Tronco-conical locking plate in distal radius fractures.

INTRODUCTION: Volar locked plates represent the most popular fixation technique for distal radius fracture (DRF). However, threaded screw-hole angular stability mechanism has some issues. The purpose of our study is to evaluate clinical and radiological outcome of a tronco-conical locking mechanism for volar plating of DRF. MATERIALS AND METHODS: Eighty patients with DRF treated with tronco-conical locking volar plates between May 2013 to December 2017 in two institutions were collected. We analysed clinical and radiological outcomes and peri-operative complications, like loss of reduction, fragment displacement, deformation or implant-related problems and surgical and other general complications. RESULTS: 78 patients were available for at final follow-up. The average follow-up period was 11.4 months (range, 6-18 months). All fractures healed within three months. Five cases of final reductions were defined unsatisfying. According to Gartland and Werley's scoring system at final follow up, 36 patients had excellent results, 40 patients had good results, one patient had fair and one patient had poor results. Five complications were observed. No complications were observed during surgical plate removal. CONCLUSION: Complications found in our study are not related to tronco-conical locking mechanism and are like those found in the literature. Further studies are needed to evaluate functional results or radiographic parameters of this new type of angular stability mechanism. Tronco-conical locking plate is an attractive alternative threaded screw-hole angular stability mechanism.

Acetabular erosion following bipolar hemiarthroplasty: A Role for the size of femoral head?

INTRODUCTION: Femoral neck fractures are the most frequent fractures in the elderly and hemiarthroplasty is the treatment of choice. The objective of this study is to identify predictive factors of acetabular erosion after bipolar hemiarthroplasty in a mobile independent population during a follow-up of ten years. MATERIALS AND METHODS: This multicenter study started in 1997 ending in 2007. Data were prospectively collected and retrospectively analyzed. Inclusion criteria were: age > 60 and < 85 years, BMI < 35, normal Abbreviated MiniMental Test score, ability to walk 0.8 km and live independently, non-pathological fracture, hip with no or minimal osteoarthritic changes, and availability of clinical and radiological follow-up. For each Patient were recorded: demographic data, comorbidities, time from fracture to surgery, characteristics of the implant, duration of surgery. Patients included underwent clinical and radiological follow-up at a minimum of ten years. RESULTS: Overall, 209 Patients met inclusion criteria. A press-fit implant was performed in 172 subjects; in contrast a cemented prosthesis was implanted in 37 patients. Nineteen patients underwent implant revision to total hip arthroplasty for acetabular erosion and pain. Classification of X-ray using Baker criteria showed a grade 0 in 54.5%, a grade 1 in 19.6%, a grade 2 in 18.1% and a grade 3 in 7.6%. Multivariate analysis revealed that the size of the femoral head (FH) was the only predictive factor of a higher risk of acetabular erosion. The Kaplan-Meier survival curve verified the risk of implant revision in Group 1 (FH sized > 48 mm) and Group 2 (FH sized < 48 mm). The probability of implant revision for acetabular erosion at ten years from surgery were 5.5% in Group 1 and 15.6% in Group 2. CONCLUSION: In bipolar hemiarthroplasty smaller head size lead to a polar wear implying a higher risk of acetabular erosion and migration; in our population this risk was consistent with the use of implant head < 48 mm diameter. Considering the absolute risk of a smaller FH size, the surgeon must evaluate the accuracy of measurement of the caliber, since as reported in previous studies, it can significantly underestimate the size.

WITHDRAWN: Acetabular erosion following bipolar hemiarthroplasty: A role for the size of femoral head?

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Injury, 50(2) (2019) 420­423, https://doi.org/https://doi.org/10.1016/j.injury.2018.11.041. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Non-unions.

Non-union of long bones is a significant consequence of fracture treatment. Bone regeneration is a complex physiological process of bone formation which can be seen during normal fracture healing. An improved understanding of the molecular and cellular events that occur during bone repair and remodelling has led to the development of biologic agents that can augment the biological microenvironment and enhance bone repair. Currently, there are different strategies to augment the impaired or "insufficient" bone-regeneration process, including the "gold standard" autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. A lack of standardized outcome measures for comparison of biologic agents in clinical fracture repair trials, frequent off-label use and a limited understanding of the biological activity of these agents at the bone repair site have limited their efficacy in clinical applications.

Proximal femoral fractures in elderly people: time to surgery. The experience of Milan's "ASST Pini/CTO".

