A new approach to local DCO in ankle fracture dislocations: external fixation with diaphyseal unicortical screws applied by local anaesthesia.

PURPOSE: Ankle fracture dislocations represent a great threat for soft tissue viability and articular instability. The use of a temporary ankle bridging ExFix plays a fundamental role in the local damage control orthopaedics while waiting for definitive synthesis. METHODS: For this prospective research, we have developed a full application protocol of innovative diaphyseal monocortical screws fixator (Unyco-OrthofixTM) exclusively under local anaesthesia. Rigid selection criteria allowed us to collect nine patients during a period of almost 2 years. VAS score was analysed for the feasibility of the procedure, and a thorough radiologic evaluation was performed. RESULTS: Results pointed out that the calcaneus pin insertion (VAS: 3.44) followed by the local anaesthetics injection (VAS: 3.22) was the most painful, without precluding to continue the procedure; fracture temporary stability was achieved in all the cases. CONCLUSIONS: The procedure of monocortical diaphyseal application in bridging external fixation is comparable to the conventional transcalcaneal traction maintaining the advantage in terms of speediness, independence from anaesthetists and feasibility within few minutes from hospital admittance even in patients under anticoagulants therapy, but increasing the stability of the reduction and improving the quality of nursing (so-called portable traction).

Temporary bridging external fixation in distal tibial fracture.

Fractures that involve the distal area of the tibia are associated with a high percentage of complications. Soft tissue oedema, swelling, blisters, skin abrasions and open wounds could compromise the outcome of these lesions. The waiting time before surgery with ORIF is mostly due to soft tissue conditions. Early application of a simple joint-spanning external fixator would achieve the initial goal of stability and the respect of soft tissue, thereby decreasing the time necessary for definitive treatment. A total of 40 consecutive patients (22 male and 18 female) with a mean age of 52 years (range 17-82 years) with distal tibial fracture treated between January 2010 and January 2013 were evaluated. Early temporary external fixation was the first treatment step. Twenty patients had pilon fractures, characterised by the intra-articular involvement of the distal tibia with metaphyseal extension, and 20 patients had malleolar fracture-dislocation. Patients were divided into two groups, A and B. Group A comprised 10 patients with ankle fracture-dislocation and bone fragmentation, who were treated with a temporary bridging external fixation that was maintained after ORIF to exploit ligamentotaxis during the first phases of bone healing. In Group B (30 patients), the external fixation was removed after ORIF. The results of the study are in line with the recent literature: temporary external fixation in high-energy trauma and fracture-dislocation of the ankle enables soft tissue to be restored, which facilitates postoperative assessment of bone fragments by CT scan. The complication rate in this study was 5% in patients with malleolar fractures and 20% in patients with pilon fractures. The maintenance of temporary external fixation after ORIF synthesis during the entire first stage of bone healing seems to be a good method of treatment that has a low rate of soft tissue complications.

The treatment of proximal humeral fractures with a "Polarus" intramedullary nail.

Proximal humeral fractures are complex lesions with difficult management problems; therefore, they pose a challenge for orthopaedic surgeons. In the literature, numerous treatment techniques have been proposed for these kinds of fractures. In our study we reviewed 30 patients with a mean age of 75 years presenting a proximal humeral fracture (Neer 2-3) and treated at our clinic with a Polarus nail, with a mean follow-up of 7 years. We obtained 73.3% of good and excellent results in line with literature. Complications were recorded in 6 of the patients (20%) recruited in our study. In particular, 3 cases of proximal screw pull-out, 1 case of deep infection and 2 cases of acromio-clavicular joint impingement syndrome. The aim of our study was to review our case histories and compare them with the literature analysing this complex type fracture and treatment options.

Augmentation of unstable pertrochanteric fractures in the osteoporotic elderly patient: operative technique for 1 or 2 head screw systems.

The incidence of proximal femoral fractures has substantially risen in the elderly. This rise has been attributed to an increase in their life span and the underlying poor bone stock and osteoporosis. One of the main reasons for revision surgery, reported to be as high as 19%, is the cut-out of the fixation device at the apex of the femoral head. Augmentation, facilitated by injecting cement (PMMA) around the apex of the proximal screw of the fixation device is considered a useful method with regards to the increased purchase between the bone and implant interface. The aim of this study is the description of the cement Augmentation operative technique for unstable osteoporotic pertrochanteric fractures with 1-2 femoral head screw devices.

Tibial plateau fractures: compared outcomes between ARIF and ORIF.

The purpose of this study is to compare arthroscopic assisted reduction internal fixation (ARIF) treatment with open reduction internal fixation (ORIF) treatment in patients with tibial plateau fractures. We studied 100 patients with tibial plateau fractures (54 men and 46 women) examined by X-rays and CT scans, divided into 2 groups. Group A with associated meniscus tear was treated by ARIF technique, while in group B ORIF technique was used. The follow-up period ranged from 12 to 116 months. The patients were evaluated both clinically and radiologically according to the Rasmussen and HSS (The Hospital for Special Surgery knee-rating) scores. In group A, the average Rasmussen clinical score is 27.62 ± 2.60 (range, 19-30), while in group B is 26.81 ± 2.65 (range, 21-30). HSS score in group A was 76.36 ± 14.19 (range, 38-91) as the average clinical result, while in group B was 73.12 ± 14.55 (range, 45-91). According to Rasmussen radiological results, the average score for group A was 16.56 ± 2.66 (range, 8-18), while in group B was 15.88 ± 2.71 (range, 10-18). Sixty-nine of 100 patients in our study had associated intra-articular lesions. We had 5 early complications and 36 late complications. The study suggests that there are no differences between ARIF and ORIF treatment in Schatzker type I fractures. ARIF technique may increase the clinical outcome in Schatzker type II-III-IV fractures. In Schatzker type V and VI fractures, ARIF and ORIF techniques have both poor medium- and long-term results but ARIF treatment, when indicated, is the best choice for the lower rate of infections.

Shwachman-Diamond syndrome.

Shwachman-Diamond syndrome (SDS) is a rare autosomal recessive disorder with exocrine pancreatic insufficiency, bone marrow failure and skeletal abnormalities. Patients frequently present failure to thrive, susceptibility to infections and short stature. A persistent or intermittent neutropenia occurs in 88-100% of patients. Bone marrow biopsy usually reveals a hypoplastic specimen with varying degrees of hypoplasia and fat infiltration. Some patients may develop myeloblastic syndrome and acute myeloblastic leukemia. The genetic defect in SDS has been identified in 2002. The osteoporosis is increased in patients with SDS, and also, bone malformations are included among the primary characteristics of the syndrome. The severity and location change with age and sexes. The typical characteristics include the following: secondary ossification centers delayed appearance, metaphysis enlargement and irregularity (very common in childhood, particularly in coastal and femur), growth cartilage progressive thinning and irregularity (possibly asymmetric growth), generalized osteopenia with cortical thinning. We describe a clinical case regarding an SDS patient with severe bone abnormalities and treated surgically for corrective osteotomy. The persistent or intermittent neutropenia that characterized this disease and the consequent risk of infection is a contraindication for short stature correction and limbs lengthening.

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing.

We studied 80 patients (56 females) with an average age of 84 years (range 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.

Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator.

OBJECTIVE: The authors report their experience in the treatment of the diaphyseal tibial fractures, using the unilateral radiolucent External Fixator (EF) XCaliber. DESIGN: A total of 100 patients (average age 35 years, range 16-76) with 103 displaced diaphyseal tibial fractures were treated with the XCaliber. There were 59 type A fractures, 35 type B, and 9 type C (according to the AO classification) and 35 were open fractures. MAIN OUTCOME MEASUREMENTS: During the last assessment, patients were evaluated for level of pain, ability to perform weight-bearing activities, and number of residual deformities. RESULTS: The average follow-up time was 24 months, 3 patients (4 fractures) were excluded for final assessment and 1 patient moved abroad. Of the remaining 98 fractures, 83 (84.7%) healed with a single operation in a mean 21 weeks (SD 3.97; 12-38 weeks), 10 fractures had a delayed union and 5 fractures proceeded to a non-union. There were 13 complications. Among them, a loss of reduction was observed in 3 cases due to overload of the EF, in 3 cases, deep pin track infections were observed and 2 fractures healed with more than 1 cm of shortening. CONCLUSIONS: The results are encouraging, since both complex and open fractures were included in this study. The XCaliber was shown to be a valid unilateral external fixator, combining the advantage of radiolucency during application and radioscopic follow-up with a stable and flexible fracture fixation. This represents the first report in the literature specifically examining treatment of tibial diaphyseal fractures with a radiolucent external fixator.

