A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma.

INTRODUCTION: Non-union rate in forearm fractures is generally less than 2% when a proper technique is used; this rate increases when ulnar lesions are involved. PATIENTS AND METHODS: We present a case series of seven young patients whose average age was 14 years (range 11-19 years) at the time of surgery and who presented with a forearm post-traumatic non-union that was previously treated in different ways (three isolated ulnar non-union, two isolated radial non-union and two combined). Average follow-up was 34 months (range 9-72 months). Surgical treatment began with the removal of the previous synthesis and with curettage of the non-union area. The Acumed ulnar rod, Acumed radial rod and Thalon elastic nail (all of them are unreamed and locked nails) together with autologous platelet-rich plasma (PRP) obtained with the Biomet System (concentration of 158.2×10(4) platelets/µL) were chosen to treat the patients. X-rays and clinical controls were conducted every 30 days until recovery. RESULTS: All patients recovered: average recovery was 23 weeks from operation (range 16-36 weeks) and nails were removed 3 months after complete healing. Six patients had excellent results and one patient had a good result (Patient 2, forearm pronosupination 60-0-40 degrees). DISCUSSION: The purpose of the case series was to establish a better way of treatment and to find a technique that could avoid the use of bone grafts, because obtaining autologous bone requires a further surgical procedure that can be really invasive depending on the amount of bone needed. CONCLUSION: All patients in the study showed complete recovery, with excellent clinical outcomes. Although there were only seven patients in this case series, and there is a need to analyse more patients, this study showed that the use of a specific locking nail system can provide proper stability to ulnar or radial atrophic non-union despite rotational forces, and when combined with autologous growth factors (PRP) is sufficient to promote bone healing in young patients without the necessity to take autologous bone grafts.

Is triaxial accelerometer reliable in the evaluation and grading of knee pivot-shift phenomenon?

PURPOSE: Dynamic laxity is clinically demonstrated with the pivot-shift (PS) test. Recently, a new system that measures the acceleration of the tibia during the PS test was validated. The goal of the present study was to use the accelerometer "KiRA" to evaluate the efficacy of measuring PS. METHODS: Between 2010 and 2011, a total of 100 patients with anterior cruciate ligament (ACL) lesions were enrolled. They underwent surgical reconstruction of the ACL. Among them, 30 patients were re-evaluated at least 6 months after surgery. Each patient underwent a clinical examination (Lachman test, anterior drawer test, and PS test) and then was subjected to an instrumental examination: KT1000 evaluation to quantify the Lachman test and KiRA to quantify the PS test. RESULTS: The accelerometer found a positive acceleration difference in favour of the pathologic knee. In the 100 patients evaluated preoperatively, the analysed acceleration parameters on the pathologic knee were found to be significantly different with respect to the contralateral joint. Correlating the clinical subjective data with numerical data, we identified mean reference values for every grade of the PS test (negative, glide, and clunk). CONCLUSION: Our experience showed us that the use of KiRA accelerometer for quantitative measurement of the PS is both promising and reliable. The efficacy of this instrument is strictly related to an inevitable learning curve and to proper execution of the test. It has the value of being easy to set up and easy to use in both the clinic and the operating room.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

"Postural Management" to prevent hip dislocation in children with cerebral palsy.

Muscolo-skeletal disorders and hip deformity play a key role on future development of motor and adaptive functions in children with cerebral palsy (CP). Lateral migration of the femoral head increases on average 7.7% per year and may progress in association with acetabular dysplasia to hip dislocation. Conservative preservation of muscle length and balance may prevent or reduce femoral head migration and acetabular dysplasia. Equipment for position lying, sitting, and standing is an established method of maintaining muscle length and joint range. French approach (Le Métayer et al) include the use of customised plaster cast orthoses, for sitting and standing positions, called siège moulé and gouttière, tailor-made according to the child's muscolo-skeletal characteristics and motor abilities. At our department, hips with clinical and radiological evidence of displacement unresponsive to pharmacological and surgical treatment were treated with postural management. The two cases we show in this paper underwent a physiotherapy programme (neurodevelopment treatment) twice a week and a seated postural programme 5 hours a day with the siège moulé. Hip radiographs were measured with the migration percentage (MP) described by Reimers. The follow-up measurements showed a progressive reduction of MP values of the hip treated, confirming the significant benefit from the combined non surgical approach. The study supports the evidence that conservative management of hip deformity with siège moulé can be successful if implemented before the development of hip dysplasia.

Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients.

The purpose of this prospective randomised clinical study was to compare the efficacy of recombinant bone morphogenetic protein 7 (rhBMP-7) and platelet-rich plasma (PRP) as bone-stimulating agents in the treatment of persistent fracture non-unions. One hundred and twenty patients were randomised into two treatment groups (group rhBMP-7 vs. group PRP). Sixty patients with sixty fracture non-unions were assigned to each group (median age: 44 years, range 19-65, for the rhBMP-7 group and 41 years, range 21-62, for the PRP group, respectively). In the rhBMP-7 group, there were 15 tibial non-unions, 10 femoral, 15 humeral, 12 ulnar, and 8 radial non-unions. In the PRP group, there were 19 tibial non-unions, 8 femoral, 16 humeral, 8 ulnar, and 9 radial non-unions. The median number of operations performed prior to our intervention was 2 (range 1-5) and 2 (range 1-5) with autologous bone graft being used in 23 and 21 cases for the rhBMP-7 and PRP groups, respectively. Both clinical and radiological union occurred in 52 (86.7%) cases of the rhBMP-7 group compared to 41 (68.3%) cases of the PRP group, with a lower median clinical and radiographic healing time observed in the rhBMP-7 group (3.5 months vs. 4 months and 8 months vs. 9 months, respectively). This study supports the view that in the treatment of persistent long bone non-unions, the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy.

Human adipose-derived stem cells as future tools in tissue regeneration: osteogenic differentiation and cell-scaffold interaction.

Tissue engineering is now contributing to new developments in several clinical fields, and mesenchymal stem cells derived from adipose tissue (hASCs) may provide a novel opportunity to replace, repair and promote the regeneration of diseased or damaged musculoskeletal tissue. Our interest was to characterize and differentiate hASCs isolated from twenty-three donors. Proliferation, CFU-F, cytofluorimetric and histochemistry analyses were performed. HASCs differentiate into osteogenic, chondrogenic, and adipogenic lineages, as assessed by tissue-specific markers such as alkaline phosphatase, osteopontin expression and deposition of calcium matrix, lipid-vacuoles formation and Glycosaminoglycans production. We also compared osteo-differentiated hASCs cultured on monolayer and loaded on biomaterials routinely used in the clinic, such as hydroxyapatite, cancellous human bone fragments, deproteinized bovine bone granules, and titanium. Scaffolds loaded with pre-differentiated hASCs do not affect cell proliferation and no cellular toxicity was observed. HASCs tightly adhere to scaffolds and differentiated-hASCs on human bone fragments and bovine bone granules produced, respectively, 3.4- and 2.1-fold more calcified matrix than osteo-differentiated hASCs on monolayer. Moreover, both human and deproteinized bovine bone is able to induce osteogenic differentiation of CTRL-hASCs. Although our in vitro results need to be confirmed in in vivo bone regeneration models, our data suggest that hASCs may be considered suitable biological tools for the screening of innovative scaffolds that would be useful in tissue engineering.

[Complications of leg diaphyseal fracture in a pediatric patient: case report]. / Complicanze di una frattura diafisaria di gamba in un paziente in età pediatrica. Caso clinico.

Fractures in pediatric age have a prominent role when the growth plates are involved, which represent the point of least resistance of the skeleton in children. Traumas in these regions can, therefore, cause chondroepiphysary detachments and alterations of vascularisation which can result in growth anomalies. The aim of this paper is to stress how an early diagnosis combined with a correct therapeutic approach can avoid the onset of deformations and serious disabilities. The case of a 14-year-old boy with an evident deformation and functional impotence of the ankle joint associated with a 7.5 cm heterometry is described. Clinically limping, widespread muscular hypotrophy and a vast zone of trophic suffering of the skin were observed. Anamnesis revealed combined a tibia/fibula fracture due to a trauma caused by crush at the age of 4 years, treated in another hospital by the implant of an intramedullary nail. Upon removal of the nail, relatives referred a progressive deformation of the articulation. Radiographic view showed the presence of an antero-medial epiphysiodesis zone of the distal tibial physis. For this condition the patient underwent a double osteotomy associated with elongation of the same limb by way of Ilizarov external fixator which was removed after 7 months resulting in an evident correction of the axis and the length of the limb. The patient was kept under observation for a follow-up of 2 years with clinical and radiographic controls.

