The treatment of complex proximal humeral fractures: analysis of the results of 55 cases treated with PHILOS plate.

Complex proximal humerus fractures are often difficult to treat. Their frequency is high, especially in the elderly, and their treatment is still controversial. The aim of this study was to analyze the clinical and radiological results achieved by patients with complex proximal humerus fractures, treated with PHILOS plate only. A cohort of 55 patients was selected. The mean age was 63.4 (range 33-89), while the mean follow-up time was 21.5 months (range 6-75). Clinical outcome was evaluated with the "Constant-Murley shoulder score." All the informations about the presence of complications were gathered, and radiological images were used to calculate the head-shaft angle. The overall mean Constant score was 61.93 ± 18.59, the Individual CS was 70 ± 20 % and the Relative CS was 83 ± 23 %. No significant differences were found between fractures Neer 3 and Neer 4 and between the surgical approaches (delta-split vs. delto-pectoral). Six patients had a fracture with dislocation, seven patients (12.7 %) had complications while in four patients a head-shaft angle beyond the normal range was found. Osteosynthesis with PHILOS plate is stable in the greater part of the cases, and it allows an earlier rehabilitation and so a good functional result, which could be compromised by a prolonged immobilization. Therefore, PHILOS plate is a good option for the treatment of complex proximal humerus fractures.

Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients.

BACKGROUND: Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of <8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt. MATERIALS AND METHODS: There were 33 patients in this study, mean age 76.6 years (range 54-85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot. RESULTS: Mean follow-up was 42.3 months (range 10-121). According to the CS, mean pain was 12.6/15 (range 3-15/15), activities of daily living 16.3/20 (range 8-20/20), ROM 21.8 (range 8-32/40) and power 5.4/25 (range 2-12/25). Total mean CS was 56.4 (range 23-80/100). The mean DASH score was 49.7 (range 32-90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28-90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %). CONCLUSIONS: Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.

Nailing treatment in bone transport complications.

A series of cases of reamed intramedullary nailings carried out after complications in regenerated bone and docking site had occurred in bone transport is presented here. Nine patients (femur = 5; tibia = 4) had treatment with resection after open fractures or infection and underwent bone transport. The mean length of regenerated bone was 9.5 cm (range 6-18 cm). After bone transport, the fixator remained in place for a mean period of 12.8 months (range 8-24 months). In six cases (femur 4; tibia 2), the thickness of the cortical wall of the regenerate column was insufficient, and in two of these, there was, in addition, nonunion of the docking site. In the two tibial cases, nailing was carried out shortly after the fixator had been removed and after refracture of the regenerated bone had occurred due to insufficient cortical thickness. In one femur, nailing was carried out for nonunion of the docking site. Follow-up involved clinical and X-ray checks. The mean follow-up was 3.9 years (range 2-6 years). In all cases, union and with complete corticalization of the regenerate column was observed at an average 6 months after nailing (range 4-11 months). Infection occurred in one tibia 4 months after nailing. The infection was treated with antibiotics, and the nail was subsequently removed. We conclude that nailing is a potential solution for regenerated bone and docking site problems but, if used after prolonged periods of external fixation, may necessitate antibiotic therapy for at least 10 days after the fixator has been removed.

Minimally invasive plate osteosynthesis in type B fibular fractures versus open surgery.

BACKGROUND: In traumatology, the search for better surgical access points has led to the increased use of the minimally invasive plate osteosynthesis (MIPO) technique. There are few studies on the treatment of distal fibular fractures with MIPO. Locking compression plates (LCP) for distal fibular fractures is generally applied after open reduction, but may involve complications to the surgical wound. In this study, we compared two groups of patients receiving either ORIF or MIPO, in order to analyse the advantages and disadvantages of the two techniques. MATERIALS AND METHODS: Two homogeneous groups of patients (18 + 18) received LCP for distal fractures of the fibula, type B, according to AO. Group A patients underwent open surgery, whereas Group B patients received plates applied with the MIPO technique. Both groups were examined physically and radiographically 1 and 3 months after the two types of procedure and then 1 year later, with functional assessment according to Olerud and Molander. RESULTS: ROM Group A: 5° reduction in tibiotarsal extension in 8 patients and 5° in supination in 1 patient; Group B: 5° reduction in extension in 7 cases. Mean healing time: 3 months (range 2-4) in Group A and 2.9 (range 2-4) in Group B. Dehiscence of the surgical wound was observed in five Group A patients, but none in Group B. Functional assessment according to Olerud and Molander was 87.4 points in Group A (range 80-100) and 95.6 in Group B (range 82-100). CONCLUSIONS: We believe that the MIPO technique for distal fractures of the fibula should be used more often, especially if soft tissue is in a critical condition. Healing times should be reduced in the more complex cases. It is important that the learning curve should be improved, to minimize exposure to radioscopy and possible damage to the superficial fibular nerve.

