The role of autologous bone graft in surgical treatment of hypertrophic nonunion of midshaft clavicle fractures

AbstractBackgroundThis study was conducted to evaluate the results of treating hypertrophic nonunion of mid-shaft clavicle fracture with a limited contact dynamic compression plate (LC-DCP) without autologous cancellous bone graft.MethodsFrom 1995 to 2008, 51 cases of hypertrophic nonunion of mid-shaft clavicle fracture were managed with open reduction and internal fixation by LC-DCP without bone graft involvement. Of these 51 cases, 30 had nonunion after failure of initial surgical treatment (Group 1), and 21 had nonunion after failure of conservative treatment (Group 2). Preoperative and postoperative case management were the same for both groups, with the average follow-up period being 20.4 months (range 18–36). Our study evaluated the radiographic results and functional outcomes of these cases according to the quick disability of arm, shoulder, and hand score.ResultsAll 51 cases resulted in uneventful unions. There was no statistically significant difference between the two groups regarding patient demography, cause of injury, preoperative and postoperative functional scores, length of operation, union time, and duration of hospitalization (p>0.05).ConclusionLC-DCP fixation is an effective method for treating hypertrophic nonunion of mid-shaft clavicle fracture. Local bone graft is sufficient to achieve necessary union, and autologous bone graft from other sites of the body appears unnecessary

Recapitulation of Fibromatosis Nodule by Multipotential Stem Cells in Immunodeficient Mice

Musculoskeletal fibromatosis remains a disease of unknown etiology. Surgical excision is the standard of care, but the recurrence rate remains high. Superficial fibromatosis typically presents as subcutaneous nodules caused by rapid myofibroblast proliferation followed by slow involution to dense acellular fibrosis. In this study, we demonstrate that fibromatosis stem cells (FSCs) can be isolated from palmar nodules but not from cord or normal palm tissues. We found that FSCs express surface markers such as CD29, CD44, CD73, CD90, CD105, and CD166 but do not express CD34, CD45, or CD133. We also found that FSCs are capable of expanding up to 20 passages, that these cells include myofibroblasts, osteoblasts, adipocytes, chondrocytes, hepatocytes, and neural cells, and that these cells possess multipotentiality to develop into the three germ layer cells. When implanted beneath the dorsal skin of nude mice, FSCs recapitulated human fibromatosis nodules. Two weeks after implantation, the cells expressed immunodiagnostic markers for myofibroblasts such as α-smooth muscle actin and type III collagen. Two months after implantation, there were fewer myofibroblasts and type I collagen became evident. Treatment with the antifibrogenic compound Trichostatin A (TSA) inhibited the proliferation and differentiation of FSCs in vitro. Treatment with TSA before or after implantation blocked formation of fibromatosis nodules. These results suggest that FSCs are the cellular origin of fibromatosis and that these cells may provide a promising model for developing new therapeutic interventions

Surgical Treatment for Osteoid Osteoma — Experience in Both Conventional Open Excision and CT-guided Mini-incision Surgery

Conventional open excision, or en bloc excision, was the standard treatment for osteoid osteoma until the development of percutaneous treatment for this tumor in the early 1990s. Most percutaneous treatments were performed under the guidance of computed tomography (CT), which could clearly demonstrate the exact location of the tumor and minimize bone destruction or resection. In order to minimize bone resection without adding to the costs of these new percutaneous instruments, we modified the percutaneous technique into a CT-guided mini-incision surgery. The patients treated with this technique were compared with those treated by conventional open excision. Methods: We retrospectively reviewed the medical charts of patients with osteoid osteoma treated between 1990 and 2004. The patients diagnosed before 2000 were all treated with conventional open excision. After 2000, some of them were treated with CT-guided mini-incision surgery. Follow-up was done either by phone or on an outpatient basis. Results: There were 23 patients with osteoid osteoma who were treated surgically between 1990 and 2004, of whom 20 were treated with conventional open excision. Six patients were treated with CT-guided mini-incision surgery, including 3 primary cases and 3 patients who had previously been treated with conventional open excision (2 recurrent cases and 1 with incomplete excision). The patients treated with CT-guided mini-incision surgery had smaller bone defects, shorter surgical time, and shorter hospital stay. The rate of recurrence or incomplete excision was 23% for conventional surgery and 0% for mini-incision surgery. Conclusion: CT-guided mini-incision surgery is effective in treating primary as well as recurrent osteoid osteoma

