Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results

Introduction

Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique.

Methods

Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures.

Results

The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p <0.001). Twenty-one complications occurred in 46 patients (46%): Seven patients had a clinical change of elbow axis: Three valgus (6%), four varus (9%); Superficial wound infection occurred in one case (2%) and ulnar nerve dysfunction in two (4%). The most common medium-term complication was post-traumatic osteoarthritis in eight cases (17%). Heterotopic ossification occurred in five patients (11%) and elbow stiffness in five cases (11%).

Conclusion

The use of the hinged elbow external fixator in the treatment of complex elbow trauma is a valid therapeutic adjunct to ligamentous reconstruction showing encouraging results with acceptable complications.

How to cite this article

Meccariello L, Caiaffa V, Mader K, et al. Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results. Strategies Trauma Limb Reconstr 2022;17(2):68–73.

Dexamethasone and Nutraceutical Therapy Can Reduce the Myalgia Due to COVID-19 - a Systemic Review of the Active Substances that Can Reduce the Expression of Interlukin-6

Background

Myalgia reflects generalized inflammation and cytokine response and can be the onset symptom of 36% of patients with COVID-19. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF- α) levels in plasma and upper respiratory secretions directly correlate with the magnitude of viral replication, fever, and respiratory and systemic symptoms, including musculoskeletal clinical manifestations.

Objective

The aim of our work is to report literature scientific investigation clinical protocol to reduce the immunomodulation and inflammatory response nutraceutical therapy associated with dexamethasone and how can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Methods

We searched in Pubmed and Cochrane the nautriceutical drugs to treat the immune modulation of organism to COVID-19. We put these keywords: immune inflammation, desease descriptions, epidemiology COVID-19; immunomodulations; IL-6; Rheumatic Symptoms; Joint; Musculoskeletal Disorders; dexamethasone; Polydatin; Zinc; Melatonin; N- Acetyl Cysteine; Colostrum; L- Glutamine; Vitamin D3.

Results

We found 61 papers. All the authors analyze them. After the Analyze we suggest the use of response nutraceutical therapy associated with dexamethasone can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Conclusion

According the scientific literature nutraceutical therapy associated with dexamethasone can reduce the expression of Interlukina-6(IL-6) and myalgia due to COVID-19.

Obesity and Bone: A Complex Relationship

There is a large literature on the relationship between obesity and bone. What we can conclude from this review is that the increase in body weight causes an increase in BMD, both for a mechanical effect and for the greater amount of estrogens present in the adipose tissue. Nevertheless, despite an apparent strengthening of the bone witnessed by the increased BMD, the risk of fracture is higher. The greater risk of fracture in the obese subject is due to various factors, which are carefully analyzed by the Authors. These factors can be divided into metabolic factors and increased risk of falls. Fractures have an atypical distribution in the obese, with a lower incidence of typical osteoporotic fractures, such as those of hip, spine and wrist, and an increase in fractures of the ankle, upper leg, and humerus. In children, the distribution is different, but it is not the same in obese and normal-weight children. Specifically, the fractures of the lower limb are much more frequent in obese children. Sarcopenic obesity plays an important role. The authors also review the available literature regarding the effects of high-fat diet, weight loss and bariatric surgery.

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability

Background:

Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children’s daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique (Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures.

Hypotheis:

The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children.

Methods:

From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 22 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique, in brief, is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation.

Results:

At the final follow-up, statistically significant differences in not weight-bearing times were found in favor of the IOLE group. There were no statistical differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion.

Conclusions:

The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.

Locking retrograde nail, non-locking retrograde nail and plate fixation in the treatment of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcomes

BACKGROUND

Distal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

METHODS

Retrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery.

RESULTS

There were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes.

CONCLUSIONS

Our results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons' experience, indications and subjective patients' aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

Scapular body fractures: Short-term results of surgical management with extended indications

INTRODUCTION

Scapular body fractures represent less than 1% of all skeletal fractures. Operative criteria and risk factors for scapular fracture instability are well defined. Non-operative management of scapular body fractures show satisfactory results but with shortening and medialization of the scapular body. The aim of this study is to evaluate if surgical treatment will result in an improved quality of life and shoulder function compared to non-operative treatment on patients suffering from a scapular body fracture.

MATERIALS AND METHODS

From a total of 381 retrospectively identified scapular body fractures, we included 45 patients. The enrolled patients were divided into two groups: the surgical treatment (ST, n = 20) group and the non-operative treatment (NOT, n = 25) group. The Non-Union Scoring System (NUSS) was used to assess bone healing on radiographs. The functional evaluation of the two groups during the follow-up were performed using the Constant Shoulder Score (CSS) and the Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Complications, reoperation rates, and time until bony union were also documented. The minimum follow-up for this study was designated as 12 months.

RESULTS

The ST group had better mean CSS and QuickDASH scores compared to the NOT group at 1, 3 and 6 months of follow-up. No statistically significant difference was detected at 12 months follow-up. ST group also demonstrated improved results in time until bone union, reduction of rehabilitation time, complications and return to work rates.

CONCLUSION

This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3 to 6 months) compared to conservative treatment.

Osteoporosis in Men: A Review of an Underestimated Bone Condition

Osteoporosis is called the 'silent disease' because, although it does not give significant symptoms when it is not complicated, can cause fragility fractures, with serious consequences and death. Furthermore, the consequences of osteoporosis have been calculated to weigh heavily on the costs of health systems in all the countries. Osteoporosis is considered a female disease. Actually, the hormonal changes that occur after menopause certainly determine a significant increase in osteoporosis and the risk of fractures in women. However, while there is no doubt that women are more exposed to osteoporosis and fragility fractures, the literature clearly indicates that physicians tend to underestimate the osteoporosis in men. The review of the literature done by the authors shows that osteoporosis and fragility fractures have a high incidence also in men; and, furthermore, the risk of fatal complications in hip fractured men is higher than that for women. The authors report the evidence of the literature on male osteoporosis, dwelling on epidemiology, causes of osteoporosis in men, diagnosis, and treatment. The analysis of the literature shows that male osteoporosis is underscreened, underdiagnosed, and undertreated, both in primary and secondary prevention of fragility fractures.