Open reduction and internal fixation of radial head fractures.

This study examines 32 patients operated for radial head fractures, mean age 48.7 years (range 26-76 years), Mason type II in 25 cases and Mason type III with 3 main fragments in 7 cases. Fractures were surgically reduced and fixed with Herbert's (12 cases) or Osteomed (20 cases) cannulated screws. The latter have a head that is <1 mm high and are only threaded distally. Both types of screw provide compression across the fracture. In Mason type II cases, the mean MEPS score was 98.4 and the DASH score 6.8. In Mason type III cases, MEPS was 99.3 and DASH 9.5. We believe that fixation can be carried out with screws alone, which are less invasive, and that the screw heads should preferably be completely buried, to avoid stiffness in prono-supination. In addition, suturing of the annular ligament and the joint capsule is made easier by the reduced invasiveness of screws. Screw treatment is effective in non-comminuted fractures of the radial head.

Locked antegrade intramedullary nailing of humeral shaft fractures.

This paper reports the results of treating 35 humeral shaft fractures with antegrade nailing in patients between the ages of 25 and 92 (mean 64.5): 14 patients were aged between 25 and 59, and 21 between 66 and 92. The nail was set in place proximally with a spiral blade and distally with 1 or 2 screws. In the first 14 cases, uncannulated humeral nailing (UHN) was carried out, and in the next 21 cannulated humeral nailing (CHN). The latter technique uses a guide wire which, in cases of an error in the length of the nail, is useful in that it allows another nail to be set in place. Main outcome parameters were fracture healing, shoulder discomfort, and radial nerve recovery. The DASH functional scoring system, modified according to Beaton et al. for subjective assessment was used, and range of motion was checked with the constant score. X-rays were used to assess fracture healing time and cases of malunion. Two patients developed non-union, one caused by a UHN which was too short, and the other by a nail blocked distally by a single screw. In 7 patients, consolidation was achieved, but with varus between 3 and 8 degrees (mean 5 degrees), without aesthetic or functional damage. In 33 out of 35 patients, shoulder functionality had mean DASH score results of 21.9, whereas shoulder range of motion reached a mean constant score (CS) of 26.5 (78.8%) with respect to the opposite shoulder. In 5 cases of stiffness, the UHN turned out to be insufficiently buried. Results improved with the CHN. Much better results were seen in the group of patients aged between 25 and 59 (mean age 43), but worse in older ones (66-92 years, mean age 78). Radial nerve palsy after surgery occurred in 2 cases, and the nerve was immediately examined. It did not appear to be trapped in the fracture in either case, and recovery was complete 6 months later. CHN appears to be a valid solution, both in younger patients, thanks to excellent results, and in older ones, who have fewer functional requirements.

Percutaneous screw fixation for scaphoid fractures.

Long-term results of percutaneous treatment for 36 scaphoid fractures, types B1 and B2 according to Herbert, are reported. Outcomes were satisfactory in nearly all cases. In three patients, the screw was too long and had to be removed, and pseudoarthrosis developed in one patient. Consolidation was observed after 6-8 weeks, less than literature reports for immobilization with casts. The percutaneous approach is particularly suitable for younger patients who work or play sports.

Plating of proximal fracture of the humerus: a study of 30 cases.

