Shoulder periprosthetic fracture in elderly patient: a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. A case report and literature review

A case of shoulder periprosthetic fracture in elderly patient. The patient underwent a minimally invasive osteosynthesis and "off-label" treatment with teriparatide. An 80-year-old woman patient following an accidental fall reported a transverse displaced diaphyseal fracture of the right humerus, distal to the stem of the inverse prosthesis. The patient suffering from severe osteoporosis and chronic ischaemic heart disease. The patient underwent fracture osteosynthesis surgery using a Hoffmann III mono-axial external fixator. Teriparatide administered at a dosage of 20 micrograms/day, for four months. At six months from the beginning of th e hybrid treatment, a complete healing of the fracture was observed radiologically and clinically. It is possible to affirm that the use of teriparatide off-label has a positive and additive effect in promoting the healing of fractures.

Arthroscopic treatment of acute acromioclavicular joint dislocation with double flip button

The ideal treatment for acute acromioclavicular joint dislocation is still controversial, both in terms of indications and surgical technique. The clinical and radiographic outcomes of 16 patients affected by acute AC joint dislocation (type III-V) and arthroscopically treated with a coracoclavicular double flip button are presented. Despite the excellent clinical results both in terms of Constant score (mean 97 points) and patient satisfaction, at a mean follow-up of 31 months the radiographs showed partial loss of reduction due to distal migration of the flip button within the upper third of the clavicle in one-fourth of the cases. The technique presented here proved to be safe and minimally invasive while delivering good aesthetic results and allowing for the treatment of associated lesions. Furthermore, the technique could benefit from more advanced retention devices, which ought to reduce or avoid migration of the flip buttons.

Presence of NGF and its receptor TrkA in degenerative lumbar facet joint specimens

In a preliminary study, the recurrent presence of nervous terminations was demonstrated with optical microscopy in several slides of degenerative lumbar facet joints and surrounding soft tissues. The purpose of this study was to prove the presence of NGF (nerve growth factor) and its receptor TrkA (tyrosine kinase receptor) with immunofluorescence. The peri/articular tissues were harvested from the lumbar facet joints of ten patients surgically treated for degenerative diseases. There were seven females (one bilateral) and two males whose mean age at surgery was 72 years (range, 67-80 years). The affected levels were L3-L4 in two cases and L4-L5 in seven cases (one bilateral). All specimens were fixed in formalin, dehydrated and enclosed in paraffin. From each specimen, four slides were obtained. Two slides were employed for the search of NGF: one was treated with specific antibodies and marked with FITC (fluorescein isothiocyanate conjugated), and the second slide was for control purposes. It was exposed to FITC, but without prior exposure to the specific antibody. The same procedure was repeated to obtain on two more slides, to repeat the search for Trka with specific antibodies. All the slides were finally studied on a fluoromicroscope. The analysis of these specimens revealed the presence of the neurotrophin (NGF) and its own receptor (TrkA) in all cases: the immunohistochemical reaction between the specimens and the specific antibodies marked with FITC was seen under fluoromicroscopy, but in none of the control cases treated with FITC only. NGF is released by mastocytes, fibroblasts and other cell types involved in the inflammatory processes. The level of peripheral NGF is increased in inflammatory processes, while the administration of exogenous NGF has a hyperalgesic effect on rats and produces muscular pain in humans. Furthermore, NGF produces hypersensitization to heat stimulation in humans and mammals in general. There is considerable evidence showing that the system constituted by the NGF and its high-affinity receptor TrkA plays a fundamental role in the molecular processes underlying the main forms of "persistent" pain. This indicates a possible therapeutic area for the antibodies that could block the NGF/TrkA system, in order to modulate the frequency and the duration of the action potential of nociceptive neurons during chronic inflammation. This study demonstrated the presence of NGF and TrkA in specimens collected from degenerative facet joints, suggesting that specific molecules could be used in order to modulate chronic pain in patients with degenerative lumbar spine.

Complex articular fractures of the distal radius: the role of closed reduction and external fixation

Twenty-two patients underwent surgery for 23 complex articular fractures of the distal radius of C.3 type, according to the AO classification. The surgical treatment consisted, in all cases, of a closed, or limited-open, reduction and external fixation. The functional and radiographic results were analysed at a mean follow-up of 40 months. This retrospective study confirms that satisfactory functional results where obtained in 12 out of the 15 wrists where all the intra and extra-articular parameters of the Fernandez' criteria where respected. For those wrists where keeping with Fernandez' criteria for intra-articular parameters and ulnar variance was not possible, four of eight had satisfactory results. As far as the acceptability criteria for radial inclination and dorsal tilt are concerned, the functional results seem to suggest that a little wider tolerance than proposed in the literature could be accepted.

