Smart instrumentation for determination of ligament stiffness and ligament balance in total knee arthroplasty.

Ligament balance is an important and subjective task performed during total knee arthroplasty (TKA) procedure. For this reason, it is desirable to develop instruments to quantitatively assess the soft-tissue balance since excessive imbalance can accelerate prosthesis wear and lead to early surgical revision. The instrumented distractor proposed in this study can assist surgeons on performing ligament balance by measuring the distraction gap and applied load. Also the device allows the determination of the ligament stiffness which can contribute a better understanding of the intrinsic mechanical behavior of the knee joint. Instrumentation of the device involved the use of hall-sensors for measuring the distractor displacement and strain gauges to transduce the force. The sensors were calibrated and tested to demonstrate their suitability for surgical use. Results show the distraction gap can be measured reliably with 0.1mm accuracy and the distractive loads could be assessed with an accuracy in the range of 4N. These characteristics are consistent with those have been proposed, in this work, for a device that could assist on performing ligament balance while permitting surgeons evaluation based on his experience. Preliminary results from in vitro tests were in accordance with expected stiffness values for medial collateral ligament (MCL) and lateral collateral ligament (LCL).

Diagnosis of periprosthetic joint infections.

Advances in implant design, surgical technique, peri-operative antimicrobial prophylaxis and laminar airflow operating room environment have made total joint arthroplasty one of the most successful surgical procedures of all times. Orthopaedic implants, however, remain prone to microbial contamination resulting in persistent risk of implant-associated infection. Treatment of infections associated with orthopaedic devices usually requires appropriate surgical intervention combined with a prolonged antimicrobial therapy. The choice of the best possible treatment regimen depends on duration and pathogenesis of infection, stability of the implant, antimicrobial susceptibility of the pathogen and condition of the surrounding soft tissue. In addition towell known diagnostic procedures new promising tools for rapid and correct microbial diagnosis are being developed as correct diagnosis of the responsible micro-organism and this is paramount for successful treatment of prosthetic joint infection.

Prothèse totale de la hanche par voie antérieure "mini-invasive" [Total hip arthroplasty through anterior "minimal invasive" approach].

Total hip replacement has seen a tremendous development and has become one of the most successful surgical interventions in orthopaedics. While during the first decades of development of total hip arthroplasty the fixation of the implant into the bone was the main concern, the focus has shifted towards surgical technique and soft tissue handling. In order to avoid permanent soft tissue damage, muscular dysfunction and concerns in regards to cosmetics, minimal invasive and anatomic approaches have been developed. We here provide a short overview on various methods of total hip replacements and we describe our technique through a minimal invasive direct anterior approach. While muscle and nerve damage is minimal, this technique allows for a rapid rehabilitation and is associated with an excellent functional outcome and a minimal risk for dislocation.

Automatic prostate segmentation in cone-beam computed tomography images using rigid registration.

We propose to evaluate automatic three-dimensional gray-value rigid registration (RR) methods for prostate localization on cone-beam computed tomography (CBCT) scans. In total, 103 CBCT scans of 9 prostate patients have been analyzed. Each one was registered to the planning CT scan using different methods: (a) global RR, (b) pelvis bone structure RR, (c) bone RR refined by local soft-tissue RR using the CT clinical target volume (CTV) expanded with a 1, 3, 5, 8, 10, 12, 15 or 20-mm margin. To evaluate results, a radiation oncologist was asked to manually delineate the CTV on the CBCT scans. The Dice coefficients between each automatic CBCT segmentation - derived from the transformation of the manual CT segmentation - and the manual CBCT segmentation were calculated. Global or bone CT/CBCT RR has been shown to yield insufficient results in average. Local RR with an 8-mm margin around the CTV after bone RR was found to be the best candidate for systematically significantly improving prostate localization.

The temporoparietal fascia flap: a versatile tool in head and neck reconstruction.

PURPOSE OF REVIEW: The article reviews recent significant advances and current applications of the temporoparietal fascia flap (TPFF) in head and neck surgery. RECENT FINDINGS: The recent literature describes a wide span of new applications of the TPFF in many areas. Significant developments and refinements in the reconstruction of orbitomaxillary composite defects and orbital exenteration cavities are reported. The TPFF combined with alloplastic framework is gaining in importance in external ear reconstruction. Innovative prefabricated skin or soft-tissue grafts based on the TPFF are used to restore facial contour or in the reconstruction of complex facial defects. The free TPFF finds a role in laryngotracheal reconstruction as a vascular carrier to support cartilage grafts. SUMMARY: Owing to its reliability and unequalled structural properties, the TPFF still plays a central role in facial reconstruction. Future investigation will likely incorporate the free TPFF as a vascular carrier of bioengineered tissues, such as cartilage and mucosa, for various head and neck indications.

