External fixator-assisted plating osteosynthesis in a rabbit model of femoral bone defects appears to be a feasible and reproducible surgical technique: preliminary insights from a bone substitute study.

PURPOSE: The aims of this study were to assess the complications associated with the use of an external fixator-assisted plate osteosynthesis technique to stabilize a femoral bone defect in a rabbit model and to evaluate if this technique could avoid the mispositioning and the displacement of the femoral fragments during the surgical procedure. METHODS: A preliminary cadaveric animal study was conducted to develop a new technique of external fixator-assisted plating. Thirty rabbits underwent a surgical procedure consisting in the creation of a femoral bone defect and, subsequently an implantation of a bone substitute through the assistance of a temporary external fixator. The fixator's ability to maintain length and alignment during surgery was documented. All intraoperative complications were prospectively collected. RESULTS: No complications related to the use of the temporary external fixator were reported. The technique successfully prevented mispositioning and dislocation during plating in all the rabbits. CONCLUSION: In a rabbit animal model, the use of an external fixator-assisted plate osteosynthesis technique appears to be feasible and effective in avoiding misposition and rotation of femoral fragments when performing osteotomy and plating to create a mid-diaphyseal femoral defect.

Correction of a Complex Foot Deformity With V and Y Osteotomy and Ilizarov Method.

Many authors consider the Ilizarov method as the best choice for correction of complex multiplanar foot deformities. Fifty-one patients, for a total of 55 feet, underwent V or Y osteotomy (respectively 32 and 23), 12 were due to congenital clubfoot outcomes, 11 were from post-traumatic pathologies, 9 from hemimelia, 7 from Charcot-Marie-Tooth, 5 from poliomyelitis, 3 from spina bifida, 2 from myopathy, 2 from poly-epiphyseal dysplasia, 1 from achondroplasia, 1 from arthrogryposis, 1 patient from Charcot's foot and 1 rheumatoid arthritis. All patients were contacted to undergo AOFAS and EQ-5D-5L questionnaire. The mean distraction time was 74.0 days (±25.3) and it was longer for V osteotomy (63.1 ± 21.1 vs 81.8 ± 25.4 days for Y and V respectively, p = .006). The average fixation time was 97.9 days (± 61.2), 90 days in the Y and 103 days in the V osteotomy groups. The mean preoperative foot length was longer in the group of Y osteotomy patients (158.7 ± 21.3 mm vs 133.5 ± 21.6 mm, p < .001). The mean length postoperatively was substantially the same (Y group 164.0 mm vs V group 167.4 mm, p < .562). The V osteotomy produces an elongation ratio of 440% with respect to that produced from the Y osteotomy (ratio length/distraction V/Y 0.44/0.1), with only 19% more in the distraction days. (81.8 V group vs 63.1 Y group). While the V osteotomy allows a lengthening of about 27%, the Y osteotomy, despite having correction potential superimposable to the V osteotomy, minimizes the elongation component.

Validation of the Non-Union Scoring System in 300 long bone non-unions.

INTRODUCTION: Non-union of long bones is a significant consequence of fracture treatment. The ideal classification for non-union of long bones would give sufficient significant information to the orthopaedic surgeon to enable good management of the treatment required and to facilitate the creation of comparable study groups for research purposes. The Non-Union Scoring System (NUSS) is a new scoring system to assist surgeons in the choice of the correct treatment in non-union surgery. The aim of this study was to determine the evidence supporting the use of the NUSS classification in the treatment of non-unions of long bones and to validate the treatment algorithm suggested by this scoring system. MATERIALS AND METHODS: A total of 300 patients with non-union of the long bones were included in the clinical study. RESULTS: A radiographic and clinical healing was reached in 60 of 69 non-unions (86%) in group 1 (0-25 points), in 102 of 117 non-unions (87%) in group 2 (26-50 points), and in 69 of 84 (82%) in group 3 (51-75 points). The mean time to clinical healing was 7.17 ± 1.85 months in group 1, 7.30 ± 1.72 months in group 2 and 7.60 ± 1.49 months in group 3. The mean time to radiographic healing was 8.78 ± 2.04 months in group 1, 9.02 ± 1.84 months in group 2 and 9.53 ± 1.40 months in group 3. DISCUSSION: There are few articles in the scientific literature that examine the classification systems for non-union. CONCLUSIONS: A statistical analysis of the first results we have obtained with the use of NUSS showed significant rates of union in all the evaluated groups. This indicates that NUSS could be an appropriate scoring system to classify and stratify non-unions and to enable the surgeon to choose the correct treatment.

Megaprosthesis in post-traumatic and periprosthetic large bone defects: Issues to consider.

