Midshaft clavicle fractures treatment: threaded Kirschner wire versus conservative approach.

Clavicle fractures are common, accounting for 2.6 to 10% of all fractures. Treatment of these fractures is usually non-surgical. Recent evidence, however, reveals that the final result of non-surgically midshaft clavicular fractures, particularly those with quite large displacements or shortening, is not like that which was previously thought. This study evaluated retrospectively all patients presented with a clavicle fracture at Emergency Department of our Institution, between January 2006 and December 2011. Fractures were classified according to Allman's radiographic classification system, modified by Nordqvist and Petersson. Patients were distinguished into two groups: one that underwent conservative treatment with a "figure-of-8" orthosis and one that underwent surgery with reduction in fracture and fixation with intramedullary threaded Kirschner wire. Pin removal was performed after 4 weeks of rest in Gilchrist bandage, after clinical and radiographic evaluation demonstrating the bone healing. The QuickDASH score and the Constant Murley Shoulder Score were used to evaluate the clinical outcomes. The radiographic outcome was evaluated at 1 and 6 months of follow-up. Database review provided a final cohort of 58 patients, with similar demographic features. There was no significant difference in qDASH and CS between the two groups. The results of qDASH and CS evaluated in function of the radiographic outcome show a statistically significant correlation between the worst qDASH and CS results and the grade of malunion in both groups. In particular, we have found unsatisfactory results when final shortening of the clavicle was 20 mm or more. On radiographic evaluation, surgical treatment demonstrated a greater efficacy in reducing initial shortening of the fractured bone; this is in opposition to conservative treatment that results very often in malunion, shortening, anatomic alterations and loss of functionality. The use of intramedullary threaded Kirschner wire for fixation of midshaft clavicle fractures is a safe procedure and is recommended in case of shortening greater than 2 cm in high-function-demand patients.

Evaluation of patello-femoral alignment by CT scans: interobserver reliability of several parameters.

Patello-femoral malalignment (PFM) is a common cause of disability often related to patello-femoral syndrome (PFS). Several causes have been taken into account; a proper diagnosis requires instrumental imaging and a methodical evaluation of different parameters. The aim of the present study was to identify the most reliable parameters for measuring patello-femoral and inferior limb alignment by CT. Twenty randomly selected patients suffering from PFS for a total of 40 knees were studied by static CT scans in order to assess patellar tilt, patellar displacement, patellar and trochlear morphology and inferior limb alignment. All known parameters were measured; the variability of the measurements between observers was evaluated by boxplots, Pearson's correlation coefficients, and infraclass correlation coefficient [ICC(2,1)] based on a two-way random effect model. Bland-Altman mean differences and 95 % limits of agreement were computed for each pair of measurements. Patellar tilt parameters appeared equally reliable; patellar displacement is best measured with BoTot that showed an ICC of 0.889; morphology is best measured with WibergTot, with an ICC of 0.862; lastly, for the inferior limb alignment parameters' analysis, FTV outperformed the others in terms of reliability. The present study allowed us to select a limited number of reliable parameters in the evaluation of patello-femoral and inferior limb alignment. The use of these parameters may also result in a more reliable comparison of studies on PFM and in a better evaluation of the treatment outcomes.

Bone-derived titanium coating improves in vivo implant osseointegration in an experimental animal model.

Coating of orthopaedic or dental Titanium (Ti) implants with extracellular bone matrix components (e.g., Type I collagen or hydroxyapatite) is usually performed to enhance their osseointegration. Aim of the present research is the evaluation of an innovative bone-derived Ti coating, containing bone apatite and Type I bone collagen preserved, in an experimental model. Coated and uncoated titanium implants were inserted into the extra-articular bone of the distal femur of twelve New Zealand White Rabbits. Labelling of bone formation was performed by sequential intraperitoneal administration of three stains. After 45 and 90 days animals were sacrificed. Bone specimens were embedded in a glycol methacrylate resin and sectioned along a plane parallel to the long axis of the implants for histomorphometric, scanning electron microscopy and energy dispersive X-ray analyses. Bone implant contact (BIC), trabecular thickness (Tb.Th) and calcium-phosphorus ratio were measured. Data were subjected to nonparametric Wilcoxon rank-sum test and Student's t test. All implants healed without adverse reactions. After 45 days from implant, significant (p < 0.05) differences in BIC (55.6 ± 17.1% vs. 29.2 ± 20.1%) and Tb.Th (108.7 ± 67.1 µm vs. 66.6 ± 48.6 µm) were observed between coated and uncoated implants. Significant (p < 0.05) differences in BIC (61.3 ± 2.1% vs. 35.7 ± 16.4%) and Tb.Th (211.4 ± 80.8 µm vs. 150.9 ± 61.5 µm) between coated and uncoated implants were also detected after 90 days. No differences were measured in calcium-phosphorous ratio. Our data indicate that Ti integration can be enhanced by the proposed surface coating. This could accelerate stable implant fixation and early or immediate loading of the device.

