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PubMed2006

Pretibial ganglion-like cyst formation after anterior cruciate ligament reconstruction: a consequence of the incomplete bony integration of the graft?

We report a case of subcutaneous pretibial ganglion, with direct communication to the tibial tunnel after an autologous reconstruction of the anterior cruciate ligament with hamstring tendons. The tibial graft fixation was with a 9 mm poly-L-lactide interference screw 5 years earlier. The screw had undergone complete resorption at the time the cyst occurred. No joint inflammatory reaction or graft insufficiency was detected. The patient underwent cyst excision and curettage of the tibial tunnel with full recovery. This complication seems to be the consequence of a direct communication between the joint and the pretibial subcutaneous tissue through a fibrous tibial tunnel and would have occurred, as there is no full osteointegration of the graft due to the resorption of the bioabsorbable interference screw.

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PubMed2006

Recurrent locking of knee joint caused by intraarticular migration of bioabsorbable tibial interference screw after arthroscopic ACL reconstruction.

Two cases are reported in which, after ACL reconstruction with autologous hamstring grafts, tibial polylactide interference screws migrated into the knee joint. Clinically, both patients presented with recurrent locking of the joint. In one case, a broken 15 mm-long tip of the screw was found intra-articularly. In the other case, the whole screw had migrated into the joint cavity. The degradation process of polylactic acid, operative technique and bone quality are discussed as possible reasons for these complications.

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PubMed2007

Double-bundle versus single-bundle anterior cruciate ligament reconstruction: a prospective, randomize clinical study.

Anatomical observation and biomechanical studies have shown that the anterior cruciate ligament (ACL) mainly consists of two distinct bundles, the anteromedial (AM) bundle and posterolateral (PL) bundle. Conventional single-bundle ACL reconstruction techniques have focused on the restoration of the AM bundle while giving limited attention to the PL bundle. The purpose of this prospective, randomized clinical study is to compare the outcomes of ACL reconstruction when using either double-bundle or single-bundle technique and bioabsorbable interference screw fixation, and similar rehabilitation with both techniques. Sixty-five patients were randomized into either double-bundle (n = 35) or single-bundle (n = 30) ACL reconstruction with hamstring tendons and bioabsorbable screw (Hexalon, Inion Company, Tampere, Finland) fixation in both groups. The evaluation methods were clinical examination, KT-1000 arthrometer measurements, radiographic evaluation, as well as International Knee Documentation Committee and Lysholm knee scores. There were no differences between the study groups preoperatively. For an average of 14 months of follow-up (range 12-20 months), 30 patients of the double-bundle group and 29 patients of the single-bundle group were available (91%). At the follow-up, the rotational stability, as evaluated by pivot shift test, was significantly better in the double-bundle group than in the single-bundle group. However, in anterior stability of the knee, there was no significant difference between the groups. None of the patients in the double-bundle group had graft failure, while four patients in the single-bundle group had. In addition, knee scores were equal at the follow-up, and all the results were significantly better at the follow-up than preoperatively, in both groups.

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PubMed2000

A new bicortical tibial fixation technique in anterior cruciate ligament reconstruction with quadruple hamstring graft.

We report a prospective series of 101 patients receiving a four-strand semitendinosus-gracilis autograft for anterior cruciate ligament reconstruction using a new bicortical tibial fixation technique with bioabsorbable interference screws. Patients (average age 32 years) were operated on between November 1997 and Mai 1998, and follow-up was at least 12 months postoperatively. The evaluation consisted of history, clinical examination, IKDC score, Cincinnati Knee Score, KT-1000 testing, standardized radiography and magnetic resonance imaging. One hundred patients were available for follow-up. There were two traumatic reruptures 6 and 11 months postoperatively. By IKDC score 87 patients were in groups A and B, 12 in group C, and 2 with a rerupture in group D. Mean Cincinnati Knee Score was 82 (range 46-100), KT-1000 manual maximum at follow-up showed an average difference of 1.7 mm between the sides. Full extension was rapidly achieved in all cases, and flexion averaged 135 degrees . Considering the enlargement caused by the bioabsorbable interference screws, the incidence of tunnel widening was 6.6% on the femoral side and 1.7% on the tibial side. Tunnel widening did not affect the clinical results. Three patients experienced an effusion after more than 6 months postoperatively. There was one infection, which settled without functional impairment after early arthroscopic lavage and intravenous antibiotics. Otherwise no complications occurred. The described technique for anterior cruciate ligament reconstruction combines the advantage of anatomical graft position with sufficient graft fixation. A short intra-articular graft construct with a strong tendon to bone interface was created. Clinically, 87% of patients had a normal or nearly normal IKDC score at follow-up. Magnetic resonance imaging revealed a considerable increase in tunnel area caused by the insertion of the interference screws. On the other hand, the development of a "fibrous interzone" between the graft and the bone tunnel was prevented in most cases. At short-term follow-up the bicortical tibial fixation proved to be efficient even with an aggressive rehabilitation program.

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PubMed2000

A novel inserter instrument (Crossbow) for installation of self-reinforced bioabsorbable arrows into meniscus tissue.

A novel inserter, Crossbow, was developed for arthroscopic installation of self-reinforced bioabsorbable meniscus arrows into meniscus tissue. The Crossbow comprises a reservoir cartridge for up to four arrows, a triggering mechanism, and an interchangeable (curved or straight) trocar for guiding and installation of an arrow. A randomized biomechanical study was carried out by installing 13-mm-long meniscus arrows into fresh porcine menisci with the Crossbow and with the standard manual inserter trocar system. The mean pull-out force for Crossbow-installed arrows was 56.8 +/- 14.2 N, and that for arrows installed with the manual system was 43.7 +/- 13.8 N; the difference was statistically significant. While Crossbow is easy and rapid to use and gives good grip of arrows into pig meniscus, it may be an attractive alternative instrument to treat bucket-handle lesions of the menisci arthroscopically.

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PubMed2000

A clinical and radiographic comparison of absorbable and non-absorbable suture anchors in open shoulder stabilisation.

The aim of this study was to compare the clinical and radiographic results using either absorbable or non-absorbable suture anchors in patients with recurrent unidirectional, post-traumatic shoulder dislocations. All patients had a Bankart lesion. One surgeon operated on 33 consecutive patients, 27 males and six females. Group A comprised 15 shoulders and group B 18 shoulders, all of which underwent a standardised open Bankart reconstruction using 3.7-mm TAG suture anchors. In group A, absorbable anchors were used, while in group B, non-absorbable ones were used. There was one re-dislocation in each group. In group A, the Rowe and Constant scores were 89 (69-98) and 89 (76-99) points, respectively. The corresponding values in group B were 87 (44-98) (not significant; NS) and 90 (71-100) points (NS). The strength measurements revealed 8.1 (3.8-12.3) kg in 90 degrees abduction in group A and 10.0 (6.7-12.0) kg in group B. Healthy control shoulders revealed 10.2 (4.5-13.2) kg (NS A and B versus controls). The external rotation in abduction was 70 degrees (40-90) in group A and 80 degrees (40-100) in group B. The value for the controls was 90 degrees (80-120) [P < 0.001 (A versus controls), P < 0.05 (A versus B) and P < 0.001 (B versus controls)]. The radiographs revealed that 9/15 (60%) in group A and 10/15 (66%) in group B had visible drill holes or cystic formations in conjunction with the drill holes (NS). Furthermore, 11/15 (73%) in group A and 10/15 (66%) in group B had signs of minor degeneration (NS). We conclude that, in terms of stability and clinical results, no differences were found between the study groups. Both groups demonstrated a restriction in external rotation as compared with the healthy shoulders in the same cohort. On the radiographs, visible drill holes or cystic formations in conjunction with the drill holes were seen with equal frequency, regardless of whether absorbable or non-absorbable suture anchors were used.

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PubMed1999

Clinical experience with PDS II augmentation for operative treatment of acute proximal ACL ruptures--2-year follow-up.

The results of prospective anterior cruciate ligament (ACL) refixation in 33 patients with high proximal rupture is reported at 20-28 months' follow-up: mean age was 31.1 +/- 12.5 years. The surgical technique was a specially developed refixation of the ACL using a multiple suture loop (modified Marshall technique) augmented with intra-articular PDS II (polydioxanon, resorbable, Ethicon, Hamburg, Germany) to avoid derangement of blood circulation and to guarantee early functional rehabilitation. All patients were operated on within 7.3 +/- 4.5 days after injury. According to the IKDC evaluation score, 22 patients showed excellent and 10 patients good subjective function. Twenty regained their pre-injury level of activity. Anterior stability was tested manually and by KT-1000 max (Medmetric, San Diego). Twenty-eight patients had a firm end-point, although there was a positive Lachman test in 16 patients. Maximal joint laxity as measured by KT-1000 showed a 1-2 mm, 3-5 mm, 6-10 mm and > 10 mm anterior drawer for 16, 14, 2 and 1 patients, respectively. Twenty-five of the evaluated knee joints had a negative pivot shift test. Three patients had a limited range of motion. The potential advantages of PDS II-augmented refixation of acute proximal ACL ruptures are anatomic reconstruction without destruction of other anatomic structures used as grafts, early functional rehabilitation and possibly better proprioception.

