Common inflammatory markers in the screening of knee arthroprosthesis infections.

Aim To evaluate the sensitivity and specificity of serum C-reactive protein (CRP) in early and late total knee arthroplasty (TKA) infections. Methods Blood tests to determine CRP levels (cut-off 10 mg/L)were conducted before surgery, at 1st day, 7th day and 15th day after surgery and at 1, 3, 6,12, 24 and 36 months. Patients had routine follow-up visits and radiological evaluations at 14 days and at 1, 3, 6, 12, 24 and 36 months. Infections were recorded and classified according to Widmer classification. The χ2 test or Fisher (in subgroups smaller than 10 patients) exact test was used to compare categorical variables. The statistical significance was set at p <0.05. Results A total of 19 infections were diagnosed during the followup. According to Widmer, five were classified as early post-operative and 14 as late chronic. All patients with early infections had suspected symptoms such as fever, swelling and pain. During the first month, 59 patients who had high CRP level but negative microbiological culture were considered as false positive representing a CRP sensitivity of 80% and a specificity of 67.6%. Fourteen patients had late chronic infection. Conclusion This study suggests that a synovial fluid aspiration should be performed in patients with persistent inflammation symptoms with or without radiographic signs of loosening. Moreover, it recommends the use of different serum and synovial tests for periprosthetic joint infection (PJI) diagnosis.

Outcomes at 2 years follow-up of sacral fractures associated with unstable vertical pelvic ring injuries in obese patients: a multicentric retrospective study.

BACKGROUND AND AIM: Sacral fractures with concomitant unstable pelvic ring injuries are severe conditions which occur in patients involved in high-energy trauma. When operative treatment is required, high surgical experience on the field is mandatory, especially in a sub-polpulation of obese patients which have increased risk of complications. The aim of this multicentric retroscpective study was to describe and analyze clinical and radiological outcomes of sacral vertical fractures in obese patients with a minimum of 2 years follow-up.   Methods: A total of 121 pelvic fractures admitted to Emergency Departments of three II level trauma centres from April 2015 to April 2021 were retrospectively reviewed. Demographics, injury mechanism, surgical data and complications were collected. The quality of life and the pelvic function were respectively measured by SF-12 questionnaires, Denis Work Scale and Majeed Score. The inter-rater agreement between the clinical scores and the Denis Work Scale was assessed.   Results: A total of 19 patients were included in the study. The average follow up was 41.16 months. The average BMI was 38.63 and the mean abdominal circumference was 128.10 cm. The average Majeed and SF-12 scores were respectively 66.47 and 74.32. Five patients were able to return to their previous employment. The post traumatic life's quality and related dysfunctions are influenced by the high BMI.   Conclusions: Faster recovery and early weight-bearing should be persued in order to minimize complications, expecially in obese patients. In these sample of patients, "triangular osteosynthesis" was the best treatment choice for sacral vertical fractures.

Interprosthetic and interimplant femoral fractures: is bone strut allograft augmentation with ORIF a validity alternative solution in elderly?

Background: Nowadays orthopedic surgeons have a new challenge to treat the interimplants fractures. Although fixation strategies exist for periprosthetic hip and knee fractures, there is no standard of care regarding the more complex interprosthetic and interimplants fractures. Objective: The aim of our study is targeting the focus on the bone strut grafting to avoid the metal hardware failure and to achieve the bone healing in these injuries. Methods: A prospective case note review of all interprosthetic or interimplants femoral fractures admitted to our trauma center. There were 11 patients (2 males and 9 females) with a mean age over 85 years old. We treated all the patients by ORIF and medial graft strut allograft to reduce the main complication leading to re-operations and morbidity or mortality is the nonunion or delayed union. The criteria to evaluate the patients during the follow-up were: the survival and complication after the surgery; the objective quality of life measured by Activities of Daily Living Score (ADL). The bone healing was measured by X-rays control as the alignment was measured by radiographic UNION SCORE, and postoperative complications. Results: All the patients reduced their ADL. In the most of cases we had a good x-rays reduction. We had not: No nonunion or Not delayed union. All patients died within 2 years from the surgery but not due by surgical complications. Conclusions: According us, the purpose of this surgery is to limit comorbidities and early mortality not to improve optimal restoration of lower limb function.

Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results.

Introduction: Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique. Methods: Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures. Results: The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p <0.001). Twenty-one complications occurred in 46 patients (46%): Seven patients had a clinical change of elbow axis: Three valgus (6%), four varus (9%); Superficial wound infection occurred in one case (2%) and ulnar nerve dysfunction in two (4%). The most common medium-term complication was post-traumatic osteoarthritis in eight cases (17%). Heterotopic ossification occurred in five patients (11%) and elbow stiffness in five cases (11%). Conclusion: The use of the hinged elbow external fixator in the treatment of complex elbow trauma is a valid therapeutic adjunct to ligamentous reconstruction showing encouraging results with acceptable complications. How to cite this article: Meccariello L, Caiaffa V, Mader K, et al. Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results. Strategies Trauma Limb Reconstr 2022;17(2):68-73.

Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice.

AIMS: To analyse the clinical practice of Italian physiotherapists within the framework of postoperative rehabilitation of rotator cuff (RC) surgery patients, and to compare it with similar studies carried out in other countries. METHODS: A web-based, voluntary, cross-sectional survey with 27 closed multiple-choice questions was developed and submitted to Italian-based physiotherapists in order to assess their clinical practice. RESULTS: Data from 1160 questionnaires were then analysed. Thirty-five percent of respondents (n = 413/1160) reported that they commence passive range of motion from the first postoperative week, while 49.2% (n = 571/1160) start during the second or third week. The majority of respondents (n = 603/1160, 52.0%) introduce active mobilisation between the fourth and the sixth week after surgery and 41.1% (n = 477/1160) introduce overhead movements between the fourth and the sixth week after surgery. DISCUSSION AND CONCLUSIONS: When managing the postoperative rehabilitation of RC surgery patients, Italian physiotherapists' practice is congruent with the guidelines published by American Society of Shoulder and Elbow Therapists (ASSET) and also with other UK surveys. However, while Italian physiotherapists manage immobilisation periods, active and passive mobilisation and the return to sport activities, according to evidence-based best practice guidelines, there is less consistency with respect to physical exercise, patient follow-up and referral.IMPLICATIONS FOR REHABILITATIONItalian physiotherapists' practice with patients following rotator cuff (RC) repair complies with evidence-based practice guidelines regarding immobilisation periods, passive and active mobilisation, and return to sport activities.There is less consistency between reported/declared practice and available evidence concerning physical exercise, patient follow-up, and referral.Physiotherapist with Orthopaedic Manipulative Physical Therapy (OMPT) training is more aligned with the current literature compared to physiotherapists without specific training, in terms of managing rehabilitation programmes, period of immobilisation and therapeutic exercise.More careful adherence to the international guidelines is recommended, in order to manage patients following RC repair in accordance with the evidence and to achieve the best possible outcomes.

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability.

BACKGROUND: Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children's daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique ( Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures. The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children. METHODS: From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 16 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation.  RESULTS: At the final follow-up, there were no differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion but there was a statistical in IOLE groups for the early weight-bearing. CONCLUSIONS: The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.

Locking retrograde nail, non-locking retrograde nail and plate fixation in the treatment of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcomes.

