AAOS issues acute Achilles tendon rupture guidelines

The American Academy of Orthopaedic Surgeons recently released a new clinical practice guideline to assist orthopedic surgeons in managing acute Achilles tendon ruptures.
The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors adopted the guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture: Guideline and Evidence Report, in December which was endorsed by the American Orthopaedic Foot and Ankle Society.

Acute Achilles Tendon Rupture

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guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. ... are strongly urged to consult the full guideline and evidence report for this ...
www.aaos.org/Research/guidelines/atrsummary.pdf

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4 Dec 2009 ... THE DIAGNOSIS AND TREATMENT OF ACUTE. ACHILLES TENDON RUPTURE. GUIDELINE AND EVIDENCE REPORT. Adopted by the American Academy of Orthopaedic Surgeons
www.aaos.org/Research/guidelines/atrguideline.pdf


 Rated recommendations
The recommendations address: what the physical exam for an acute Achilles tendon rupture should entail; the role of imaging in diagnosing these ruptures; the selection of nonoperative and operative treatments; postoperative care; and information concerning return to sports.
In a three-page summary document, the work group that developed the guideline noted that clinicians should read the full guideline and its evidence report. Only then, based on the circumstances presented by the patient, should orthopedists make treatment decisions for these types of injuries.
The AAOS guideline contains 16 recommendations, each of which is rated according to the strength of its recommendation as moderate, weak or inconclusive. Two of the recommendations are based on consensus among work group members, according to the guideline summary appearing on the organization’s Web site.

Postoperative treatment

The most strongly recommended practices, which appear in recommendations numbered 11 and 12, pertain to postoperative treatment protocols and were ranked as moderate strength. In the 11th recommendation, the group wrote, “We suggest early (less than 2 weeks) postoperative protected weight-bearing for patients with acute Achilles tendon rupture who have been treated operatively.”
For the 12th recommendation, they wrote, “We suggest the use of a protective device that allows mobilization by 2 to 4 weeks postoperatively.”
Members of the work group noted in the summary that they were unable to recommend for or against eight practices for acute Achilles tendon ruptures which had inconclusive strength and emphasized that the guideline specifically applies to management of acute Achilles tendon ruptures.

Topics of interest : Orthopaedic Journals

Journal of Orthopaedic Surgery is the official publication of the Asia Pacific Orthopaedic Association.

A reciprocating ledge technique in closing wedge osteotomy for genu valgum in adolescents

 

 

Intramedullary nailing and plate osteosynthesis for fractures of the distal metaphyseal tibia and fibula

 

 

Tibiotalocalcaneal arthrodesis using a supracondylar femoral nail for advanced tuberculous arthritis of the ankle

 

Terrible triad of the elbow

 

Early adolescent nutritional rickets

Subcapital femoral neck fracture after fixation of an intertrochanteric fracture with a proximal femoral nail: a report of two cases

 

Primary intra-osseous liposarcoma of the femur: a case report

 

 

Shock wave nonunion therapy (ESWT) comparable to surgery in hypertrophic nonunions

Six months after both treatments, radiographic and clinical healing occurred in about 70% of patients. - By Susan M. Rapp

ORTHOPAEDICS TODAY EUROPE 2010; 13:14Extracorporeal shock wave therapy (ESWT)
- provides pain relief
- effective as surgery in resolving hypertrophic nonunions of the femur, tibia and radius.
- noninvasive treatment that focuses pulsed shock waves on targeted areas.
- promote healing by improving the vascularity of tissue and blood supplies.
- "orthopaedic surgeons and their patients now have more options to help repair a fracture that does not respond to initial treatment.”

Healing of various types of nonunion fractures with extracorporeal shock wave therapy was found comparable to surgical results 6 months after both treatments. Images: Cacchio A

-In study of 126  patients with femoral, tibial or radial nonunions into three groups.
- 1st two groups’ nonunions were treated with ESWT therapy in four sessions, 1 week apart, which each focused 4,000 ESWT impulses on the nonunion site.

-  in group 3 patients received intramedullary nailing, plate fixation or the two combined for their nonunions.

- Based on radiographic and clinical outcomes, the rate of healing within 6 months of treatment was 70%, 71% and 73% in groups 1, 2 and 3, respectively.

- patients examined at 12 and 24 months (after treatment), there were no significant differences in terms of healing. Scans of the bones proved noninvasive shock wave therapy worked just as effectively as surgery”.

Nonunion persisted for 12 months after this 64-year-old woman’s right humerus fracture was fixed surgically.

A fracture callus is evident in this X-ray of the humerus 6 months after extracorporeal shock wave treatment.

- cases, such as atrophic nonunions or malaligned fractures, where using shock waves may not be as effective.