Systemic exposure to tobramycin after local antibiotic treatment with calcium sulphate as carrier material.

INTRODUCTION: Osteoset(®) T is a calcium sulphate void filler containing 4% tobramycin sulphate, used to treat bone and soft tissue infections. Despite systemic exposure to the antibiotic, there are no pharmacokinetic studies in humans published so far. Based on the observations made in our patients, a model predicting tobramycin serum levels and evaluating their toxicity potential is presented. METHODS: Following implantation of Osteoset(®) T, tobramycin serum concentrations were monitored systematically. A pharmacokinetic analysis was performed using a non-linear mixed effects model based on a one compartment model with first-degree absorption. RESULTS: Data from 12 patients treated between October 2006 and March 2008 were analysed. Concentration profiles were consistent with the first-order slow release and single-compartment kinetics, whilst showing important variability. Predicted tobramycin serum concentrations depended clearly on both implanted drug amount and renal function. DISCUSSION AND CONCLUSION: Despite the popularity of aminoglycosides for local antibiotic therapy, pharmacokinetic data for this indication are scarce, and not available for calcium sulphate as carrier material. Systemic exposure to tobramycin after implantation of Osteoset(®) T appears reassuring regarding toxicity potential, except in case of markedly impaired renal function. We recommend in adapting the dosage to the estimated creatinine clearance rather than solely to the patient's weight.

Delayed primary versus late secondary wound closure in the treatment of postsurgical sternum osteomyelitis.

Sternal osteomyelitis and poststernotomy mediastinitis is a severe and life-threatening complication after the cardiac surgery. The incidence ranges up to 3% with a mortality rate up to 29%. In addition, postoperative infections after sternotomy are associated with prolonged hospital stay, increased healthcare costs and impaired quality of patient life, representing an economic and social burden. The emergence of increasing antimicrobial resistant bacteria augments the importance of postsurgical infections since the antimicrobial choices are becoming limited. Furthermore, the incidence of infection is an indicator for the quality of patient care in the international benchmark studies. Although several therapy strategies are nowadays present in clinical practice, there is a lack of evidence-based surgical consensus for treatment of this surgical complication. In most cases the poststernotomy mediastinitis involves surgical revision with debridement, open dressing and/or vacuum-assisted therapy. After the granulation tissue on open chest wound is achieved, secondary closure and/or reconstruction with vascularized soft tissue flaps, such as omentum or pectoral muscle is performed. It seems there is a need for more effective surgical treatment of poststernotomy wound infections, which may address the prolonged hospitalization and reduce the number of surgical interventions and with this also the perioperative morbidity. In light of this we propose a randomized study comparing new delayed primary closure of the sternum to the secondary vacuum-assisted closure.

Les fractures du pilon tibial. Etude rétrospective à long terme de 51 fractures traitées par réduction sanglante et ostéosynthèse [Fractures of the tibial pilon. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis].

PURPOSE OF THE STUDY: Fracture of the tibial pilon is a rare injury and its treatment remains difficult. The aim of this study was to report the complications and long term results of internal fixation using a technique which respects soft tissues and in which little material was used. MATERIAL: From 1985 to 1990, 48 patients with 51 fractures of the tibial pilon were treated by open reduction and internal fixation. All patients were submitted to a clinical and radiological review. METHODS: Both the Rüedi/Allgöwer and the AO-classification were used and determined by standard X-rays. Surgical procedure was performed with a 2 or 3 1/3 tube AO-plates and the peroneus was always fixed if fractured. Intraoperative reconstruction was analyzed. Subjective and objective scoring were used according to Olerud and Molander and the ankle arthritis was scored according to the classification determined by the SOFCOT in 1992. RESULTS: A minimal follow-up of 1 year for all cases was obtained, based on our own files. Thirty-eight patients (40 fractures) were evaluated after an average period of 88 months (56 to 124 months). Five patients developed cutaneous infection, three developed deep infection and four developed superficial skin necrosis. One aseptic non-union necessitated reoperation after 14 months. Two ankles had joint fusion after 19 and 25 months respectively due to severe arthritis. In six cases infectious and non-infectious complications led to surgical revision. According to the Olerud and Molander score, 15 per cent of the results were excellent, 45 per cent were good, 30 per cent were fair and 10 per cent poor. DISCUSSION: Literature shows a wide range of results following this surgical procedure. This is due to the difference in the type of trauma, classification system used, material used for the internal fixation and method of evaluation. The classification system of Rüedi and Allgöwer is the most commonly used but has a rather subjective tendency, especially between type II and type III. Treatment is difficult, especially for comminutive fractures associated with soft tissue damage. In this case, open reduction and internal fixation could increase iatrogenic lesions. For this reason surgical procedure can be delayed for several days, little material is used and soft tissue manipulation is reduced to minimum. In other study reports, the use of external fixation with or without minimal internal fixation have produced less complications without improving long term results. CONCLUSION: Analysis and comparison of study reports are difficult because of the absence of consensus in classification system and evaluation methods. The AO-classification, apparently the most objective, will probably be more and more used in the future. Treatment must be adapted to the bony lesion and soft tissue damage. Open reduction and internal fixation must be reserved for a specific group of lesion.

Fractures du calcanéum: du traumatisme aux séquelles [Fractures of the calcaneus: the injury and its sequelae]

The calcaneus gives shape to the heel. Its special position places it in direct contact with the floor, upon which rests the weight of the body. It assures the transition between the vertical skeleton and horizontal surface of the foot, thus permitting ambulation. The calcaneus is subjected to high physical stress, yet at the same time its complex articulating surfaces permit fine adaptation to the ground. Fractures of the calcaneus result from a high energy injury, usually a fall from a height. The treatment of such fractures poses difficult problems. The functional sequelae of the injury may be severe, prolonged, and frequently results in a permanent disability. This is due not only to the type of fracture, but the orthopaedic management as well. Careful evaluation of the patient, fracture pattern, soft tissue condition, and treatment modalities is obligatory to achieve the optimal result.

Bone propeller flap: a staged procedure.

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized "double-barrel" fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.

Plunging when drilling: effect of using blunt drill bits.

OBJECTIVE: : Plunging when drilling can be a detrimental factor in patient care. There is, although, a general lack of information regarding the surgeon's performance in this skill. The aim of this study was to determine the effect that using sharp or blunt instruments had on the drill bit's soft tissue penetration, using a simulator. MATERIALS AND METHODS: : Surgeons taking part in an International Trauma Course were invited to participate. Two groups were defined: experienced and inexperienced surgeons. Twelve holes were drilled in the following order: 3 holes with a sharp drill bit in normal bone (SNB), 3 holes with a sharp drill bit in osteoporotic bone (SOB), 3 holes with a blunt drill bit in normal bone, and 3 holes with a blunt drill bit in osteoporotic bone. Mean values and Student t tests were used for statistical analysis. RESULTS: : Thirty-seven surgeons participated, 20 experienced and 17 inexperienced surgeons. Mean plunging depths for SNB, SOB, blunt drill bit in normal bone, and blunt drill bit in osteoporotic bone were, respectively, 5.1, 5.4, 21.1, and 13.9 mm for experienced surgeons and 7.6, 7.7, 22, and 15.9 mm for inexperienced surgeons. Drilling with SNB and with SOB was statistically different, with inexperienced surgeons plunging 2.5 mm (P = 0.31) and 2.6 mm (P = 0.042) deeper, respectively. There was a difference (P < 0.001) between sharp and blunt drill bits in all drilling conditions for both the groups. CONCLUSIONS: : Our study showed a significant difference in plunging depth when sharp or bunt drill bit was being used. Surgeons, regardless of their experience level, penetrate over 20 mm in normal bone and over 10 mm in osteoporotic bone.

Fibrosarcoma-like lipomatous neoplasm: a reappraisal of so-called spindle cell liposarcoma defining a unique lipomatous tumor unrelated to other liposarcomas