In recent years, plate osteosynthesis with angular stable implants is frequently used for severely displaced three- and four-part proximal humeral fractures. The aim of this study is to evaluate early results of these fractures treated with insertion of LCP or Philos plates. We present results in 30 cases of proximal humeral fractures, 17 with 3 parts according to Neer and 13 with 4 parts, treated with Locking Compression Plates (LCP, 14 cases) and Philos plates (16) by the deltopectoral approach. Patients were checked with standard X-rays and clinical evaluation, according to the Constant-Murley shoulder score, Individual Constant score and Relative Constant score. Mean follow-up time was 21 months (range 6-42 months). The mean Constant-Murley shoulder scores were Pain 10.6 (3-15), Activities of Daily Living 15.3 (2-20), Range of Motion 26.8 (12-40) and Power 10.3 (3-25) and Total 63 (25-97). The Individual Constant score was 68.6% (27-98%) and the Relative Constant score 85.4% (36-130%). Fractures in 3 parts (of the surgical or anatomic humeral neck and major tubercle) had a mean Constant score of 69.1 (17 cases), but this fell to 55 (13 cases) in those in 4 parts (neck, major and lesser tubercles). Late necrosis of the humeral head occurred in two cases, both with 4-part breaks. We thus believe that 3-part fractures, in which both reduction and stable osteosynthesis are easier, show favourable prognosis and should be clearly distinguished from 4-part ones during assessments. The deltopectoral approach offers good exposure and is especially recommended in 4-part fractures, also because it provides a good view of the lesser tubercle. The osteosynthesis must be stable if early mobilisation of the shoulder and proper recovery of range of motion are to be achieved. As well as reduction and stabilisation of the tubercles, it is also important to restore the neck/shaft angle and stabilise it with oblique screws fitting the plate to avoid varus malposition.

The Ilizarov method in the treatment of nonunion of the tibial pylon.

The results of the treatment of 18 cases of nonunion of the tibial pylon using the Ilizarov method are presented. The level of the nonunion was divided into A (epiphyseal, 2 cases), B (from 1 to 4 cm from the joint rima, 7 cases), and C (from 4 to 7 cm from the rima, 9 cases). Nonunion was atrophic in 12 cases, hypertrophic in 2, and infected in 4. Bone grafts were applied in 8 atrophic cases, while bone resection with transport or resection-shortening was performed in the 4 cases with infection, or resection-shortening and then lengthening in 2 cases. Consolidation was always achieved. Range of movement was very compromised in 9 cases, of which 5 initially presented with joint fracture, while another 4 had had septic complications after fracture.

The Ilizarov method in the treatment of malignant neoplasms of the tibia.

A total of 3 malignant neoplasms of the tibia are presented: 1 is a mesenchymal chondrosarcoma of the tibial pylon (male aged 14 years), and 2 are cases of squamous skin carcinoma of the leg with tibial infiltration (1 male and 1 female aged 32 and 64 years, respectively). The resections carried out (16.5 cm on the average) were treated by bone transport. Simple transport was used in the first patient, double in the other two. At the end of transport a second surgical stage involving astragalotibial arthrodesis was performed in the first case, and revision of the junction site of bone segments transported with application of autoplastic bone grafts was performed in the other two. The regenerate obtained was slowly corticalized in the first patient, submitted to various cycles of chemotherapy during the course of distraction. In the other two cases, which were not treated by chemotherapy during distraction, corticalization occurred over a shorter amount of time. Follow-up was obtained after 10 years in the first case, and after 2 years in the other 2 patients. There was no long-term recurrence.

Vascular leiomyoma of the limbs.

After reporting the most significant data in the literature, the authors present 5 cases of vascular leiomyoma of the limbs (1 in the upper limb, 4 in the lower limb) in subjects of both sexes. In all of the patients, diagnosis was only possible thanks to histological examination, confirmed by an immunohistochemical examination. In none of the cases was there recurrence of neoplasm after surgical exeresis.

Aseptic nonunion and delay in consolidation in the tibia: treatment by intramedullary nailing and using the Ilizarov method.

The authors present a clinical-radiographic study on two groups of patients affected with aseptic nonunion and delays in consolidation of the tibia treated by intramedullary nailing (24 cases) and Ilizarov method (29 cases). Nailing was locked in 12 cases and associated with resection of the fibula in 15 (in 8 locked nailing). Autoplastic bone grafts were applied in 3 cases of atrophic nonunion. The Ilizarov method was used with different procedures: standard assembly in 23 patients, of which 6 with the application of autoplastic grafts for atrophic nonunion. En bloc resection of the atrophic nonunion was carried out in 6 patients followed by removal (4 cases) or lengthening (2 cases). Parafocal osteotomy according to Paltrinieri was reserved for closed hypertrophic nonunion with severe varus and procurvatum. The data for this study allow the authors to conclude that intramedullary nailing is preferable in delays in consolidation and in hypertrophic nonunion without angular defects or hypometria, while the Ilizarov method is more indicated in atrophic nonunions and in hypertrophic nonunions with hypometria and angular defects.