Mitotic activity in chondrocyte transplantation from the in vitro phase to the in vivo phase.

The transplantation of devitalized allogenic matrices vehiculating autologous chondrocytes, previously isoled and seeded on them could be a solution to the problem of repairing lesions of the joint cartilage. For the matrix/cell "composite" to be "graftable" the cells must continue to duplicate and produce cartilaginous matrix even after transport in vivo. The present study analyzes the mitotic activity of chondrocytes planted on devitalized allogenic cartilage and grafted in living animals. Chondrocytes of joint cartilage of lambs were isolated enzymatically and then seeded in vitro on devitalized allogenic cartilaginous matrices for 3 weeks. At the end of the co-culture period, these matrix/chondrocyte composites were transplanted in subcutaneous pockets of athymic mice. The experimental and control samples were evaluated subsequent to explantation by histological study and incorporation of tritiated thymidine. The results obtained revealed an important decrease in the values for the incorporation of thymidine beginning from experimental time 0 (pre-implant evaluation) up to day 28 after implantation, followed by a mild increase at the experimental time of 42 days. This study demonstrated the tendency of articular chondrocytes cultivated in vitro and subsequently transplanted in vivo on a support of devitalized allogenic cartilaginous matrix to modify mitotic activity from very high values for the first experimental times, typical of the in vitro phases of cellular expansion, to very low values, more similar to the behavior of articular chondrocytes in vivo.

Estudio de la actividad mitotica entre las fases in vitro e in vivo en el trasplante de condrocitos / Mitotic activity in \"in vitro\" and \"in vivo\" chondrocyte transplantation

El trasplante de matrices alogenicas desvitalizadas portadoras de condrocitos autologos, previamente aislados y sembrados sobre ellas, podria ser una solucion al problema de la reparacion de las lesiones del cartilago articular. El presente estudio analiza la actividad mitotica de los condrocitos sembrados en cartilago alogenico desvitalizado e implantados en animales vivos. Se aislaron enzimaticamente condrocitos de cartilago articular de cordero, y se sembraron "in vitro" sobre matriz cartilaginosa alogenica desvitalizada durante 3 semanas. Al final del periodo de cocultivo, se trasplantaron los compuestos de matriz y condrocitos en bolsillos subcutaneos de ratones atimicos. Las muestras experimentales y las de control fueron evaluadas luego de extraidas mediante el estudio histologico y tras la incorporacion de timidina tritiada. Los resultados obtenidos mostraron una disminucion importante de los valores de incorporacion de timidina a partir del tiempo experimental cero (evaluacion preimplante) hasta el dia 28 del implante, seguido por un leve aumento hacia el dia 42 del estudio. La experiencia ha demostrado la tendencia de los condrocitos articulares (cultivados "in vitro" y sucesivamente trasplantados "in vivo" sobre un soporte de matriz cartilaginosa alogenica desvitalizada) de modificar su propia actividad mitotica desde valores muy altos, correspondiendo a los primeros dias experimentales (tipico de las fases "in vitro" de expansion celular) hasta valores muy bajos, similares a la conducta de los condrocitos articulares "in vivo"

Osteoid osteoma and eosinophilic granuloma of the lumbar vertebral body.

The authors describe a case of osteoid osteoma in a child and another of eosinophilic granuloma in an adult, localized in a lumbar vertebral body. A study by CT scan images, which is rather typical in the case of osteoid osteoma, could led to chronic osteitis or even to atypical osteoid osteoma in the case of eosinophilic granuloma. Histological examination defined diagnosis, and the two cases healed after surgical excision by anterior approach.

Parenteral calcitonin for metabolic bone disease associated with primary biliary cirrhosis.

