The surgical treatment of nonunion of the proximal metaphysis of the femur.

Nonunion of the proximal femur is a severe pathology, often provoked by the inopportune or improper use of a therapeutic aid: nonsurgical (primary nonunion), surgical (secondary nonunion). Surgical treatment of this nonunion may thus be characterized by different degrees of difficulty, depending on whether or not it is the sequela of surgery or of nonsurgical treatment. In lax nonunion, with atrophy of the segments and regions of necrotic bone interposed, modeling resection is required to correct the functional axes. The condylar blade-plate may be opposed by a cortical graft--to improve stability of the assembly--protecting the medial wall and providing the screws with excellent hold.

Aseptic nonunion of the humeral shaft.

A total of 78 cases of aseptic nonunion of the humeral shaft treated at the third division of the Rizzoli Orthopaedic Institute between 1980 and 1997 were evaluated. There was a mean time of 19 months between trauma and definitive treatment. Surgical treatment consisted in osteosynthesis with a plate and bone grafting in 75 cases, and synthesis with screwed bone grafting alone in 3 cases. Consolidation was obtained in 96% of cases. The bone graft used (homo- or autoplastic) encountered complete osteointegration in a maximum time of 8 months. Postoperative motility of the shoulder and elbow were comparable to the preoperative findings.

Dislocation of the proximal femoral epiphysis in acetabular fractures.

Acetabular fractures are often associated with dislocation of the proximal femoral epiphysis. The dislocation may be of three types, based on the type of fracture to which it is associated: anterior, central, posterior. In anterior and in central dislocation epiphyseal necrosis of the proximal femur has never been observed, while in posterior dislocation necrosis has been observed in 23% of cases. Diagnosis of posterior dislocation is of essential importance so that it may be reduced immediately, decreasing the risk of necrosis. The authors report a review of 192 fractures of the acetabulum to which dislocation of the femoral epiphysis was associated, treated between 1980 and 1996 at the IIIrd Division of the Rizzoli Orthopaedic Institute.

Intra- and extra-pelvic lesions associated with unstable fractures of the pelvic ring.

Fracture of the pelvis is often caused by high-energy trauma, and for this reason it is frequently associated with fractures in other regions, hemorrhages, or severe lesions of the organs. Based on an analysis of the results, obtained by a review of 68 cases of unstable fracture of the pelvis treated at the IIIrd Division of the Rizzoli Orthopaedic Institute between 1980 and 1995, the authors make several suggestions concerning diagnosis and therapy for the evaluation and treatment of these patients.

Valgus-lateralization osteotomy: notes on surgery.

There are specific forms of nonunion secondary to per-inter-subtrochanteric fractures that make surgical planning a critical phase. In cases such as these, it may be useful to transform the center of the nonunion into an osteotomy plane. Because of the anatomotopographical features, course and progression of the lesion, cases such as these constitute a pathology that is difficult to define in terms of a therapeutic protocol. The authors report the surgical technique used in 4 cases of nonunion of the proximal metaphysis of the femur.

Rigid fixation with plate and bone graft in failures of intramedullary osteosynthesis for the treatment of diaphyseal nonunion of the femur.

Fractures and diaphyseal nonunion of the femur are normally treated by intramedullary nailing. In cases in which nailing fails, nonunion is treated by reaming of the canal and substitution of the nail with one of a more adequate caliber. Rarely, however, due to unfavorable mechanical conditions or in cases of atrophic nonunion or with scarce vascularization the biological conditions for healing are absent. In cases such as these, nonunion must be treated by rigid internal fixation with a plate, aided by the use of cortical graft on the opposite side. The authors present 7 cases of diaphyseal nonunion of the femur treated between 1994 and 1996 using rigid fixation (plate and graft) as a salvage method, as a result of numerous previous failures in surgery. The results were favorable in all of the cases without complications.

Inveterate fractures of the acetabulum.

The authors reviewed 44 inveterate fractures of the acetabulum treated surgically by internal osteosynthesis. The definition of inveterate fracture concerns lesions that are treated from 21 to 90 days after trauma. Based on an analysis of this series several features of a prognostic and therapeutic nature may be determined. In particular, it may be observed just how difficult it is to standardize therapeutic strategies in relation to polymorphism and anatomopathologic progression of the lesions.

Aseptic nonunion of the tibia treated by intramedullary osteosynthesis.

The authors report 52 cases of aseptic nonunion of the tibia treated by intramedullary osteosynthesis. The means of synthesis used were the Küntscher nail, the Eiffel Tower Rush nail, and the Grosse-Kempf nail. Which means of synthesis was used depended on the site and the features of the nonunion. Healing occurred in all of the cases after an average of 5 months. Mean follow-up was 4.5 years.

Revision of the femoral prosthetic component according to the Wagner technique.

The authors report the preliminary results they obtained using the Wagner technique for revision of the prosthetic stem by transfemoral access. Between January 1992 and June 1993 a total of 20 patients were treated by reimplantation of the prosthetic stem according to the Wagner technique. At minimum 12-month follow-up, based on the Harris Score System, results were excellent, good and fair in 16 cases. Results were not satisfactory in 4 cases after sinking of the prosthesis exceeding 2 cm or due to mid-distal pain with loading.

Lesions of the sciatic nerve in fractures of the acetabulum.