The term "spindle cell liposarcoma" has been applied to liposarcomas (LPSs) composed predominantly or exclusively of spindled cells. These tumors have been considered variants of well-differentiated LPS (WDL), myxoid LPS, and spindle cell lipoma, suggesting that this is a heterogenous group of lesions. Using strict morphologic criteria and molecular and immunohistochemical analyses, we have identified a homogenous group of spindle cell lipomatous tumors, histologically and genetically distinct from other forms of LPS, which we have called "fibrosarcoma-like lipomatous neoplasm." Cases classified as "spindle cell LPS" or "low-grade LPS with spindle cell features" were reviewed. Final selection criteria included: (1) an exclusive low-grade spindle cell component resembling fibrosarcoma; (2) a mixture of bland fibroblastic cells resembling the preadipocyte and early-adipocyte stage of embryonic fat; and (3) molecular-genetic analysis that excluded other forms of lipomatous tumors. Of the initial 25 cases identified, comparative genomic hybridization (CGH) was uninformative in 2 cases; 5 were reclassified as WDL on the basis of molecular data (MDM2 amplification) and 6 as spindle cell lipoma (CGH profiles with a few gains and losses including a constant loss of chromosome 13 and frequent losses of chromosomes 16 and 6). The 12 remaining cases showed flat CGH profiles; of these cases, 11 were negative for DDIT3 gene rearrangements, and 1 result was uninterpretable. Patients ranged in age from 15 to 82 years (mean 50 y); male patients were affected slightly more often (7:5). Tumors arose in the deep (6) and superficial (3) soft tissue of the groin (4), buttock (3), thigh (2), flank (1), shoulder (1), and paratesticular tissue (1) and ranged in size from 2 to 20 cm (mean 7.5 cm). Clinical follow-up in 11 patients (9 mo to 20 y; mean 68 mo) showed no recurrences or metastases. As defined above, "fibrosarcoma-like lipomatous neoplasm" is a unique lipomatous tumor that should be distinguished from WDL/(low-grade) dedifferentiated LPS and myxoid LPS on combined histologic/molecular features because of its better prognosis.

Krikothyreotomie mit dem "Quicktrach"-Koniotomiebesteck [Cricothyreotomy using the Quicktrach coniotomy instrument set].

Percutaneous cricothyroidotomy may be a lifesaving procedure for airway obstruction, which cannot be relieved by endotracheal intubation and can be performed with specially designed instruments. A new device, the "Quicktrach", was evaluated by an anatomical preparation, flow and resistance measurements, and puncture of the cricothyroid membrane in 55 corpses. The size of the parts of the instrument (needle, plastic cannula, depth gauge) in relation to the size of the larynx is adequate, thus there is little likelihood of perforation of the posterior wall of the larynx. Resistance of the plastic cannula is sufficiently low to allow for adequate ventilation. The duration of time until the cannula is positioned properly in the trachea is significantly shorter, when an incision prior to the puncture is done (83 +/- 88 seconds without incision versus 35 +/- 41 seconds with incision; mean +/- SD). The "Quicktrach" is easy to apply even by inexperienced persons. The incidence of damage to the larynx (lesions including fractures of the thyroid, cricoid and 1. tracheal cartilage in 18%; soft tissue injury in 9%) is relatively high, however considering the live saving character of the procedure these numbers appear to be acceptable. Technical problems which occur with the use of the device are discussed and suggestions for improvement are made.

Le syndrome de Moebius

Renal osteodystrophy is an amalgam of a number of distinct pathological conditions, in particular, hyperparathyroidism and osteomalacia. In addition, there may be a change in the guantity of bone, i.e., osteopenia (osteoporosis) or osteosclerosis. While bone biopsy may be the most reliable method for detecting these lesions, it is not yet a routine procedure in many centers. Radiological assessment of the bones, therefore, is the most widely used method for assessing the type and severity of the bone lesions in patients with chronic renal failure. This article reviews the world literature and pays attention to conventional radiological techniques as well as macroradiography. In addition, studies in which radiological appearances are correlated with histological appearances are described. Mention is also made of the effects on radiological bone disease of dialysis and transplantation. Consideration is also given to the manifestations of soft-tissue calcification, both of the vascular and subcutaneous type, and to the effects of treatment.

Léiomyosarcome de la veine cave inférieure. A propos de trois observations [Leiomyosarcoma of the inferior vena cava. Three cases].

We report three new cases of leiomyosarcoma of the inferior vena cava observed between 1985 and 1990. Two of them developed in women and one in a man. The age of the patients were 56, 29 and 57 years. The three tumors have been removed completely. One patient received postoperative radio- and chemotherapy and is well 68 months after excision. One patient developed liver metastasis 18 months after resection despite chemotherapy and died after 3 years. The last one refused postoperative radio- and chemotherapy, developed massive local recurrence and pulmonary metastasis three months postoperatively, and is still alive with disease after 8 months. The diagnostic modalities of these rare tumors as well as the problems created by their surgical resection and the need for a complementary treatment are discussed.