FUNCTION OF PERIPHERAL NERVES ENTRAPPED IN CALLUS. AN EXPERIMENTAL STUDY IN RABBITS.
Α.Christodoulou, P.Givissis, J.Mavromatis, G.Karkavelas,
Δημοσιεύθηκε εκτεταμένη περίληψη στο Journal of Bone and Joint Surgery Supplement II 75-B, 101, 1993.
Δημοσιεύθηκε εκτεταμένη περίληψη στο Revue de Chirurgie Orthopedique 384, 1993.
Aνακοινώθηκε στο 1st European Congress of Orthopaedics EFFORT.
Paris 20-23 April 1993.
Searching the effect of the developing and mature callus on the entrapped peripheral nerve, fracture was caused surgically to twelve rabbits, a segment of bone of two cms was removed, and the sciatic nerve was coiled around the fracture. An intramedullary osteosynthesis with a k-wire followed. The union of all fractures was successful, and the sciatic nerve was in all cases entrapped in the callus. The function of the nerve was evaluated with EMG studies and clinical examinations. In the histopatological examination, done after the division of the animals in four groups, the way the callus affected the nerves was examined. Their sucrification was done at the 3rd, 6th, 9th and the 16th postoperative week.
Additionally in the four pilot groups, EMG and microscopic examination studied the function of the sciatic nerve after:
I) segmental devascularization with or without immobilization of the ispilateral limb.
II) Segmental devascularization or pressure And.
III) Resection and removal of 1cm of the nerve trunk.
According to the results, the callus didn’ t strangle the sciatic nerve, in none of the main groups and it was well developed in some distance from it.
The nerve damages observed were mainly of ischemic type, accompanied mainly by degeneration of nerve fibers, damage of the myeline sheath and some thickening of the supporting connective tissue, improvement of the function was obvious in all nerves in the long time survival groups and EMG studies, confirm that.
A hypothesis is defined: < the electrical resistance of nerves against the squeezing callus>, assuming the electronegativity ata the fracture site the continuity of the nerve trunk, which is able to conduct and produce electronegativity.
The delayed exploration of the paretic nerve after a fracture is supported by this study, as the calluw does not affect entrapped nerve.
THE EFFECT OF REPEATED PARTIAL PERIOSTEAL DIVISION ON TIBIAL GROWTH
Chr. Dimitriou, G. Kapetanos, P. Givissis, F. Sayech, V. Tzarou,
Δημοσιεύθηκε εκτεταμένη περίληψη στο Journal of Bone and Joint Surg. Vol. 75-B: 164, 1993
Δημοσιεύθηκε εκτεταμένη περίληψη στο Revue de Chirurgie Orthopaedique et rιparadrice de l’ appareil moteur. Vol. 79, 537 1993 N’ Special
The close connection and equilibrium between the function of the growth plates and the periosteum in the immature skeleton is well known.
It has been shown experimentally that a medial hemicircumferential division of the tibial periosteum resulted in a valgus deformity.
The present experimental study investigated the effect of repeated hemicircumferential division on tibial growth.
Twelve N. Zealand white rabbits six weeks of age, were used as the experimental animals. The experiments were performed on the medial aspect of the upper tibia of the right leg. The left tibial was used as the control side. The hemicircumferential periosteal division was made medially below the pes anserinus to the middle of the posterior aspect of the tibia. The same periosteal division was repeated twice at two operated and control sides were recorded weekly. Roentgenologic examination consisted of determination of the valgus and the axial angles as well as the diaphyseal length of the tibia. Certain differences in the development of the right tibia compared to the control side were observed.
SPINAL LESIONS. DIAGNOSTIC VALUE OF THE HARLOW WOOD BIOPSY NEEDLE
A. Christodoulou, G. Kapetanos, P. Givissis, S. Bintas, J. Pournaras, P. Symeonides.
Δημοσιεύθηκε εκτεταμένη περίληψη στο Journal Bone Joint Surg.
75B: 196, 1993
Τo πρόσθιo τμήμα τoυ σπ. σώματoς δεν είναι εύκoλo να πρoσπελασθεί σε διαγνωστικά πρoβλήματα (όγκoι – φλεγμoνές).
