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PubMed2005

[Excision of heterotopic new bone around the elbow in patients with head injury: 51 cases].

PURPOSE OF THE STUDY: Neurogenic paraosteoarthropathy of the elbow is a frequent complication in head injury patients. The functional impairment may be severe. The purpose of this work was to evaluate the efficacy of our medico-surgical approach and to determine indications for surgery. MATERIAL AND METHODS: We analyzed retrospectively a continuous series of 44 patients (51 elbows) with neurogenic heterotopic new bone of the elbow joint managed from 1993 to 2000. The heterotopic bone had developed on a central deficit limb in 70% of the patients. Flexion-extension was limited in all patients, and pronation-supination in nine. The ulnar nerve was compressed by the heterotopic bone in half of the patients. A 3D reconstruction CT-scan with contrast injection was obtained in all patients. We consider did not the classical criteria for bone maturation to assess operability. Using an adapted approach, we removed the heterotopic new bone to enable complete elbow motion. Associated procedures were performed in fifteen patients due to persistent intraoperative joint stiffness related to muscle-tendon retraction. We did not prescribe diphosphonates or radiotherapy postoperatively. RESULTS: At 45 months follow-up, one patient had been lost. Relative gain was considered very good in 34 elbows, good in 13 and fair in 3. There were no cases of lost motion. There were no recurrences causing joint limitation, but two of nine cases of radioulnar synostosis recurred. DISCUSSION: Neurogenic paraosteopathy of the elbow impairs joint function and may lead to ulnar nerve compression. The goal of surgery is to improve function. The analysis of our results show that early surgery yields good results without complementary treatment, irrespective of the patient's overall functional deficit or cognitive status and irrespective of the localization of the hetertopic bone. The essential prognostic factor for the quality results is the neurological status of the limb, particularly the degree of spasticity and muscle-tendon retraction.

Adult↗
PubMed2000

Bone regeneration in segmental defects with resorbable polymeric membranes: IV. Does the polymer chemical composition affect the healing process?

Diaphyseal segmental defects 10 mm in length in the radii of 36 skeletally mature rabbits were covered with tubular microporous membranes prepared from poly(L/D-lactide) (18 rabbits) and poly(L/DL-lactide) (18 rabbits) to determine whether chemical composition of the membrane affected the bone healing in the defect. The results of a previous study in which similar defects of the rabbits radii were not covered with membranes or covered with poly(L-lactide) membranes were used as controls. The control defects were rapidly filled with overlying muscle and soft tissues, producing a radio-ulnar synostosis. The osseous activity of control defects was limited to the bone ends. The defects covered with membranes were progressively filled with new bone. At 1 year, complete bone regeneration in the defects covered with the poly(L/D-lactide) membrane was found in 16 cases, no regeneration in 1 animal and pseudoarthrosis in 1 animal. For the poly(L/DL-lactide) membrane there was complete bone regeneration in 17 cases (1 animal died during surgery). The quality of the interface between the new bone and the membrane seemed to be affected by the chemical structure of the polylactides used for membranes preparation. For poly(L/D-lactide), the connective tissue layer entirely separated the new bone from the polymeric membrane. This has been observed before for poly(L-lactide) membranes. In the case of poly(L/DL-lactide) the new bone was formed in some places in direct contact with the membrane and the membrane fragments were osteointegrated. The differences in chemical composition of the polylactide membranes did not have an evident effect on the bone regeneration process in segmental defects of the rabbit radii.

Animals↗
PubMed1987

Growth deformities.

This article discusses principles of corrective osteotomy and describes operative plans for specific growth deformities such as premature closure of the distal ulna, asynchronous growth of the radius and ulna in achondroplastic breeds, retarded growth of the distal radius, retarded growth of the proximal radius, and synostosis of the radius and ulna.

Animals↗
PubMed2005

[Superficial US of superficial bones].