A new prognostic pelvic injury outcome score

Aim To propose a new prognostic classification system for pelvic injuries based on a new detailed and all-encompassing evaluation of the injury pelvic outcome score and to check the prognostic value of this classification and evaluate its reliability and reproducibility. Methods From January 2017 to June 2020 from 156 pelvic fractures treated at our hospitals, 98 patients with pelvic fractures were recruited according to inclusion and exclusion criteria. All patients compiled three scores (New Score System, Majeed Score, SF-12) sessions two times during the hospital stay to evaluate the endpoint before the trauma and two years after the trauma. All patients carried out three tests independently. The evaluation of three scores included a pelvic and general complication after the surgery, the times needed to compile three score system. For reliability of the new score systems we evaluated the inter-observer or intraobserver agreement, the prediction strength of each score, and a prognostic value. Results A total of 98 patients were enrolled (74 were males and 24 females) with mean age of 43.6 (±18.6) (range 16-75) years. Tau B Kendall value was 0.827 for the new score system, 0.673 for the Majeed score, 0.746 for SF-12, there was p<0.05 for the new score system. Conclusion The new score system is prognostic, reliable, reproducible and can become a useful instrument to adequately correlate the long-term outcomes of pelvic injury fractures. Also, it provides a better evaluation of pain, work, sexual possibilities and satisfaction, balance-sitting-walking and psychological status.

Platet Rich Plasma or Hyperbaric Oxygen Therapy as callus accellerator in aseptic tibial non union. Evaluate of outcomes

Background and aim of the work:

The incidence of long bone non-unions has been estimated to range between 5-10%. Nonunion of fracture is a delayed complication of fracture. A large bone resection, associated with Ilizarov’s osteo-distraction technique, is commonly used in these cases. The war experience was very important for dealing with these injuries. The purpose of this study is to report whether the use of Platelet Rich of Plasma(PRP) or Hyperbric Oxygen Therapy(HOT) as an adjuvant to the osteogenic distraction of Ilizarov with respect to the classical method has advantages.

Methods:

From 183 tibial non union, we enrolled 50 patients suffering by Type B according ASAMI non union classification. We divided the patients into two groups. The first group was a retrospective group of patient treated by Ilizarov Tecnique plus PRP. Instead the second group, patients were treated by Ilizarov Tecnique associated with HOT. The chosen criteria to evaluate the two groups during the clinical and radiological follow-up were: the complication after the surgery in the two groups; the duration of surgery; the objective quality Bone results and functional results were evaluated according to ASAMI classification while the subjective quality of life correlated with Ilizarov frame function by the Short Form 12 Health Survey (SF-12); The correlation between bone regenerate/bone healing and X-rays. The evaluation endpoint was set at 12 months from the remotion of Ilizarov’s frame for both groups.

Results:

In comparing the complications of the two populations, there were a significant statistically difference(p<0.05) in the local skin inflammation and Dockin Point Skin retraction for HOT group while in refracture p<0.05 was for group PRP. From the SF-12 we discovered not statistically differences p<0.05. The average correlation between Bone Regenerate-Bone Healing/ X-rays is absolutely in the PRP as in the HOT, p>0.05. The average Time for remove Ilizarov’s Frame in months was 15.37(±7.34; range 9–32) in PRP while in HOT was15.22(± 7.83; range 9–31), p>0.05.

Conclusions:

From our study we can conclude that the association of HOT and PRP with the Ilizarov technique does not improve the functional outcomes but allows a more rapid healing of the regenerated bone and therefore an early removal of the device and a corresponding improvement in the quality of life. (www.actabiomedica.it)

Reliability of S.A.R.A. (sterilization and reimplantation autograft) technique in long bone open fractures

The reimplantation of small or large extruded bone segments is one of the most complex clinical management scenarios in the treatment of open fractures. No consensus exists regarding the efficiency of this technique. The aim of the study was to analyse the clinical and radiological outcomes of Sterilization and Reimplantation Autograft (S.A.R.A.) technique in open fractures. Therefore, fifteen skeletally mature patients with Gustilo-Anderson -IIIB type fractures treated with autograft reimplantation, were included in this study. The sample size was divided in two groups: patients with a loss of small segments (Group A - less than 5 cm) and those with large segments (Group B - greater than 5 cm). Eight patients belonged to Group A and seven to Group B. The treatment of contaminated bone may be performed by the following protocols: saline rinse, povidone-iodine scrub and saline rinse, retain periosteum, immersion in antibiotic solution (clindamycin and gentamicin and metronidazole), washing with physiological solution, acute reimplantation in Group A or reimplantation after 21 days in Group B after a bone freezing at -80°C. The Radiographic Union Score (RUS), pain visual analogic score (VAS), patient satisfaction and return to work were assessed at a mean follow-up of 24 months. No cases of superficial or deep infection were reported at 2-year follow-up. The fractures achieved a complete union in 14 patients; one patient belonging to Group A had a malabsorption of the replanted bone. Furthermore, povidone-iodine scrub, antibiotic solution immersion, and washing with physiological solution preserved the articular surface morphology. This study suggests that reimplantation of extruded short or long segments may represent a reliable alternative to amputation in open long bone fractures. Further studies are needed to define the most efficient technique for sterilizing the bone autograft to reduce the complication rate.

Bone grafiting combined with Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union

Distal radius fractures are the most common type of upper limb fractures in adults. Non-union after distal radius fracture is rare, serious and unpredictable. The aim of our paper is to analyse the clinical and radiological outcomes of bone grafting and Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union. We enrolled 13 patients with distal radius aseptic non-union. The following parameters were evaluated: The surgical time, elbow, forearm and wrist range of motion, the subjective quality of life and the wrist function measured by Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Pain Visual Analogic Score (VAS) and the complication rate. Bone union was measured using the radiographic union score as described by Radiographic Union Score (RUS). The evaluation endpoint was set at 24 months after surgery. All patients achieved fracture union. Grip strength improved by 12.4 kg. There was also improvement in wrist flexion, in wrist extension, and forearm pronosupination. These ranges of motion and grip strength improvements were statistically significant. Only 6 patients returned to full activity. This surgical technique represents a reliable alternative for treatment of distal radius aseptic non-unions. Further studies are needed to assess the long-term clinical results of this surgical procedure.