Clinical and ultrasound results after arthroscopic repair of the rotator cuff

The literature reports good functional results obtained with arthroscopic repair of the rotator cuff, but the incidence of anatomical healing has not been sufficiently studied. Ultrasound examination makes it possible to accurately document the healing process of the tendon at the bone, gathering information that may be useful in a comparison with clinical data. A total of 43 consecutive arthroscopic repairs of rotator cuff injuries were considered, that had made use of anchors and non-resorbable suturing. A total of 42 patients were willing to undergo clinical monitoring with an associated ultrasound examination after 3, 6 and 12 months. When ultrasound examination after 6 and 12 months was carried out, 36 patients presented with anatomical healing of the rotator cuff. The total percentage of repair failures was 14.3% and increased to 23% if we take into consideration the subscapular tendon alone. Constant score went from a preoperative mean of 51.25 to a mean of 78.21 after 12 months (p<0.001). Arthroscopic repair of the rotator cuff leads to anatomical healing of the tendons in a high percentage of cases, obtaining good functional results. The absence of healing is associated with lower values for recovery of strength at clinical follow-up. The advanced age of the patients (p<0.001) and the extensive injuries that involve several tendons (p=0.002) are negative prognostic factors.

Stem revision: special implant versus primary device

The purpose of hip revision surgery is to relieve pain and restore hip function, while improving hip biomechanics and bone stock. The entity of bone stock impairment due to lysis indicates to the surgeon which revision stem he would preferably choose. Modern literature has described several options for stem revision, ranging from primary cemented/less implants in the case of limited proximal bone defects, to special revision stems where a massive femoral bone stock impairment is present. There are many classifications of the femoral bone-stock loss in the literature but most authors seem to agree that the treatment of minimal proximal defects should be performed with primary implant stems. The need to bridge a bigger bony gap makes distal fixation a good deal. Two options are described for this purpose: the Wagner stem and modular stems. Wagner's concept consists of a distal fixation based on the interference of the straight tapered titanium alloy stem at the level of the femoral isthmus, while longitudinal fins provide rotational stability. A wide variety of modular stems was lately developed to prevent major complication associated to the Wagner's stem, but some new problems arose from proximal overfill of the canal, difficult in assembly and fretting corrosion. Early experience with the new ZMR taper (Zimmer, Warsaw, IN, USA) modular revision stem is reported.

Femoral revision with special stems

None.

Peritalar release in the treatment of congenital talipes equinovarus clubfoot

It is the purpose of this retrospective study to evaluate the results of the surgical treatment of congenital talipes equinovarus clubfoot. Seven patients affected with congenital talipes equinovarus clubfoot, 2 of which bilateral, treated surgically using peritalar release according to Simons were re-examined. The long-term follow-up results obtained after an average of 4 years were evaluated from clinical, morphofunctional, and radiographic points of view, and with the help of a photopodogram and computed baropodometry. The subjective satisfaction of the patients was also evaluated. Results were considered to be good in all of the cases. In conclusion, surgery involving peritalar release allows for correction of abduction of the forefoot, and restores physiological calcaneal valgus, re-balancing standing on the plantar surface; the persistence of an area of hypostanding in the forefoot operated on and of mild, residual cavus of the plantar arch do not, thus, seem to influence the good results obtained.

The surgical treatment of fractures of the proximal end of the tibia: a review of cases as related to prognostic factors

It is the purpose of this retrospective study to analyze factors capable of influencing clinical-functional and radiographic results, such as type of fracture, age of the patients, type of trauma, delay in treatment, associated lesions. A total of 33 fractures treated by open reduction and internal stabilization for fractures of the proximal tibia classified according to the AO were re-evaluated. Clinical and radiographic evaluation were obtained by assessing arthrosis, axis, and sinking of the tibial plateau. The clinical and functional results were satisfactory in 72.2% of cases, and radiographic ones were satisfactory in 63.6% for gonarthrosis, in 81.6% for axis, and in 84.8% for sinking. In conclusion, factors capable of influencing the results, such as type of fracture, age of the patient, and type of trauma, in addition to variables that the surgeon must monitor, such as reconstruction of the joint, alignment, synthesis, treatment of meniscal lesions, were observed.