Although bones are not well imaged by US this imaging modality can be helpful in the assessment of bone surface and can be complementary to standard radiographs. A focal irregularity of the hyperechoic cortical line indicates a fracture, a cortical avulsion, a local bulging of the cortex or a foreign body related or not to previous surgery. Subperiosteal collections either purulent or hemorrhagic are easily detected and can be aspirated under US guidance if an infection is suspected. US also allows diagnosis of epiphyseal fractures when involving the distal epiphysis of the metatarsals, radial head, humeral head (Hill-Sachs fracture) growing cartilages... US examination of joints can detect osteophytes and marginal erosions (allowing early diagnosis of rheumatoid arthritis together with visualization of hyperaemic pannus and joint effusion) Cortical continuity in a location where in normal conditions a joint space is found indicates a synostosis. In children US, by directly visualizing the cartilaginous component of the non ossified bones, allows detection and serial follow-up of many congenital malformation (pes equinus...). US may be obtained in all patients where standard radiographs are not diagnostic because of it is efficient, non-invasive and relatively inexpensive.

Bone Diseases↗
PubMed1998

A large family with type IV radial polydactyly.

This study examines one of the largest pedigrees with radial polydactyly type IV (uncomplicated polysyndactyly) comprising a total of 69 individuals, of whom 26 have been affected over six generations. Typical manifestations of the pedigree were bilateral radial and ulnar digital duplications, as well as syndactyly between the middle and ring fingers and the second and third toes. There was no craniofacial anomaly in any of the 17 cases examined physically. This observation suggests that radial polydactyly type IV and Greig craniofacial-synostosis syndrome with similar digital manifestations are clinically-distinct entities.

Fingers↗
PubMed1982

Experimental investigations into the clinical significance of bone growth at viscerocranial sutures.

The development of a viscerocranial suture under physiological conditions was investigated in a total of 37 pigs and the effects of various traumas on expected sutural bone growth were observed. Different operations were carried out on one side only in the vicinity of the zygomaticotemporal suture in 18-25 day old piglets. The animals were sacrificed six months after the operation. The skulls of some of the animals were macerated and subjected to macroscopic and radiological investigation. Both zygomatic arches were removed from each of the remaining animals and used for the production of undecalcified microtome and ground sections. Intravital fluorochrome labelling was used to determine the asymmetric growth at this suture; this is interpreted as being the formation of new bone following passive expansion of the sutural region. After injury or transplantation of the periosteum and after the healing of a narrow bone defect or fracture we observed either a continuous suture from the outset or the formation of a new fissure after osseous regeneration. Similar findings were also made after the transplantation of compact rib fragments into a sutural defect without subsequent bridging of the defect. Only after the transplantation of autologous pieces of cancellous rib into an osseous defect in the sutural region was sutural ossification, accompanied by distinct deformation of the skull observed. As a clinical consequence of this it may be presumed that trauma or operation in the region of a suture has a considerable effect on the growth of the visceral cranium only if it results in premature synostosis.

Animals↗
PubMed1995

Clinical results of the one-bone forearm.

Between 1973 and 1991, 19 patients underwent creation of a one-bone forearm at our institution as treatment for radioulnar instability secondary to trauma ("type 1" patients) or tumor resection or congenital deformity ("type 2" patients). Seventeen had failed previous reconstruction attempts. Ten one-bone forearms were constructed in neutral rotation, and nine in varying pronation (mean, 24 degrees). The distal ulna was absent or excised at the time of surgery in nine patients, partially excised in two, and shortened in one. At a mean follow-up interval of 42 months, the primary union rate was 68%, and the secondary rate was 74%. Using a rating scale devised for this study, 37% excellent, 32% good, 26% fair, and 5% poor results were noted. Poor results were statistically associated with previous trauma (type 1 patients), infection, severe nerve injury, and multiple previous surgical procedures. This is a retrospective study, and because of the limitations of such studies, no correlation of results with forearm rotational position, preoperative wrist or elbow dysfunction, fusion location, distal ulna excision or synostosis union was noted. Significant complications were noted in 10 patients, with a higher rate in type 1 patients. Although one-bone forearm construction remains a viable salvage option for forearm instability in selected patients, results may be less predictable than previously reported.