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PubMed1999

Meniscus repair.

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PubMed2001

Biomechanical properties of quadruple tendon and patellar tendon femoral fixation techniques.

Two femoral fixation techniques for quadruple hamstring tendon grafts were compared under cyclic loading with the patellar tendon: the rectangular inserted pin (TransFix) and biodegradable interference screw fixation of the quadruple tendon and titanium interference screw fixation of the middle third of the patellar tendon. Porcine specimens were mounted onto a tension load machine, and the tendon-fixation-femur-complex was tested for stiffness, displacement during 800 cycles of loading between 50 and 250 N and ultimate tension load. TransFix fixation showed the greatest stiffness at 183.6 N/mm ( P<0.05). The least displacement under cyclic loading was observed for the titanium interference screw followed by the TransFix and biodegradable interference screw ( P<0.01). The ultimate tension load was greatest for the TransFix fixation at 1303+/-282 N, followed by patellar tendon fixation with 763+/-103 N and the biodegradable interference screw fixation with 480+/-133 N ( P<0.001). To reduce initial elongation of the graft and displacement at the fixation site, preconditioning of both the tendon and tendon-fixation complex is especially important when using quadruple tendons. TransFix fixation provides better stability and greater stiffness and pull-out strength than the other techniques. This finding is of clinical relevance to surgeons of the anterior cruciate ligament.

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PubMed2005

Bulk and surface modifications of polylactide.

This article reviews various methods of modifying the bulk and surface properties of poly(lactic acid) (PLA) so that the polymer may be used as a drug carrier in a drug delivery system (DDS) and as a cell scaffold in tissue engineering. Copolymerization of lactide with other lactone-type monomers or monomers with functional groups such as malic acid, copolymerization of lactide with macromolecular monomer such as poly(ethylene glycol) (PEG) or dextran, as well as blending polylactide and natural derivatives and other methods of bulk modification are discussed. Surface modifications of PLA-type copolymers, such as surface coating, chemical modification, and plasma treatment are described. Cell culture technology proves the efficiency of bulk and surface modification and the potential application of PLA in tissue engineering.

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PubMed2004

Quantification, localization, and expression of IGF-I and TGF-beta1 during growth factor-stimulated fracture healing.

Because of the increasing interest on stimulating fracture healing, knowledge about the role and chronology of growth factors during the healing process is important. The purpose of this study was to quantify the protein concentration of IGF-I and TGF-beta1 during rat tibial fracture healing 5, 10, and 15 days after fracture using ELISA methods and to analyze the distribution of the proteins and the related mRNA expression in the fracture callus by immunohistochemistry and in situ hybridization. The following three groups were analyzed: Fractured tibiae intramedullary stabilized with K-wires coated with IGF-I and TGF-beta1 compared with fractures stabilized with uncoated K-wires and unfractured tibiae. The weight of the callus increased during the healing process in both experimental groups. The protein concentration of IGF-I and TGF-beta1 in the fracture callus showed significant changes between the investigated time points and treatment groups compared with the unfractured tibia. IGF-I increased with healing time whereas TGF-beta1 revealed a constantly elevated level at the investigated time points. Mesenchymal cells, osteoblasts, osteocytes, proliferating and immature chondrocytes, and osteoclasts expressed both growth factors. No differences in the expression and localization pattern of the growth factors were detectable among the groups. Using the different methods for quantification and visualization of the growth factors, no differences (except the increased IGF-I concentration at day 15 in the growth factor group) were seen between the normal and the growth factor-stimulated fracture healing as an indication for physiological healing after exogenous growth factor treatment.

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PubMed2000

Bacterial adherence to silver nitrate coated poly-L-lactic acid urological stents in vitro.