BACKGROUND: Distal third femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem (high morbidity and mortality). No consensus on best surgical option has been achieved. This study aims to investigate radiographic, mineral bone densitometry and clinical outcomes of locking retrograde intramedullary (LRN) nailing, non-locking retrograde intramedullary nailing and anatomical locking plate to surgically treat distal third femoral shaft fractures in young adults. Our hypothesis was that there is no significant statistical difference among the surgical options in terms of results (radiographic, bone densitometry and outcomes assessment). METHODS: Retrospective study: 90 patients divided into three groups (group 1 LRN, group 2 NLRN, group 3 plating). Average age was respectively 42.67 (± 18.32), 44.27 (± 15.11) and 42.84 (± 18.32) years. Sex ratio F:M was respectively 2.75, 2.33 and 2.00. AO Classification, KOOS, NUSS and RUSH score, VAS, DEXA scans and plain radiographs were used. Evaluation endpoint: 12 months after surgery. RESULTS: There were no statistical differences in terms of surgery time, transfusions, and wound healing. Results were similar with regard to average time of bone healing, RUSH scores, VAS, KOOS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. CONCLUSIONS: Our results showed no statistical difference in the use of LNR, NLNR and plating for treatment of distal third femur shaft fractures in terms of radiographic, bone densitometry and clinical outcomes. Good subjective and objective results are provided by all three techniques. The choice among the studied techniques must be based on surgeons' experience, indications and subjective patients' aspects. The absence of relevant similar data in the published literature does not allow definitive validation (or rejection) of our hypothesis. A more powered study with a bigger cohort is needed for definitive validation.

Open Reduction and Internal Fixation Using Double Plating with Biological and Artificial Bone Grafting of Aseptic Non-unions of the Distal Humerus: Clinical Results.

AIM: Intra-articular non-union of fractures is an uncommon but complex problem because in general, it is characterised by marked instability, pain, strength loss and significant functional limitation. The aim of this study is to report our prospective medium-term outcomes of the treatment of intra-articular, distal humeral aseptic non-unions using open reduction and internal fixation, augmented with artificial bone. MATERIALS AND METHODS: A retrospective case series of 16 patients with intra-articular, aseptic non-unions of the distal humerus was analysed for range of motion, pain, Mayo Elbow Performance Scores (MEPS) and Oxford Elbow Scores (OES) after 12 months. Mean age was 44 years (range, 18-84 years) and mean total follow-up was 43 months (range, 24-62 months). RESULTS: All subjective and objective scores were significantly higher 12 months after treatment with internal fixation and artificial bone augmentation; the mean improvement on the MEPS was 18 points and 17 points on the OES. All patients returned to work, most without limitations. Autografts had worse outcomes compared to allografts regarding post-operative pain and time to return to work. No adverse events related to the artificial bone augmentation were seen and all fractures consolidated. CONCLUSION: The use of two locking plates and bone graft augmentation with autografts or allografts with artificial bone grafts is a successful treatment of intra-articular distal humeral non-unions after hardware failure or biological limitations. CLINICAL SIGNIFICANCE: The use of artificial bone in the treatment of septic non-unions of the upper limb is safe. When no autograft is possible because of concurrent morbidity, it can be used alone or combined with an allograft to reconstruct the affected bone without leading to extra morbidity or complications. HOW TO CITE THIS ARTICLE: Rollo G, Vicenti G, Rotini R, et al. Open Reduction and Internal Fixation Using Double Plating with Biological and Artificial Bone Grafting of Aseptic Non-unions of the Distal Humerus: Clinical Results. Strategies Trauma Limb Reconstr 2021;16(3):144-151.

Scapular body fractures: Short-term results of surgical management with extended indications.

INTRODUCTION: Scapular body fractures represent less than 1% of all skeletal fractures. Operative criteria and risk factors for scapular fracture instability are well defined. Non-operative management of scapular body fractures show satisfactory results but with shortening and medialization of the scapular body. The aim of this study is to evaluate if surgical treatment will result in an improved quality of life and shoulder function compared to non-operative treatment on patients suffering from a scapular body fracture. MATERIALS AND METHODS: From a total of 381 retrospectively identified scapular body fractures, we included 45 patients. The enrolled patients were divided into two groups: the surgical treatment (ST, n = 20) group and the non-operative treatment (NOT, n = 25) group. The Non-Union Scoring System (NUSS) was used to assess bone healing on radiographs. The functional evaluation of the two groups during the follow-up were performed using the Constant Shoulder Score (CSS) and the Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH). Complications, reoperation rates, and time until bony union were also documented. The minimum follow-up for this study was designated as 12 months. RESULTS: The ST group had better mean CSS and QuickDASH scores compared to the NOT group at 1, 3 and 6 months of follow-up. No statistically significant difference was detected at 12 months follow-up. ST group also demonstrated improved results in time until bone union, reduction of rehabilitation time, complications and return to work rates. CONCLUSION: This study suggests that surgical treatment for extraarticular scapular fractures can achieve better short-term functional outcomes (3 to 6 months) compared to conservative treatment.

