cases of non-union in 19 metacarpal and phalangeal fractures.     

Genetic analysis of the cap5 locus of Staphylococcus aureus

BACKGROUND: Fifteen patients with femoral shaft fractures complicated by infected nonunions were treated with a two-stage protocol. METHODS: In the first stage, radical debridement was performed along with antibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting and the external skeletal fixator was used until bony union was achieved. The time between the first and second stages of treatment was 2 to 6 weeks. The debrided bone defects ranged from 0.5 to 15 cm. Autogenous iliac cancellous bone grafting was performed in 11 patients, and microvascularized osteoseptocutaneous fibular transfer was performed in 4 patients. RESULTS: Wound healing and bone union were achieved in all 15 cases. The duration of external fixation of these patients ranged from 7 to 15 months, with an average of 9 months. Minor pin-track infection was seen in seven patients. Postoperative infection after the second-stage bone grafting occurred in three patients. These three infections were arrested by limited debridement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case, stress fracture occurred at 11 months after microvascularized fibular transfer; this was managed with another 5 months of external skeletal fixation. With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits. The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. CONCLUSION: We have found that our two-stage treatment with antibiotic beads local therapy, definitive external skeletal fixation, and staged bone grafting is an acceptable treatment protocol for the management of femoral diaphyseal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.     

Compression of the upper cervical spinal cord causing symptoms of brainstem compromise. A case report

STUDY DESIGN: A case is reported in which a flexion-induced compression of the upper cervical spinal cord caused symptoms of brainstem compromise in the absence of radiographic evidence of osseous instability. OBJECTIVES: A 41-year-old woman developed postoperative cervical instability with flexion-induced neurologic symptoms referable to the brainstem. The instability was caused by direct compression at the third cervical vertebral body, which in turn was caused by differential movements between the neuraxis and skeletal elements in the upper cervical spine. SUMMARY OF BACKGROUND DATA: Pathologic processes at the craniocervical junction may cause brainstem compromise with neurologic symptoms. The mechanism of brainstem involvement is usually either vertebrobasilar insufficiency or direct mechanical compression. In cases where the brainstem is compressed by skeletal elements, the compressing osseous structures usually are the walls of the foramen magnum or the odontoid process, or, less frequently, the atlas or axis vertebrae. Symptoms of brainstem dysfunction caused by dynamic compression at the level of the third cervical vertebra in the absence of hindbrain herniation are unusual and, to the best of the authors' knowledge, have not been described previously. METHODS: The patient underwent initial examination, evaluation, and periodic follow-up examination with magnetic resonance imaging from the time of her first visit until 26 months after the surgical treatment. The patient experienced postsurgical instability with dynamic compression by the C3 vertebral body, which caused brainstem compromise. Surgical treatment consisted of decompressive C3 corpectomy and fusion of C2 to C6, supplemented by anterior fixation. RESULTS: After undergoing surgical decompression of C3, reconstruction, and anterior internal fixation of C2 to C6, the patient had dramatic neurologic improvement. Diplopia, paresthesia, and nystagmus disappeared immediately after surgery. Swallowing difficulties, hoarseness, and vertigo improved gradually. At follow-up examination 26 months after surgery, the patient was asymptomatic. Magnetic resonance imaging showed good position of the construct, with no evidence of compression of the spinal cord or brainstem. CONCLUSIONS: Instability of the cervical spine may result in symptoms of brainstem dysfunction, even in the absence of hindbrain herniation. This instability is explained by the differential movement between the bony structures and neuraxis in the upper cervical region. Diagnosis and adequate management of this instability alleviates the neurologic symptoms and prevents possible hazardous complications.     

The classification of gunshot wound-induced pseudarthroses

On the basis of clinico-roentgenological and special investigations of 153 patients the authors have developed a working classification of false joints and indicators of osteogenic activity allowing indications for using more adequate methods of treatment to be elaborated. False joints with sequesters were treated by resection of ends of fragments and apparatus compression. Consolidation of false joints of the bone regenerate was reached by fast fixation of fragments by the apparatus with microdistraction and following compression.     