Proximal femoral fractures in elderly patients represent a rapidly increasing socio-economic problem. The functional recovery and the mortality rate are influenced by a substantial quantity of variables, including the waiting time for surgical treatment ("time to surgery"). This study aims at investigating the average waiting time, and ascertaining the causes and effects, together with other non-modifiable variables, on the outcome for patients admitted to Milan's Istituto Ortopedico Gaetano Pini (Gaetano Pini Orthopaedic Institute) with a proximal femoral fracture. Data have been collected from 234 patients, between May and November 2015. Parameters recorded and analysed included fracture type, presence of comorbidities (Charlson Index (CCI)), the ASA (American Society of Anesthesiology) score, day of the week presenting to hospital, the type of treatment received, the functional recovery, and the patient's condition on discharge. In 46.4% of cases, the duration of preoperative stay prior to surgery was found to be in line with what is recommended in the literature (<48 h). In 20% of cases, the time to surgery was found to exceed 96 hours. The data collected that pertain to the distribution of the sample and the comorbidities were shown to be in line with the literature. A statistical significant difference was found between day of the week that the patient was admitted to hospital and the waiting time for surgery.

Treatment of an atrophic clavicle non-union with the chamber induction technique: a case report.

The gold standard technique for treating non-union of the clavicle is based on corticocancellous bone graft harvested from the iliac crest and fixation with a plate. In cases of large clavicular defects, this surgical procedure becomes ineffective and only a complex bone reconstruction can be considered. In the herein study we report on a clavicular non-union which was associated with a 4cm bone defect that was managed successfully with optimum fixation and the Chamber Induction Technique (C.I.T)-formation of the masquelet membrane- and subsequent biological augmentation with a composite bone graft.

Core decompression and biotechnologies in the treatment of avascular necrosis of the femoral head.

Avascular necrosis (AVN) of the femoral head (FH) causes 5% to 12% of total hip arthroplasties (THA). It especially affects active male adults between the third and fifth decades of life. The exact worldwide incidence is unknown. There are only few data related to each country, but most of it relates to the United States.Non-surgical management has a very limited role in the treatment of AVN of the FH and only in its earliest stages. Core decompression (CD) of the hip is the most common procedure used to treat the early stages of AVN of the FH. Recently, surgeons have considered combining CD with autologous bone-marrow cells, demineralised bone matrix or bone morphogenetic proteins or methods of angiogenic potential to enhance bone repair in the FH.Manuscripts were deemed eligible for our review if they evaluated treatment of early stage AVN of the FH with biotechnology implanted via CD. After application of eligibility criteria, we selected 19 reports for final analysis.The principal results showed that only by correctly mastering the therapeutic principles and adopting proper methods specifically oriented to different stages can the best therapeutic effect be achieved. Combining CD with biotechnology could result in a novel long-lasting hip- preserving treatment option.Furthermore, more refined clinical studies are needed to establish the effectiveness of biotechnology treatments in AVN of the FH. Cite this article: EFORT Open Rev 2017;2:41-50. DOI: 10.1302/2058-5241.2.150006.

Complications in proximal humeral fractures.

Necrosis of the humeral head, infections and non-unions are among the most dangerous and difficult-to-treat complications of proximal humeral fractures. The aim of this work was to analyse in detail non-unions and post-traumatic bone defects and to suggest an algorithm of care. Treatment options are based not only on the radiological frame, but also according to a detailed analysis of the patient, who is classified using a risk factor analysis. This method enables the surgeon to choose the most suitable treatment for the patient, thereby facilitating return of function in the shortest possible time. The treatment of such serious complications requires the surgeon to be knowledgeable about the following possible solutions: increased mechanical stability; biological stimulation; and reconstructive techniques in two steps, with application of biotechnologies and prosthetic substitution.

Long endomedullary nail in proximal third humeral shaft fractures.

INTRODUCTION: Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking. MATERIALS AND METHODS: Forty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. RESULTS: Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. CONCLUSIONS: The results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. STUDY DESIGN: retrospective, cohort of cases. LEVEL OF EVIDENCE: IV.

Comparative evaluation of MicroDTTect device and flocked swabs in the diagnosis of prosthetic and orthopaedic infections.