Parafocal osteotomy and the Ilizarov method in the treatment of femoral pseudarthrosis. Case report.

The case presented is that of a man aged 54 years, with hypertrophic pseudarthrosis shortening by 3 cm and a femoral mechanical axis measuring 13 degrees varus. Parafocal osteotomy according to Paltrinieri was carried out with the aim of correcting the varus femur, the shortening and, secondarily, of obtaining recovery from the pseudarthrosis. Osteosynthesis was achieved by the Ilizarov apparatus. Axial correction and lengthening were obtained after 33 days. The fixator was removed after 5 months and 10 days, during which the nonunion appeared healed.

Subcutaneous rupture of the tendon of the long head of the biceps brachii in subacromial impingement syndrome.

Ruptures of the long head of the biceps brachii are mostly of degenerative nature, secondary to subacromial impingement and morphological changes in the bicipital groove. Clinical findings are typical. Treatment is controversial, as it may either be surgical or non-surgical. The authors considered only those cases in which tendinous rupture was the first manifestation of pathology caused by wearing, with typical deformity of the profile of the arm. The favorable results of surgical treatment in 14 patients aged from 38 to 70 years, followed-up after an average of 10.9 years, are reported. Among surgical methods used, tenodesis at the bicipital groove currently constitutes the method of choice.

Extensimetric monitoring of healing in the treatment with the Ilizarov apparatus. A multicenter clinical trial.

The results of a multicentric review are reported using the extensimetric instrumentation applied to the Ilizarov device. This clinical trial the follows same theoretical and experimental preliminary studies, outlines the advantages and current limits of the method, and sets the bases for further clinical and experimental research.

Voluntary hip dislocation in Down's syndrome: report of two cases.

Two cases of monolateral voluntary hip dislocation in Down's syndrome are reported. No surgical procedure was permitted by the family in either case, thus showing the natural evolution of the joint morphology. In the case observed a year after the onset of hip dislocation CT Scan already showed an initial smoothing of the posterior acetabular wall. In the other case, after a 9 year follow-up, the voluntary hip dislocation was followed by progressive subluxation and fixed dislocation at the end. This suggests that only early surgical treatment can prevent this outcome.

Spondylocostal dysplasia (Jarcho-Levin syndrome).

The authors report 3 cases of rare spondylocostal dysplasia (Jarcho-Levin syndrome) associated with multiple visceral anomalies (V.A.C.TE.R.L. syndrome). The difficulty encountered in treating the disease because of the complexity and multiplicity of the visceral anomalies, and the extent and type of associated vertebral deformities is emphasized. The cases described revealed a moderate amount of progression, and were able to be treated non-surgically. It is also emphasized that even when there is moderate scoliosis associated costal deformities may cause anti-cosmetic thoracic gibbosity.

Baropodometric studies in patients submitted to Grice-Green operation for primary valgus pronated flat foot.

This study reports the results of a computerized baropodometric analysis of the function of primary valgus pronated flat foot submitted to talocalcanear arthrodesis according to the Grice-Green method (Grice, 1952; 1955) as modified by Vigliani et al., (1978). Our purpose was to document any anomalies in the behaviour of such feet, which up until now have been based on conventional evaluation (plantar imprints, podoscopy, etc.), which are much less sensitive than those of modern electronic systems.

Arthrodesis of the knee: a baropodometric evaluation of the long-term results.

A study of plantar loading has a place in orthopaedic literature today thanks to the studies conducted by various authors (Stott et al., 1973; Braun et al., 1980, Corvi et al., 1985; Salsano et al., 1986; Pisani, 1987). It is the purpose of this study to report the results obtained by using the baropodometer to study the static and dynamic functions of the foot in patients who were submitted to arthrodesis of the knee 15 or more years ago.

Our experience in occipito-cervical fusion.

Occipito-cervical fusion for congenital and post-traumatic anomalies of the axis was used to treat 5 patients; the results obtained are analyzed. The authors also discuss the advantages of using autoplastic bone graft which remains stable in time, without creating disabling sequelae in the patient.