Treatment of nonunion of the humerus using the Ilizarov external fixator

Ilizarov's method of monofocal compression was used in 30 humeri with a diaphyseal pseudarthrosis. Twenty-one patients had previous surgery but had loosening of the osteosynthesis material. Nine patients initially were treated with a hanging cast, resulting in interfragmentary distraction. Fourteen nonunions were hypertrophic, and 16 were atrophic, of which six were infected. A complete circular frame was used only in the first nine patients, whereas the remaining 21 patients were treated with the modified semicircular fixator. Union was obtained in all but two patients, with an average consolidation time of 4.5 months (range, 2.5-10 months). No patient required additional bone grafting. Apart from superficial pin tract infection seen in most of the patients, three had a minor temporary sensory neurologic problem. Four patients experienced a second fracture after removal of the fixator that required a second application of an Ilizarov frame. Although similar results with regard to union are reported after plate osteosynthesis, there was no radial nerve palsy or deep infection in this series, indicating that the treatment by the Ilizarov technique is associated with less complications. The authors' findings suggest that the Ilizarov method is a reliable treatment for humeral nonunions, even after multiple previous operations or in the event of infection.     

Fractures of the elbow

Elbow fractures encompass a spectrum of severity from low energy nondisplaced fractures to high energy fractures with associated severe soft-tissue injury. Treatment is based on fracture pattern, patient age, bone quality, associated soft-tissue injuries, and associated fractures. The basis for treatment relies on the knowledge of the complex osseous and soft-tissue anatomy of the elbow. The goals of operative and nonoperative treatment are to achieve a stable, anatomic reduction that allows early motion to maximize function.     

Failures after operation for skeletal metastatic lesions of long bones

This study was based on 192 patients treated surgically for 228 metastatic lesions of the long bones from 1986 through 1995. The survival rate was 0.3 at 1 year after surgery. The surgical treatment consisted of resection and reconstruction of the involved bone (18), intralesional curettage (133), or stabilization only (77). Reconstruction was achieved by an endoprosthesis in 54 cases, by an osteosynthetic device in 162, by cement only in 10. In two cases no reconstruction was performed. The local failure rate was 11% and the median time to failure was 8 months. Local failure was most frequent in patients with kidney cancer (24%) and in diaphyseal and distal femoral lesions (20%). Among 162 operations involving osteosynthetic devices, 22 (14%) were failures as compared with one of 54 (2%) endoprostheses. Sixty percent of the patients received preoperative or postoperative radiotherapy. Five of the six patients who had surgery for local tumor progression had not received radiotherapy. Eight of 10 nonunions and all five patients who developed a stress fracture had been treated with radiotherapy. It is concluded that endoprosthetic reconstructions are preferable to osteosynthetic devices. The skeletal complications associated with radiotherapy may be circumvented by the use of endoprostheses.     

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.     

Treatment of tibial defects and nonunions using ipsilateral vascularized fibular transposition

Eight patients had nine ipsilateral vascularized fibular transpositions (IVFTs) in the period 1978-1987. The procedure, which involves no microvascular anastomosis, was done for difficult problems of the tibia including two long-standing posttraumatic nonunions, three allograft nonunions after tumor surgery, and four segmental tibial defects also after tumor surgery. The average duration of problems before surgery was 3.5 years, and the patients averaged 3.1 procedures before IVFT. The patients were followed for an average of 52.4 months. The average time to union was 4.2 months, and in all patients the grafts healed within six months. Late fracture of the graft developed in two patients after fixation removal; one required an additional procedure, and both eventually healed. Ipsilateral vascularized fibular grafting is a useful alternative to conventional, nonvascularized grafts for difficult tibial nonunions and segmental defects. It offers the advantages of a vascularized graft (early healing and hypertrophy), yet avoids the time-consuming microvascular anastomosis and distant donor site morbidity of free fibular grafts.     

