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BACKGROUND AND OBJECTIVES: The aim of the present study was to review the long-term results in patients who had undergone modular prosthetic reconstruction of the knee, following a failed arthrodesis performed after the resection of bone tumors. METHODS: We reviewed 16 desarthrodeses and prosthetic reconstructions of the knee following a failed artificial arthrodesis after bone tumor resection. Desarthrodeses and subsequent knee megaprosthesis were performed after breakage of the arthrodesis implant in 11 cases and following presumed eradication of infection in five cases. RESULTS: The mean follow-up was 15.9 years. The mean post-operative range of knee flexion was 70°, but only four patients had active extension of the knee. Functional results, according to the MSTS system, were satisfactory in 11 patients. Complications included deep infections in five patients, aseptic loosening in three patients, breakage of the joint hinge in one patient, and patellar tendon avulsion in one patient. Despite a high rate of complications, all but two patients were satisfied. CONCLUSION: Our findings indicate that conversion of oncological knee arthrodesis to total knee arthroplasty should be taken into consideration only after giving the patient extensive information about the high risk of serious complications.

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INTRODUCTION: A patient with a neglected, compound acutely ruptured false aneurysm of the brachial artery which developed after a periprosthetic fracture of the right humerus, is reported. CASE PRESENTATION: An 84-year-old Greek woman underwent right shoulder hemiarthroplasty 2 years before a periprosthetic fracture which was treated conservatively in another hospital. After removing the U-slab herself, she noticed the development of an ulcer on the mid-humerus, with continuous oozing but no fever. This led to above-elbow amputation in an attempt to save the patient's life. CONCLUSION: It is hoped that by awareness of such a possibility coupled with an early diagnosis based on the clinical picture and imaging modalities, such unfortunate results can be avoided in the future. In case of increasing displacement at the fracture site and excessive local swelling, the possibility of the presence of a false brachial aneurysm should be ruled out despite the presence of normal perfusion of the hand and palpable radial and ulnar pulses.

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OBJECTIVE: Although the literature on degenerative disease of the cervical spine contains numerous articles studying the changes on levels adjacent to a fusion, there exist very few such studies concerning cervical spine stabilization for trauma. METHODS: Over a 16-year period (1989-2005), one hundred and twelve patients underwent stabilization of the lower cervical spine (C3-T1) for subaxial cervical spine injuries, either with an anterior or posterior procedure, or both. Eighty-one patients with adequate follow-up were included in the study and 3 groups were identified: Group A, consisting of 8 patients who underwent anterior stabilization and developed Adjacent Level Ossification Development (ALOD), Group B, comprising 53 patients who were anteriorly plated but who did not develop ALOD and Group C, comprising 20 patients who received posterior stabilization. RESULTS: Eight out of 61 patients (13.1%) who were anteriorly operated developed ALOD in 11 adjacent levels (Group A). Severe (grade 3) ossification was noted in 6/8 patients at the cranial adjacent level, and in 2/8 patients at the caudal one. Three out of 8 patients presented with early ALOD at 3, 4 and 18 months respectively. Despite the radiographic abnormalities showing ossification, all the patients had an uncomplicated course without symptoms. All the radiographs of Group B and Group C patients demonstrated grade 0 ossification for both the cranial and caudal adjacent levels. CONCLUSION: Adjacent-level ossification in cervical spine injuries may appear very early in the postoperative period and it can have a different course than in the degenerative disc disease population, at least in some patients. The first cephalad level adjacent to a fusion appears to be at greater risk. However, even when ALOD is evident radiographically, it very rarely produces any symptoms.

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BACKGROUND: The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. METHODS: Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. RESULTS: All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. CONCLUSIONS: The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