Adult↗
PubMed1995

Post-traumatic irreducible nondissociative carpal instability: a case report.

We present a case that is unusual in two respects. To our knowledge, it is the first clearly documented instance in the literature of a post-traumatic, irreducible nondissociative volar intercalated carpal instability to result from a known wrist flexion force and a known dorsal capsuloligamentous tear. Second, the same wrist revealed a coalition at both intraosseous levels of the proximal carpal row: a synfibrosis at the scapholunate joint and a synostosis at the lunotriquetral joint. Treatment by open removal of an interposed capsuloligamentous flap from the radiocarpal joint, followed by alignment of carpal elements, temporary internal fixation, and repair of the damaged dorsal capsule and ligaments gave an excellent result.

Accidental Falls↗
PubMed1977

Congenital deficiency of the ulna.

Twenty-three patients with ulnar ray deficiency were studied and the deformities described by combining Kummel's and Swanson's classifications. An individualized, functionally oriented management program is recommended with early resection of the fibrocartilaginous remnant to prevent shortening, radial bowing, and possible malrotation. Rotational deformity can be corrected by wedge osteotomy, rotation osteotomy, or proximal radial ulnar synostosis. Improved motion at the elbow can be obtained by release of contractures or resection of the radial head. Wrist deformity may require resection of the ulnar remnant and a wedge osteotomy of the radius.

Adolescent↗
PubMed2000

Tibiofibular syndesmosis and ossification. Case report: sequelae of ankle sprain in an adolescent football player.

Heterotopic ossification development within the interosseous membrane of the ankle is an uncommon occurrence after routine ankle sprains. We present a case of a high school football player who sustained a syndesmosis ankle sprain. After 4 weeks, he continued to have pain, swelling, and range of motion restriction despite being treated with cryotherapy, NSAIDs, supportive taping, and progressive rehabilitation. The radiographs revealed a heterotopic ossification within the interosseous membrane of the distal extremity. The patient was initially treated conservatively and went on to have surgical excision with an excellent result. Symptomatic patients will require definitive surgery even without frank synostosis.

Adolescent↗
PubMed2002

Comparing and contrasting methods for tenodesis of the ruptured distal biceps tendon.

The evidence is clear that anatomic reinsertion is the best treatment for an active, compliant patient with an acute distal biceps rupture or a subacute rupture without significant proximal retraction of the tendon. Patients with partial tears and chronic ruptures require surgical attention when persistently symptomatic. Biceps tenodesis through dual incisions or a single anterior incision is a safe, highly reliable, and effective operation. The posterior interosseous nerve is potentially at risk with either approach. This risk is minimized by avoiding exposure and retraction of the nerve. Heterotopic ossification and subsequent proximal radio-ulnar synostosis are reported complications of the two-incision technique. The incidence of this devastating complication has been reduced, but not eliminated, by using a limited posterior forearm muscle-splitting incision and by not exposing the ulna. It is the authors' belief that a single anterior incision with suture anchor fixation of the distal biceps (in the manner described herein) is the surgical treatment of choice for most distal biceps ruptures. Compared with the two-incision method, the posterior interosseous nerve is at no more risk and the chance of heterotopic ossification is diminished. The secure fixation obtained and the limited surgical exposure required allow for early mobilization and rapid return of function.

Elbow Joint↗
PubMed1997

[Functional treatment of isolated fractures of the ulnar diaphysis in adults. A prospective study apropos of 10 cases and review of the literature].

In this prospective study, ten consecutive isolated fractures of the ulna were treated by short-arm plaster cast (an average of 16.8 days) with immediate mobilization in our institution since January 1995. The minimum follow-up was eight months and the longest was two years. All fractures were closed. The median age of the patients was 36.7 years (17 to 61), the male to female ratio was 7 to 3. The patients were seen and radiographed every two weeks until bridging external callus was detected by same surgeon. Monteggia fractures-dislocation, open fractures, fractures with elbow or wrist dislocation and gunshot fractures were also excluded. The fracture involved the distal third in 5 cases, the distal quarter in 4 cases and the middle third in one case. Seven fractures were displaced between 2.5 and 6 mm, but no fracture needed reduction. All patients returned to work a mean of 4 months after the accident. Some angulation was found in most cases, but it rarely exceeded 10 degrees. In this study, the average healing time was 8 weeks and there were no non-unions. We did not encounter any synostosis between the radius and ulna in our patients. Motion at the wrist and elbow was always restored. All patients were satisfied by the functional method. The method that we have described can be safely recommended as treatment of choice for these fractures. Completely displaced, Monteggia fractures, comminuted or gunshot fractures of the ulna should be treated by other methods.

Adolescent↗
PubMed1998

Rapid palatal expansion. Part 2: Dentoskeletal changes in cats with patent versus synostosed midpalatal suture.

Intercanine expansion (C-C) following rapid palatal expansion is made up of sutural displacement (Sd-Sd), tooth tip (Tt-Tt), tooth displacement (Td-Td), and alveolar process tipping and bending (At+b-At+b). The involvement of these four components was studied on 10 rapid palatal expansion treated and two control cats during an active phase (25 days), a retention phase (60 days), and a relapse phase (60 days). The midpalatal suture was analyzed for linear measurements, radiopaque versus radiolucent zones and optical density from occlusal radiographs. Nine treated cats exhibited sutural split and one treated cat showed no split as a result of synostosis of the suture. The contribution of the four constituents [(Sd-Sd):(Tt-Tt):(Td-Td):(At+b-At+b)] to the C-C expansion changed from active to relapse phase from [45%:15%:25%:15%] to [50%:25%:25%:0%] in the animals with sutural split and from [0%:40%:60%:0%] to [0%:0%:100%:0%] in the cat without sutural split, implying the major role of sutural displacement in patent suture, and tooth displacement in synostosed suture. The latter indicates the potential buccal corticalis fenestration, dehiscence or perforation in synostosed suture undergoing RPE. In patent suture (animals with sutural split), optical density increased during rapid palatal expansion (soft tissue build-up) and decreased during retention (remineralization) and relapse phases (medial convergence of the palatal processes). In the animal without sutural split, a continuous decrease in the optical density (predetermined ossification) was found. The progressive six-fold surge in coefficient of variation of C-C expansion during the relapse phase indicates limitation in predicting rapid palatal expansion stability. Clinically, the use of serial occlusal radiographs during rapid palatal expansion is recommended to evaluate patency and extent of retention period.

Animals↗
PubMed1995

Perspectives on craniofacial asymmetry. V. The craniosynostoses.

The craniosynostoses are both etiologically and pathogenetically heterogeneous and many syndromes have been delineated. The present paper highlights well-known craniosynostoses that can present asymmetrically. These include plagiocephaly resulting from premature unilateral synostosis of the coronal or lambdoid sutures. Apert syndrome, and Saethre-Chotzen syndrome.

Acrocephalosyndactylia↗
PubMed1998

Posterior maxillary anatomy: implications for Le Fort I osteotomy.

The most common site of haemorrhage in maxillary osteotomies is the posterior maxilla. Better understanding of the anatomy in this region may minimize possible vascular complications. The aim of the study was to study the osteology of the posterior maxillary region and establish clinical safety guidelines for the Le Fort I osteotomy Thirty human dry skulls were selected and assessed by a combination of direct inspection, computerized imaging and computed tomography (CT) scan analysis. Results showed that the presence of maxillary third molars influenced the transverse angulation of the posterior vertical cut. Synostosis of the pterygomaxillary junction was noted in 12% of samples. The mean length of the medial sinus wall from the piriform rim to the descending palatine canal at the Le Fort I level was 34 mm. The three-dimensional CT-reconstructed descending palatine canal ran at 60 degrees anteroinferiorly to the palatine plane and slightly medially to the exit through the greater palatine foramen.