[Risk factors for hip fracture in elderly persons]. / Fattori di rischio per frattura di femore in persone anziane.

OBJECTIVE: The aim of this observational study, promoted by the Health Authorities of the Regione Veneto (Italy), is to assess the prevalence of the most relevant environmental and individual risk factors in subjects with a recent hip fracture. METHODS: Patients aged more than 60 years of both genders with a recent hip fracture not associated with malignancies, were administered questionnaires on dietary habits, sun exposure, and disability score. A complete family, pharmacological and pathology history was collected together with information on previous falls, details of the fracture index, and anthropometric data. In all subjects, blood was taken for the measurement of serum 25 hydroxy-vitamin D (25OHD). RESULTS: The study included 704 patients (573 women and 131 men). Mean age was 81 ± 8 years (range 60-102). Severe pre-fracture disability was a common feature (58%) associated with multiple co-morbidities (84%), more frequently cardiovascular and neurological diseases, and specific medications. In a large proportion (86%) of the patients, environmental or individual risk factors for falling were found. Vitamin D insufficiency (serum 25OHD levels < 75 nmol/l) was quite common (70%), particularly in the regional Health Districts were strategies for preventing vitamin D deficiency were not implemented (91%). Only a small proportion (17%) of the study population had been evaluated and treated for osteoporosis. CONCLUSIONS: In senile patients with a recent hip fracture, pre-existing disability, multiple co-morbidities, high risk of falling and inadequate intake of calcium and vitamin D is relatively common. Community and case-finding interventions aimed at selecting subjects at high risk of osteoporosis, preventing vitamin D and dietary calcium deficiency, and increasing awareness on the environmental risks of falling are highly warranted.

Internal femoral osteosynthesis after external fixation in multiple-trauma patients.

In this study the authors evaluate the results of internal synthesis of femoral fractures in polytraumatised patients initially treated by external fixation (EF). From January 2002 to December 2005, 39 femurs in 37 polytraumatised patients (average age 34.2 years, range 18-44) with closed fractures and an ISS>20 were initially treated with EF. There were three groups: Group A, 13 cases when conversion to internal osteosynthesis occurred after 4-7 days (average 5.6 days); Group B, 11 cases with a 4-6-month interval before internal osteosynthesis, and after investigation using MRI and scintigraphy with labelled leucocytes; Group C, the remaining cases treated definitively with EF. Time of healing, lower limb function, time of return to previous activities and short and long-term complications were evaluated at the follow-up. The average time of follow-up was 23 months. In Group A the time of bone healing was 123 days; there were no events of embolism but one case of pseudoarthrosis and one case of instrument failure. In Group B the time of bone healing was 274 days, with one case of pseudoarthrosis and one case of deep infection. In Group C the average healing time was 193 days, with 3 cases of screw (half-pin) osteolysis. Functional recovery was delayed by the presence of other fractures. EF is a simple, quick and safe procedure to stabilise fractures in polytraumatised patients. According to damage control orthopaedic (DCO) concepts, it is possible to replace EF with internal synthesis after an interval as this reduces the risks of internal osteosynthesis when performed in the emergency period. EF can also be maintained as definitive treatment but should a change to internal synthesis be needed, it is possible to do it safely after excluding bone infection.

Treatment of non-union of the humerus using the Orthofix external fixator.

An Orthofix monolateral axial external fixator was used to treat 31 patients with non-union of the humeral shaft, 30 of whom had been previously treated surgically. In seven cases the non-union was hypertrophic and one of these cases had been treated by simple fixation anol compression, the others by fixation, bone grafting and decortication; in 20 cases the non-union was hypotrophic and had been treated by fixation and decortication with bone grafting. The remaining four cases had septic non-union, treated by debridement of the focus of infection and fixation, followed in three cases by a bone graft and osteomuscular decortication once the infection had been eradicated. The fracture site consolidated in all patients in a mean time of 4.9 months. Five patients required further surgery: three in the group with infected non-union and two who had had a new bone graft and application of the external fixator, one because of a refracture (the patient was receiving chronic treatment with antimitotic agents) and one because of persistent non-union. There were no major complications (e.g. radial nerve palsy, joint stiffness, deep infection), and only six cases of pin track infection (5% of the screws implanted). The authors believe that this method is reliable, effective and low risk provided that the patient is cooperative; furthermore, the monolateral axial external fixator is tolerated well and allows movement of the shoulder and elbow throughout the period of treatment.

The use of external fixation in fractures of the tibial pilon.

The authors report the results of a review of 25 cases of fracture of the tibial pilon, treated by external fixation and minimal internal synthesis. Fractures were classified according to Rüedi and Allgower; they were: type 2: 11 (of which one exposed); type 3: 4 (of which 6 exposed). Complications observed during treatment were: pseudarthrosis: 1; osteomyelitis: 2; healing in valgus at 10 degrees: 2; osteolysis of the distal screws of the fixator: 4; these were all resolved with further surgery, except for an osteomyelitis that required amputation. Follow-up ranged from 3 to 10 years and clinical and functional evaluation, based on the Olerud and Molander score system revealed 80% good (56%) and excellent (24%) results.

External dynamic fixation in fractures of the humerus: can it still be considered treatment of second choice?

The authors report 40 patients affected with diaphyseal fracture of the humerus treated by dynamic axial fixator (FAD Orthofix). Minimum follow-up was 2 years. A clinical and radiographic retrospective study was conducted with the purpose of verifying the validity of external fixation as treatment of choice in diaphyseal fractures of the humerus. The results were evaluated considering healing time, extent and type of complications, long-term clinical, radiographic and functional findings. Results were: excellent: 35; good: 2; fair: 2; poor: 1. Complications were: nonunione: 1; reimplantation of FAD screws: 1; 4 infections of the screw holes, 3 realignments due to secondary displacement, 1 re-fracture after removal of the implant. There were no iatrogenic lesions of the radial nerve, or infections of the fracture site. The authors conclude that this semi-invasive, versatile and well-tolerated method, may be considered a valid alternative to conservative treatment, or to internal fixation even in cases of single trauma, despite limits related to the degree of collaboration of the patient, particularly with regard to debridement of the screw holes and periodical clinical and radiographic monitoring.

Biomechanical factors in designing screws for the Orthofix system.

In a monolateral external fixation system, bone grip is achieved optimally using half pins. This article reports the mathematical modeling used to design the screws and the drills of the Orthofix system. The diameter of the shank must be such that there is no risk of fracture at the screw entry point. It must also provide high strength under weight-bearing deformation stresses. The shape of the threaded part must allow the highest possible bone-gripping strength while minimizing slackening in relation to external and internal loads. The thermal effects of drilling and screw insertion must be considered to minimize necrotic damage that may stimulate reabsorption phenomena around the screw. The design of the different components of the pins must vary according to all the above factors to ensure optimal interaction between the fixator, screw, and bone.

Lengthening in the congenital short femur.

The fundamental concepts underlying lengthening surgery for the congenital short femur were gained from experience in treating 35 cases by means of chondrodiatasis and callotasis.

Psychologic, vascular, and physiologic aspects of lower limb lengthening in achondroplastics.

Achondroplastic patients having lengthening surgery of the lower limbs were preoperatively evaluated from psychologic, functional, vascular, and endocrinometabolic points of view. Long-term research is required to determine effects of surgical correction of achondroplasia from both psychologic and various physical points of view.

Epiphyseal distraction. Chondrodiatasis.

Chondrodiatasis is a limb-lengthening technique involving slow, controlled, symmetric epiphyseal distraction. The clinical and histological differences between this technique and distraction epiphysiolysis are described. Results are given for the elongation of 170 bone segments in 75 children (41 with limb-length discrepancies and 34 with achondroplasia). All patients were operated upon while the growth plate was still open with maximum bone maturation corresponding to Risser 2.

Epiphyseal distraction. Hemichondrodiatasis.

Hemichondrodiatasis is a technique of closed, gradual, asymmetric distraction of the growth plate to correct angular deformities in growing children. This report describes the technique and the results achieved in 35 operated lower extremity segments, 14 involving the femur and 21 involving the tibia. The best results were achieved in posttraumatic deformities when the bone bridge occupied less than 20%-30% of the epiphyseal plate. The procedure is best performed toward the end of growth, or earlier if a progressive deformity exceeds 15 degrees - 20 degrees.

Lengthening of the lower limbs in achondroplastic patients. A comparative study of four techniques.

We report our experience of lengthening by over 30% a total of 117 lower limbs in achondroplastic patients. We have compared four methods: transverse osteotomy, oblique osteotomy, callotasis of the shaft and chondrodiatasis of the epiphysis. Chrondrodiatasis of the femur and callotasis of the tibia are the techniques which gave fewest complications.