Effectiveness of teriparatide combined with the Ilizarov technique in septic tibial non-union.

Aim The septic non-union is a common compliance in bone healing due to bone infection. Bone resection, associated with Ilizarov osteo-distraction technique, is commonly used in these cases. The aim of this study was to analyse clinical and radiological results of teriparatide in combination with the Ilizarov technique and to compare this treatment with the standard treatment. Methods Forty adult patients underwent surgery because of type C of the Association for the Study and Application of Methods of Ilizarov (ASAMI) classification non-union were enrolled. The patients were divided in two groups: those treated with Ilizarov technique (Norm group) and those treated with Ilizarov technique combined with teriparatide injection (Teri group). Surgical duration, complication rate, bone healing status, clinical and functional outcomes were assessed according to the A.S.A.M.I. classification in the mean follow-up of 12 months. The subjective quality of life was assessed by the Short Form Survey (SF)-12. Results Teri group showed less time wearing Ilizarov's frame (p <0.05) than the Norm group and a statistical significance in the inter-rater reliability Cohen's k (p>0.05) respect to Norm according the score between the bone healing and clinical outcome results. There was no statistically significant difference between the two groups in other parameters that were assessed. Conclusion A benefit of teriparatide was found as adjuvant in the treatment of septic non-union.

Comparing hand strength and quality life of locking plate versus intramedullary k wire for transverse midshaft metacarpal fractures.

Aim In the scientific literature there are no papers that clarify which method of surgical fixation in transverse metacarpal fractures has the best functional outcomes. The aim of this study was to compare the hand strength obtained using two different methods in the treatment of these fractures. Methods A total of 52 patients who presented a transverse metacarpal fracture were enrolled. They were divided in two groups: 26 patients treated with K-wire (IMN) and 26 patients treated with plate and screws (PW). The evaluation criteria were: fracture healing time, performed force testing collected ultimate tensile strength and grip, the Disability Arm Shoulder and Hand (DASH) score, and the range of motion of the hand. Results In both groups obtained results were comparable in terms of full hand function, healing and total range of motion and DASH. Results in group K were slightly better than group PW in terms of strength and grip pain within 3 months from osteosynthesis. Conclusion Neither of the two techniques, either in the literature or in biomechanical studies, shows to have superior functional outcomes for fixation of transverse metacarpal fractures. Since the K-wire is cheaper and has no intrinsic complications as compared with plating (such as scar and tendon irritation), fixation with the latter is preferable to the plate in the treatment of these fractures in non-expert hands.

A new prognostic pelvic injury outcome score.

Aim To propose a new prognostic classification system for pelvic injuries based on a new detailed and all-encompassing evaluation of the injury pelvic outcome score and to check the prognostic value of this classification and evaluate its reliability and reproducibility. Methods From January 2017 to June 2020 from 156 pelvic fractures treated at our hospitals, 98 patients with pelvic fractures were recruited according to inclusion and exclusion criteria. All patients compiled three scores (New Score System, Majeed Score, SF-12) sessions two times during the hospital stay to evaluate the endpoint before the trauma and two years after the trauma. All patients carried out three tests independently. The evaluation of three scores included a pelvic and general complication after the surgery, the times needed to compile three score system. For reliability of the new score systems we evaluated the inter-observer or intraobserver agreement, the prediction strength of each score, and a prognostic value. Results A total of 98 patients were enrolled (74 were males and 24 females) with mean age of 43.6 (±18.6) (range 16-75) years. Tau B Kendall value was 0.827 for the new score system, 0.673 for the Majeed score, 0.746 for SF-12, there was p<0.05 for the new score system. Conclusion The new score system is prognostic, reliable, reproducible and can become a useful instrument to adequately correlate the long-term outcomes of pelvic injury fractures. Also, it provides a better evaluation of pain, work, sexual possibilities and satisfaction, balance-sitting-walking and psychological status.