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STUDY DESIGN: Retrospective study of a prospectively followed cohort. OBJECTIVE: To summarize the complications after instrumented stabilization of cervical spine injuries in a single-institution series, and to discuss management of unstable injuries with respect to the complication rate between the 2 approaches (anterior and posterior). SUMMARY OF BACKGROUND DATA: The anterior approach to the cervical spine has been criticized for destruction of the anterior elements in the presence of posterior instability. The data came mainly from biomechanical studies and older clinical studies with earlier implants. However, there has been growing evidence ever since, that anterior decompression and instrumented fusion alone is an adequate form of treatment for unstable cervical spine injuries. METHODS: Over a 16-year period (1989 to 2005), 112 patients were treated in our institution for unstable cervical spine injuries using either anterior, posterior stabilization, or both. A patient was considered to have an unstable injury if he had 5 points or more in the White and Panjabi instability checklist. At least 1-year follow-up was necessary for a patient to be included in the study, which yielded a total of 97 patients. Seventy-four patients underwent anterior stabilization (group A) and 23 patients underwent posterior stabilization (group B). Three patients in the posterior surgery group required supplemental anterior cervical stabilization. RESULTS: Clinically significant complications occurred in 9/74 (12.2%) patients of group A. Three of 74 patients (4%) were reoperated owing to significant screw backout causing dysphagia, no purchase of the screws being completely in the adjacent disc and screw breakage, respectively. In group B, clinically significant complications were recorded in 4 (17.4%) patients, with an overall reoperation rate of 4% (1/23). Statistical analysis did not reveal significant differences between the 2 groups. CONCLUSIONS: Anterior instrumented fusion is at least as efficient as the posterior procedure in the management of cervical spine injuries and it also has several advantages. Most of such injuries, including the dislocations, can be managed with anterior instrumented fusion alone. Simple means of immobilization such as the hard collar suffice, and secondary posterior fixation is rarely, if ever, necessary.

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BACKGROUND: Spinal cord injury without radiographic abnormalities (SCIWORA) is thought to represent mostly a pediatric entity and its incidence in adults is rather underreported. Some authors have also proposed the term spinal cord injury without radiologic evidence of trauma, as more precisely describing the condition of adult SCIWORA in the setting of cervical spondylosis. The purpose of the present study was to evaluate adult patients with cervical spine injuries and radiological-clinical examination discrepancy, and to discuss their characteristics and current management. METHODS: During a 16-year period, 166 patients with a cervical spine injury were admitted in our institution (Level I trauma center). Upper cervical spine injuries (occiput to C2, 54 patients) were treated mainly by a Halo vest, whereas lower cervical spine injuries (C3-T1, 112 patients) were treated surgically either with an anterior, or posterior procedure, or both. RESULTS: Seven of these 166 patients (4.2%) had a radiologic-clinical mismatch, i.e., they presented with frank spinal cord injury with no signs of trauma, and were included in the study. Magnetic resonance imaging was available for 6 of 7 patients, showing intramedullary signal changes in 5 of 6 patients with varying degrees of compression from the disc and/or the ligamentum flavum, whereas the remaining patient had only traumatic herniation of the intervertebral disc and ligamentum flavum bulging. Follow-up period was 6.4 years on average (1-10 years). CONCLUSION: This retrospective chart review provides information on adult patients with cervical spinal cord injuries whose radiographs and computed tomography studies were normal. It furthers reinforces the pathologic background of SCIWORA in an adult population, when evaluated by magnetic resonance imaging. Particularly for patients with cervical spondylosis, special attention should be paid with regard to vascular compromise by predisposing factors such as smoking or vascular disease, since they probably contribute in the development of SCIWORA.

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BACKGROUND: The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. METHODS: Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. RESULTS: All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. CONCLUSIONS: The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.

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The objective of this study was to identify the sexual adjustment of females with severe cervical spinal cord injuries (SCI) using the Female Sexual Function Index (FSFI). The 19-item questionnaire of the FSFI concerns sexual function and satisfaction in sex life. This study, conducted by the Orthopaedic and Psychiatry Departments of Patras University, used a sample of a series of 39 consecutive female patients with severe traumatic SCI. We compared these female patients with an age-economic-educational level- and marital status-matched control group of the general population. Sexual activity was lower among females with SCI, but the desire, the emotional quality of sex life and overall sexual satisfaction did not differ from the controls. These results demonstrate that sexual life in females with SCI remains almost unaffected.

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BACKGROUND: To eliminate the need for allogeneic blood transfusion in patients undergoing elective total knee arthroplasty, we established and tried a protocol of combined methods, which is characterized by effectiveness, ease in application, and safety. It is based on perioperative administration of human recombinant erythropoietin plus iron and folic acid, mild acute normovolemic hemodilution, meticulous surgical technique, postoperative blood salvage through a closed-wound drainage system, and lower transfusion triggers. DATA SOURCES: Sixty-one patients entered the protocol, and the results were retrospectively compared with the ones obtained from 58 consecutive patients who were operated on in the past before the use of any blood saving technique. CONCLUSIONS: Only 5 patients of those who entered the protocol finally needed allogeneic blood transfusion, receiving a total number of 7 units, which is remarkable when compared with the 50 patients before the application of the protocol who required 111 units. Consequently, the utilization of allogeneic blood was reduced by 94%, a statistically quite significant result (P <0,001). We believe the protocol should be included in orthopedic surgeons' alternatives for blood saving in elective total knee arthroplasty.

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