Treatment of Nonunion of Humeral Shaft Fracture with Dynamic Compression Plate and Cancellous Bone Graft

This study was conducted to evaluate the treatment of aseptic nonunion of the humeral shaft with a dynamic compression plate (DCP) and cancellous bone graft. Methods: One hundred and five cases of nonunion of a humeral shaft fracture between 1982 and 2001 were analyzed retrospectively. The study population comprised 66 males and 39 females with an average age of 46.2 years (range, 17–81 years). Sixty-seven fractures were defined as atrophic nonunion, and 20 as hypertrophic nonunion, whereas 18 could not be defined clearly. All the fractures were managed by open reduction and internal fixation with DCP and cancellous bone graft. The mean follow-up period was 20 months (range, 14–28 months). Results: All nonunion fractures united within an average of 16 weeks (range, 10–26 weeks). Complications included 4 patients with temporary radial-nerve palsies, and 3 patients with wound infections. At the final follow-up, shoulder and elbow functions of the operated limbs were all satisfactory. Conclusion: Fixation by DCP with supplemental cancellous bone graft is a reliable and effective treatment for nonunion of a humeral shaft fracture

Surgical Treatment of Open Diaphyseal Fractures of Both the Radius and Ulna

This study was designed to determine the effects of surgical treatment of acute, open and displaced diaphyseal fractures of both the radius and ulna by early debridement, reduction and internal fixation with a dynamic compression plate (DCP). Methods: From 1991 to 2003, data from 25 patients with acute, open and displaced diaphyseal fractures of both the radius and ulna were collected and evaluated retrospectively. Twenty-four patients were managed with early surgical debridement, open reduction and internal fixation with a DCP, and 1 fracture was reduced and fixed 3 days after the initial injury. The mean follow-up period was 74.7 months (standard deviation [SD], 38.6 months; range, 16-150 months). All patients had complete functional and radiographic assessments. Results: Twenty-four patients (96%) achieved normal union in a mean of 20.2 weeks (SD, 3.8 weeks; range, 12-24 weeks). One patient with an open type I fracture had nonunion. Functional outcomes showed that 15 patients had excellent results, 8 had satisfactory results, 1 had an unsatisfactory result, and there was 1 failure. There was 1 delayed superficial wound infection. Conclusion: Early meticulous debridement, good open reduction and internal fixation with a small DCP proved very effective in the management of type I and II open fractures of both the radial and ulnar diaphyses

A Facile Technique to Make Articulating Spacers for Infected Total Knee Arthroplasty

To treat total knee arthroplasty, 2-stage revision, including removal and reimplantation, remains the standard treatment for the infected arthroplasty. Articulating cement spacer has been shown to provide better functional results after reimplantation. However, its cost as a manufactured product is not always easily affordable and the choice of antibiotics is not flexible either. The authors have developed a method for surgeons to make cement-on-cement articulating spacers themselves by using an impression-taking technique with polydimethyl siloxane. The current study was conducted to test their clinical efficacy. Methods: Fifteen patients with infected total knee arthroplasties were prospectively treated with 2-stage revision using articulating spacers made by this technique. The clinical assessment included intraoperative finding, surgical records, radiographic and laboratory examination and final functional scores. All the patients were regularly followed-up. Results: Fourteen of the 15 patients (93.3%) had infection eradicated, of which 13 patients received revision arthroplasty successfully. The average interval between the resection arthroplasty and the final procedure was 3.5 months. During this period, most of the patients could sit comfortably with bent knees and walk with partial weight-bearing. No patients had secondary bone loss. The range of motion after revision surgery achieved an average of 110 degrees. The average Hospital for Special Surgery score was 90.5 points, and none had recurrent infection after an average of 47.5 months of follow-up. Conclusion: Treating infected total knee arthroplasty with these self-made articulating spacers eradicates infection effectively, improves the life quality before reimplantation and provides good final results without significant complications