Allograft versus autograft in forearm aseptic non-union treatment

Non-union in forearm fractures is an uncommon challenging clinical condition for orthopaedic surgeons. The complex anatomy and biomechanics of the upper limb make this surgery very demanding. The accurate restoration of the normal anatomy is mandatory to obtain bone healing. Infections and important bone loss further reduce the therapeutic success. The use of bone graft in atrophic non-union may significantly reduce the bone healing time with good clinical results. The aim of the study was to compare fresh-frozen bone (FFB) allograft and autograft in the treatment of forearm aseptic non-union. Inclusion criteria were patients aged between 18 to 75 years old with forearm aseptic shaft non-union treated with plating and bone grafting. The Authors retrospectively evaluated minimum 12-month follow-up with standard X-rays and clinical outcomes. All non-unions were classified according Association for the Study and Application of the Method of Ilizarov (ASAMI) classification for long bones. The sample size was divided in two groups: patients treated with FFB allograft (Allograft Group) and patients treated with iliac crest autograft (Autograft Group). The mean patient age was 33.58±16.72 (18-75) years old in Allograft Group and 33.28±17.24 (18-75) in Autograft Group. The mean follow-up was 62.6 months (±12.3, range 12-160) in Allograft Group and 64.4 (±12.4; 12-160) in Autograft Group. The mean bone union time after the surgery was 101.6 (±14.6; 82 -156) days in Allograft while 117.6 (±14.6; 90 -180) days for autograft. The Radiographic Union Score was 26.8 (±2.2; range 24.3-30) in Allograft while 26.9 (±2.8; range 24.1-30) in Autograft. A correlation between clinical and radiographic outcomes was found (Cohen κ: 0.86±0.11 in Allograft Group; Cohen κ: 0.85±0.10 in Autograft Group, p=0.051). The preoperative surgical planning is essential to apply this technique: the adequate cortical graft length is the key point to gain adequate implant stability. A meticulous surgical technique is mandatory to obtain good clinical and radiological outcomes. The study reported a good reliability of FFB allograft for large non-union bone defects. This technique may represent a feasible alternative to bone transport or amputation, as it allows the return to daily life activities. Further studies are needed to assess the long-term clinical results of this surgical procedure.

Grafting and fixation after aseptic non-union of the humeral shaft: A case series

PURPOSE

Non-unions after humeral shaft fractures are seen frequently in clinical practice at about 2-10% after conservative management and 30% after surgical treatment. Non-union, displacement of structures and fixation failure can be hazardous complications. The purpose of our study was to evaluate the outcomes of an on-lay bone graft strut construction with bone chips as grafting augmentation in the management of aseptic non-unions of the humeral shaft.

METHODS

From 124 eligible patients with a humeral shaft non-union, we included 48 patients. In all cases an anterolateral humeral approach was used, with an on-lay bone graft using an allograft strut construction and with bone substitute augmentation in the non-union gap. To assess the bone healing on radiographs, we used the non-union scoring system according to Whelan. Patients were followed with objective and subjective scores.

RESULTS

In all 48 patients we achieved full bone healing without major complications. The average period of union was 124 days. In 40 cases after healing the alignment was neutral, valgus deformation occurred in 6 cases a varus deformation in 2 cases. At twelve months after surgery, all patients recovered with satisfactory range of motion of shoulder and elbow and a good quality of life, without any radial nerve palsies or other major complications.

CONCLUSION

Given the satisfactory results of full bone healing, recovery of the range of motion and the lack of major complications as seen in this study, we find that plating with supporting allograft as a good choice of treatment in the cases of aseptic non-union of the humeral shaft.

Radiographic, Bone Densitometry and Clinic Outcomes Assessments in Femoral Shaft Fractures Fixed by Plating or Locking Retrograde Nail

Introduction:

Distal femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved.

Aim:

This study aims is to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing and anatomical locking plate to surgically treat distal femoral shaft fractures in young adults based on the hypothesis that there is no statistical difference among the two surgical options in terms of results (radiographic, bone densitometry and outcomes assessment).

Methods:

Retrospective study: 30 patients divided into 2 groups (Group 1 LRN, Group 2 Nailing). Average age was 42.67±18.32 for Group 1 and 42.84 ±18.32 for Group 2 (range of age 18-65 for both groups). Gender Ratio (male: female) was 2.75 (11:4) for both Group 1 and 2. AO Classification, NUSS and RUSH score, VAS, Dexa scans, plain radiographs were used. Evaluation endpoint: 12 months after surgery (mean follow up 16.24).

Results:

No statistical difference in terms of surgery time, transfusions, wound healing. Similar results with regard to average time of bone healing, RUSH scores, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. Only one patient of each group had reduction of mineral bone densitometry values.

Conclusion:

No statistical difference about the use of LNR or Nailing for treatment of distal femur shaft fractures in terms of radiographic, bone densitometry and outcomes has been found accordingly to our results. Good subjective and objective results are provided by both techniques. The choice among the two techniques must be based on surgeons’ experience, indications and subjective patients’ aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with bigger cohort is needed for definitive validation.

Comminuted Bilateral Simultaneous Fracture and Luxation of the Proximal Humerus with an Injury to the Right Axillary Artery

INTRODUCTION

Among all of the shoulder dislocation cases, only 1% is related to fractures. The simultaneous bilateral fracture and dislocation happen very rarely and it is seldom related to a trauma. An injury to the axillary artery related to a humerus fracture is an exceptional event.

CASE REPORT

A 58-year-old male with no particular background who, after falling from a 5 m height, presented a fracture and dislocation of both of his shoulders and showed no pulse in his right arm due to an injury to his axillary artery. The peculiarity of this injury increases when the axillary artery injury is added to the bilateral fracture and luxation of the humerus. We present the case and revise literature.

CONCLUSION

The treatment for these complex injuries requires a multidisciplinary surgical approach. To treat these injuries, an early diagnose is essential regarding the fact that the prognosis is directly related to the time elapsed without blood circulation. That is why it is necessary to look for these arterial injuries in case of a proximal humerus fracture.

Five year long term results of total joint arthroplasties in the treatment of trapeziometacarpal osteoarthritis

INTRODUCTION

Trapeziometacarpal (TMC) osteoarthritis is a common disease. Patients with advanced disease who have failed conservative treatment have different surgical options, including total joint prosthesis. The aim of this study was to investigate the long-term outcome and complications of trapeziometacarpal (TMC) total arthroplasty.