The evolution of new prosthetic and osteosynthetic devices has led to more surgical indications, and this is accompanied by an increased incidence of septic complications in orthopaedic and trauma surgery in the general population. The strategy for choosing surgical or therapeutic (conservative) treatment is based on the identification of the pathogen: knowledge of the aetiological agents is an essential element in the decision-making process to ensure the most effective treatment is administered. The pathogen also needs to be considered in the challenging case of doubtful infection, where perhaps the only sign is inflammation, for a more accurate prediction of progression to either sepsis or healing. Biofilm-related infections and low-grade infections may fall into this category. Biofilm slows the metabolism of microorganisms and prolongs their survival, which renders them resistant to antibiotics. Moreover, when microorganisms are embedded in the biofilm they are poorly recognised by the immune system and the infection becomes chronic. As recently demonstrated, isolation and identification of bacteria in biofilm is difficult as the bacteria are concealed. The development of an effective means of sample collection and laboratory methods that can dislodge bacteria from prosthetic surfaces has therefore become necessary. The primary aim of the study was to evaluate the reliability of an innovative technology (MicroDTTect), specifically applied to collect and transport explanted samples (prostheses, osteosynthetic devices, biological tissues), and compare with flocked swabs. The MicroDTTect system is quick and simple to use and, most importantly, is a closed system that is totally sterile and safe for the patient being treated. It contains a specific concentration of dithiotreitol (DTT) that can dislodge bacteria from the biofilm adhering to prosthetic surfaces. The numbers of positive and negative samples were measured to compare the MicroDTTect methodology with swab collection in 30 procedures. The results showed that MicroDTTect had a higher sensitivity compared to swabs (77% and 46%, respectively), and was associated with more positive results than swabs (35% and 20%, respectively). These preliminary results show that MicroDTTect is superior to swab collection for bacterial identification in orthopaedic surgery. The early identification of microorganisms that cause sepsis may help improve treatment strategies and the efficacy of therapy, which will lead to an increased healing rate, reduced severity of sequelae and improved quality of life.

Reconstruction of patellar tendon following implantation of proximal tibia megaprosthesis for the treatment of post-traumatic septic bone defects.

INTRODUCTION: Latest advances made in joint replacement implants allows reconstruction of entire limbs. These special prostheses or megaprostheses were originally designed for the treatment of severe oncological bone loss. Nowadays, however, the indications and applications of these devices are expanding to other orthopaedic and trauma clinical conditions. Since 2008 we have implanted 152 megaprostheses in non-oncological conditions: 87 were implanted for post-traumatic failures aseptic/septic (represented by complex non-unions and critical size bone defects); 26 total femur, 52 distal femur and 9 proximal tibia. In this group of patients bone and soft tissues conditions are completely different compared to patients with oncological back ground. The presence of infection and previous surgeries can lead to adhesion, scar interference, muscular and tendon impairment and skin problems that lead to reduced function and severe joint stiffness. The purpose of this study is to evaluate the results of treatment of reconstruction of patellar tendon during implantation of proximal tibia megaprosthesis for the treatment of septic post traumatic critical bone defects. PATIENTS AND METHODS: In this retrospective study, we evaluated 9 patients treated with proximal tibia megaprosthesis who underwent patellar tendon reconstruction. All patients presented a complete patellar tendon disruption at the time of prosthesis implantation. Procedures of reconstruction included a tendon-plasty of quadriceps and/or patellar tendons, a pie crusting of quadriceps fascia, a reinforcement of the apparatus with synthetic tendon graft substitutes (LARS) and a medial gastrocnemius muscular flap to reconstruct the extensor mechanism and obtain skin coverage when needed. The average follow up was 18 months (9-36). For each of the cases, we analysed the complications occurred regarding septic recurrence, patellar fracture, quadriceps and patellar tendon rupture and number of reinterventions. The clinical outcome was assessed by the WOMAC Score. RESULTS: In all cases there was no infection recurrence or skin related problems. None of the patients require prosthesis revision due to loosening or device failure. No patellar fracture or quadriceps tendon failure was recorded. One patient presented a rupture of the reconstructed patellar tendon due to a trauma incident 18 months after the implantation and he required revision surgery. From a clinical point of view the average WOMAC score was 62.4 at 1 month rising to 72.6 at 3 months, 78.2 at 6 months, 76.4 at 1 year and 74.8 at 18 months. CONCLUSION: When proximal tibia megaprosthesis is implanted and there are soft tissue and patellar tendon deficiency, soft tissue reconstruction can be achieved by appropriate lengthening of the tendon and a gastrocnemius flap reinforced by LARS. Such an approach allows restoration of the extensor mechanism and coverage of the prosthesis in an area where skin problems are frequently very common.

Clinical effectiveness of Osigraft in long-bones non-unions.