Extraosseous Osteogenic Sarcoma

Extraosseous osteogenic sarcoma is a very rare malignant neoplasm. Out of the more than 400 cases of soft tissue sarcomas on file in our hospital, only 2 were extraosseous osteogenic sarcomas. Both were situated in the thigh. The first case was initially diagnosed as a hematoma and treated by marginal excision. The diagnosis of high-grade osteosarcoma primarily arising in soft tissue was made from histopathologic examination. Radiotherapy of 60 Gy in 30 fractions was given postoperatively. The second patient, primarily diagnosed as having a soft tissue sarcoma, was treated by wide excision. The final pathologic report was high-grade extraosseous osteogenic sarcoma. Adjuvant chemotherapy was given postoperatively. Both patients are alive without local recurrence and distant metastasis at postoperative 90-month and 107-month follow-up, respectively

Orbital Metastatic Osteosarcoma

A 15-year-old girl with right tibial osteosarcoma, diagnosed 22 months previously, developed right orbital and skull base metastases, with symptoms including painful protrusion of the right eyeball and severe visual impairment. She underwent embolization of the metastatic tumor, local irradiation, and chemotherapy followed by intralesional resection of the mass because extensive involvement of the skull base precluded complete surgical resection. The best corrected visual acuity in her right eye initially decreased to 20/200, then dropped to no light perception after embolization, and then improved to counting fingers at 50 cm after radiotherapy. The symptoms of pain and proptosis subsided completely. After 24 months of follow-up from the presentation of orbital metastasis, the patient's right-eye vision remained unchanged. The surgical specimen revealed a necrotic tumor similar to osteosarcoma. In conclusion, orbital metastasis of osteosarcoma is rare, but may lead to severe visual impairment. Combined radiotherapy, chemotherapy and surgery can partially relieve symptoms, but cannot completely eradicate the tumors

Malignant Lymphoma in an Atomic-bomb Survivor

Atomic bomb survivors outside of Japan are few and often hard to follow-up. Spinal malignant lymphoma among these survivors is rare in established studies from Japan or the United States. Here, we report an 81-year-old woman, who experienced the atomic bomb explosion in Nagasaki when she was 19 years old, who presented with papillary thyroid carcinoma when she was 70 years old. Both follicular lymphoma over the right elbow region and vertebral malignant lymphoma were found when she turned 81 years old. Bone scan did not show any increased uptake of isotope. However, thoracolumbar spine magnetic resonance imaging showed multiple infiltrative soft tissue masses involving vertebral bodies at the T10–11 level. Computed tomography-guided biopsy further showed lymphocyte infiltration. Fortunately, the neurological deficit was improved after chemotherapy. The diagnosis of malignant lymphoma in atomic bomb survivors should be more careful and aggressive, even when their bone scan results show negative findings. In addition, the authors suggest that atomic bomb survivors should be followed-up carefully throughout their entire life

An Alternative Solution to Achieve Primary Stability in Cementless Revision Hip Arthroplasty for Femur Ectasia

Revision total hip arthroplasty is technically demanding, especially when treating a large defective femur. The aim of this study was to evaluate the clinical results of cementless total hip arthroplasty revision in patients with advanced femoral bony defects. Methods: By using the canaloplasty technique, which osteotomized the proximal femur to reduce the width of canal, 12 patients were enrolled and underwent revision operation. Patients were evaluated by radiographic examination and Harris hip score before and after the index procedures. Results: The average length of follow-up was 38.7 months. All the osteotomies united at a mean of 5.3 months. Structural allografts were used on six patients to augment the thinned cortices. A total of 11 femoral components (91%) achieved and maintained stability at the last follow-up. One patient was complicated with early stem subsidence and another with deep infection. Both patients were treated successfully without late sequelae. The mean Harris hip score improved from 37.2 to 75.0 after the operation (p < 0.05). Conclusion: The canaloplasty technique could be an alternative solution to help revision surgery in some younger patients with advanced femoral defects