[18F]FDG PET/CT in non-union: improving the diagnostic performances by using both PET and CT criteria.

PURPOSE: Complete fracture healing is crucial for positive patient outcome. A major complication in fracture treatment is non-union. Infection is among the main causes of non-union and hence of osteosynthesis failure. For the treatment of non-union, it is crucial to understand whether a fracture is not healing because of an underlying septic process, since the surgical approach to non-unions definitely differs according to whether the fracture is infected or aseptic. We aimed to assess the diagnostic performance of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography-computed tomography ([18F]FDG PET/CT) in the evaluation of infection as possible cause of non-union. METHODS: We retrospectively evaluated images of 47 patients treated in our trauma center who, between January 2011 and June 2017, underwent preoperative [18F]FDG PET/CT aiming to exclude infection in non-union. Clinical data, diagnostic examinations, laboratory and microbiology results, and patient outcome were collected and analyzed. [18F]FDG PET/CT images were visually and semiquantitatively evaluated using the maximum standardized uptake value (SUVmax). Imaging findings, as assessed by an experienced nuclear medicine physician and an experienced musculoskeletal radiologist, were compared with intraoperative microbiological culture results, which were used for final diagnosis (reference standard). The diagnostic performance of [18F]FDG PET/CT in detecting infected non-union was assessed. RESULTS: Twenty-two patients were not infected, while the remaining 25 had positive intraoperative microbiological results. C-reactive protein (CRP) was within the normal range in 13 cases (five with a final diagnosis of infection) and higher than normal in 25 patients (13 with a final diagnosis of infection). Infection was correctly detected on visual analysis of PET/CT images in 23 cases, while 2/25 infected patients had no significant [18F]FDG uptake and were considered false negatives. In seven cases, [18F]FDG PET/CT showed false positive results; 15/22 disease-free patients were correctly diagnosed. The diagnostic accuracy of [18F]FDG PET/CT in the final diagnosis of infection was 81% (38/47); its sensitivity, specificity, positive predictive value, and negative predictive value were 92%, 68%, 77%, and 88% respectively. The likelihood ratio for a positive test (LR+) was 2.89 and for a negative test, 0.12. Pretest probability of disease was 53%. Post-test probability based on LR+ was 77%. CONCLUSION: [18F]FDG PET/CT is a promising tool for diagnoses of infected non-unions. Both PET and CT images should be interpreted to achieve a high sensitivity (92%) and a very good negative post-test probability (12%).

Ilizarov Technique in Severe Pediatric Foot Disorders.

The treatment of foot disorders in pediatric age with Ilizarov method is reserved for complex cases, cases in which it is not possible to perform acute corrections or cases that need bone and soft-tissue lengthening. Ilizarov method permits to correct any deformity. Correction can be achieved progressively with a closed procedure or combining the external fixator with a treatment involving soft or bone tissues. Complications are frequent; however, most of them do not affect the outcome of the treatment.

Alternative Use of the Ilizarov Apparatus Set in Case of Complications During Intramedullary Nail Removal: A Case Report.

CASE: We present 2 case reports: the first, a diaphyseal fracture of the humerus treated with a Marchetti nail resulting in a nonunion in 2017. The second, a fracture of the femur treated with a Kuntscher nail in 1989. A gunshot injury to that femur in 2014 evolved in nonunion and displacement. In both cases, the old nails were removed by using pieces of the Ilizarov apparatus. CONCLUSIONS: In case of complications, the versatility of the Ilizarov apparatus allows us to connect the intramedullary element to the universal extraction system; it proves itself to be an excellent cost-effective extraction system.

Risk factors for achilles tendon rupture: A matched case control study.

PURPOSE: The purpose of this study was to elucidate whether body mass index (BMI), activity level, and other risk factors predispose patients to Achilles tendon ruptures. MATERIALS AND METHODS: A retrospective review of 279 subjects was performed (93 with Achilles tendon rupture, matched 1:2 with 186 age/sex matched controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. RESULTS: The rupture group mean BMI was 27.77 (95% CI, 26.94-28.49), and the control group mean BMI was 26.66 (95% CI, 26.06-27.27). These populations were found to be statistically equivalent (p=0.047 and p<0.001 by two one-sided t-test). A significantly higher proportion of those suffering ruptures reported regular athletic activity at baseline (74%) versus controls (59%, p=0.013). CONCLUSION: There was no clinically significant difference found in BMI between patients with ruptures and controls. Furthermore, it was found that patients who sustained ruptures were also more likely to be active at baseline than their ankle sprain counterparts.

Case studies of kyphoplasty and vertebroplasty integrated by anti-osteoporotic therapy.

In severe osteoporosis with recent vertebral compression fracture, drug treatment with anabolic agent in the first 18 months can stimulate the healing process and reduce the rate of progression, preventing new fractures and improving the quality of life of the patient. The sequential therapy with bisphosphonates for at least another 12 months can help to maintain balanced bone turnover markers without the incidence of new fractures. The association of kyphoplasty or vertebroplasty and anti-osteoporotic drugs can be limited by national rules of eligibility. Hence the need for shared treatment protocols.