MATERIALS AND METHODS

One hundred and forty-seven patients with TMC osteoarthritis were surgically treated with TMC arthroplasty, and one hundred and thirty-seven patients were seen for follow-up (102 women and 35 men). At follow -up patients were asked to complete a visual linearanalogue scale (VAS) for satisfaction with the result of the operation and persisting pain from the thumb, the Spanish validated Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to evaluate function of the affected hand.(9) The radiological examination consisted of posterior-anterior and oblique radiographs. In preoperative radiographs Eaton-Little was used, and in postoperative radiographs were assessed with regard to implant loosening and alignment.

RESULTS

The subjective outcome was satisfactory in 126 cases (92 %), 14 (12 %) patients would undergo the same procedure in the other hand. The DASH questionnaireswere 19.55 (range 5.6-33,5) on average, and EVA was 1 on average. The mean key pinch strength was 5.8 Kg at 5 years follow-up. The most frequent postoperative complication was De Quervain tenosynovitis (21%), other complications were: Cup loosening (3.6%), traumatic dislocation (3,6%). The prosthesis was removed in nine cases (7%). There were four intraoperative complications. The survival rate for ARPE prosthesis was 92,7% at 60,5 months. TMC total arthroplasty offers a reliable treatment alternative in patients with thumb carpometacarpal joint osteoarthrosis which conservatives' treatment had failed.

CONCLUSIONS

The TMC joint prosthesis is an option for patients with TCM osteoarthritis, provides satisfactory outcomes and has a low failure rate.(www.actabiomedica.it).

Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not?

BACKGROUND

There is a high incidence of blood transfusion following hip fractures in elderly patients.

AIM

The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery.

MATERIALS AND METHODS

Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer).

RESULTS

Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05).

CONCLUSION

Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss.

A new plate design to treat displaced 3-4 parts proximal humeral fractures in comparison to the most tested and used plate: clinical and radiographic study

Aim Proximal humeral fractures are common and most complex patterns currently represent a challenge for surgeons. Difficulties in obtaining good anatomical reduction (particularly of great tuberosity) often lead to unsatisfactory results; choices often fall onto prosthesis implantation against fixation options. The aim of this study was to compare a new design of proximal humeral plate with the most used plates in the treatment of these injures by analysing outcomes and complications. Methods Two hundred patients with proximal 3 or 4 parts humeral fracture were enrolled (Neer 3-4). First group treated with PGR Plate composed of 98 patients. Second group treated with Philos Plate composed of 102 patients. Evaluation criteria were Non-Union Scoring System, duration of surgery, complications, objective quality of life and elbow function (Constant Shoulder Score), subjective quality of life and elbow function (Oxford Shoulder Score), post-op radiographs, centrum collum diaphyseal angle. Evaluation endpoint was 12 months. Results There was no statistically significant difference between the groups with regard to the selected evaluation parameters. Achievement of good shoulder range of motion and ability to perform normal daily living activities was obtained in both groups. The PGR had a positive impact on treatment results of varuspattern of proximal humeral fractures. Conclusions The PGR allowed good clinical and radiographic results in the treatment of proximal humeral fractures, comparable to those obtained with Philos. Also, PGR had the advantage to aid and keep the anatomical reduction of patterns of fracture involving the greater tuberosity.

Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

INTRODUCTION

Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and the ipsilateral tibia. It is usually associated with several complications and mortality. This study was designed to present our experience with the treatment of this injury.

MATERIAL AND METHOD

This study was performed between January 2004 and December 2014. 224 cases of floating knee injuries gathered from the 34,480 lower extremities trauma files were studied, and the target information recorded. The injuries most frequently occurred in subjects between 16 and 35 years of age (60.71%), and in male subjects (85.71%). The most frequent mechanism of injury was traffic accident (92.85%). External fixation was the common type of treatment (82.14%) in emergency or as a definitive treatment. The treatment was performed within 24 h of the trauma. We performed a 36-month follow up with clinical examination, radiographs, assessing the complications, and using the Modified Cincinnati Rating System Questionnaire (MCRSQ) and the Karlström/Olerud Score (KOS) to evaluate the progression of the outcomes.

RESULTS

Early complications included 8 cases of compartment syndrome, 60 open fractures and 24 partially amputated limbs. A total amputation was performed in 3 patients. The most common late complication was heterotopic calcifications of the knee (n = 68, 30.6%). Good scores for MCRSQ and KOS were obtained only after patients were sent to a reference center for knee surgery.

CONCLUSIONS

Our experience revealed that the complication rate associated with floatingknee injuries remains high, regardless of the performed treatment. Surgeons should focus on reducing complications while treating these severe injuries.

Spinal fusion achieves similar two-year improvement in HRQoL as total hip and total knee replacement. A prospective, multicentric and observational study

INTRODUCTION

Total hip and knee arthroplasty (THA/TKA) are surgical procedures with proven benefits. Although the literature reports outcomes of fusion of the lumbar spine comparable to those of THA/TKA in general health-related quality-of-life (HRQoL) questionnaires, functional assessment is nevertheless needed for these results to be of use in clinical practice and management. Aim of our study was to prove that lumbar spinal fusion has similar if not better outcomes than THA/TKA using intervention-specific HRQoL questionnaires and functional assessment questionnaires.

MATERIALS AND METHODS

Observational, ambispective, multicentre study of three cohorts undergoing lumbar spinal fusion (n = 115), THA (n = 119) and TKA (n = 253). Patients were evaluated using the Short-Form-12 (SF-12), Harris-Hip-Score, Hospital for Special Surgery Scale (HSS) and Oswestry Low Back Pain Disability questionnaires. A minimum follow-up of two years was conducted.

RESULTS

The SF-12 showed significant improvement in all groups. The SF-12 physical component summary score indicated a more severe pre-operative status (p = 0.031) in the THA cohort. The mental component summary score indicated a less severe pre-operative status in the TKA cohort (p = 0.008) and greater post-operative improvement in the TKA and THA cohorts across follow-up (six months p = 0.021; one year p = 0.012; two years p = 0.042). Functional assessment indicated greater pre-operative disability in the THA group. At two years of follow-up, functional improvement according to the Harris, HSS and Oswestry questionnaires were 152.01%, 50.07% and 41.14% respectively.

CONCLUSIONS

This study demonstrates that lumbar spinal fusion and total knee and hip arthroplasty are comparable in terms of functional improvement when thoroughly studied with health, quality-of-life and functional assessment questionnaires.