Η διαγνωστική αξία της κλειστής βιoψίας με βελόνη είναι συνάρτηση τoυ μεγέθoυς τoυ τεμαχίoυ δηλ. της διαμέτρoυ της βελόνης. Εξήντα έξη ασθενείς υπέστησαν 70 κλειστές βιoψίες με βελόνη, με τoπική αναισθησία αφoύ είχε πρoηγηθεί λεπτoμερής κλινικός και παρακλινικός έλεγχoς. Η μέθoδoς έχει υψηλή διαγνωστική αξιoπιστία, είναι απoδεκτή απ’ τoν ασθενή και δεν είχαμε μείζoνες επιπλoκές. Στα μειoνεκτήματα της μεθόδoυ συγκαταλέγoνται η ακτινoβoλία στην oπoία εκτίθενται oι γιατρoί και τo μικρό σχετικά κoμμάτι oστoύ πoυ λαμβάνεται ιδιαίτερα για τις περιπτώσεις όγκων.
SPINAL LESIONS – DIAGNOSTIC VALUE OF THE HARLOW WOOD BIOPSY NEEDLE.
A.Christodoulou, G.Kapetanos, G.Zidrou, P.Givissis, J.Pournaras
Δημοσιέυθηκε στο Abstracts of Posters of 4th Congress of the European Federation of National Associations of Orthopaedics and Traumatology, page 73, Nο. 259, 1999
Τhe diagnostic success of closed vertebral biopsy with the Harlow
Wood needle of 3mm internal diameter was evaluated prospectively.
238 patients, 138 men and 100 women, aged 21-83 years have undergone a total number of 241 closed vertebral needle biopsies over a ten year period (1987-1997). The levels of the spine which were punctured ranged from T3 to S1. In each case specimens were sent for 1) microscopy and cultures for aerobic and anaerobic microorganisms as well as for mycobacterium of tuberculosis. 2) histopathology and 3) cytology.
124 patients were proved to suffer from spinal infection (53 tuberculosis, 44 staphylococci of various types and 27 other microorganisms). 68 patients were diagnosed to have a tumour (57 malignant and 11 benign). Malignancy, was excluded in 20 patients, while diagnisis was impossible in 26 patients.
No major complication was noted. Minor complications were: pulsing bleeding in 18 patients which was adequately controlled with haemostatic sponge though the trephine guide , nerve root irritation in 3 patients, transiert paragleria in one patient and tuberculous sinus in one patient. The diagnostic yield of the needle was 89% with 80,6% accurate diagnosis and 8,4% exclusion of malignancy. The rate of diagnostic failure was 10,9%. The method is simple, repeatable, acceptable by the patient, can be undertaken without general anaisthesia as a day case and offers access to parts of the spine instead of a major procedure.
TREATMENT OF SCAPHOID FRACTURES WITH BIO-ABSORBABLE RODS
P. Givissis, C. Sinopidis, D. Karataglis, J.Pournaras
Δημοσιεύθηκε στο Poster Book of VII Congress of the federation of the European Societies for surgery of the hand, page 61 No. 103, 2000
The past twelve years the introduction of bioabsorbable materials into orthopaedic surgery offered a full range of biodegradable implants for the fixation of fractures. Although their biomechanical properties are similar to those of traditional metallic implants, there is no need for removal of the hardware or danger from hardware migration, the possibility of reactive synovitis and osteolysis has made their use less popular.
We report 3 patients with fractures of the scaphoid waste, which were treated with internal fixation with bioabsorbable rods. Through a dorso–radial approach to the scaphoid the fracture was indentified, reduced and fixed with two to three 1.1mm rods made of poly-L-lactic acid (PLLA). In two cases additional bone graft was used due to multi-fragmentation of the fracture. Post operative a below elbow cast was applied with the proximal phalanx of the thumb included. After six weeks the wrist was mobilised under the supervision of the therapist.
Results: The follow up was 23 months median. Union was obtained in all the patients. One month from the removal of the cast all the patients were pain free with a functional range of movement and grip strength symmetrical. Return to function was to pre injury level. Magnetic resonance imaging (MRI) at the latest follow up did not show any signs of osteolysis.
Although the number of patients is very small to generate conclusions, these three case reports suggest that fixation of scaphoid fractures with PLLA rods is an alternative to the alternative to the traditional implants.
UNCEMENTED THREADED HYPROXYAPATITE COATED ACETABULAR COMPONENT IN TOTAL HIP ARTHROPLASTY
Pournaras J, Petsatodes G, Trapotsis S, Givissis P.