Late-diagnosed large osteochondral fracture of the lateral femoral condyle in an adolescent: a case report.

In this case report, we describe a large osteochondral fracture of the anterolateral femoral condyle in an adolescent athlete while dancing. At 3 months after the misdiagnosed injury, the condylar defect was covered by a layer of disorganized fibrous tissue rich in blood vessels. To achieve good repair, an accurate curettage of the fractured surfaces, a precise reduction, and a stable internal fixation of the fragments were performed. Two poly-L-lactic acid bioabsorbable screws were used to obtain appropriate compression. At the 2-year follow-up, the patient was asymptomatic and had resumed her previous dancing activity. An MRI scan showed no interruptions of the cartilage layer at the boundary with the healthy tissue, but cartilage thinning and extensive subchondral remodeling were detected.

Purified collagen I oriented membrane for tendon repair: an ex vivo morphological study.

Injured tendons have limited repair ability after full-thickness lesions. Tendon regeneration properties and adverse reactions were assessed ex vivo in an experimental animal model using a new collagen I membrane. The multilamellar membrane obtained from purified equine Achilles tendon is characterized by oriented collagen I fibers and has been shown to sustain cell growth and orientation in vitro. The central third of the patellar tendon (PT) of 10 New Zealand White rabbits was sectioned and grafted with the collagen membrane; the contralateral PT was cut longitudinally (sham-operated controls). Animals were euthanized 1 or 6 months after surgery, and tendons were subjected to histological and Synchrotron Radiation-based Computed Microtomography (SRµCT) examination and 3D structure analysis. Histological and SRµCT findings showed satisfactory graft integration with native tendon. Histological examination also showed ongoing angiogenesis. Adverse side-effects (inflammation, rejection, calcification) were not observed. The multilamellar collagen I membrane can be considered as an effective tool for tendon defect repair and tendon augmentation.

Matrix-induced autologous chondrocyte implantation (MACI) in the knee.

PURPOSE: Matrix-induced autologous chondrocyte implantation (MACI) has been in use for chondral defect repair since 2000, but to date, only little is known about its histological outcomes in the repair of knee cartilage defects. This prospective multicentre study aims to evaluate (1) the quality of the repair tissue obtained from biopsies taken during second-look arthroscopy and (2) the relationship between the histological outcome, the macroscopic appearance of the repair and the patients' functional status. METHODS: Thirty-three second-look core biopsies from 30 patients treated with MACI were analysed. At the time of biopsy, the surgeon reported the reason for the second-look arthroscopy, the quality of the repair tissue and the patient's functional status on a standardised form. Biopsies together with patient data were sent to our centre to undergo blind histological evaluation and data analysis. RESULTS: The median overall ICRS II histological score of the examined population was 57 (1st-3rd quartile 41-75). According to the ICRS cartilage repair assessment (CRA) arthroscopic evaluation, 10 biopsies (30%) were classified as normal, 17 (51%) as nearly normal, 4 (12%) as abnormal and 2 (6%) as severely abnormal. The histological outcome was not significantly related either to the macroscopic appearance of the lesion or to the patient's functional status at the time of biopsy. CONCLUSIONS: In the examined population, the macroscopic appearance of the repair tissue gave an overly favourable impression in comparison with the real histological composition of the tissue, which was possibly still maturing in many cases. The healing process after MACI needs to be better understood through a larger histological study, and a longer follow-up is needed to better clarify the relationship between histology and long-term functional status. LEVEL OF EVIDENCE: IV.

Arthroscopic knee cartilage repair with covered microfracture and bone marrow concentrate.

In recent years several single-stage cartilage repair approaches have been devised to treat focal cartilage lesions. These usually associate microfracture (MFX) and a coverage scaffold. We describe a novel arthroscopic technique that combines MFX, autologous bone marrow concentrate (BMC), and a protective scaffold. Bone marrow aspirate from the iliac crest is centrifuged to obtain BMC. The cartilage defect is debrided, MFX holes are created, and the final defect is measured by use of a bent K-wire. The scaffold is then shaped to match the defect, immersed in BMC, introduced into the joint with a grasper, and fixed in place with a mixture of fibrin glue and BMC. This technique aims to augment the original single-stage procedure with a number of mesenchymal stem cells and growth factors contained in the BMC, to increase the defect filling and the rate of hyaline-like cartilage regeneration. The procedure combining MFX, BMC, and a protective scaffold is inexpensive and reproducible and has already shown the ability to regenerate hyaline-like cartilage. Its use as an alternative to autologous chondrocyte implantation requires further investigation.