Bony Debris Research Articles

Bone Cutter versus Oscillating Saw for Ray Amputation: A Protocol for Randomised Controlled Feasibility Trial comparing Outcomes between Metatarsal Methods of Transection (MetaMet)

Background Ray amputation is commonly performed for irretrievable digital infections and/or ischemia, particularly in diabetic foot disease. Re-ulceration and reoperation rates after toe amputation range from 43-65%. Numerous studies have investigated patient-dependent factors of wound healing, including diabetes, malnutrition, smoking, and renal failure. However, there has been minimal research on the impact of technical surgical factors on patient outcomes. Methods This protocol describes a single-center, prospective, randomized controlled, assessor-blinded feasibility study comparing outcomes after ray amputation between two accepted methods: metatarsal transection, manual bone cutter (BC), or an oscillating microsaw (OS). The inclusion criteria were adults undergoing toe amputation via metatarsal transection capable of providing informed consent. The exclusion criteria were significant peripheral arterial disease (ABPI <0.4) and en bloc resection of three or more toes. Participants will be allocated to one of two parallel groups in a 1:1 fashion using randomization by minimization, stratifying for chronic kidney disease (eGFR <60 mL/min/1.73 m2) and palpable pulses. The primary objective was to gather sufficient data to accurately power a future definitive trial. Secondary outcomes included differences between the two trial arms in re-operation and readmission rates at six months, time to wound healing post-index procedure, and patient-reported postoperative pain scores. Ethical approval was granted for recruitment in January, 2023. Discussion We hypothesized that an OS reproducibly achieves a smoother and more precise cut and produces less bony debris to act as an infective nidus with minimal inter-surgeon variation. Due to a lack of guiding evidence, surgeon preference for ray amputation technique evolves from the ‘apprenticeship’ training model, personal experience, and local equipment availability. We aimed to provide robust data to guide decision-making as the incidence of diabetes increases and the number of minor amputations increases. Trial Registration ClinicalTrials. gov registration NCT05804565 on 26/03/2023

Cam-Type Impingement: Ensuring an Ideal Femoroplasty

When conservative measures have failed, arthroscopic femoroplasty has proven highly efficacious in treating femoroacetabular impingement (FAI) and improving hip joint mechanics. It is best to approach this in a systematic manner with preoperative planning and intraoperative confirmation. Plain radiographs, MRI and/or CT are helpful in the preoperative assessment with identifying the location and shape of the cam deformity. Understanding the extent of the cam lesion prior to surgical intervention will aid in the resection process. The resection can then be confirmed by an intra-operative fluoroscopic exam and arthroscopic dynamic motion evaluation under direct visualization. Using the trough technique, the resection can be marked using the cortical-cancellous border as a depth landmark. When performing the resection, a smooth contour should be performed, with an understanding that both over and under resection can be problematic. Adequate resection should be ensured by testing range of motion, with fluoroscopic imaging, to obtain a circumferential view of the resected area. It is essential to understand how to position the lower extremity in order to obtain different fluoroscopic views of the femoral head neck junction clock-face. Once complete, a thorough irrigation of the joint should be performed to remove bony debris. An ensuing capsular closure should be performed to minimize the risk of iatrogenic hip instability.

Endoscopic Insertional Achilles Reconstruction with Double Row Suture Bridge Reconstruction: A Technique Tip

Category:Ankle; ArthroscopyIntroduction/Purpose:Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with non- surgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery (MIS) and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infectionMethods:The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using MIS techniques while also incorporating a percutaneous double row suture anchor repair. The technique utilizes four portals to access two endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double row suture anchor repair.Results:With over 75 surgeries performed, there have been zero wound complications and patients have been able to return to full weight bearing within 10 days after surgery. Follow up outcome data is currently being collected and will be reported as a case series once sufficient patients have completed their follow up.Conclusion:This study presents double-row repair following an endoscopic assisted MIS calcaneoplasty and Achilles debridement. The technique combines the benefits of the double row suture bridge repair with a minimal incision technique to debride the insertional tendinosis. In order to adequately debride the tendon and the posterior calcaneal tuberosity, the tendon foot print is elevated as the burr removes the bone at the insertion. The anterior portion of the tendon, which may be a pain generator as well, isdebrided endoscopically with the shaver. Finally, a double row suture bridge repair is performed in order to allow early weight bearing and rehabilitation.