No satisfactory treatment is available for metabolic bone disease associated with primary biliary cirrhosis. On the basis of the similarities to postmenopausal osteoporosis, the rationale exists for calcitonin to be tested in clinical studies in patients with primary biliary cirrhosis-associated osteoporosis. We evaluated the effect of calcitonin on bone metabolism and mineral density in 25 women with primary biliary cirrhosis and severe osteopenia. After 6 mo of observation, patients received a synthetic calcitonin or a control treatment consisting of less than one hundredth of the recommended dose of porcine calcitonin. The two treatments were administered in sequence to each patient for two 6-mo periods, with a 3-mo washout between them, according to a crossover design. After the observation period, oral calcium supplementation was started. Bone mineral density was measured by dual-photon absorptiometry of the lumbar spine at study entry and at the beginning and the end of each treatment period. During the observation period bone mineral density fell by 3.5% whereas during the following 6 mo it increased in both the patients who received calcitonin (4.3%) and those who received the control treatment (4.9%). Conversely, after the crossover, bone mineral density decreased during both calcitonin (-2.7%) and control treatment (-2.9%). A significant difference was observed between the two periods but not between the two treatments or between the two sequences of treatment administration. In conclusion, our findings indicate that parenterally administered calcitonin for 6 mo is ineffective in halting bone loss in patients with primary biliary cirrhosis-associated metabolic bone disease, whereas calcium supplementation may have a transient beneficial effect.

A clinical trial on the effects of a combination of elcatonin (carbocalcitonin) and conjugated estrogens on vertebral bone mass in early postmenopausal women.

The study was carried out to determine the effect of a combination regimen of a small dose of calcitonin added to conjugated estrogens with medroxyprogesterone acetate on vertebral bone mass in early postmenopausal women. Comparisons were made with groups of women on calcitonin alone, on conjugated estrogens with medroxyprogesterone acetate alone, or on no treatment. The study was carried out over a 2-year period. The results of the study suggest that the combined regimen of calcitonin and estrogens increased vertebral bone mass in early postmenopausal women to a greater extent than calcitonin alone or estrogen alone. Increases in vertebral bone mass of 11.2% after 1 year and 9.2% after 2 years were demonstrated using the combined regimen. Both estrogens alone and calcitonin alone were, however, very effective in preventing rapid bone loss in the postmenopausal women studied.

Ultrasound in degenerative cystic meniscal disease of the knee.

Ultrasonography of the knee joint using small-parts probes was performed on 27 patients with clinical findings suggestive of meniscal cystic degeneration. Surgical or arthroscopic confirmation of sonographic findings was obtained in all cases. Sonography delineated the shape and structure of the meniscal profile and any degenerative changes. In the initial stage (6/27 patients, 22%), minor structural irregularities could be observed. Small, round, transonic cysts were found in 8 patients (30%); these lay mainly within the meniscus and were movable during stress flexion of the leg. In more advanced cases (8/27, 30%), larger cysts sometimes protruded on the skin surface. In 3 patients (12%), the soft tissue swelling was associated with a normal sonographic aspect of the menisci, but sonography could demonstrate an effusion of extra-articular origin. Ultrasound is a simple and effective method for the assessment of degenerative cysts of the menisci. It allows a reliable differential diagnosis between meniscal cysts and other causes of soft tissue swelling, and it is well suited for monitoring the course of the disease.

[Congenital multiple arthrogryposis. Report of a case]. / L'artrogriposi multipla congenita. Contributo casistico.

Six patients affected by arthrogriposis multiplex congenita (AMC) are studied and the detected alterations, the adopted treatment and the obtained results are described and discussed. Notwithstanding the limited number of considered cases, it is underlined that a precocious, constant and protracted treatment can considerably help these patients to gain a certain degree of self-sufficiency though it can not heal serious deformations. This result is also supported by the cases published by the literature.

Ultrasonic diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee.

High resolution ultrasonography of the knee was performed on 82 young patients with clinically suspected Osgood-Schlatter disease and on 30 normal subjects; in 45 pathological cases (55%) comparative X-ray films were taken. The ultrasound pictures were equally or more effective than X-ray images in 45/45 cases; their value was particularly marked for soft tissue study. The typical sonographic changes of the ossification center, of the cartilage, and of the surrounding soft tissues are described and classified, both for Osgood-Schlatter and for Sinding-Larsen-Johansson diseases. These signs are based mainly upon cartilage swelling and edema, fragmentation of the ossification center, thickening of the patellar tendon, and bursitis of the infra-patellar bursa. Ultrasonography is proposed as a simple and reliable method for the diagnosis of knee joint osteochondrosis. The ultrasound picture is also suitable for periodical follow-up the course of the disease.