G Hatzikostas General Hospital

Ioánnina, Greece

G Hatzikostas General Hospital

Ioánnina, Greece

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Pneumaticos S.G.,National and Kapodistrian University of Athens | Panteli M.,University of Leeds | Triantafyllopoulos G.K.,National and Kapodistrian University of Athens | Papakostidis C.,G Hatzikostas General Hospital | Giannoudis P.V.,University of Leeds
Surgeon | Year: 2014

Objectives: To review current treatments utilising biological enhancement modalities and their efficacy for the management of lower limb long bone aseptic non-unions. Materials & methods: A systematic review of English articles using PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, supplemented by a manual search of bibliographies. Results: Thirteen manuscripts met the inclusion criteria reporting on 428 patients. The overall healing had a pooled estimate of effect size at 94.3%. The calculated summarised estimate of effect size for deep infection rate (413 patients) was 2.3%. Three subgroups were then created on the basis of the exact type of graft used at the non-union site (ABG, BMP-7, BMP-7 + ABG). Comparison between the above subgroups revealed that ABG resulted in approximately 3-fold increase of the odds of healing compared with the use of BMP-7. Combined use of ABGs and BMP-7 improved the odds of healing by 3.5 times compared with BMP-7 alone. However, the previous median operations prior to the implantation of ABG or BMP-7 treatment was 1.09 versus 2.3 respectively (p = 0.02). Although the implantation of ABG was associated with a greater incidence of infection the documented differences did not reach significance. Conclusions: Although ABG was found to have a higher success rate compared to BMP-7 (95% Vs 87%), patients treated with BMP-7 had a higher number of previous failed interventions, statistically significantly so (BMP-7 is used for the treatment of more recalcitrant non-unions). It is the surgeon's judgement that should determine the most suitable treatment modality, depending on the nature and characteristics (personality) of the non-union and the patient. © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.


PubMed | University of Leeds, G Hatzikostas General Hospital and National and Kapodistrian University of Athens
Type: Journal Article | Journal: The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland | Year: 2014

To review current treatments utilising biological enhancement modalities and their efficacy for the management of lower limb long bone aseptic non-unions.A systematic review of English articles using PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, supplemented by a manual search of bibliographies.Thirteen manuscripts met the inclusion criteria reporting on 428 patients. The overall healing had a pooled estimate of effect size at 94.3%. The calculated summarised estimate of effect size for deep infection rate (413 patients) was 2.3%. Three subgroups were then created on the basis of the exact type of graft used at the non-union site (ABG, BMP-7, BMP-7+ABG). Comparison between the above subgroups revealed that ABG resulted in approximately 3-fold increase of the odds of healing compared with the use of BMP-7. Combined use of ABGs and BMP-7 improved the odds of healing by 3.5 times compared with BMP-7 alone. However, the previous median operations prior to the implantation of ABG or BMP-7 treatment was 1.09 versus 2.3 respectively (p=0.02). Although the implantation of ABG was associated with a greater incidence of infection the documented differences did not reach significance.Although ABG was found to have a higher success rate compared to BMP-7 (95% Vs 87%), patients treated with BMP-7 had a higher number of previous failed interventions, statistically significantly so (BMP-7 is used for the treatment of more recalcitrant non-unions). It is the surgeons judgement that should determine the most suitable treatment modality, depending on the nature and characteristics (personality) of the non-union and the patient.


Panteli M.,University of Leeds | Papakostidis C.,G Hatzikostas General Hospital | Dahabreh Z.,Sydney Orthopaedic Research Institute | Giannoudis P.V.,University of Leeds
Knee | Year: 2013

Background: To examine the safety and efficacy of topical use of tranexamic acid (TA) in total knee arthroplasty (TKA). Methods: An electronic literature search of PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, identifying studies published in any language from 1966 to February 2013. The studies enrolled adults undergoing a primary TKA, where topical TA was used. Inverse variance statistical method and either a fixed or random effect model, depending on the absence or presence of statistical heterogeneity were used; subgroup analysis was performed when possible. Results: We identified a total of seven eligible reports for analysis. Our meta-analysis indicated that when compared with the control group, topical application of TA limited significantly postoperative drain output (mean difference: -. 268.36. ml), total blood loss (mean difference. = -. 220.08. ml), Hb drop (mean difference. = -. 0.94. g/dL) and lowered the risk of transfusion requirements (risk ratio. = 0.47, 95CI. = 0.26-0.84), without increased risk of thromboembolic events. Sub-group analysis indicated that a higher dose of topical TA (>. 2. g) significantly reduced transfusion requirements. Conclusions: Although the present meta-analysis proved a statistically significant reduction of postoperative blood loss and transfusion requirements with topical use of TA in TKA, the clinical importance of the respective estimates of effect size should be interpreted with caution. Level of evidence: I, II. © 2013 Elsevier B.V.