For more information: Angelo Cacchio, MD, can be reached in the Department of Physical Medicine and Rehabilitation, San Salvatore Hospital of L’Aquila, via L. Natali 1, 67100 L’Aquila, Italy; +39-862-607235; e-mail: angelo.cacchio@tin.it. He has no direct financial interest in any products or companies mentioned in this article.
J. Lawrence Marsh, MD, can be reached at the Department of Orthopaedics, 200 Hawkins Drive, Suite 1181RC, Iowa City, IA 52242-1088 U.S.A. ; e-mail: j-marsh@uiowa.edu. He has no direct financial interest in any products or companies mentioned in this article.

• Reference:

Cacchio A, Giordano L, Colafarina O, et al. Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions. J Bone Joint Surg (Am). 2009;91:2589-2597.

Metal foam : New material that mimics bone may create better biomedical implants

Orthosupersite
North Carolina State University Researchers developed a “METAL FOAM”  having similar elasticity to bone heading to a new generation of implants that avoid bone rejection.
Characteristics:
- lighter than solid aluminum

- made of 100% steel or a combination of steel and aluminum
- “extraordinarily high-energy absorption capability”
- light weight
- modulus of elasticity similar to that of bone.
- its rough surface  foster bone growth into the implant

Modulus of elasticity

- Modulus of elasticity determines the load bearing of an implant when placed into bone.
- “If the modulus of elasticity of the implant is too much bigger than the bone, the implant will take over the load bearing and the surrounding bone will start to die,”
- “This will cause the loosening of the implant and eventually ends in failure.

Avoiding stress shielding

- modulus of elasticity for the foam is much closer to the 10 to 30 GPa of natural bone than the 100 GPa of titanium.
- light weight of the foam is attributed to its porous nature.
- on ability of the foam to avoid taking on too much load bearing from the surrounding bone “composite foam can be a perfect match as an implant to prevent stress shielding.”

• References:

Vendra L, Rabiei A. Evaluation of modulus of elasticity of composite metal foams by experimental and numerical techniques. To be published in the March 2010 issue of Materials Science and Engineering A.
 www.ncsu.edu 

Comparison of Different Lateral Tibia Locking Plates in Schatzker V tibial plateau fractures

A Biomechanical Comparison of Three Different Lateral Tibia Locking Plates

By Bennie Lindeque, MD, PhD; Todd Baldini, MS
ORTHOPEDICS 2010; 33:18

Purpose:  -how well laterally placed modern tibia locking plates used in the treatment of Schatzker V tibial plateau fractures would uphold the medial plateau during axial loading.

- Fifteen third generation Sawbone tibias were obtained and an osteotomy was cut beneath the medial plateau to recreate Schatzker V type plateau fractures. Three groups were created (n=5 per group). Each group was plated with either a Synthes 4.5-mm LCP proximal tibial plate, a Zimmer NCB proximal tibia plate, or a DePuy Polyax tibial plate.
- A vertical load was applied over the medial plateau using an Instron servohydraulic test machine. Load measurements were analyzed at 2 and 3 mm of subsidence as well as load to failure.
- Failure was defined as closure of the wedge osteotomy or the medial condyle collapsing.
- The Synthes and DePuy plates both held up better than the Zimmer plate at 2 and 3 mm of subsidence. Despite this fact, all plates tested held up well above physiological forces of full and partial weight bearing and therefore would be appropriate for the treatment of Schatzker V type tibial plateau fractures

.

The knee is one of the major weight bearing joints of the lower extremity, therefore proper fracture fixation following injury is of the utmost importance.
- These fractures can be divided into 4 groups: distal femur versus proximal tibia and intra-articular versus extra-articular.
-This article focuses on fixation of Schatzker V tibial plateau fractures with large medial defects.¹
- Overall, tibial plateau fractures account for 1.2% of all fractures.²
- In the past, this type of plateau fracture has been treated with medial and lateral fixation^3-5 or even a combination of internal and external fixation.^6-8 But with the advent of locking plates, it has been shown to be as effective in maintaining reduction and stability during healing with unilateral plating as with the traditional methods.⁹ It has also proven to be an effective technique to offer more fixation strength, which can be of benefit to patients with osteoporotic bone.¹⁰

The purpose of this study was to determine whether modern locking plates would be able to uphold a medial plateau fracture above physiological forces.

Lateral Locking Plates
Each company’s plates used different screw configurations, screw sizes, materials, and were of different lengths (Table 1)

Figure 1: Synthes (A), Zimmer (B), and DePuy (C) lateral tibia locking plates.

The shortest plate available was used from each company and every hole was filled. If there was a variable angle to the proximal subchondral locking screws, the screws were placed as far apart as possible.

Results

The load data is shown in Table 2. The DePuy Polyax plate had a significantly larger failure load than the Synthes locking compression plates or Zimmer noncontact bridging plates with further analysis. The Synthes locking compression plate and DePuy Polyax plates proved to carry significantly larger loads than the Zimmer noncontact binding plate when looked at with the Tukey-Kramer HSD test.

The stainless steel Synthes locking compression plates all failed by condyle collapse when the Sawbone fractured at the distal screw. The titanium Zimmer noncontact bridging and titanium DePuy Polyax plates all failed by osteotomy closing without plate breakage.

Discussion

The aim of this study was to ascertain whether 3 different modern locking plates would be strong enough to uphold a Schatzker V fracture under physiological loading conditions and secondarily to directly compare 3 different proximal, lateral tibia plates with locking and nonlocking options in the treatment of Schatzker V type tibial plateau fractures. The use of fully locked and hybrid locking/nonlocking plating systems have been recognized as appropriate treatment of proximal tibial fractures, even with significant bone loss medially.^10,12,13

Conclusion

Based on our data, the Synthes and DePuy plates both held up better than the Zimmer plate at 2 and 3 mm of subsidence. Despite this fact, all plates tested held up well above physiological forces of full and partial weight bearing and therefore would be appropriate for the treatment of Schatzker V type tibial plateau fractures.

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Orthopedics Today : Jan-Feb 2010 : Topics of Interest

Orthopedics Today :Feb 2010 : Topics of Interest
1. THA may be beneficial for young patients with Down syndrome and osteoarthritis
Between 8% and 28% of young people with Down syndrome are estimated to have osteoarthritis of the hip. Improved biomaterials and increased life expectancy for this group may make total hip arthroplasty an attractive option for these patients, according to an orthopedic researcher.  

2. Blood transfusions can increase the risk of infection in orthopedic patients
Despite an unknown etiology, transfusion with allogenic blood products predisposes patients to an increased risk of infection. Koval and colleagues reported an infection rate of 27% as opposed to 15% in transfused vs. nontransfused patients undergoing open reduction and internal fixation for hip fracture, out of a cohort of 687 patients. Interestingly, the incidence of urinary tract infection is also considerably higher in patients undergoing orthopedic procedures and receiving blood transfusion, pointing to the possible transfusion-induced immunomodulation (TRIM). 

3. Cytokine biomarkers in orthopedics offer enormous diagnosis and prognosis potentials
the four cytokine biomarkers denote a pathogenic process within a joint correlating to pain in a patient with meniscal pathology. They exist in local inflammatory sites in picomolar concentrations that can increase by thousand-folds in response to pathogenic processes, making them good biomarkers. we found fascinating in our study was the ability of inflammatory cytokines to predict operative pathology. Two patients who had a positive MRI for meniscal pathology were found during arthroscopy to have no significant pathology requiring operative intervention and no evidence of inflammatory cytokines was detected 
4. New minimally invasive technique may be useful to decompress lumbar nerve roots 
Using a new endoscopic technique to treat patients with spondylosis-induced lumbar nerve root compression shows promising results, according to researchers from Japan.“Although spinal fusion is the gold standard to treat spondylolysis and spondylolisthesis, decompression without fusion can be effective procedure for certain patients,”
For the procedure, about a one-finger width skin incision is needed to insert the endoscope.

5. Endoscopy successful in treating snapping iliopsoas tendon

Study in details all articles and more at.....
http://www.orthosupersite.com/
 

New collagen-modifying Osteogenesis Imperfecta gene discovered

1. New collagen-modifying osteogenesis imperfecta gene discovered
Most types of osteogenesis imperfecta (OI), also known as brittle bone disease, that have been identified relate to a dominant mutation in collagen. The type involving the newly discovered Cyclophilin B gene corresponds to a recessive trait, and individuals need two defective copies of the Cyclophilin B gene to develop OI.
The gene is needed to make the protein Cyclophilin B, part of a complex that modifies collagen by folding it into a precise molecular configuration before it is secreted from cells.  
Reference:

Barnes AM, Carter EM, Cabral WA, et al. Lack of Cyclophilin B in osteogenesis imperfecta with normal collagen folding. N Engl J Med. 2010. E-pub ahead of print.

  Read more..