Current evidence, based primarily on case series, suggest that the eptotermin alfa (recombinant bone morphogenetic protein-7 (rhBM-7)), which is commercialized as Osigraft with an indication for tibial non-union, used in monotherapy or polytherapy, is a safe and effective therapy for long bones non-unions of lower and upper limbs. No previous study has compared the safety and the efficacy of Osigraft and the "gold standard" treatment for recalcitrant long-bones non-union, autologous bone graft (ABG). This study aims to compare the effectiveness of Osigraft and ABG in the treatment of post-traumatic, persistent long bone non-unions. In particular, the present study will focus exclusively on complex persistent non-unions, excluding simpler cases, in which it is likely that a simple revision of the osteosynthesis will be sufficient to promote union, and extremely severe cases in which there is an indication for amputation and prosthesis. The study addresses the following research question: 1. Is the effectiveness of eptotermin alfa comparable to that of ABG in the treatment of complex long bone non-unions? 2. Are there significant differences in the prevalence of adverse events between patients treated with eptotermin alfa and those treated with ABG? The study is an observational, retrospective study, located in one Experimental Recruiting Center (Ospedale Universitario G. PINI - Milano). The study was conducted with ethics approval and according with the existing Italian law. Demographic and clinical data were collected from patients Clinical Medical Records and other existing documentation, through a web based eCRF. The treatment (surgery with Osigraft or ABG) effectiveness was evaluated comparing the number of success cases (primary endpoint) and the length for clinical and radiological healing (secondary end-points). The treatment safety was evaluating comparing the prevalence of Adverse Events. Osigraft was demonstrated to be statistically equivalent to ABG with respect to the primary and secondary end point of surgical success. The treatment success was statistically comparable across all the anatomical regions considered, both in patients treated with Osigraft and in patients treated with ABG. The use of Osigraft when compared to autograft was associated with statistically lower intraoperative blood loss and shorter operative times. In addition patients treated with Osigraft developed statistically less peri-operative and late onset adverse events, compared to ABG. The difference was substantially due to the occurrence of pain at donor site in patients treated with ABG.

Preliminary experience with Piccolo Composite™, a radiolucent distal fibula plate, in ankle fractures.

The radiolucent plate has many advantageous properties in the treatment of complex ankle fractures, particularly trimalleolar fractures. Surgeons may sometimes have difficulty observing the posterior malleolus after synthesis of lateral malleolus with a traditional plate because common materials of conventional plates are not radiolucent. In this study, the authors highlight the importance of the radiolucent property in the treatment of ankle fractures and describe their preliminary experience with a carbon fibre-reinforced polyetheretherketone distal fibula plate, with good results at 4 months' follow-up and no signs of tissue inflammatory reaction.

Cost effectiveness of tibial nonunion treatment: A comparison between rhBMP-7 and autologous bone graft in two Italian centres.

Current evidences show that recombinant human bone morphogenetic protein 7 (rhBMP-7, eptotermin alfa) can be considered an effective alternative to autologous bone graft (ABG) in the treatment of tibial nonunions. Few studies, so far, have analysed the costs of treating tibial nonunions with either rhBMP-7 or ABG and none of them has specifically considered the Italian situation. The aim of the present study was to capture, through observational retrospective methods, the direct medical costs associated with the treatment of tibial nonunions with rhBMP-7 or ABG in Italy and to compare the cost effectiveness of the two interventions. The secondary objective was to perform a cost-reimbursement analysis for hospitalisations associated with the two treatments. Data of 54 patients with indication for tibial nonunion were collected from existing data sources. Of these patients, 26 were treated with ABG and 28 with rhBMP-7. The study captured the direct medical costs for treating each tibial nonunion, considering both inpatient and outpatient care. The hospital reimbursement was calculated from discharge registries, based on diagnosis-related group (DRG) values. A subgroup of patients (n=30) was also interviewed to capture perceived health during the follow-up, and the quality-adjusted life years (QALYs) were subsequently computed. The two groups were similar for what concerns baseline characteristics. While the medical costs incurred during the hospitalisation associated with treatment were on average €3091.21 higher (P<0.001) in patients treated with rhBMP-7 (reflecting the product procurement costs), the costs incurred during the follow-up were on average €2344.45 higher (P=0.02) in patients treated with ABG. Considering all costs incurred from the treatment, there was a borderline statistical evidence (P=0.04) for a mean increase of €795.42, in the rhBMP-7 group. Furthermore, the study demonstrated that, without appropriate reimbursement, the hospital undergoes significant losses (P=0.003) when using rhBMP-7 instead of ABG. In contrast to these losses, in Italy, the average cost to achieve a successful outcome was €488.96 lower in patients treated with rhBMP-7 and, additionally, the cost per QALY gained was below the cost-utility threshold of $50,000.