Δημοσιεύθηκε στο Abstract Book pag. 72 of EFFORT
Rhodes, June 3-7 2001
We studied the influence of the surgical correction of the idiopathic curve on the height of the children an the relation between the elasticity of the curve, the achieved correction and the increase in height.
Thirty eight children, 27 girls and 11 boys with a mean age of 13 (12-19) years underwent posterior spinal fussion with segmental instrumentation (Luque rods or Hartshill rectangles and sublaminar wiring). Their height was measured preoperatively and at the 10th day postoperatively after the unsupported mobilization. It was measured as well, the scoliotic curve pre operatively on standing and lateral bending films and post operatively on standing films.
There was an average increase in height of 4 (2-7)cm with an average correction of the curve of 57%. Twenty six patients measured an increase of more than 3cm (pre op. standing aver. 63o, lateral bending aver. 37o, post op. standing aver. 24o). Twelve patients measured and increase of less than 3cm (pre op. standing aver. 56o, lateral bending aner. 34o, post op. standing aver. 25o).
Segmental spinal correction increases directly the height of the patient in an average of 4cm.
A COMPARATIVE STUDY OF THE SURVI-VORSHIP OF THE SOUTER-STRATHCLYDE TOTAL ELBOW ARTHROPLASTY IN RHEUMATOID ARTHRITIS PATIENTS UNDER AND ABOVE 50 YEARS OF AGE
S C Talwalkar, P Givissis, I A Trail and J K Stanley
Δημοσιεύθηκε στο Journal of Bone and Joint Surgery – British Volume, Orthopaedic Proceedings 2005 , Vol. 87-B, Issue SUPP II, 165
Our study examines a group of patients less than fifty years of age who underwent Total Elbow Arthroplasty with the Souter Strathclyde Elbow Replacement and compares their survivorship with a dataset of older group of patients.
309 patients were who underwent standard long stemmed Souter Implants as a primary procedure for rheumatoid arthritis over the last 16 years were included in this study. Patients were divided into two groups according to the their age at the time of surgery. In the first group of older patients greater than or equal to 50 years of age (Mean Age =64.4 years) there were 263 patients with a mean follow up of 7.3 years. The second group consisted of patients less than 50 years of age (Mean Age 42.04 years) who had a longer mean follow up period of 9.3 years. The survivorship of the implants for three different failure events was compared for both groups. The radiographs were evaluated using the Kaplan-Meir survival analyses, to produce survival curves for revision, revision due to aseptic loosening of the humeral component and finally gross loosening of the humeral implant (Hidex>1). For each terminal event there were two curves and the age group analyses were all non-significant when log rank tested. The rates of loosening/revision were comparable in all curves.
We set out to determine the role of age as predictive factor for loosening. Our conclusions were that Total Elbow Arthroplasty is suitable for younger patients with rheumatoid elbow. Using survivorship data there does not appear to be any difference in loosening when compared to patients of an older age group. As previously published the position of the humeral component within the humerus is crucial for long-term survivorship. Thus age alone should not be the sole discretionary factor for withholding the benefits of elbow Arthroplasty in younger patients.
BICONDYLAR DISTAL HUMERUS FRACTURES TREATED WITH A TRANSOLECRANON OSTEOTOMY AND ACUMED TITANIUM PLATES
Givissis P., Hatzisymeon A., Papadopoulos P., Petsatodes G., Christodoulou A., Pournaras J.
Δημοσιεύθηκε στο Journal of Bone and Joint Surgery – British Volume, Orthopaedic Proceedings 2006, Vol. 88-B, Issue SUPP I. 177
Purpose: To evaluate the functional outcome following internal fixation of bicondylar distal humerus fractures (AO type C) using the ACUMED modified titanium plates. Material-Methods: Fourteen patients (9 male, 5 female) aging 18 to 78 years (av. 54 y.) with bicondylar distal humerus fractures, between September 2002 and May 2004, were included in our study. All of them underwent open reduction and internal fixation. The articular surface was reduced through a transolecranic approach using one or two compression screws and the fractures was then fixated using the modified titanium ACUMED plates. Results: Postoperative follow-up ranged from 6 to 24 months (av. 12 m.). The results were evaluated using the Mayo Clinic Score. The mean range of elbow flexion-extension was 115o. Nine patients had an excellent/good result, 3 had affair and 2 a poor result. One patient underwent a second procedure for symptomatic metalwork. In one case there was soft tissue infection that resolved successfully with antibiotic administration. Conclusion: The internal fixation of bicondylar AO (type C) distal humerus fractures with the ACUMED plates through a transolecranic approach is an extensive but atraumatic operation that offers excellent reduction and a stable osteosynthesis leading to a good functional outcome.