Endoscopic Haglund’s Resection and Percutaneous Double-Row Insertional Achilles Repair

Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with nonsurgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double-row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infection. The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using minimally invasive surgery techniques while also incorporating a percutaneous double-row suture anchor repair. The technique utilizes 4 portals to access 2 endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double-row suture anchor repair.Levels of Evidence: Level V.

Radiologic Features of Primary Intracranial Myxomas from the Skull Base: 14 Case Reports and Literature Review

Primary intracranial myxomas (PIMs) are extremely rare benign tumors that arise from the skull base. The aim of this study was to characterize the radiologic manifestation of PIMs in a series of 14 cases. We reviewed the imaging and clinical data of 14 patients with pathologically proven PIMs. Assessed features of lesions include shape, margin, bony destruction, attenuation and/or signal intensity, and pattern of enhancement. Extremely high-density foci indicating calcification or bony debris within the tumors were observed in 5 cases on computed tomography images. On magnetic resonance images, the tumors demonstrated heterogeneous hypointensity on T1-weighted images (T1WI) and hyperintensity on T2-weighted images (T2WI). A honeycomb pattern on enhanced T1WIs was observed in 63.6% (7/11) of the cases. Radiologic findings of PIMs include calcified foci or bone debris on computed tomography, heterogeneous hypointensity on T1WI and predominantly hyperintensity on T2WI, and honeycomb appearance on enhanced T1WI.

Optimal Colostomy Placement in Spinal Cord Injury Patients

Barring unusual circumstances, sigmoid colostomy is the optimal technique for management of defecation in spinal cord injury (SCI) patients. We sought to provide evidence that a sigmoid colostomy is not difficult to perform in SCI patients and has better long-term results. The St. Louis Department of Veterans Affairs has a Commission on Accreditation of Rehabilitation Facilities (CARF)-approved SCI Unit. We reviewed the operative notes on all SCI patients who received a colostomy for fecal management by three ASCRS-certified colorectal surgeons at the St. Louis Department of Veterans Affairs from January 1, 2007 to November 26, 2012. There were 27 operations for which the recorded indication for surgery suggested that the primary disorder was SCI. Fourteen had traumatic SCI of the thoracic and/or lumbar spine and were evaluable. Of these 14 patients, 12 had laparoscopic sigmoid colostomy and two had open sigmoid colostomy. We encountered one evaluable patient with a remarkably large amount of retroperitoneal bony debris who successfully underwent laparoscopic sigmoid colostomy. In conclusion, sigmoid colostomy is the consensus optimal procedure for fecal management in SCI patients. Laparoscopic procedures are preferred. Care providers should specify sigmoid colostomy when contacting a surgeon.

Charcot spine neuroarthropathy and hip heterotopic ossification

Charcot spine neuroarthropathy and heterotopic ossification (HO) are known complications of complete spinal cord injury. Heterotopic ossification occurs most frequently around the hip joint. The clinical significance of HO ranges from an incidental finding on radiographs to total ankylosis leading to severely limited range of motion [1,2]. A 54-year-old man with complete T10 spinal cord injury for 34 years was admitted to the authors’ institution with left distal femur fracture. Plain radiograph of the left hip showed severe HO (Fig. 1). Plain radiograph of the spine showed spine dislocation at L3–L4 with osteolysis of the L3 and L4 vertebral bodies (Fig. 2). Computed tomography scan of the spine showed three-column body destruction and bony debris in the paraspinal area characteristic of Charcot spine neuroarthropathy (Fig. 3).

Damage to apparel layers and underlying tissue due to hand-gun bullets

Ballistic damage to the clothing of victims of gunshot wounds to the chest can provide useful forensic evidence. Anyone shot in the torso will usually be wearing clothing which will be damaged by the penetrating impact event and can reportedly be the source of some of the debris in the wound. Minimal research has previously been reported regarding the effect of bullets on apparel fabrics and underlying tissue. This paper examines the effect of ammunition (9 mm full metal jacket [FMJ] DM11 A1B2, 8.0g; and soft point flat nose Remington R357M3, 10.2g) on clothing layers that cover the torso (T-shirt, T-shirt plus hoodie, T-shirt plus denim jacket) and underlying structures represented by porcine thoracic wall (skin, underlying tissue, ribs). Impacts were recorded using a Phantom V12 high speed camera. Ejected bone debris was collected before wound tracts were dissected and measured; any debris found was recovered for further analysis. Size and mass of bony debris was recorded; fibre debris recovered from the wound and impact damage to fabrics were imaged using scanning electron microscopy (SEM). Remington R357M3 ammunition was characteristically associated with stellate fabric damage; individual fibres were less likely to show mushrooming. In contrast, 9 mm FMJ ammunition resulted in punch-out damage to fabric layers, with mushrooming of individual fibres being more common. Entry wound sizes were similar for both types of ammunition and smaller than the diameter of the bullet that caused them. In this work, the Remington R357M3 ammunition resulted in larger exit wounds due to the bullet construction which mushroomed. That fabric coverings did not affect the amount of bony debris produced is interesting, particularly given there was some evidence that apparel layers affected the size of the wound. Recent work has suggested that denim (representative of jeans) can exacerbate wounding caused by high-velocity bullet impacts to the thigh when the bullet does not impact the femur. That more bony debris was caused by Remington R357M3 rather than 9 mm FMJ ammunition was not surprising given the relative constructions of these two bullets, and is of interest to medical practitioners.

MRI spectrum of bone changes in the diabetic foot

(1) To assess the prevalence of bone marrow changes in the diabetic foot and (2) to discuss the clinical significance of these changes. 85 patients with radiographic and magnetic resonance imaging (MRI) foot examinations were selected. Inclusion criteria were clinical diagnosis of diabetes and bone changes on radiographs and MRI. The material was selected from the image storage (PACS) system. We searched for vascular (infarct and necrosis), traumatic (bruise and occult fractures), destruction and debris, dislocation, osteochondritis, osteomyelitis. Five patients had bilateral examinations. A total of 90 feet were evaluated. From 90 feet, 17 (18.9%) presented with vascular changes, from them, 11 feet had infarct and 6 feet had necrosis. Twenty (22.2%) feet had traumatic changes; of them, 10 (50%) had edema on MRI. Five (25%) cases had occult fracture on MRI; and 5 (25%) had visible fracture on both X-ray and MRI. Bone destruction was detected in 8 (8.9%) feet. Bony debris was visualized in three of them. Bone dislocation was visualized in 11 (12.2%) feet. There was evidence of osteochondritis in twenty-four (26.7%) feet. Osteomyelitis was diagnosed in ten (11.1%) feet. Diabetic foot is a challenge for both clinicians and radiologists due to its complexity. The bone derangements inherent to the diabetic foot can be evaluated with high accuracy with MRI.

In vitro scanning electron microscopic comparison of inner surface of exposed and unexposed nonresorbable membranes

The purpose of this study was to analyze the attached tissues and the membrane surface condition according to barrier membrane exposure. The selected patients underwent implant surgery with guided bone regeneration, then were surgically reentered to remove the membrane when the membrane was exposed early or when the second surgery of implant was done. The membranes used in the study included titanium mesh (Jeil Medical Co., Seoul, Korea), Frios titanium shield (Dentsply Friadent, Mannheim, Germany), and TR-Goretex membrane (W. L. Gore & Associates, CA, USA). Group 1 included 9 cases that had membranes that were exposed during an early period. Each membrane was removed in 3-6 weeks. Group 2 included 8 cases that had membranes that were not exposed and each membrane was removed in 12-24 weeks during the second surgery period of implants. Removed membrane samples were observed with scanning electron microscopy. The membrane surface condition and the observed tissues were significantly different between the exposed membrane group and the unexposed membrane group (P < .05). In the majority of the cases of early exposed membranes, organic film and soft tissues were observed beneath the membrane. Bony debris was observed in only 1 sample from the exposed group. In the exposed group, the degree of membrane damage was more severe than in the unexposed group. The membrane surface condition and the observed tissues had no significant difference among the 3 kinds of membranes (P > .05). The observed tissues and the membrane surface condition were affected by the membrane exposure. If the membrane is exposed, the soft tissue and organic film interfere with direct contact to the bone, and this affects the barrier membrane surface condition and bony tissues.

Distal Biceps Tendon Reconstruction With Tendoachilles Allograft: A Modification of the Endobutton Technique Utilizing an ACL Reconstruction System

Distal biceps tendon ruptures typically occur with biceps contraction against resistance with the elbow flexed at 90 degrees. Anatomic repair is the gold standard in active patients. Numerous surgical techniques are available; however, the Endobutton might offer several advantages. We describe a novel technique for chronic distal biceps reconstruction using a modification of the Endobutton technique with an anterior cruciate ligament (ACL) drill guide as well as tendoachilles allograft. The Endobutton technique might offer several advantages, including direct tendon-to-bone healing, less bony debris to limit heterotopic ossification, less heating of the bone, ease of use, a biomechanical superiority, and excellent clinical outcomes.

Dental implants – pertinent papers 2002–2003: A personal view

T u c t s r o o a i i s when custom-made bridges and crowns fitted at the time of placement implants is the norm. This paper stresses the importance of careful planning and notes failures associated with bruxism; this harks back to similar warnings in earlier papers about implants. The benefits of accelerated care for patients are clear; we are, however, reminded that this is associated with a slightly higher risk of failure than the traditional approach.

HETEROTOPIC BONE FORMATION IN ASSOCIATION WITH PELVIC FRACTURE AND URETHRAL DISRUPTION

Purpose The initial and secondary management of pelvic fracture associated with disruption of the membranous urethra is the subject of a wide literature containing varied and controversial viewpoints. We have noted the presence of heterotopic bone formation surrounding the area of urethral injury in patients undergoing delayed repair. We investigated the etiology, incidence and risk factors associated with such an injury, as well as potential means of prophylaxis. Materials and Methods We reviewed the current literature on heterotopic bone formation with similar traumatic injury. While instances of severe urethral disruption of this type are fortunately rare in children, we describe prepubertal boys with such an injury complicated by heterotopic ossification. Results The incidence of heterotopic ossification reported in children and adolescents is 3 to 15%, which is less than 15 to 80% reported in adults. Risk factors associated with traumatic heterotopic ossification include prolonged operating time, hematoma formation, degree of bony debris, devitalized muscle and concomitant infection. Prophylaxis with single low dose radiation or nonsteroidal anti-inflammatory drugs has been shown to be effective in the prevention of heterotopic ossification and may be beneficial in this patient population. Conclusions Heterotopic bone formation associated with severe traumatic injury in the presence of devitalized tissue resulting in the pathological formation of new bone is rare. This complication is only associated with the most severe pelvic fractures. Prophylaxis in these most severe cases with low dose radiation or nonsteroidal anti-inflammatory drugs can prevent the formation of heterotopic bone.

Foreign Body Granulomatous Response to Particulate Bony Debris

SummaryArchival material was retrieved in order to histologically assess the body’s response to micron-sized, necrotic bony particles. Specimens were obtained from (1) human bone grafts in a subcutaneous or muscular pouch of athymic nude mice, (2) a massive bone allograft replacing a patient’s humerus, (3) rabbits’ healing tibial cortical bone defects littered with finely dispersed bony particles, (4) periprosthetic tissues of patient’s aseptically loosened artificial joints and (5) interfacial membranes of intramedullary nails used for fixation of patients’ fractured long bones. Necrotic bony debris was found to induce a giant celled granulomatous reaction. In sections of undecalcified samples stained by the von Kossa method, small calcific particles were observed to be present within polykaryonic macrophages (foreign body giant cells) and surrounded by mononuclear macrophages. It is concluded that a foreign body-type giant celled granulation tissue participates in the degradation of micron-sized, necrotic bony detritus, whether the disintegrating bone is of the xeno-, alio- or autogenic provenance.Histological examination of von Kossa-stained sections, of undecalcified specimens, revealed a giant celled granulomatous response to bony debris. Irrespective of whether or not the disintegrating bone was of auto-, alio- or xenogeneic provenance, micron-sized bony particles were found to be phagocytosed by polykaryonic macrophages of the granulation tissue.

Three rare causes of unilateral exophthalmos.

Unilateral exophthalmos may be caused by a wide variety of intra- and extraorbital diseases (3, 7, 13, 22, 23, 27). We have recently seen 3 unusual cases of unilateral exophthalmos, one due to a papilloma of the frontal sinus, the second to an orbital epidermoid tumor (cholesteatoma), and the third to myeloma. All three are here reported with a brief review of the literature. Case Reports Case I: The patient, a 54-year-old white female, was admitted to Jersey City Medical Center in May 1965 because of progressive proptosis of the right eye, double vision, and bifrontal headache for three years. Eye Examination: There was conspicuous exophthalmos of the right eye. Vision in the right eye was 20/50 and in the left 20/25. Exophthalmometer readings were 28 mm in the right eye and 16 mm in the left. Intraocular tension as measured by a Schiøtz tonometer with 5.5 g weight was 20 mm Hg (right) and 17.3 mm Hg (left). There were striae throughout the fundus, but disk and macula were spared. Roentgen Examination: The skull radiographs showed an expanding lesion arising in the frontal sinus, destroying the superior orbital wall on the right side (Fig. 1). Despite the fact that no mucosal thickening of the sinuses was evident, the lesion was thought to be a mucocele which originated in the frontal sinus and was destroying the orbital roof. A lateral projection air orbitotomogram revealed a 4 × 5-cm oval mass which arose from the frontal sinus and extended to involve the superior portion of the right orbit, causing marked proptosis (Fig. 2). Operative Findings: The orbit contained a gelatinous material and multiple thin bony plaques representing bony debris from the superior orbital wall, which was almost totally destroyed. Further exploration revealed a large granulomatous cauliflower-like tumor, arising from the frontal sinus and extending downward to displace the globe forward and down. There was no direct invasion of the globe. The pathologic diagnosis was papilloma arising in the frontal sinus (Fig. 3). Case II: The patient, an obese, 38-year-old Negro female, was admitted to Jersey City Medical Center in September 1965 with a six-month history of progressive protrusion of the left eye. Eye Examination: In the right eye vision was 20/50; in the left 20/25. The fundi were clear. Exophthalmometer readings were 17 and 27 mm in the right and the left eye, respectively. Intraocular tension with 5.5 g weight was 14.6 mm Hg on the right and 17.3 mm Hg on the left. Roentgen Examination: Routine skull radiographs and tomograms showed considerable sclerosis of the left orbit with a localized bony defect or dehiscence, suggestive of a dermoid or epidermoid tumor (Figs. 4 and 5). During the air orbitotomography, about 6 cc of dark brownish, oily fluid was aspirated from the cystic mass, which was well delineated by air (Fig. 6). The aspirated fluid contained large quantities of cholesterol crystals.

A NEW INSTRUMENT FOR CLEANING RHINOPLASTIC SAWS

The instrument illustrated in the accompanying figure is a new instrument devised for the purpose of removing the bony debris from the Joseph saws employed in corrective rhinoplasty. This instrument is a three-sided file that is triangular shaped to fit into the interstices of the saw teeth. Wire or bristle brushes will not remove bony debris that is wedged deep between the saw teeth, whereas this instrument will do so. The file is drawn between the teeth diagonally until the saw is completely clean. The file is sterilized and the saws checked at operation before using them. There is considerable evidence to indicate that the transfer of bony debris from one patient to another may be attended by a postoperative foreign body reaction that is almost indistinguishable from an infection. 1 I have noted a distinct drop in the number of such postoperative complications since I have avoided this transfer of