Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?

INTRODUCTION: Ankle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested. METHODS: Patients were divided according to Bartonícek classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis. RESULTS: Clinical outcome worsened with the severity of Bartonícek classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement. DISCUSSION: We recommend conservative treatment for Bartonícek type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.

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.

Femoroacetabular impingement: biomechanical and dynamic considerations.

Femoroacetabular impingement (F.A.I.) is a pathologic process caused by an abnormal shape of the acetabulum, of the femoral head, or both. F.A.I., often referred to as idiopathic, may be secondary to slipped capital femoral epiphysis, congenital hypoplasia of the femur, Legg-Calvé Perthes disease, post-traumatic mal-union and protrusio acetabuli. From 2009 to 2012 we studied 21 patients (14 males), with a mean age of 52 (33 y - 75 y), affected by idiopathic F.A.I. Every patient underwent pelvic and hip joint X-rays and CT scan with 3D reconstructions, in order to evaluate the morphology of the pelvis and the hip joint and the torsion of the lower limbs (Femoroacetabular ante-retroversion). Our results show an average femoral ante-version angle of 12,4° (15°-20° physiological range) in patients affected by CAM impingement and an average acetabular ante-version angle of 13,5° (15°-20° physiological range) for those with PINCER impingement. These values, in patients affected by F.A.I., are probably related to morphologic and biomechanical features that may lead to the onset of idiopathic femoroacetabular impingement. In the literature, other studies partially support our findings, suggesting a more critical approach to a patient with idiopathic F.A.I. extending evaluations to nearby articulations.

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.

The biocompatibility of porous vs non-porous bone cements: a new methodological approach.

Composite cements have been shown to be biocompatible, bioactive, with good mechanical properties and capability to bind to the bone. Despite these interesting characteristic, in vivo studies on animal models are still incomplete and ultrastructural data are lacking. The acquisition of new ultrastructural data is hampered by uncertainties in the methods of preparation of histological samples due to the use of resins that melt methacrylate present in bone cement composition. A new porous acrylic cement composed of polymethylmetacrylate (PMMA) and ß-tricalciumphosphate (ß-TCP) was developed and tested on an animal model. The cement was implanted in femurs of 8 New Zealand White rabbits, which were observed for 8 weeks before their sacrifice. Histological samples were prepared with an infiltration process of LR white resin and then the specimens were studied by X-rays, histology and scanning electron microscopy (SEM). As a control, an acrylic standard cement, commonly used in clinical procedures, was chosen. Radiographic ultrastructural and histological exams have allowed finding an excellent biocompatibility of the new porous cement. The high degree of osteointegration was demonstrated by growth of neo-created bone tissue inside the cement sample. Local or systemic toxicity signs were not detected. The present work shows that the proposed procedure for the evaluation of biocompatibility, based on the use of LR white resin allows to make a thorough and objective assessment of the biocompatibility of porous and non-porous bone cements.

A preformed antibiotic-loaded spacer for treatment for septic arthritis of the shoulder.

BACKGROUND: Total shoulder arthroplasty infections are rare, depending on the use of antibiotic prophylaxis, the local blood supply, the axial load gradient and the proximal location of the shoulder. The purpose of this study was to evaluate the results of treatment for infections in total shoulder arthroplasty and septic arthritis using a preformed antibiotic-loaded spacer. MATERIALS AND METHODS: Seven shoulders in as many patients were treated for infected arthroplasty or septic arthritis without previous surgery. A preformed antibiotic-loaded spacer was always applied. Patients were evaluated at the final follow-up with the Constant Score (CS), the Secec Elbow Score (SES), and the American Shoulder and Elbow Society Score (ASESS). RESULTS: The mean follow-up was 40, 71 months after spacer implant. Infection was always confirmed preoperatively by the leukocyte and neutrophil counts in the aspirated synovial fluid, and intra-operative biopsy and pathologic analysis. Positive bacterial cultures were found in 5 cases: 3 MRSA and 2 Staphylococcus epidermidis. The mean SES increased from 34.43 before spacer implant to 77.29 at final follow-up, ASESS ranged from 14.86 to 21.14, and CS from 40.28 to 79.14. CONCLUSION: A preformed antibiotic-loaded spacer is intended to release gentamicin alone, but we can consider adding vancomycin to increase antibiotic spectrum. An early diagnosis and an immediate treatment can prevent a persistent infection and severe soft-tissue damage. The use of a preformed antibiotic spacer allows maintaining joint function at the intermediate stage in two-stage treatment.

Acrylic bone cement: current concept review.

Acrylic bone cement has had for years an important role in orthopedic surgery. Polymethylmethacrylate (PMMA) has been extended from the ophthalmological and dental fields to orthopedics, as acrylic cement used for fixation of prosthetic implants, for remodeling osteoporotic, neoplastic and vertebral fractures repair. The PMMA bone cement is a good carrier for sustained antibiotic release in the site of infection. Joint prostheses chronic infection requires surgical removal of the implant, in order to eradicate the infection process. This can be performed in the same surgical time (one-stage procedure) or in two separate steps (two-stage procedure, which involves the use of an antibiotic-loaded cement spacer). The mechanical and functional characteristics of the spacers allow a good joint range of motion, weight-bearing in selected cases and a sustained release of antibiotic at the site of infection. The improvement of fixation devices in recent years was not accompanied by the improvement of elderly bone quality. Some studies have tested the use of PMMA bone cement or calcium phosphate as augmentation support of internal fixation of these fractures. Over the past 20 years, experimental study of acrylic biomaterials (bone cement, bioglass ceramic, cement additives, absorbable cement, antibiotic spacers) has been of particular importance, offering numerous models and projects.

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.

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.