The Advantages of Type III Scaphoid Nonunion Advanced Collapse (SNAC) Treatment With Partial Carpal Arthrodesis in the Dominant Hand: Results of 5-year Follow-up

Introduction:

The SNAC wrist (Scaphoid nonunion advanced collapse) is one of the complications following scaphoid fractures treated conservatively and one of the causes of wrist arthritis that the hand surgeon has to face most frequently. In these cases surgical management is usually warranted.

Materials and Methods:

In the set time frame of 6 years we treated 15 SNAC wrist cases. On average patients underwent surgery five years after the trauma. All patients were treated via dorsal incision with partial carpal arthrodesis and total scaphoidectomy, associated with denervation of the posterior interosseous nerves. A plaster cast was applied to all patients for 3 weeks postoperatively. In the preoperative stage, X-rays of the healthy contralateral limb were taken for the measurement of the normal radiocarpal joint space. Clinical and radiographic follow-ups were conducted at 1,3, 6 and 12 months from the trauma; then every 12 months. Criteria for the evaluation of patients: visual analog pain scale (VAS), average time of radiographic fusion of wrist bones, Active Range of Wrist Motion (WAROM), subjective Mayo Wrist Score (MWS) and The Short Form ( 36) Health Survey (SF-36), return to the main tasks and complications. The evaluation endpoint was set at 60 months. Average time of surgery: 48.3 minutes. Average time of arthrodesis consolidation: 67.8 days. The VAS and WAROM showed a gradual improvement in seriated controls, returning to values almost identical to pre-trauma at a 5-year follow-up. By this time, the MWS and SF-36 scores were similar to pre-trauma. On average, the return to pre-injury daily activities occurred in 12.5 months after surgery. There were no complications.

Conclusions:

The partial carpal arthrodesis is a safe and effective procedure for the treatment of SNAC wrist cases. Our results show a progressive and significant improvement in ROM, VAS and great satisfaction from the patient.

Clinical Comparison Between Shortening Osteotomy of the Proximal Phalanx Neck and Arthrodesis in Hammer Toe Surgery at Mid-TermFollow-Up

The treatment of hammer toe has been advocated for years, and many procedures have been proposed with skeletal and soft tissue intervention. The purpose of the present study was to compare arthrodesis of the proximal interphalangeal joint with shortening osteotomy of the proximal phalanx neck. In most cases, both procedures have been associated with elongation of the extensor apparatus, capsulotomy of the metatarsophalangeal joint, and stabilization with a Kirschner wire. To experiment with a technique that respects the anatomy and joint function, we used a distal subtraction osteotomy of the proximal phalanx neck. We compared a series of 78 patients, divided in to 2 groups: 38 (48.7%) treated with arthrodesis and 40 (51.3%) with shortening osteotomy. Patients were aged 22 to 78 years, with a mean final follow-up period of 56.6 (range 24 to 96) months. For clinical evaluation, we used the American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score, and a subjective rating scale. The results were comparable between the 2 techniques; however, we report faster functional recovery in the group treated with shortening osteotomy (p < .0001), with an adjunctive advantage of preserving the integrity of the proximal interphalangeal joint. Thus, according to our results, this technique is comparable to arthrodesis.

WITHDRAWN: Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) (2019) 453–461, https://doi.org/https://doi.org/10.1016/j.injury.2018.12.009. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Foot Loading and Gait Analysis Evaluation of Nonarticular Tibial Pilon Fracture: A Comparison of Three Surgical Techniques

The aim of our study was to investigate which technique among hybrid external fixation, plate and screws, and intramedullary nailing produces better outcomes in foot loading when treating type 43.A1, 43.A2, and 43.A3 fractures, according to the AO classification. From November 2011 to December 2014, 34 patients, including 25 (73.5%) males and 9 (26.5%) females with an average age of 32.3 (range 16 to 67) years, with a type A tibia fracture were treated with intramedullary nailing, plate and screws, or hybrid external fixation. The patients were divided into 3 groups: 16 (47%) received hybrid external fixation, 10 (29.4%) received plate and screw fixation, and 8 (23.5%) received intramedullary nailing fixation. The follow-up protocol included clinical and radiologic evaluations performed at 15 days, 1 month, 3 months, 6 months, and 12 months after surgery. The selected outcome parameters for the 3 groups were as follows: visual analog scale for pain of the traumatized tibia, interval from surgery to weightbearing, average time required for fracture recovery, subjective and objective Ovadia-Beals scores, baropodometric examination at 12 months, walking recovery at 12 months, outcomes, and surgical complications. The endpoint assessment was set at 12 months. The results showed that incorrect reduction of a type A tibia fracture can lead to changes in the sagittal balance line for foot loading and pace training. In conclusion, these findings have shown that the experience of the surgeon in the reduction of the fracture and knowledge of the method of synthesis is essential.

Efficacy of the "Salento technique", a modified two-incision approach in distal biceps brachii tendon repair. Surgical description and outcomes analysis

INTRODUCTION

The biceps brachii lesion needs to be treated surgically. A modified two incisions technique is proposed and reviewed. Material and Methods: All patients were treated with the same technique. The outcomes were measured with the Quick-DASH Score (QDS), and the Mayo Elbow Performance Score (MEPS). Postoperative complications and distal biceps tendon strength were registered also.

RESULTS

At one year from the trauma, the QDS and the MEPS were excellent in all patients. 72.97% fully recovered and returned to work after 6 months from the trauma.

DISCUSSION

This technique, thanks to its preservation of anatomical structures, provides great outcomes.

Comminuted Bilateral Simultaneous Fracture and Luxation of the Proximal Humerus with an Injury to the Right Axillary Artery

Introduction

Among all of the shoulder dislocation cases, only 1% is related to fractures. The simultaneous bilateral fracture and dislocation happen very rarely and it is seldom related to a trauma. An injury to the axillary artery related to a humerus fracture is an exceptional event.

Case Report

A 58-year-old male with no particular background who, after falling from a 5 m height, presented a fracture and dislocation of both of his shoulders and showed no pulse in his right arm due to an injury to his axillary artery. The peculiarity of this injury increases when the axillary artery injury is added to the bilateral fracture and luxation of the humerus. We present the case and revise literature.

Conclusion

The treatment for these complex injuries requires a multidisciplinary surgical approach. To treat these injuries, an early diagnose is essential regarding the fact that the prognosis is directly related to the time elapsed without blood circulation. That is why it is necessary to look for these arterial injuries in case of a proximal humerus fracture.

Validity and Reliability of Mini-Invasive Surgery Assisted by Ultrasound in Achilles Tendon Rupture

Introduction:

The surgical treatment for Achilles tendon rupture has become very popular in the last years, because of the good outcomes and the low re-rupture rate.

Aim:

The aim of this study is to compare the results between open surgery and percutaneous ultrasound-assisted surgery.

Methods:

All patients who underwent an Achilles tendon surgical repair in the last 3 years were included, resulting in a total of 56 patients (40 M and 16 F) with an average age of 53 years. Of these patients, 36 were treated with an open suture, while 20 with a mini invasive ultrasound assisted suture. At a minimum follow-up of one year, patients were evaluated echografically, using both the Achilles Tendon Rupture Total score (ATRS) and the McComis score, and performing the ultrasounds bilaterally to assess both the structure and the diameter of tendons.

Results:

Both groups of patients showed an average ATRS score >80. The McComis score was 54.18 vs. 56.25 (p>0.05). Plantar flexion and dorsal flexion work were not similar (p>0.05). On average, the calf circumference of the operated side was decreased compared to the healthy side between the groups (p>0.05). The thickness of the operated tendons evaluated with ultrasound measurement compared to the average tendon, (p <0.05).

Conclusion:

The ultrasound-assisted tenorrhaphy is a reliable treatment with good clinical and functional outcomes; anyway, the percutaneous technique and the open surgery show similar results.

Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: is There a Real Difference in Skin Complication? A Retrospective Study in Three Level I Trauma Center

Introduction:

Not enough literature is available to evalute the wound complication rate of plates type in distal fibular fractures.

Aim:

The aim of our study was to compare wound complications of using a third tubular plate compared to LCP distal fibula plate.

Material and Methods:

This study is a retrospective single-centre study in which was performed plating of fibula in closed ankle fractures. 93 patients were included in our study and assigned in two groups, based on using of different implant : in group A 48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distal fibula plate. There were no significant differences in the baseline characterisctics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evalueted at 1-3-12 months and clinical examination was made at 12 months using AOFAS clinical rating system. Categorical data, grouped into distinct categories, were evalueted using Chi-square test. We considered a p value < 0.05 as statistically significant.

Results:

The wound complications rate of the overall study group was 7.6%. There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%); plate removal was performed earlier in the locking plate because of wound complications.

Conclusions:

Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distal fibula plate and conventional one-third tubular plate. Controversy still exists about the best method for the fracture reduction.

Dhs plus anti-rotational screw vs cannulated screws for femoral neck fractures: an analysis of clinical outcome and incidence regarding avn

The aim of this study was to compare the union time, functional outcome and complications in patients with femoral neck fractures treated with percutaneous cannulated screws or dynamic hip screw (DHS) plus antirotational screw. We selected 117 consecutive patients having a hip fracture at any level within the Garden classification, treated at the Orthopedics and Traumatology Clinic in Perugia from 2010 to 2011. Average patient age was 67.8 years. Patients received either a treatment including cannulated screws (group I) or a DHS plate with anti-rotational screw(group II). All patients were followed up for a minimum of 1 year. The Harris Hip Score at 12 months was used to evaluate functional outcome. Between the two treatment groups, the differences in union time and functional outcome were not statistically significant. Moreover blood loss was significantly lower in group I. The results of our study did not suggest a superiority of one surgical technique over the other, when considering the union time and functional outcome. Regarding complications, the incidence of avascular necrosis was found to be significantly related to the Garden classification but not to synthesis type. Level of evidence: IV, Retrospective case series.

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon

BACKGROUND

To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA.

METHODS

We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used.

RESULTS

Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary's angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery.

CONCLUSIONS

Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

The Challenges of Monoaxial Bone Transport in Orthopedics and Traumatology

BACKGROUND

Bone defects represent the main challenging problem for the orthopedic surgeon and, consequently, they increase the duration of hospitalization, risk of complications and health expenditures. The aim of our observational, descriptive and retrospective study is to evaluate the outcomes of patients treated with a mo-nolateral external fixator for bone defects greater than 3 cm.

MATERIAL AND METHODS

Between January 2003 and January 2013, 21 patients were treated at our center by bone transfer with a monolateral external fixator. The main etiologies were trauma in 17 cases (80.9%) and tumors in 4 cases (19.1%). Mean follow-up was 5 years for non-union and 3 years for tumors. Our clinical evaluation was based on ASAMI (Association for the Study ad Application of the Methods of Ilizarov) scores during this follow-up period.

RESULTS

The functional outcomes, based on ASAMI scores, were excellent in 12 cases, good in 7 and poor in 2.

CONCLUSION

1. A review of the literature related to our experience shows that bone transport is an effective tech-nique to repair loss of bone in the lower limbs. The use of a system of external fixation enables corrective actions throughout the treatment that can be in-dividualized on a case-by-case basis. In our experience, the LRS fixator (Orthofix) is a sta-ble, easy-to-use and very handy device. 2. In situations where soft tissue reconstruction procedures are needed, the size and shape of the splint should be such as not to constitute an obstacle. Fur-thermore, the use of pins rather than transfixation wires eliminates the risk of neuro / vascu-lar injury such as may occur during the application of a circular fixator. 3. The analysis of the cases presented here indicates that where possible the technique of bone transport produces good results and can often salvage the limb. Amputation should be reserved only for cases where the general and / or local preoperative status indicate that the surgeon can expect a poor result or when the compliance of the patient is determined to be inadequate.

Effect of trochleocapitellar index on adult patient-reported outcomes after noncomminuted intra-articular distal humeral fractures

BACKGROUND

Anatomic surgical reduction of intra-articular fractures of the distal humerus is important to achieve the best long-term outcomes and prevent post-traumatic arthritis. In this study we compared the radiographic reduction using the trochleocapitellar index. We also correlated the trochleocapitellar index to the functional outcomes next to the comparison of the triceps brachii lifting approach and olecranon osteotomy approach, 2 common approaches for distal humeral fractures.

METHODS

From January 2006 to June 2016, patients with elbow fractures were registered in 4 centers. The trochleocapitellar index, a ratio between the angle of the capitellum and the trochlea to the midline of the distal humerus on anterior-posterior radiographs, was calculated for included patients. Functional outcomes were measured using the Oxford Elbow Score and the Mayo Elbow Performance Score. Bone healing was measured using radiographic union scoring.

RESULTS

There were 86 patients enrolled: 46 in the olecranon osteotomy group and 40 in the triceps lifting group. Functional outcomes and bone healing did not differ between the approaches. Functional results had a medium correlation with the trochleocapitellar index, which did not differ between the 2 approaches (olecranon osteotomy group, κ = 0.56; triceps lifting group, κ = 0.57; P = .7932).

CONCLUSIONS

The trochleocapitellar index has a moderate predictive value on the functional results after 12 months after open reduction and internal fixation of intra-articular distal humeral factures. There is no difference in reduction, as measured by trochlear index and functional outcome scores, between the olecranon osteotomy approach and the triceps brachii lifting approach groups.

Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation of outcomes

INTRODUCTION

Distal tibial fractures are the most common long bone fractures. Several studies focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture.

MATERIALS AND METHODS

We collected data on 81 patients with distal tibial fractures (distance from the joint between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight bearing time.

RESULTS

No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%).

DISCUSSION

Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.

Grafting and fixation of proximal humeral aseptic non union: a prospective case series

Background

Fractures of the proximal part of the humerus represent almost 4-5% of all fractures. The rate of non union is estimated to be 1.1 to 10%. Non union, displacement, and fixation failure can be hazardous complications for these injuries. The purpose of our study was to evaluate the outcomes of plate and bone strut allograft with bone chips grafting augmentation in the management of proximal humeral aseptic non union.

Methods

We treated 16 aseptic non union proximal humeral fractures by the medial humeral shaft bone strut allograft and lateral plate and screws with bone chips grafting. The patients' ages were between 55 and 70 years. The chosen criteria to evaluate the group during the clinical and radiological follow-up were the quality of life measured by The Short Form (12) Health Survey (SF-12), shoulder function and related quality of life measured by the Constant Shoulder Score (CSS) compared with healthy side, bone healing measured by X-rays, and postoperative complications. The follow-up was perfor med with clinical and radiographic controls at 1, 3, 6 and 12 months. Surgical time and international units of red blood cells transfused were also calculated. The evaluation endpoint was set at 12 months.

Results

The X-rays bone healing occurred in our group on average of 126.4 days after surgery. The surgical time and blood loss were consistent with standard surgical procedures. The quality of life and functional recovery were excellent after plate and bone strut allograft.

Conclusions

Surgical techniques that increase mechanical stability, while incorporating bone biology, are effective aids for treating problematic fractural patterns.

The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem?

Introduction

The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step.

Materials and methods

Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months.

Results

Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle.

Conclusions

The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion. The return to pre-injury quality of life has to be our main goal.

Tantalum in type IV and V Paprosky periprosthetic acetabular fractures surgery in Paprosky type IV and V periprosthetic acetabular fractures surgery

PURPOSE

Periprosthetic acetabular fractures represent a growing and serious complication of total hip arthroplasty (THA). The purpose of the study is to report our experience in the use of tantalum for the treatment of Paprosky type IV and V periprosthetic acetabular fractures.

METHOD

We analyzed 24 patients with type IV and V periprosthetic acetabular fractures. Patients were treated with a revision surgery using tantalum components, in some cases in association with posterior plating. Outcomes were evaluated using VAS, Harris hip score and considering the average time of integration of the acetabulum and the number of complications. The endpoint evaluation was established at 24 months.

RESULT

Results show that the average time of integration of the neoacetabulum in tantalum was 12.3 months (range 6-18 months). The average VAS pain is 8.7/10 cm at time 0 and gradually returns to basic pre-injury values in the following months. The average value of HHS at time 0 is 13.5 points. This value tends to increase progressively until reaching a mean score of 89.3 points at 24 months, higher than the average pre-trauma value of 84.3 points.

CONCLUSION

Periprosthetic fractures of the acetabulum with bone loss are a rare but potentially disastrous complication of total hip prostheses. Their management and therapeutic choice will test the ability of the orthopedic surgeon. It is important to determine the type of fracture and characteristics in order to pursue an adequate therapeutic strategy. The modern biomaterials, such as porous tantalum, offer a greater potential in replacing bone loss, promoting bone regrowth and obtaining a stable implant.

Comparison of Plate, Nail and External Fixation in the Management of Diaphyseal Fractures of the Humerus

INTRODUCTION

Humeral shaft fractures are quite common in orthopedics and represent 1-3% of adult fractures. The surgical treatment is the a better choice in order to obtain a reduction and stable alignment and to prevent the complications. The goal of this study was to compare the three techniques (IMN, LCP and EF) in the treatment of diaphyseal fractures of the humerus in the adult patient.

MATERIALS AND METHODS

We examined 79 patients with diaphyseal fractures of the humerus. 32 were treated with plaque (LCP), 26 with intramedullary nail (IMN) and 21 with eternal fixer (FE) The clinical and radiographic follow-up was done at 1.3, 6 and 12 months. As rating scales we used the ASES and SF-36. We recorded all the complications.

RESULTS

The median follow-up was 11.5 months (9-16). The operative time was significantly smaller in the case of FE (47 ') with a statistically significant difference compared with other techniques. Even the blood loss was lower in the case of FE (60ml), compared to nails (160ml) and LCP (330ml) p <0.05. We had no differences in the duration of hospitalization and the ASES SF-36 score. We had 2 cases of non-union in the LCP group, 1 case in the IMN group and no cases in the FE group. In IMN group we had one case of radial transient paralysis. We did not have any deep infection, in the FE group 8 patients we had superficial secretions from pins.

CONCLUSION

From the results of our study, it is clear that the treatment of humeral shaft fractures guarantee overlapping results with the use of plates, of intramedullary nails, or with the external fixator. Consequently, the choice of which technique to use should be determined based on the experience of the operator and patient compliance.

Bunionette

PURPOSE

The purpose of this study is to review the most recent literature available on the treatment of bunionette (also named tailor's bunion) with percutaneous and minimally invasive techniques. Focusing especially on clinical outcomes, studies related to this type of techniques were examined in order to evaluate the success of this practice that is, fusion rate and complications. The hypothesis is that these techniques are safe and successful procedures.

METHODS

In July 2015, a topical review of the PubMed/MEDLINE, EMBASE, and Google Scholar databases was conducted using the keywords percutaneous (OR mini-invasive OR minimally invasive) AND bunionette (OR tailor's bunion) AND treatment (OR surgery). Studies reporting the outcomes of the surgical treatment of bunionette were also included in our review.