LATE RESULTS OF CONSERVATIVE TREATMENT OF FRACTURE OF THE NECK OF THE FIFTH METACARPAL
P. Givissis, E. Balabanidou, K. Ditsios, A. Christodoulou, J. Pournaras
Δημοσιεύθηκε στο Journal of Hand Surgery: European Volume
Volume 32, Supplement 1, June 2007, Page 117
Background: The Fracture of the Neck of the Fifth Metacarpal represents 20% of all hand fractures and 51-68% of all metacarpal fractures. Is most common in young men and treated most of the times conservatively.
Aim:To evaluate the long term results of the conservative treatment concerning any residual symptoms or malformation problems.
Method: From 2000 to 2004 46 patients were treated with boxing glove bandaging for a Fracture of the Neck of the Fifth Metacarpal.
18 patients reevaluated from an independent observer (39.1%)
16 men, 2 women
Mean age 38.8 (range 18-70)
Mean follow up 3.5 years (not less than 2 years)
– Dominant hand or not
– Patient’s subjective satisfaction
– Long term Pain (Analog visual scale 1- 10)
– Clinical deformity
– Radiological angulation
– Recovery of movement & grip strength ( Jamar Dynamometer)
Finally we have added another clinical parameter the “hand shaking test” where the same independent observer (Female) was shaking hands with the patients and recording the presence of pain or discomfort.
Results: The aforementioned parameters were calculated as follows : 0-2: Excellent, 3-7: Good, 8-15:Poor.
11 Patients had Excellent results, 6 Patients Good and 1 Patient Poor .
However, five of the patients (30%) had a positive “hand shaking test” (not included the patient with the poor result).
Discussion/Conclusion: The majority of the patients were fully satisfied by the function of their hand, despite any residual deformity, or angulation, or even limitation of finger movements. The conservative treatment of the subcapital fracture of the fifth metacarpal with boxing- glove bandaging is sufficient in most of the cases. The fact of the pain during the “hand shaking test” should be further studied.
Upper limb fractures treated with bioabsorbable materials
P. Givissis, D. Kapoutsis, K. Ditsios, A. Christidoulou, J. Pournaras
Δημοσιεύθηκε στο Journal of Hand Surgery: European Volume
Volume 32, Supplement 1, June 2007, Page 26
Background: During the last two decades bioabsorbable materials have been introduced for the treatment of Upper Limb fractures. Their widespread acceptance has been partly hampered by early reports regarding soft tissue reactions during the fast degradation process and the suboptimal mechanical properties of these implants. Second generation implants composed mainly of polylactic acid (PLA) with improved strength and a slower degradation rate seem to eliminate these drawbacks.
Aim:To evaluate the clinical application of bioabsorbable plates and screws in the treatment of metacarpal and ulna fractures.
Method: Our study includes 10 patients with displaced metacarpal or ulna fractures (7 patients–9 metacarpals and 3 patients-3 Ulnae) who have been treated with a bioabsorbable polymer, blended of L-lactide, DL-lactide,Glycolide and Trimethylene Carbonate (TMC).
In all cases under axillary block or general anaesthesia an ORIF with bioabsorbable plates and screws was done followed by protection splint for two weeks.
They followed up for an average of 1.6 years (1.2 – 2.7 years)
Results: All the metacarpal fractures were united with excellent final outcome, but in two cases there were foreign body reactions with swelling and sterile abscess formation 10 months and 15 months respectively. Both of them required surgical Debridement which resolved the problem.
In all the cases of the Ulna fractures we had a material failure where the plates were broken within the first three weeks .One case required reoperation with metallic implants and the other two were treated with plaster for 8 weeks.
Discussion/Conclusion: The ideal implant would be made of a bioabsorbable material which has appropriate initial strength to meet the biomechanical demands, degrades in a predictable fashion remaining sufficiently strong until the bone has healed, causes no deleterious tissue responses and disappears completely. According to our experience these requirements were not met especially for the Ulna fractures.