Papakostidis C.,G Hatzikostas General Hospital | Bhandari M.,G Hatzikostas General Hospital | Bhandari M.,McMaster University | Giannoudis P.V.,G Hatzikostas General Hospital | Giannoudis P.V.,University of Leeds
Bone and Joint Journal | Year: 2013

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of refracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection. ©2013 The British Editorial Society of Bone & Joint Surgery.


Papakostidis C.,G Hatzikostas General Hospital | Papakostidis C.,University of Leeds | Papakostidis C.,Teaching Hospital Policlinico Umberto Rfis1 | Papakostidis C.,Chapel Allerton Hospital | And 12 more authors.
Injury | Year: 2015

The aim of the present study was to evaluate the effect of timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. We undertook a systematic review of the literature adhering to the PRISMA guidelines. There were 7 eligible reports for the final analysis. The methodological quality of component studies was assessed with the Coleman Methodology Score (CMS). Each included study was assigned a score independently by the two reviewers. The final score of each individual study constituted the average value of the scores given by the two reviewers. The agreement between the two assessors was tested with intraclass correlation coefficient (ICC). The CMS ranged from 37 to 64 within component studies (mean: 46.5, SD: 10.8, median: 41). The ICC was 0.94 (95% CI: 0.69-0.99), implying a nearly perfect agreement between the two assessors. Based on the available data regarding the timing of operative fixation of the femoral neck fractures, 4 discreet pairs of comparison groups could be created: (1) fractures fixed within 6 h from injury versus fractures fixed after 6 h from injury; (2) fractures fixed within 12 h versus after 12 h; (3) fractures fixed within 24 h versus after 24 h; and (4) fractures fixed within 6 h versus after 24 h. Outcome measures were analyzed within each one of the above pairs of treatment groups. The following subgroups analyses were a priori decided: (1) initial fracture displacement (displaced vs. undisplaced fractures); (2) fixation method (cannulated screws vs. sliding hip screw); (3) quality of reduction (anatomic vs non-anatomic reduction). This study failed to prove any essential association between timing of NOF fracture internal fixation and incidence of AVN. With respect to non-union though, it indicated that delay of internal fixation of more than 24 h could increase substantially the odds of non-union. © 2015 Elsevier Ltd.


Papakostidis C.,G Hatzikostas General Hospital | Tosounidis T.H.,University of Leeds | Tosounidis T.H.,Chapel Allerton Hospital | Jones E.,University of Leeds | And 2 more authors.
Acta Orthopaedica | Year: 2016

Background and purpose - The value of core decrompression for treatment of osteonecrosis of the femoral head (ONFH) is unclear. We investigated by a literature review whether implantation of autologous bone marrow aspirate, containing high concentrations of pluripotent mesenchymal stem cells, into the core decompression track would improve the clinical and radiological results compared with the classical method of core decompression alone. The primary outcomes of interest were structural failure (collapse) of the femoral head and conversion to total hip replacement (THR).Patients and methods - All randomized and non-randomized control trials comparing simple core decompression with autologous bone marrow cell implantation into the femoral head for the treatment of ONFH were considered eligible for inclusion. The methodological quality of the studies included was assessed independently by 2 reviewers using the Cochrane Collaboration tool for assessing risk of bias in randomized studies. Of 496 relevant citations identified, 7 studies formed the basis of this review.Results - The pooled estimate of effect size for structural failure of the femoral head favored the cell therapy group, as, in this treatment group, the odds of progression of the femoral head to the collapse stage were reduced by a factor of 5 compared to the CD group (odds ratio (OR) = 0.2, 95% CI: 0.08-0.6; p = 0.02). The respective summarized estimate of effect size yielded halved odds for conversion to THR in the cell therapy group compared to CD group (OR = 0.6, 95% CI: 0.3-1.02; p = 0.06).Interpretation - Our findings suggest that implantation of autologous mesenchymal stem cells (MSCs) into the core decompression track, particularly when employed at early (pre-collapse) stages of ONFH, would improve the survivorship of femoral heads and reduce the need for hip arthroplasty. © 2015 Nordic Orthopaedic Federation.


PubMed | University of Leeds and G Hatzikostas General Hospital
Type: Journal Article | Journal: Acta orthopaedica | Year: 2016

The value of core decrompression for treatment of osteonecrosis of the femoral head (ONFH) is unclear. We investigated by a literature review whether implantation of autologous bone marrow aspirate, containing high concentrations of pluripotent mesenchymal stem cells, into the core decompression track would improve the clinical and radiological results compared with the classical method of core decompression alone. The primary outcomes of interest were structural failure (collapse) of the femoral head and conversion to total hip replacement (THR).All randomized and non-randomized control trials comparing simple core decompression with autologous bone marrow cell implantation into the femoral head for the treatment of ONFH were considered eligible for inclusion. The methodological quality of the studies included was assessed independently by 2 reviewers using the Cochrane Collaboration tool for assessing risk of bias in randomized studies. Of 496 relevant citations identified, 7 studies formed the basis of this review.The pooled estimate of effect size for structural failure of the femoral head favored the cell therapy group, as, in this treatment group, the odds of progression of the femoral head to the collapse stage were reduced by a factor of 5 compared to the CD group (odds ratio (OR) = 0.2, 95% CI: 0.08-0.6; p = 0.02). The respective summarized estimate of effect size yielded halved odds for conversion to THR in the cell therapy group compared to CD group (OR = 0.6, 95% CI: 0.3-1.02; p = 0.06).Our findings suggest that implantation of autologous mesenchymal stem cells (MSCs) into the core decompression track, particularly when employed at early (pre-collapse) stages of ONFH, would improve the survivorship of femoral heads and reduce the need for hip arthroplasty.


Papakostidis C.,G Hatzikostas General Hospital | Kanakaris N.,Academic Unit of Trauma and Orthopaedic Surgery | Dimitriou R.,Academic Unit of Trauma and Orthopaedic Surgery | Giannoudis P.V.,Academic Unit of Trauma and Orthopaedic Surgery
European Journal of Radiology | Year: 2012

Objective: To evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures. Methods: A systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications. Results: All component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%). Conclusion: TAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control. © 2011 Elsevier Ireland Ltd. All rights reserved.


Papakostidis C.,G Hatzikostas General Hospital | Psyllakis I.,Academic Unit of Trauma and Orthopaedic Surgery | Vardakas D.,G Hatzikostas General Hospital | Grestas A.,G Hatzikostas General Hospital | Giannoudis P.V.,Academic Unit of Trauma and Orthopaedic Surgery
Injury | Year: 2011

Dynamisation of a previously interlocked intramedullary nail is believed to stimulate an osteogenic response due to increased load across the fracture site. The purpose of this study was to retrospectively investigate fracture patterns that could tolerate dynamisation without the risk of major complications. Thirty patients (24 males) with an average age of 33 years (17-90) were studied. As many as 21 suffered from a fresh femoral fracture, whereas the remaining nine patients suffered from femoral nonunions. Four patterns of osseous lesion were recognised in terms of mechanical stability under a dynamic nail and biological activity at the fracture/nonunion site: stable/hypertrophic, stable/atrophic, unstable/hypertrophic and unstable/atrophic osseous lesions. Complete union (within 6 months) occurred in 21 patients. Six fractures united within the 7th-11th post-dynamisation month and, in the remaining three cases, a nonunion developed. Significant femur shortening (>20 mm) was noticed in four patients and rotational malalignment in one patient. Logistic regression analysis revealed high odds ratio (OR = 70, 95% confidence interval (CI) 2.5-1998) for the unstable/atrophic pattern of osseous lesion to develop major complications. In the unstable/atrophic pattern of osseous lesion, dynamisation should never be done, as it could lead to significant complications. © 2011 Elsevier Ltd. All rights reserved.


We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

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