Two-stage bone-and-strut technique in the treatment of septic non-unions in the upper limb.

Aim To report the results of a two-stage reconstruction of septic non-unions of the upper limb using the bone-and-strut technique with a follow-up of more than two years. Methods A total of 19 patients (12 males and seven females; age 27 to 85 years) were included in this cohort study. The evaluation endpoint was set at 24 months. Radiographic union, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, pain and return to work were assessed. All patients were treated with debridement and antibiotic therapy. At a second stage, the nonunion focus was filled with a cancellous bone allograft. Stability was provided using a locking plate and a bone strut. Results After 24 months, the QuickDASH scores improved from a median of 28 (interquartile range, 13 - 35 points), to a median of 78 (interquartile range, 70 - 89 points). Mean pain scores improved from 8.1 (range, 0.3-10) to 0.6 (range 0-2). Radiographic and clinical union was seen in all patients. The majority of patients returned to work or previous activities when retired. A new neurological deficit, recurrence of infection, or other surgery-related adverse events were not observed. Conclusion The two-stage bone-and-strut technique is a safe and effective technique in the treatment of septic non-unions of the upper limb. The union rate is high, the complication rate is acceptable and return return-to-work is high. Recurrence of infectious sequelae during a follow-up period of at least two years was not seen. The patient-reported outcomes increased significantly.

Radiographic and functional outcome of complex acetabular fractures: implications of open reduction in spinopelvic balance, gait and quality of life.

Aim To investigate the effects of surgical reduction of complex acetabular fractures on spine balance, postural stability and quality of life. Methods Twenty-six patients with acetabular fractures surgically treated by open reduction and internal fixation were divided into two groups according to the amount of reduction. Group A consisted of 18 patients with satisfactory reduction (≤2 mm), and group B of eight patients with incomplete reduction (>2 mm). Functional outcome was measured with Harris Hip Score (HHS), Oswestry Disability Index (ODI), and Short Form (12) Health Survey (SF12). Radiological parameters were assessed with standing whole spine, pelvis and hip X-rays, including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and sagittal vertical axis (SVA). Follow-up intervals were 1, 3, 6 and 12 months and annually thereafter. Gait analysis and baropodometry were performed after 24 months of operation. Results Mean HHS, ODI, and SF-12 was improved during the first postoperative year in both groups. After two years average scores kept improving for group A, but worsened for group B. Mean PI, PT, and SS increased in both groups during the first postoperative year, with further increase after two years only in group B. After two years, 16 (89%) patients in group A and four (50%) in group B had a balanced spine (SVA <50 mm). Gait analysis and baropodometry showed greater imbalance and overload for group B compared to group A. Conclusion In the long term, incomplete reduction of associated acetabular fractures may lead to poor outcome because of secondary spinopelvic imbalance, with posture and gait impairment.

Comparing the use of preformed vs hand-made antibiotic spacer cement in two stages revision of hip periprosthetic infection.