INTRODUCTION: The recent evolution of prosthesis technology has enabled the surgeon to replace entire limbs. These special prostheses, or megaprostheses, were developed for the treatment of severe oncological bone loss; however, the indications and applications of these devices have expanded to other orthopaedic and trauma situations. For some years, surgeons have been implanting megaprostheses in non-oncological conditions, such as acute trauma in severe bone loss and poor bone quality; post-traumatic failures, both aseptic and septic (represented by complex non-unions and critical size bone defects); major bone loss in prosthetic revision, both aseptic and septic; periprosthetic fractures with component mobilisation and poor bone stock condition. The purpose of this study was to evaluate retrospectively the complications during and after the implantation of megaprosthesis of the lower limb in post-traumatic and prosthetic bone loss, and to propose tips about how to avoid and manage such complications. MATERIALS AND METHODS: All the complications and difficulties we have encountered during or after the implantation of megaprosthesis in non-oncology patients were evaluated retrospectively. A total of 72 patients were treated with large resection mono-and bi-articular prostheses between January 2008 and January 2014. RESULTS: The main critical problems found in the study were: restoration of the correct length and rotation of the limb; reconstruction of the knee extensor mechanism; trochanteric reconstruction; stability/dislocation of the implant; mobility/range of motion (ROM) of the implant; skin cover; sepsis, and bone quality. CONCLUSION: Megaprosthesis in severe bone loss can be considered as an available solution for the orthopaedic surgeon in extreme, appropriately selected cases. This type of complex surgery must be performed in specialised centres where knowledge and technologies are present. Patients with severe bone loss should not be treated in the same way as oncology patients because life expectancy is definitely longer; therefore, the surgical technique and the system implantation must be extremely rigorous to ensure longevity of the prosthesis. The characteristics of the bone and soft tissue conditions in these patients are very different from those presented by oncology patients, which creates critical problems that the surgeon should be able to manage to avoid serious complications.

Incidence of donor site morbidity following harvesting from iliac crest or RIA graft.

INTRODUCTION: Clinical management of non-union of long bone fractures and segmental bone defect is a challenge for orthopaedic surgeons. The use of autologous bone graft (ABG) is always considered the gold standard treatment. Traditional techniques for harvesting ABG from iliac crest usually involve several complications, particularly at the donor site. The Reamer-Irrigator-Aspirator (RIA) is an intramedullary reaming system that generates a large volume of cancellous bone material in a single-step reaming process; this bone material can be collected and potentially used as an ABG source. Our interest is to compare the complications associated with the standard technique of harvesting from iliac crest with those of the innovative RIA harvesting device. MATERIALS AND METHODS: A database of 70 patients with long bone non-unions was studied. The patients were divided into two groups according to the surgical harvesting technique used: RIA system ABG (35 patients) and iliac crest ABG (35 patients). RESULTS: At the 12-month follow-up, pain at the donor site was reported in no patients in the RIA system ABG group and five of 35 patients (14.28%) in the iliac crest ABG group. Local infections at the donor site were found in no patients in the RIA system ABG group compared with five patients (14.28%) in the iliac crest ABG group. There were no fractures in the RIA system ABG group and one case (2.85%) of anterior superior iliac spine (ASIS) dislocation in the iliac crest ABG group. No systemic infections were detected in either group. DISCUSSION: We analysed the scientific literature on the use of RIA technique to collect ABG for use in patients with anthropic-oligotrophic non-unions, with a focus on the complications associated with this technique. CONCLUSION: RIA bone graft for the treatment of non-unions and segmental bone defect of long bones seems to be a safe and efficient procedure with low donor site morbidity.

Megaprosthesis in large bone defects: opportunity or chimaera?

INTRODUCTION: The development of new megaprosthesis for the treatment of large bone defects provides important options to orthopaedic oncologic surgeons for the replacement of skeletal segments, such as the long bones of the upper and lower limbs and the relative joints. We implanted megaprosthesis using either a one-step or two-step technique depending on the patient's condition. The aim of this study was to evaluate retrospectively both clinical and radiological outcomes in patients who underwent lower limb megaprosthesis implant. MATERIALS AND METHODS: A total of 32 patients were treated with mono- and bi-articular megaprosthesis subdivided as follows: proximal femur, distal femur, proximal tibia and total femur. The mean follow-up of patients was about 18 months (range 3 months to 5 years). Clinical and serial radiographic evaluations were conducted using standard methods (X-ray at 45 days, 3, 6, 12, 18 and 24 months) and blood parameters of inflammation were monitored for at least 2 months. RESULTS: Although the mean length of follow-up was only 18 months, the first patients to enter the study were monitored for 5 years and showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. During surgery and, more importantly, in pre-operative planning, much attention should be given to the evaluation of the extensor apparatus, preserving it and, when necessary, reinforcing it with tendon substitutes. DISCUSSION: Megaprosthesis in extreme cases of severe bone loss and prosthetic failure is a potential solution for the orthopaedic surgeon. In oncological surgery, the opportunity to restore functionality to the patient (although not ad integrum) is important for both the patient and the surgeon. The high mortality associated with cancer precludes long-term patient follow-up; therefore, there is a lack of certainty about the survival of this type of prosthesis and any medium- to long-term complications that may occur. Nevertheless, patients should be considered as an oncologic patient, not because of the disease, but because of the limited therapeutic options available. CONCLUSIONS: Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases.