Unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. A prospective study.

INTRODUCTION: Few clinical studies have analyzed the utility of distal interlocking screws in stable and unstable intertrochanteric fractures treated with intramedullary devices. We performed a prospective analysis comparing short unlocked versus short dynamic and short static distal locked intramedullary nails. MATERIALS AND METHODS: Nine level-II trauma centres were involved in the study. 240 patients over the age of 65 with a stable (AO/OTA 31-A1) or unstable intertrochanteric fracture (AO/OTA 31-A2) were prospectively investigated. The same type of nail was used in every patient. Patients were randomly divided into 3 groups according to the type of distal locking used. Intra-operative variables were examined and patients were followed clinically and radiographically at 1, 3, 6, 12 months postoperatively. All complications were recorded. RESULTS: A total of 212 patients completed 1 year of follow-up visits. In the Unlocking Group (UG) the operation time, blood loss, fluoroscopy time, total length of incision were significantly decreased compared to both the Dynamic Group (DG) and the Static Group (SG) (p < 0.05). Conversely, no reliable differences in intraoperative variables were noted between the Dynamic Group and the Static Group (p > 0.05). In terms of time of fracture union we found no differences among the three Groups (p > 0.05). Moreover, no cases of limb shortening >1 cm or varus collapse were detected in any group. The 3 Groups were similar in terms of HHS, SF-12 and Barthel index results at 1-year follow-up (p > 0.05). Finally, no significant differences were demonstrated across the three Groups in terms of major complications. CONCLUSIONS: This clinical study further confirms the hypothesis that short intramedullary nails do not need to be locked for stable and unstable intertrochanteric fractures.

Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study.

We investigated whether a proximal femoral nail can be implanted without a distal locking screw in AO/OTA 31-A1 and 31-A2 pertrochanteric stable femur fractures. A multicentre, randomised study was conducted in six level-two trauma centres in our area (Puglia, Italy). A total of 333 patients received their allocated intervention (162 in the locking group [LG] and 171 in the unlocking group [UG]) and 266 patients were included in the final analysis at 1year. Our data showed no statistically significant difference between the two groups at 1-year follow-up for ability to walk, SF-36 questionnaire results, residual pain (visual analogue scale [VAS] score) and level of overall satisfaction. There were also no statistically significant differences between groups for mortality and length of hospital stay. Conversely, the UG was associated with shorter operation and fluoroscopy times, shorter surgical incision length, and less blood loss and residual thigh pain. Pertrochanteric stable fractures (31-A1, 31-A2) can be treated successfully with intramedullary nails without distal locking, reducing patient and clinical personnel radiation exposure and sanitary costs (surgery time and screws costs).

Heel displaced intra-articular fractures treated with mini-calcaneal external fixator.

INTRODUCTION: Treatment of displaced heel fractures is controversial; however, ORIF is widely described in the literature to be the gold-standard. Percutaneous reduction and monolateral external fixation is gaining increasing attention because it provides a good and stable reduction, and minimises soft tissue complications due to open surgery, such as deep infections and delays in wound healing. The aim of this study was to show that the new Orthofix Calcaneal Minifixator (six pins) provides a greater stability than the four-pin version to enable a better and more stable reduction, an earlier weight-bearing (30 days) and improved functional outcomes. METHODS: A series of 69 consecutive closed heel intraarticular displaced fractures treated with the new Orthofix Calcaneal Minifixator were evaluated. Patients were assessed clinically with the Maryland Foot Score and radiologically with standard radiographs. RESULTS: The clinical results at follow-up were excellent in 37 cases (53.6%), good in 27 (39.2%), fair in two (2.9%) and poor in three (4.3%). The mean preoperative Böhler's angle was 5.2˚ (range 0-18˚) and the mean postoperative value was 28.5˚ (range 16-38˚). CONCLUSION: The excellent functional outcomes were despite some radiological images of imperfect posterior facet anatomical reduction and seemed to correlate with the use of a good and stable minimally-invasive surgical technique. This technique enabled early weight-bearing, minimised complications, respected the delicate biology of this anatomical site and restored the good heel volume and Böhler angle.

Arthroerisis with Giannini's endo-orthotic implant and Pisani's talocalcaneal arthroerisis. A comparison of surgical methods.

In this paper the Authors report the results gained after the treatment of paediatric idiopathic flat foot by means of Pisani's talocalcaneal arthroerisis and arthroerisis with Giannini's endo-orthotic implant. Two groups of patients have been treated according to the two techniques. According to clinical, radiographic and functional tests, the Authors believe that both the techniques can offer good results to correct idiopathic flat foot of childhood and they highlight the lower invasivity and less damage for the structures of sinus tarsi when Pisani's talocalcaneal arthroerisis is applied.

The surgical treatment of hallux valgus using distal metatarsal osteotomy and stabilization with a hallux splint. Preliminary results.

The preliminary results of the surgical treatment of hallux valgus using subcapitate chevron-type osteotomy of the 1st metatarsal modified using a dynamic interfragmentary device are reported. The method satisfies the need to restore angular metatarsophalangeal and intermetatarsal values and improves metatarsal pain caused by hallux valgus correction, which influences the cosmetic results.

Gorham's disease: a rare case of multicentric localization.

Gorham's disease is described as a rare form of massive non-familiar idiopathic osteolysis with a self-limiting nature, where the simil-angiomatous tissue destroys the bone, that is substituted by fibrous tissue. One case of Gorham's disease is presented, that is interesting because of the sites in which the pathology is localized and because of its multicentricity. The authors reached a diagnosis by carefully studying clinical and laboratory evidence as well as imaging and anatomo-histopathological findings, confirmed by the data reported in the literature.

Multiple osteoid osteoma. A clinical case.

Osteoid osteoma is a benign tumor occurring frequently during the growth years. It may be found in any of the skeletal segments, and it is often present as an isolated neoformation. In some rare cases it may involve more than one segment or it may be multicentric. The authors report their experience with a case of double localization of metachronous osteoid osteoma.

Catterall versus Herring classification in Perthes' disease.

It is the purpose of this study to compare the prognostic value of the Herring classification (lateral pillar) with that of the Catterall classification. The material is constituted by 45 patients affected with Perthes' disease and reviewed an average of 24 years after onset. At follow-up the hips were divided into three classes based on joint congruency as suggested by Stulberg. The Catterall classification demonstrated overall a better predictive value for the Herring system. Instead, the most satisfactory reproducibility seems to be that of Herring: 80% as compared to 42% for the Catterall classification.

Meyer's dysplasia epiphysealis.

Meyer's femoral cephalic dysplasia (FCD) is a rare affection that is often confused with Perthes' disease from which it differs in terms of both treatment and prognosis. A constant feature is the absence of the nucleus of ossification that does not occur until 15-18 months of age; at times there are multiple nuclei of ossification, so that the epiphysis has a "morulated" aspect. Fusion of the various centers of ossification occurs at about 5 years of age. The epiphysis does not collapse and it preserves its density and its structure. Differential diagnosis involves Perthes' disease and other pathologies such as multiple dysplasia epiphysealis, hypothyroidism, dyschondroplasia.

Anterior cruciate ligament reconstruction. A comparison of 2 techniques.

This work compares the results of 2 different techniques of anterior cruciate reconstruction performed by 2 surgeons with the same rehabilitation program and same criteria of results evaluation. Forty-five patients were operated on using semitendinous tendon autograft, (average followup, 8 years 4 months), and 30 patients using bone patellar tendon bone autograft (average followup, 7 years 5 months). Functional results were evaluated using the Lysholm and Tegner rating systems, and clinical laxity or stability were evaluated using the Lachmann and Jerk tests. Articular stability and function were significantly better in the patients operated on using bone patellar tendon bone autograft.