Abstract:

After attempting various types of research performed in different laboratories, this article describes the author’s research that began in 1980 on rats, and continued since 1993 on monkeys. Also presented are results of the first clinical cases regarding operations performed either by rerouting the ulnar nerve to the lower limbs, or connecting the rostral stump of the severed cord with peripheral nerves of the hip to obtain rudimentary, but efficient, walking. Recovery occurred well in advance of the expected time, and continues to improve daily. This connection functioned even if the axons that activated the single muscles were from mother cells dispersed in different regions of the brain cortex, which fire together—such as in a teleassembly. Furthermore, function occurred although the upper motorneuron uses the neurotransmitter glutamate, whereas motor end plates use receptors for Acetilcholine. These data are under new investigation to determine whether the upper motorneuron changes the transmitter, or if the motor end plate changes its receptors.

Authors:

Giorgio Brunelli, M.D.

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Abstract:

The objective of this study was to restore stepping-forward and ambulatory function in paraplegic patients with chronic injuries. Two to four normal vascularized intercostal nerves above the spinal cord injury site were obtained by cutting in the distal end at the midclavicular line. The proximal ends were disconnected from the levatores costarum. Nerves were then transferred to the vertebral canal through a submuscle tunnel and sutured with the selected fascicula of lumbar nerve roots (L1/2 or L3/4) by epiperneurial neurorrhaphy in the subdura or extradura. If the selected intercostal nerve was not of sufficient length to reach the specific lumbar region, a sural nerve segment was isolated, sheared into two segments, and attached to the intercostal nerve for grafting. Twenty-three patients, whose injury sites were between the thoracic T9 and T12 levels, were followed postoperatively for a period ranging from 2 to 11 (average: 3.5) years. Of these patients, 18 (78%) regained the stepping-forward function and were able to walk with crutches or other ambulatory assistive devices. In addition, 21 (91%) patients had improved thigh sensation. This intercostal nerve rerouting procedure restores significant stepping-forward and, in turn, ambulatory function and thigh-muscle sensation in paraplegic patients.

Authors:

Shaocheng Zhang, M.D., Laurance Johnston, Ph.D., Zhenwei Zhang, M.D., Yuhai Ma, Ph.D., Yuhua Hu, M.D., Jialin Wang, M.D., Ping Huang, M.D., Shuping Wang, M.D.

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Abstract:

Arthroscopic reconstruction of the anterior cruciate ligament (ACL) with a bone-patellar tendon-bone graft in the press-fit technique is an efficient procedure, which provides high primary stability without use of implants and thus ensures early functional rehabilitation. The procedure is based on graft harvest with an oscillating hollow saw, which allows collection of cylindrical bone blocks. Femoral fixation using a template and file has been standardized to an extent that ensures secure press-fit fixation. Tibial anchorage is achieved by refilling the tibial tunnel with the bone cylinder removed previously. Primary stability is at least equivalent to that achieved with interference screw or staple fixation, and has been evaluated in a pull-out study in ovine knees. Two major problems encountered with revision procedures—metal removal or tunnel enlargement—may be avoided effectively. In a prospective study of 32 patients, postoperative computed tomography (CT) evaluation after three months showed presence of cancellous bone material inserted into the tibial tunnel. Postoperative tunnel enlargement seen frequently with other procedures can be avoided in almost all knees. Revision procedures after press-fit fixation can be done without problems. This procedure provides a cost-efficient alternative for reconstruction of the ACL, because it does not require implants.

Authors:

Harald Boszotta, M.D.

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Abstract:

Endoscopic spine surgery is evolving rapidly due to improvements in surgical technique, endoscope design, and instrumentation. The current technique expands on the basic features and principles of Kambin’s access to the spine through the triangular zone. A standardized method for foraminal surgery, the Yeung Endoscopic Spine System (YESS)™ (Richard Wolf Surgical Instrument Company, Vernon Hills, Illinois, USA) technique is proposed: (1) A protocol for optimal instrument placement by identifying the skin window, annular window, anatomic disc center, and disc inclination plane through topographical coordinates calculated by lines drawn on the skin from the C-Arm image. Adjustments in the trajectory are made to accommodate individual anatomic considerations and the pathologic disorders to be accessed. (2) Evocative Chromo-Discography™. (3) Selective Endoscopic Discectomy™. (4) Thermal discoplasty and annuloplasty. (5) Endoscopic foraminoplasty. (6) Accessing the epidural space in the axilla between the traversing and exiting nerve root. (7) Partially resecting the posterior annulus to get beneath the herniated fragment, if needed. This technique allows access to the epidural space from the lumbar disc as far cephalad as the middle of the vertebral body and approximately 2-3 mm caudally. The foraminal approach is routinely accessible from T-10 to L4-5. L5-S1 can be accessed with special techniques that include foraminoplasty of the lateral facet. Surgical results continue to improve, consistent with refinement of indications and techniques for specific conditions treatable by this endoscopic method.

Authors:

Anthony T. Yeung, M.D., Christopher A. Yeung, M.D.

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Abstract:

The OrthoPilot® (Aesculap, Tuttlingen, Germany) Knee Navigation System represents a computed tomograpahy (CT)-free system. In older software versions, a rigid-body at the iliac crest was necessary to calculate the centre of the hip. The latest software versions, 3.0 and 4.0, use a new mathematical algorithm to reconstruct the mechanical axis. Using the OrthoPilot® system, an intraoperative cinematic study can be done that results in calculation of the mechanical axis and navigation of resection cuts. According to flexion- and extension-gap balancing, the anterior/posterior (a.p.) position and rotation of the femoral component also are navigated. Thirty navigated SEARCH® (Aesculap, Tuttlingen, Germany) total knee arthroplasties (TKA) using the software version 3.0 of an uninterrupted series were evaluated, versus 30 navigated knees using older software and a manual group. Results concerning alignment were determined to be superior to the older navigation and manual groups. The number of cases with a good mechanical axis, 0; low; or 2° of deviation from optimum, was reached in 17 of the manual, 19 of the older-version, and 27 of the newer-version navigation cases. More features were solved in a convincing manner. The numbers of ouliers were diminished. Navigation in TKA using the OrthoPilot® has become more safe and effective.

Authors:

Ulrich Clemens, M.D., Rolf K. Miehlke, M.D.

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Abstract:

The goal of using navigation systems in total hip arthroplasty (THA) is to minimise malpositioned components, increase range of motion, and decrease the risk of dislocation, which may result in long- term stability. The two systems used to navigate the acetabular component are CT-based and fluoroscopybased. Between May 2001 and May 2002, surgery was performed on 153 patients using navigation systems for cup positioning. The CT-based system was used in 46 patients and fluoroscopy-based system in 107. The diagnoses were primary osteoarthritis in 120 of the patients, and secondary osteoarthritis following congenital and post-traumatic deformities in 33. The outcomes of the operations were investigated clinically and radiologically. Mean variation of the postoperative abduction angle to the preoperative planning was 2.7° (0-8) after CT-based navigation and 3.9 (0-9) after fluoroscopy-based navigation. After the first 30 surgeries with each system, the operating time was extended by 9 minutes using the CT-based system and by 13 minutes with the fluoroscopy-based system compared to hand implantation. Also, the preoperative planning using the CT-based system was more time-consuming. No additional planning was necessary when the fluoroscopy-based system was used. Both systems were accurate and provided an improved reproducible quality. The CT-based system provided a link between the preoperative planning and intraoperative placement of acetabular components. Only a minimal difference was noted when compared to the fluoroscopy-based procedure; however, the timeconsuming set up remains a problem. The advantage in using the CT-based system is the three-dimensional feed back of anatomic landmarks, but a disadvantage is the time-consuming preoperative procedure (CT-scan, data transfer, planning). For this reason the CT-based method should be performed in cases of congenital and posttraumatic deformities. The fluoroscopy-based method is easier to handle in routine cases with normal anatomy or lesser deformities. Both systems present an excellent additional tool to improve reproducible quality in THA.

Authors:

Robert Hube, M.D., Andreas Birke, M.D., Werner Hein, M.D., Stefan Klima, M.D.

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Abstract:

Total knee replacement (TKR) has been well accepted as the definitive knee- salvage procedure. Existence of a predictable, reproducible, salvage procedure has allowed for re-evaluation of other surgical techniques, such as unicompartmental arthroplasty, to prolong or preserve knee function. Knee osteoarthritis has been described as highly segmental, primarily medial, and slowly progressive. Loss of articular cartilage is compensated by development of sclerotic bone, which although it supports weight, it deforms with weightbearing and produces pain. Ligament imbalance is not compensated. A mini-invasive knee arthroplasty has been developed that features the following three criteria: (1) minimizes physiologic damage, (2) minimizes interference in life style, and (3) avoids interference with future treatment options. Unicompartmental knee arthroplasty can, therefore, be performed as a low-morbidity outpatient procedure while preserving bone for future TKR—in essence, a pre-TKR procedure. Techniques include limited surgical exposure, internal landmarks for prosthetic insertion, and pain management to facilitate out-patient status.

Authors:

John A. Repicci, D.D.S., M.D.

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Abstract:

Osteoarthritis (OA) is a debilitating, degenerative disease of the articular cartilage and synovial fluid. Approximately 20 million Americans suffer from this disease for which no cure exists as yet. The primary goals of current OA therapy are centered on controlling pain; improving, preserving, or both, joint function and mobility; and improving health-related quality of life—but not on reversing the disease process. Current treatment options of OA consist of both non-pharmacological and pharmacological modalities. Nonpharmacological therapy that consists of patient education and physical/occupational therapy is a primary component of OA management, either rendered alone or in combination with pharmacological treatment. The several options for pharmacological treatment include acetaminophen, nonspecific NSAIDs, and COX-2 specific inhibitors. Many of these drugs, however, are beset with serious side effects. For patients with severe OA not responsive to medical treatment, nonsurgical interventions such as viscosupplements and injectable compounds that mimic healthy synovial fluid or surgical interventions are two likely options. The former, however, have not been shown unequivocally to be effective. Future treatment modalities for OA are geared toward reversing the disease process and may include disease-modifying drugs and gene therapy.

Authors:

Gurkirpal Singh, M.D.

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