Injury of the dens axis in early childhood. Clinical case report and discussion

Because of the special features of the subdental synchondrosis, fractures of the odontoid process in childhood can be seen as a separate entity. The subdental synchondrosis must be regarded as sort of an intervertebral disc and not as a growth plate. Among the generally rare fractures of the cervical spine in children this type ist the most common. Usually conservative treatment with a cast-fixation like the halo fixateur or the minerva jacket leads to consolidation. We report on the case of a 2-year-old girl with a fracture of the odontoid process who developed a unilateral syndrome hours after the accident. The treatment was conservative with a halo-like cast fixation. Nine weeks after the fixation bony consolidation was achieved and the cast could be removed. In the first days after fixation full neurological recovery had occurred. In early childhood (till the 7th year of life) according to the literature, patterns of neurologic dysfunction are incomplete injuries of the spinal cord and have the potential for recovery [4, 5, 7, 9, 10, 12].     

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries.     

Combined fractures of the femoral and tibial shafts in the same limb

This paper reports a study of ipsilateral fractures of the femoral and tibial shafts in 21 patients treated according to a detailed plan including shock treatment, prophylaxis against fat embolism, soft-tissue and fracture treatment. Death due to hypovalaemic shock was eliminated and the incidence of fat emboliism (9-5%) reduced in comparison with an earlier series. The tibial fracture was stabilized by plaster or internal fixation as soon as conditions allowed. In most cases the femoral fracture was treated by medullary mailing. Results have improved compared with earlier series. All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89%).     

Treatment of humeral shaft fractures by retrograde locked nailing

From 1992 to 1994, 29 middle and 19 distal humeral shaft fractures (39 acute fractures, six nonunions, and three pathologic fractures) in 48 patients were treated by retrograde locked nailing. The first eight acute fractures were treated with Seidel nails, the other 40 fractures with specially designed humeral locked nails. Nails were inserted from the supracondylar (6) or the olecranon fossa (42) entry portal. With a single operation, all acute fractures and nonunions achieved osseous union without serious complications. The average time to union was 8.2 weeks for acute fractures and 14.2 weeks for nonunions. Recovery of shoulder function was complete. Elbow motion was excellent in all but one nonunion that resulted from a Type IIIB open fracture. Two patients with supracondylar entry had apex to posterior angular malunion. One patient with a distal comminuted fracture had varus malunion. Three patients had an iatrogenic bony split, but healing was unaffected. Patients with pathologic fractures maintained satisfactory arm function postoperatively. Given the few complications and good functional recovery seen in this study, retrograde locked nailing appears to be a good alternative treatment in middle and distal humeral shaft fractures. The olecranon fossa approach, with more linearity to the humerus, is preferred. In the authors' experience, humeral locked nails are inserted more easily and are associated with fewer complications than are Seidel nails.     

Coefficient of Consolidation by Inflection Point Method

The coefficient of consolidation in the Terzaghi theory of consolidation has been commonly determined by fitting the theory to observed compression with time in an incremental loading oedometer test. The Terzaghi theory is applicable to compression and swelling. A similar coefficient governed by horizontal permeability is used in the Barron formulation of consolidation with vertical drains. The most widely used graphical methods of Casagrande and Taylor, which fit the theory to observed data at 50 and 90% primary compression, respectively, are rather laborious. The inflection point method requires only a visual identification of the inflection point on the compression versus log time curve. The values of coefficients of consolidation by the simple inflection point method are quite similar to those from the Casagrande method.     

Rat mandibular distraction osteogenesis: II. Molecular analysis of transforming growth factor beta-1 and osteocalcin gene expression