RESULTS

The search yielded a total of 111 publications from PubMed/MEDLINE, EMBASE, and Google Scholar. After evaluating abstracts and full-text reviews, 9 articles were included in this review. Treatment methods were divided into 2 main surgical treatment categories: with or without fixation of the osteotomy. The most commonly used technique was that with fixation. The scores of success for techniques with and without fixation were 93.5 and 97.8, respectively.

CONCLUSION

The current evidence for the treatment of bunionette deformity is limited to retrospective case series. Therefore, no conclusion can be made regarding the gold standard technique for bunionette deformity. The results published are very satisfactory, but the literature is still poor.

LEVELS OF EVIDENCE

IV: Topical review.

Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique

INTRODUCTION

The aim of our study is to demonstrate the effectiveness of Steadman microfracture technique in the management of high-grade chondral defects at the level of the knee by clinical follow-ups at eleven years.

MATERIALS AND METHODS

This is a study conducted on fifteen patients suffering from Outerbridge grade III and IV chondral lesions of the knee, who underwent Steadman microfracture surgery between 2003 and 2004. Selective exclusion criteria to prevent that other treatments or comorbidities could invalidate the results were used. Patients were clinically evaluated with Lysholm and IKDC scale scores before surgery and at follow-ups at eleven years.

RESULTS

There has been an improvement in the Lysholm scores (59.33 ± 18.2 at time zero vs 82.13 ± 14.16 at time t; p value: 0.0342) and in the IKDC scores (45.13 ± 17.07 at time zero vs 68.66 ± 21.47 at time t; p value: 0.04) that appears statistically significant.

DISCUSSION

Currently microfracture surgery is not indicated in patients with high-grade chondral defects, but at the same time, it is a technique of easy execution, low cost and good results. The clinical improvement observed appears statistically significant, but we have also noticed a slight clinical worsening in two patients, possibly caused by: improper treatment, new trauma, incorrect rehabilitation and age at time of surgery.

CONCLUSIONS

The study has shown significant clinical improvements in patients, despite the fact that indications to the use of microfracture are still very limited and selective. It's essential to underline the importance of the single patient assessment process, taking into account a variety of aspects including the site, the number and extent of the lesion, the degree of functionality, activity level, age and previous trauma. This shows the importance of a comprehensive assessment of the patient in order to choose the most suitable surgical option, which not necessarily has to strictly adhere to standard practice.

Reliability, Feasibility and Value of Ecography in Clinical-functional Results in Patients Affected by Carpal Tunnel Syndrome: is There a Correlation?

Background:

The aim of this study was to evaluate how the ultrasound examination in the carpal tunnel diagnosis could contribute to the clinical and neurophysiological evaluation. This was done by evaluating the cross-sectional area (CSA) and its correlation with symptoms and functionality data assessed by the BTQC questionnaire.

Methods:

60 patients were subjected to open CTR for idiopathic carpal tunnel syndrome. The median nerve CSA was assessed both pre-operatively and in follow-up at 4 and 12 weeks. The Boston Carpal Tunnel Questionanaire (BCTQ) was proposed at the same time.

Results:

BCTQ score significantly improved after 4 weeks, but there was a less significant increase at 12 weeks for both the BCTQ-S and the BCTQ-F. The 4-week CSA, however, did not appear to have markedly improvement, where as the 12-week CSA turned out to be statistically significant. The correlation between BCTQ and CSA shows that post-surgery, the reduction of CSA of the median nerve is correlated with the symptomatic and functional reduction in patients.

Conclusions:

The study shows that the symptomatology and the functionality of the hand after surgery for the carpal tunnel resolves quickly. Furthermore, the reduction of the CSA proves to show that the use of ultrasound can help in the evaluation of patients with this state.

Percutaneous screws CT guided to fix sacroiliac joint in tile C pelvic injury. Outcomes at 5 years of follow-up

Introduction: The treatment of the sacroiliac joint (SIJ) vertical instability is a matter of current discussions and remains controversial. The aim of our study is the evaluation of the surgical management of SIJ vertical instability involving the use of cannulated screws introduced under CT guidance and local anesthesia.

Materials and methods: In the set time frame of 7 years, 96 poly-trauma patients with Tile's type C fracture of the pelvis with vertical instability of the SIJ were treated. The average distance between the two stumps was 73.4 mm (range: 43–100 mm). All patients were treated with anterior stabilization and subsequent stabilization with cannulated screws (Asnis^® Stryker^® 6 mm, an average length of 70 mm; range from 55 to 85 mm) of the sacroiliac fracture. The clinical and radiological follow-up was performed with follow-up plain radiograph and Majeed score (from 1 to 60 months after injury).

Results: The consolidation of pelvic fractures was obtained after an average of 63 days. The average Majeed score was as follows: 96 points at 1 month, 84 points at 3 months, 62 points at 6 months, 44 points at 12 months, 42 points at 24 months, 32 points at 36 months, 28 points at 48 months and 28 points at 60 months. Complications were as follows: not fatal deep vein thrombosis in five cases, skin infection at the entry point of the screws in six cases, screw breakage in one case and loosening of the screws in one case. Radiological evidence of fracture consolidation was achieved on average at 63 days. Forty-seven patients managed to get back to their pre-trauma employment at the end of the convalescence period.

Conclusions: Our results suggest that the stabilization of SI Tile type C fracture/dislocations with CT-guided percutaneous cannulated screws is a valid and feasible management option and associated with a low complication rate.

Management of Cyclops Syndrome: A case report

Anterior Cruciate ligament (ACL) is a typical athletic injury. One of the most frequent complication after ACL reconstruction is reduced range of motion (ROM) due to the impingement on the inter-condylar notch of a fibrous tissue mass, defined as Cyclops Syndrome. We report the case of a 25 years old male, who underwent reconstruction of ACL with Gracilis-semitendinosus (GR-ST) tendons with delayed onset of loss of knee extension seven years after ACL reconstruction. Clinical and magnetic resonance image (MRI) findings were consistent with Cyclops syndrome. The patient underwent arthroscopy in May 2015, which revealed a fixed fibrous nodule impinging on the inter-condylar notch in extension that was treated by mechanical shaving, radiofrequency ablation remodeling inter-condylar notch and releasing of the ACL transplant. After surgery our patient returned to his routine activities after 5 days and started running about 10 days later, without anterior knee pain and without deficit of hyperextension.