Adult↗
PubMed1997

[Oxycephaly, a severe craniosynostosis. Apropos of a series of 129 cases].

AIMS: The authors analyse a series of patients with oxycephaly in order to detail the definition of this craniosynostosis and its functional prognosis. PATIENTS AND METHODS: The medical records of 129 oxycephalic patients were reviewed. Skull X-rays, ophthalmologic examination, mental level assessment, intracranial pressure monitoring and CT scan were analysed. The more recent patients were also analysed by MRI. Operated on or not, the patients were followed-up, particularly as far as the mental evolution is concerned. Mean follow-up was 3 years 7 months. RESULTS: One third of the patients came from North Africa, where oxycephaly seems predominant. Mean age at diagnosis was 6 years. Past history of rickets was found in 15% of the patients. On X-rays, the vast majority of the patients presented with multisutural synostosis involving both coronal and sagittal sutures, and diffuse digital prints. At the first mental assessment, one third of the patients had an IQ below 80. Papilledema was found in 17%. The monitoring of intracranial pressure showed an increased pressure in almost two thirds of the patients. Sixty-four percent of the patients with increased intracranial pressure had a normal fundoscopy. Out of 16 patients explored by MRI, 12 had a Chiari I malformation. Postoperatively, all papilledemas disappeared, and the intracranial pressure returned to normal in all cases with preoperative increased intracranial pressure. The mental level seemed to stabilize, the mean postoperative IQ being strongly correlated with the preoperative level. In non-operated patients, the mental level worsened significantly. CONCLUSIONS: Oxycephaly is a late-appearing craniosynostosis, with a high risk of ophthalmologic and mental complications. Based on the present series, the operation seemed effective in preventing these complications.

Adolescent↗
PubMed2003

Neurocranial suture autotransplantation and periosteal dura stripping to provide a passive growth site in craniosynostosis--a case report.

AIM: The behaviour of a neurocranial suture autograft in a plagiocephalic infant is described. PATIENT AND METHODS: In a 7-month-old girl, born with right-sided unicoronal synostosis, part of the left-sided unicoronal suture was transplanted to the right-sided synostosectomy site. Also, in the pathological area, the periosteal 'layer' of the dura was surgically removed. The suture autotransplantation was integrated into the classical concept of radical remodelling, planned in a computer design environment. Growth of the suture was monitored by CT. RESULTS: Suture patency and osseous growth within the autograft could be demonstrated over a 1-year period. CONCLUSION: Neurocranial suture autotransplantation together with the prohibition of fusion-inducing dural signals seems to be a promising technique in the treatment of certain premature synostoses. This warrants a prospective clinical trial.

Bone Transplantation↗
PubMed1994

Histomorphological analysis of the effect of rigid fixation on growing sutures in the rabbit.

The effect of internal rigid fixation (IRF) on bone growth was studied in an experimental model set up in the rabbit. The frontonasal suture of the right side was surgically bridged by a microplate. As reference for bone growth, four screws were placed symmetrically in the four bony segments including the frontonasal suture on both sides. The suture development was followed dynamically for 40 days on the basis of the position of the screws established radiographically. The rate of bone formation along the sutural bones was evaluated by means of the tetracycline labelling technique. The structure of the newly formed bone and its degree of mineralization were respectively analysed under polarized light and with microradiography. It was demonstrated that IRF prevents growth of the sutural membrane but not of the osteogenic process; as a consequence the constrained sutures soon undergo synostosis. This fact must be taken into consideration when IRF is employed in children in order to avoid delayed removal of the plate irreversibly stopping the growth of the constrained suture.

Animals↗