Between 1982 and 1992 a total of 211 fractures of the acetabulum were operated. There was lesion of the sciatic nerve in 21 cases, the pathogenesis and evolution of which were studied. Clinical follow-up was obtained at least 2 years after occurrence of neurological deficit and supported in 13 cases by electromyography. Based on an analysis of the literature and of these series it is observed how spontaneous recovery of paralysis is not rare, even if it requires a long period of time. The presence of various levels of lesion, which are not easily diagnosed, and which are not easily attacked surgically, calls for a prudent attitude with regard to neurolysis.

Internal fixation in unstable fractures of the pelvis. Preliminary notes.

The authors report the preliminary results of the surgical treatment of unstable fractures of the pelvic ring. Between 1989 and 1993 a total of 12 unstable fractures were treated by internal fixation. Short-term radiographic and functional results were satisfactory. The authors attribute an essential role to preoperative planning by conventional radiographic assessment and CT scan with multiplanar reconstructions, associated with carefully performed internal osteosynthesis.

Fractures of the lower end of the humerus in the adult.

The authors report their experience in the treatment of 34 fractures of the lower end of the humerus treated surgically over the last 6 years. The fractures are divided into four types in assessing the functional results; open and closed; those involving and not involving the joint. Satisfactory clinical results were obtained in 22 of the 34 cases (64%). Complications were directly related either to the severity of the lesion (comminuted and open fractures) and/or inadequate surgical technique.

The role of osteosynthesis in the treatment of fractures of the humerus.

Rigid osteosynthesis is widely indicated in fractures of the humeral diaphysis because it abolishes the need for external immobilisation and thereby facilitates early functional recovery. In simple fractures, osteosynthesis was used according to the principles of the Swiss AO school (rigid fixation in axial compression). In complex fractures we added a homoplastic cortical graft on the opposite side to the plate. A follow-up survey of 74 patients was carried out (minimum 8 months, maximum 10 years). There were two cases of complete paralysis of the radial nerve, which quickly regressed. There was one severe infection which resulted in pseudarthrosis, but this was due to an error of judgement because this was an open fracture with exposure of the fragments. This complication aside, the functional results were excellent, and completely justify this method of treatment.

The treatment of fractures of the acetabulum involving both anterior and posterior columns.

Over a period of 20 years, 35 cases of fracture of the acetabulum involving both columns were treated by operation in our unit. These were followed up after a minimum of 8 to a maximum of 20 years. The Iselin approach, even when extended forwards by partial disinsertion of the gluteal muscles, allowed good reduction only when there was little or no displacement of the ilio-pubic column. In the other cases, it was necessary to use a combined anterior and posterior approach, or the Letournel approach, but the latter was reserved for cases with very severe displacement or comminution of the fragments when it is essential to have access and control of the iliac and acetabular complex in its entirety. The clinical and radiographic results of fractures involving both columns are not unlike those observed in other complex fractures of the pelvis: good reduction and osteosynthesis is synonymous with good function even in the long term.

The surgical treatment of inveterate fractures of the acetabulum.

Any fracture of the acetabulum which is not adequately treated within 3 weeks poses a considerable surgical problem. Reduction is difficult, callus has already begun to form between the displaced fragments, and the risks of complications are therefore increased. Our material consists of 35 cases, subdivided into 18 fractures submitted for treatment between 3 and 12 weeks after injury, and 17 fractures submitted for treatment beyond the 12 week limit. In the first group the incidence of complications (ischaemic necrosis, arthrosis, infection) was high; satisfactory results were obtained only when the fracture was of the simplest type. In the second group, malunion had to be accepted, and treatment was concerned solely with improving function by correcting malposition and relieving or eliminating pain. The surgical methods adopted depended on the circumstances: corrective osteotomy, arthrodesis or total prosthetic replacement.

The Grosse-Kempf blocked nail in the treatment of diaphyseal and metadiaphyseal fractures of the tibia.

The use of the Grosse-Kempf nail in the treatment of fractures of the tibia is limited for two reasons: (1) the medullary canal may be too narrow to permit adequate reaming to accommodate the instrumentation; (2) complex or comminuted fractures rarely occur without severe soft tissue involvement or exposure of the fracture. The authors report 24 cases treated since 1981. They describe the radiographic features, indications for treatment, time for union, and programme of rehabilitation. These are practically identical to those found in a previous report on femoral shaft fractures. In the present series, the only complication was a false aneurysm of the posterior tibial artery which was successfully treated surgically with no loss of function.

Transverse fractures of the acetabulum.

From a total case material of 356 fractures of the acetabulum we have been able to analyse in depth 188 fractures treated surgically--77 transverse, 21 T-fractures and 90 transverse associated with posterior rim fractures. These lesions, although sharing certain anatomical and radiographic features, have peculiar characteristics which are important to define for purposes of treatment. Posterior dislocation of the femoral head is frequently associated with posterior rim fractures and central dislocation with transverse and T-fractures. Traumatic arthritis as a late complication was studied with particular reference to the quality of reduction of the fracture. When this results in an irregular articular surface early arthritis is the usual outcome; when it results in an acetabular cavity wider than the diameter of the femoral head, arthritis is delayed usually for more than 10 years, and subsequently progresses very slowly.