Indian Journal of Orthopaedics : 2010| January-March | Volume 44 | Issue 1 ; Table of Contents

Indian Journal of Orthopaedics
2010| January-March  | Volume 44 | Issue 1 
Table of Contents 

EDITORIALS   Indian Journal of Orthopaedics: The journey so far p. 1 Anil K Jain, DK Sahu [ABSTRACT]  [HTML Full text]  [PDF] Scoliosis - The current concepts p. 5 Dilip Kumar Sengupta, John K Webb [ABSTRACT]  [HTML Full text]  [PDF] REVIEW ARTICLE The natural history of adolescent idiopathic scoliosis p. 9 Hee-Kit Wong, Ken-Jin Tan [ABSTRACT]  [HTML Full text]  [PDF] ORIGINAL ARTICLES Dorsal arthrodesis in prepubertal New Zealand white rabbits followed to skeletal maturity: Effect on thoracic dimensions, spine growth and neural elements p. 14 Federico Canavese, Alain Dimeglio, Charles D'Amato, Donatella Volpatti, Marie Granier, Marco Stebel, Fabio Cavalli, Bartolomeo Canavese [ABSTRACT]  [HTML Full text]  [PDF] Results of the spine-to-rib-cage distraction in the treatment of early onset scoliosis p. 23 Marco Teli, Alessio Lovi, Marco Brayda-Bruno [ABSTRACT]  [HTML Full text]  [PDF] The evaluation of short fusion in idiopathic scoliosis p. 28 Wiwat Wajanavisit, Patarawan Woratanarat, Thira Woratanarat, Kitti Aroonjaruthum, Noratep Kulachote, Wajana Leelapatana, Wichien Laohacharoensombat [ABSTRACT]  [HTML Full text]  [PDF] Adolescent idiopathic scoliosis: Retrospective analysis of 235 surgically treated cases p. 35 Ranjith Unnikrishnan, J Renjitkumar, Venugopal K Menon [ABSTRACT]  [HTML Full text]  [PDF] Posterior scoliosis correction for adolescent idiopathic scoliosis using side-opening pedicle screw-rod system utilizing the axial translation technique p. 42 Saumyajit Basu, Sreeramalingam Rathinavelu, Prashant Baid [ABSTRACT]  [HTML Full text]  [PDF] Spinal loop rectangle and sub laminar wiring as a technique for scoliosis correction p. 50 Shekhar Y Bhojraj, Raghuprasad G Varma, Abhay M Nene, Sheetal Mohite [ABSTRACT]  [HTML Full text]  [PDF] Intraspinal anomalies in scoliosis: An MRI analysis of 177 consecutive scoliosis patients p. 57 S Rajasekaran, Vijay Kamath, R Kiran, Ajoy Prasad Shetty [ABSTRACT]  [HTML Full text]  [PDF] Multimodal intraoperative neuromonitoring in corrective surgery for adolescent idiopathic scoliosis: Evaluation of 354 consecutive cases p. 64 Vishal K Kundnani, Lisa Zhu, HH Tak, HK Wong [ABSTRACT]  [HTML Full text]  [PDF] Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures p. 73 Ali Humadi, Rajit H Alhadithi, Sabhan I Alkudiari [ABSTRACT]  [HTML Full text]  [PDF] Outcome analysis of pelvic ring fractures p. 79 Ramesh K Sen, Lokesh A Veerappa [ABSTRACT]  [HTML Full text]  [PDF] Gap nonunion of forearm bones treated by modified Nicoll's technique p. 84 Dinesh K Gupta, Gaurav Kumar [ABSTRACT]  [HTML Full text]  [PDF] Outcome of Gartland type II and type III supracondylar fractures treated by Blount's technique p. 89 Antoine de Gheldere, Damien Bellan [ABSTRACT]  [HTML Full text]  [PDF] CASE REPORTS Cervical neurofibromatosis with quadriparesis: Management by fibular strut graft p. 95 Wichien Laohacharoensombat, Wiwat Wajanavisit, Patarawan Woratanarat [ABSTRACT]  [HTML Full text]  [PDF] Extramedullary hemopoiesis with undiagnosed, early myelofibrosis causing spastic compressive myelopathy: Case report and review p. 98 Udita Dewan, Niraj Kumari, Awadesh Jaiswal, Sanjay Behari, Manoj Jain [ABSTRACT]  [HTML Full text]  [PDF] Primary synovial osteochondromatosis of a subdeltoid bursa p. 104 Anil Kumar, Arvind Aggarwal, Virender K Sahni [ABSTRACT]  [HTML Full text]  [PDF] Pseudoaneurysm as a complication of ankle arthroscopy p. 108 Olubusola A Brimmo, Selene G Parekh [ABSTRACT]  [HTML Full text]  [PDF] LETTER TO EDITOR Nonsecretory multiple myeloma, how to make a diagnosis? p. 112 Viroj Wiwanitkit [ABSTRACT]  [HTML Full text]  [PDF] BOOK REVIEW Basic Methods of Medical Research p. 113 Piyush Gupta [ABSTRACT]  [HTML Full text]  [PDF] OBITUARY The life and legacy of Ignacio Ponseti p. 114 Matthew B Dobbs, Shah Alam Khan [ABSTRACT]  [HTML Full text]  [PDF]