BACKGROUND: The number of periprosthetic joint infections (PJI) is continuously increasing because of the increasing number of arthroprostheses performed every year. Two-stage revision, using antibiotic-loaded spacers, remains the gold standard for their treatment. The aim of our study is to compare the use of preformed vs hand-made spacers in hip arthroplasty infections evaluating infection eradication, bone loss and clinical/functional outcomes. METHODS: From January 2010 to December 2017 we performed a prospective nonrandomized study. We pooled 50 patients affected by infected hip joint replacements, and divided them in 2 groups, one receiving commercially preformed spacers and the other receiving hand-made spacers. The study endpoint was set at 12 months. Intra-operative and peri-operative complications, Harris Hip Score (HHS), Short Form 12 Health Survey, intra-operative and radiological evaluation of bone loss were collected. Data were analyzed using descriptive statistics, T-test and Fisher Exact test. RESULTS: We found a statistically significant differences (p < 0.05) between the two groups in favour of the VancogenX group for the following variables: surgical time, first and second stage intraoperative complication rates, infection eradication. Moreover, the preformed-spacers group had better results in the preservation of bone stock, even though the difference was not statistically significant (p > 0.05). CONCLUSION: Our results support the use of preformed antibiotic spacers, even though more studies are needed.

Surgical treatment of multifragmentary segmental femur shaft fractures with ORIF and bone graft versus MIPO: a prospective control-group study.

Aim Multifragmentary segmental femoral shaft fracture is a high energy injury frequently associated with life-threatening conditions. The aim of this study was to compare the use of bio metallic open reduction internal fixation (ORIF) (plate with allograft bone strut) with minimally invasive plate osteosynthesis (MIPO) fixation for the treatment of multi-segmental femoral shaft fracture in terms of outcomes, bone healing and complications. Methods Forty patients with segmental femoral shaft fractures were included and divided into two groups: 20 patients treated with ORIF+, 20 with MIPO. All fractures were classified according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) and Winquist and Hansen Classification. Evaluation criteria were: duration of follow up and surgery, Non-Union Scoring System, Pain Visual Analogic Scale (VAS), objective quality of life and hip function, subjective quality of life and knee function, quality of life the Short Form-12 Survey Questionnaires (SF-12), bone healing and femoral alignment (radiographs), Radiographic Union Score for Hip (RUSH). Results Better results of ORIF in terms of complication rate, RUSH, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients' outcomes (Cohen k) were obtained, and similar results for the length of follow up, surgery duration, perioperative blood transfusion, wound healing. No statistical difference for Harris Hip Score (HHS), Knee Society Score (KSS), quality of life (SF-12). Conclusions The ORIF and bone strut allograft technique had better results compared to the MIPO technique with regards to complication rate, RUSH, VAS, regression between RUSH and VAS, and average correlation clinical-radiographic results and patients' outcomes (Cohen k) in the surgical treatment of multifragmentary segmental femoral shaft fractures.

Tibial diaphyseal fractures in children: indications and limitations of the treatment with monolateral and hybrid external fixator.

Aim To report our indications and limitations about the use of external fixation in children. Methods It was retrospectively reviewed all tibial fractures treated with monolateral and hybrid external fixator, at our three Centres. It was included 32 fractures which did not show an acceptable reduction after an attempt under anaesthesia. The exclusion criteria were: open fractures, children with previous fractures of the lower limbs, with skeletal congenital diseases, fractures involving the physis and with neurovascular involvement. All fractures were classified according to the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification. An outcome was evaluated according to the time needed to obtain radiographic bone healing, the range of motion (ROM) of the ankle, the asymmetry of the lower limbs, the malunion, and complications. Results The average time of consolidation was 10.66 weeks (6-17 weeks). There were no cases of deep infection, but only seven cases of superficial pin infections. No patients reported loss of ROM of the knee or ankle. We had zero cases of residual angle greater than 5°, and in all cases the difference in length between the limbs was <1 cm. Conclusion The external fixation is a viable technique in the treatment of tibial fractures in children. Therefore, the external fixation, both monolateral and hybrid, should be considered a viable treatment for this type of fracture.

Strut graft vs. traditional plating in the management of periprosthetic humeral fractures: a multicentric cohort study.