Distraction osteogenesis is a powerful technique capable of generating viable osseous tissue by the gradual separation of osteotomized bone edges. Although the histologic and ultrastructural changes associated with this process have been extensively delineated, the molecular events governing these changes remain essentially unknown. We have devised a rat model of mandibular distraction osteogenesis that facilitates molecular analysis of this process. Such information has significant clinical implications because it may enable targeted therapeutic manipulations designed to accelerate osseous regeneration. In this study, we have evaluated the expression of transforming growth factor beta-1, a major regulator of osteogenesis during endochondral bone formation and development, and osteocalcin, an abundant noncollagenous extracellular matrix protein implicated in the regulation of mineralization and bone turnover. The right hemimandible of 36 adult male rats was osteotomized, and a customized distraction device was applied. Animals were allowed to recover and, after a 3-day latency period, were distracted at a rate of 0.25 mm twice daily for 6 days followed by a 2- or 4-week consolidation period. Distraction regenerate was harvested after the latency period, days 2, 4, or 6 of distraction, and after 2 or 4 weeks of consolidation and processed for Northern analysis (n = 4 at each time point) and immunohistochemical localization of TGF-beta1 (n = 2 at each time point). Six sham-operated animals (i.e., skin incision without osteotomy) were also killed (immediately postoperatively), and the mandibles were harvested and prepared in a similar fashion. Equal loading and transfer of RNA for Northern analysis was ensured by stripping and probing membranes with a probe against GAPDH (a housekeeping gene). Our results demonstrate that the spatial and temporal patterns of TGF-beta1 mRNA expression and protein production coincide with osteoblast migration, differentiation, and extracellular matrix synthesis. In addition, we demonstrate that TGF-beta1 production may be an important regulator of vasculogenesis during mandibular distraction osteogenesis. Finally, we have shown that osteocalcin gene expression coincides temporally with mineralization during rat mandibular distraction osteogenesis.     

Osteosynthesis of forearm bones using the Polfix method with use of atypical implants--preliminary report

A new method of forearm bones fragments fixation in patients with fractures and/or nonunion is presented. Screws within Polfix external fixator have been replaced by threaded Kirschner wires. The fixator and surgical technique are described, long-term results of treatment of 13 fractures/nonunions in 7 patients are demonstrated.     

Tissue preparation in combined scapula flap for microsurgical reconstruction of defects of the oromaxillofacial area]

Nowadays, in congenital or acquired large oro-maxillofacial defects microsurgical reconstruction is mainly performed by revascularized osseous, osteocutaneous, or osteomyocutaneous distant flaps. The aim of reconstruction includes not only restoration of stable continuity and esthetic contour, but also the restoration of a functioning "chewing organ". For reconstruction in maxillary and midface defects, we prefer the scapular flap for a single-step reconstruction. Tissue prefabrication results in osseointegrated implants and thin mucosal linings with stable soft tissue conditions at the time of microsurgical reconstruction. Following dental restoration, full oral function is given. This single-stage procedure improves the psychosocial situation of the patient considerably when compared with conventional multi-stage reconstruction.     

Long-term results of hydroxyapatite application in the treatment of periodontal osseous defects

The aim of the present study was to evaluate in long-term clinical trials the effectiveness of hydroxyapatite (HA) bioceramics employed in dentistry in the treatment of periodontal osseous defects. The technology of obtaining the studied HA was developed at the Faculty of Material Science and Ceramics, University of Mining and Metallurgy, Cracow, Poland. A population of 90 patients was subjected to implantation of HA granules. The results of initial and final investigations based on periodontal indices, determination of osseous defects depth and X-ray studies were compared. The follow-up was 6 and 12 months, 2, 3 and as much as 4 years. All the studied parameters showed a significant improvement that was confirmed by statistical evaluation. Ceramic HA was found to be a fully and totally useful material in the reconstruction of periodontal defects. As demonstrated by X-ray studies, the reconstruction of osseous defects proceeded faster within the first 2 years and subsequently the process became slower.     

Open reduction and internal fixation of forearm fractures in children

We retrospectively reviewed 16 children younger than 13 years with 17 fractures of the shafts of the radius or ulna or both who had undergone an open reduction-internal fixation (ORIF). ORIF was performed when a closed reduction was deemed unacceptable in 14 radius fractures and for three unstable open fractures of the radius. The average age was 9.4 +/- 2.3 years (range, 5.0-12.5). Of the 14 fractures with an unacceptable closed reduction, soft-tissue interposition was encountered in seven. Fixation was secured by plates and screws, percutaneous Steinmann pins, or intramedullary Steinmann pins. There were no delayed unions or nonunions, no infections, and no neurovascular injuries. The average follow-up was 12.3 months; all 17 fractures had excellent results (forearm rotation loss of < 10 degrees). Our study indicates that excellent results can be expected with no increased risk of complications if the treating physician elects to proceed with an ORIF in a pediatric forearm fracture with proper indications.