DELAYED FOREIGN BODY REACTION TO ABSORBABLE IMPLANTS IN METACARPAL FRACTURE TREATMENT
Stavros Stavridis; Panagiotis Savvidis; Konstantinos Ditsios; Panagiotis Givissis; and Anastasios Christodoulou
Δημοσιεύθηκε στο Journal of Bone and Joint Surgery – British Volume, Vol 93-B, 2011, Issue SUPP_II, 139.
Aim of the study: The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after fracture healing had been completed, in metacarpal fractures treated with third generation bioabsorbable implants.
Materials and Methods: 12 unstable, displaced metacarpal fractures in 10 consecutive patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with third generation absorbable plates and screws (Inion® OTPSTM Biodegradable Mini Plating System), where resorption is supposed to occur within 2 to 4 years. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m) and were examined both clinically and radiologically. For patients without appearance of foreign body reaction the minimum follow-up time was 24 months.
Results: Fracture healing was uneventful in all cases. A foreign body reaction was observed more than a year postoperatively in 4 patients, who were subjected to surgical debridement and implant remnants removal. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. 2 further patients reported a self subsiding transient local swelling.
Conclusion: Our results indicate that modern absorbable implants with longer degradation period have not eliminated the problem of foreign body reaction, but simply postponed it at a later time postoperatively. Patients treated with bioabsorbable implants should be advised of this possible late complication and should be followed for at least two years, possibly longer.
ILIAC CREST REGENERATION AFTER BEEN HARVESTED FOR AUTOLOGOUS BONE GRAFTS. A PROSPECTIVE STUDY OF 18 PATIENTS WITH A MEAN FOLLOW-UP OF 14 YEARS
A. Christodoulou; P. Antonarakos; A. Boutsiadis; P. Givissis; and E. Christodoulou.
Δημοσιεύθηκε στο Journal of Bone and Joint Surgery – British Volume, Vol 93-B, 2011, Issue SUPP_III, 363
Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis.
Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest.
All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site.
CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area.
In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects
BLOOD MANAGEMENT IN SCOLIOSIS SURGERY. COMPARISON OF PREOPERATIVE AUTOLOGOUS BLOOD DONATION WITH INTRA-OPERATIVE BLOOD SALVAGE (BLOOD SAVER) SYSTEMS
Petros Antonarakos, Anastasios Christodoulou, Panagiotis Givissis, Lamprini Katranitsa, Panagiotis Simeonidis and Achilleas Boutsiadis
Δημοσιεύθηκε στο Orthopaedic Proceedings
A supplement to The Bone & Joint Journal,
J Bone Joint Surg Br 2012 vol. 94-B no. SUPP XXXVII 424
AIM Retrospective study comparing the effectiveness of preoperative autologous blood donation versus intra-operative blood saver systems in minimizing the need for allogeneic blood transfusion in scoliosis surgery.
MATERIALS – METHODS Between 2003–2009, 37 of the patients (4–33, mean age 20y) who underwent scoliosis surgery, were divided in two groups. The first group (20 patients, mean age 18.7y) underwent autologous blood predonation, prerequisities were body weight over 50 kgr and Hgb above 11 mg/dl. The second group (17 patients, mean age 21.5y) consisted of patients who did not meet the above prerequisities and blood saver was used intra-operatively. Duration of surgery and perioperative Haemoglobulin (Hgb) levels were recorded in both groups.
RESULTS In group A an average of 4 autologous blood units per patient were predonated (3–5 units/patient) and the mean transfusion rate was 3.4 autologous blood units/patient. Only one patient was transfused with one allogeneic blood unit while of the 81 predeposited autologous blood units 15 were wasted (18.5%). In Group B intra-operative autotransfusion systems salvaged 302.9 ml/patient (150–500 ml/patient) while the mean transfusion rate was 2.1 allogeneic blood units/patient.
CONCLUSIONS The use of intra-operative autotransfusion systems seems to reduce the need for allogeneic blood transfusion when compared with preoperative autologous blood donation. However, the lower preoperative Hgb in Group B have to be taken under consideration. Further studies need to prove the effectiveness of these methods so that perioperative blood management minimizes the need for allogeneic blood transfusion in scoliosis surgery.