The purpose of this study was to see whether it is possible to prevent bacterial adherence to bioabsorbable self-reinforced L-lactic acid polymer (SR-PLLA) urological stents. The SR-PLLA stents were coated with silver nitrate blended epsilon-caprolactone/L-lactide copolymer. The adherence of five bacterial strains (Pseudomonas aeruginosa, Enterococcus faecalis, Proteus mirabilis and two strains of Escherichia coli) to coated and non-coated SR-PLLA wires were tested. It was found that silver nitrate coating prevented the adherence of bacteria (except E. faecalis) to SR-PLLA stents. The preventive effect correlated with the silver nitrate concentration. It was also found that silver nitrate coating reduced the amount of bacteria in ambient urine. In conclusion, silver nitrate coating may reduce stent-associated bacterial infections by preventing the adherence of bacteria. Further studies are needed to confirm its efficacy and safety in clinical practice.

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PubMed2006

MRI of menisci repaired with bioabsorbable arrows.

OBJECTIVE: To analyze with conventional magnetic resonance imaging (MRI) the signal appearance of menisci repaired with bioabsorbable arrows. DESIGN AND PATIENTS: Forty-four patients with 47 meniscal tears treated with bioabsorbable arrows underwent follow-up conventional MRI examination. The time interval between the surgery and MRI varied from 5 to 67 months (mean 26 months). Twenty-six patients also had concurrent repair of torn anterior cruciate ligament. The following grades were used to classify meniscal signal intensity: (a) G0; low signal intensity on all sequences and regular configuration in every plane, (b) G1; increased signal intensity within the meniscus, not extending to the meniscal surface, (c) G2; increased signal intensity linear in shape, which may or may not communicate with the capsular margin of the meniscus, without extending to the meniscal surface, and (d) G3; increased signal intensity extending to the meniscal surface. RESULTS: Thirteen menisci (27.5%) had normal signal intensity, 13 menisci (27.5%) Grade 1 signal intensity, 9 menisci (19%) Grade 2 signal intensity and 12 menisci (26%) Grade 3 signal intensity. The time difference between operation and MRI was statistically significant between the G0 (36 months) and G3 groups (14 months; P = 0.0288). There was no statistical significance in different grades between medial and lateral meniscus or between patients with operated or intact ACL. On physical examination sixteen patients reported slight symptoms, seen evenly in each group. CONCLUSION: No difference was seen in different grades between patients with operated or intact ACL. The highest incidence of menisci with a Grade 3 signal was seen in patients where surgery was within the last 18 months.

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PubMed2003

Plug migration and cement mantle assessment in total hip replacement.

We reviewed a series of consecutive total hip replacements with cemented femoral components. Modern cementing techniques were followed in all cases, but two different medullary plugs were used-one was polyethylene and the other bioabsorbable gelatin. Cement mantle quality and plug migration were assessed by three different observers (X, Y, and Z); their findings did not agree. This was particularly evident when the cement mantles were assessed. There was a better cement mantle grading and less distal migration with polyethylene plugs, although there was no significant statistical difference between the two groups.

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PubMed2004

The minimal approach: an innovation in facial cosmetic procedures.

Plastic surgery is a rapidly growing field, particularly the use of less invasive procedures such as biodegradable dermal fillers and botulinum toxin. Aging is a complex process involving two important factors: volume loss throughout the face, and repetitive muscle movements that cause wrinkles and folds. Dermal fillers work by providing support for facial structures, whereas botulinum toxin reduces the mimetic effects. In combination, these products can be used effectively to reshape and rejuvenate the face and neck. Dermal fillers can be used throughout the face to raise the eyebrows, fill the tear trough, reshape the nose, lift the nose tip, fill nasolabial folds and oral comissures, fill the cheeks, raise the cheekbones, reshape the jaw line, and rejuvenate the neck area. This "minimal approach" offers a faster, less painful, and less costly alternative or complement to surgical facelifts. A variety of biodegradable injectable products are currently available, the most common of which are collagen- or hyaluronic acid-based. Using these products in combination takes advantage of their hydrophobic and hydrophilic properties and can provide better and longer-lasting results. The addition of botulinum toxin can further extend the duration of results by reducing the mimetic stress that can break down the polymers. With regular maintenance treatments, the minimal approach using dermal fillers and botulinum toxin can give patients a "whole new look" with a fast and relatively painless lunchtime procedure.

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PubMed2004

Complications of bioresorbable fixation systems in pediatric neurosurgery.