Aim The gradual increase in shoulder implants in active elderly patients has appeared in a parallel increase in periprosthetic humeral fractures. The aim of this study was to investigate the advantages of using strut grafting with plate fixation during periprosthetic humerus fractures. Methods Thirty patients diagnosed with periprosthetic humeral fracture were divided into two groups. The first group of 15 patients (PS) underwent plate, ring, screws and strut allografts. The second group with resting 15 patients (PWS) was treated with only plate and screws. The criteria to evaluate the groups during followup were the Constant Shoulder Score (CSS) and Oxford Shoulder Score (OSS); the bone healing was measured by X-rays, controls measured by radiographic union score (RUS), and complications. The follow up was terminated at 12nd month in both groups. Results The difference between the two groups in all parameters was not significant. However, all patients gained adequate shoulder motor skills for normal daily living activities. All fractures were healed. Only two complications were registered, and blood loss was minimal. Conclusion We believe a revision to reverse shoulder prosthesis with a long-stem implant with or without cortical strut allograft augmentation to be safe and appropriate in the management of these complex injuries, though technically challenging, and having good results for normal activities daily life.

Grafting and fixation after aseptic non-union of the humeral shaft: A case series.

PURPOSE: Non-unions after humeral shaft fractures are seen frequently in clinical practice at about 2-10% after conservative management and 30% after surgical treatment. Non-union, displacement of structures and fixation failure can be hazardous complications. The purpose of our study was to evaluate the outcomes of an on-lay bone graft strut construction with bone chips as grafting augmentation in the management of aseptic non-unions of the humeral shaft. METHODS: From 124 eligible patients with a humeral shaft non-union, we included 48 patients. In all cases an anterolateral humeral approach was used, with an on-lay bone graft using an allograft strut construction and with bone substitute augmentation in the non-union gap. To assess the bone healing on radiographs, we used the non-union scoring system according to Whelan. Patients were followed with objective and subjective scores. RESULTS: In all 48 patients we achieved full bone healing without major complications. The average period of union was 124 days. In 40 cases after healing the alignment was neutral, valgus deformation occurred in 6 cases a varus deformation in 2 cases. At twelve months after surgery, all patients recovered with satisfactory range of motion of shoulder and elbow and a good quality of life, without any radial nerve palsies or other major complications. CONCLUSION: Given the satisfactory results of full bone healing, recovery of the range of motion and the lack of major complications as seen in this study, we find that plating with supporting allograft as a good choice of treatment in the cases of aseptic non-union of the humeral shaft.

Feasibility and value of non-locking retrograde nail vs. locking retrograde nail in fixation of distal third femoral shaft fractures: radiographic, bone densitometry and clinical outcome assessments.

Aim Distal femoral shaft fractures are characterized by increasing incidence and complexity and are still considered a challenging problem. No consensus on best surgical option has been achieved. The aim of this study is to investigate mineral bone densitometry, radiographic and clinical outcomes of locking retrograde intramedullary nailing (LRN) and non-locking retrograde intramedullary nailing (NLRN) regarding surgical treatment of distal femoral shaft fractures in adults based on the hypothesis that there is no statistical difference among the results of both surgical options. Methods Retrospective study: 30 patients divided into 2 groups (Group 1 LRN, Group 2 NLRN). Average age was 42.67±18.32 for Group 1 and 44.27±15.11 for Group 2 (range of age 18-65 for both groups). Gender ratio (male:female) was 2.75 (11:4) for both groups. AO Classification, Non Union Scoring System (NUSS) and Radiographic Union Score Hip (RUSH), Visual Analogic Score (VAS), Dexa scans, plain radiographs were used. Evaluation endpoint: 12 months after surgery. Results No statistical difference was obtained in terms of surgery time, transfusions or wound healing. There were similar results regarding average time of bone healing, RUSH scores, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients outcomes. Only one patient of LRN group had reduction of mineral bone densitometry values. Conclusion No statistical difference in terms of radiographic, bone densitometry and clinical outcomes among LNR and NLNR for the treatment of distal femur fractures was found. The presence of no statistical difference regarding radiological findings is the main factor supporting our hypothesis given their strong objectivity.