OBJECTIVE: Bioresorbable devices are an attractive alternative to metal instrumentation for internal fixation of bone, and have been used extensively in orthopedic and craniofacial surgery. In neurosurgery, the reported literature is predominantly confined to pediatric craniofacial procedures, with encouraging results and minimal complications. We have used bioreabsorbable plates and screws in cranial and spinal pediatric neurosurgery procedures. We report four complications related to their usage. MATERIALS AND METHODS: Bioabsorbable instrumentation was used in pediatric patients for fixation of bone after cranial or spinal procedures. RESULTS: Four patients developed complications related to the instrumentation: 2 following cranial surgery for epilepsy, 1 after correction of a growing skull fracture, and 1 after laminotomy for an intramedullary tumor. Two patients had fibrous encapsulation with granuloma formation and 2 patients had osteolysis following the fixation. CONCLUSION: Bioabsorbable fixation devices for the stabilization of bone following craniotomy and laminotomy in pediatric patients may be associated with complications, including granuloma formation and osteolysis.

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PubMed1999

Comparison between the biofragmentable anastomosis ring and stapled anastomoses in the extraperitoneal rectum: a prospective, randomized study.

Serious complications can be carried by intestinal anastomoses, particularly in the distal and proximal part of the gastrointestinal tract. The biofragmentable anastomosis ring (BAR) has been shown to be a safe anastomotic technique, but its clinical applicability in the extraperitoneal rectum has not yet been completely established. This study compared BAR anastomoses and stapled anastomoses in the middle rectum. Thirty-six consecutive patients initially suitable for elective colorectal anastomosis in the middle rectum were enrolled into this study. All patients had intraperitoneal rectum carcinoma, and 31 underwent a colorectal anastomosis in the middle extraperitoneal rectum. They were randomly allocated to a stapled technique or BAR anastomosis. Intraoperative findings and technical drawbacks, tumor behavior, and postoperative course were recorded. All patients were followed up, and late stenosis rate was investigated by endoscopy. The procedure was carried out in each of the 15 patients randomized to receiving a BAR anastomosis. No major difficulties were encountered, and the time needed was even less than that required for a stapled anastomosis. One patient in the stapled group had an early bleeding that required a further laparotomy. No significant differences in postoperative complications were noted between the two groups, although one patient with stapled anastomosis experienced a clinical leakage that needed loop colostomy. Biofragmentability was regular; buttons were eliminated in 3 weeks without any bowel disturbance. BAR ring insertion in the deep pelvis did not produce a shorter colonic resection. The late stenosis rate was similar between the groups. This study shows that in extraperitoneal middle rectum BAR anastomosis is as feasible and safe as the stapled method. The latter is more expensive, and manual suture is more difficult. Therefore the BAR is now the method of choice for this anastomosis in the authors' unit.

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PubMed2005

The effect of low intensity ultrasound and bioabsorbable self-reinforced poly-L-lactide screw fixation on bone in lateral malleolar fractures.

INTRODUCTION: There are no previous reports of low intensity pulsed ultrasound therapy in connection with bioabsorbable fracture fixation. In this randomised, prospective, double-blind and placebo-controlled study, the effects of ultrasound on bone mineral density and bone healing were examined in lateral malleolar fractures fixed with a bioabsorbable self-reinforced poly-L-lactide screw (SR-PLLA). MATERIALS AND METHODS: Thirty adult patients with SR-PLLA screw-fixed lateral malleolar fracture underwent ultrasound therapy 20 min daily for 6 weeks. Half of the patients were provided randomly with a sham ultrasound device. Bone mineral density and bone healing were assessed by dual-energy X-ray absorptiometry (DXA) and by radiographs. RESULTS: Bone mineral density of the fractured lateral malleolus tended to increase slightly during 12 weeks of follow-up. The increase was symmetrical and statistically non-significant between the ultrasound and non-ultrasound group. All the fractures healed uneventfully. The biocompatibility of the bioabsorbable SR-PLLA fixation device and low intensity pulsed ultrasound was good. Despite the slight tendency for more frequent callus formation in the ultrasound group, no statistically significant effect of low intensity pulsed ultrasound on lateral malleolar fracture healing could be observed. CONCLUSION: It was not possible to observe any statistically significant effect of low intensity pulsed ultrasound on lateral malleolar fracture healing in this study. Further studies are needed to examine the role of ultrasound therapy in the healing of fractures treated with bioabsorbable fixation devices.

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