Arthroscopic biceps tendon tenodesis: the anchorage technical note.

Treatment of long head biceps (LHB) tendon pathology has become an area of renewed interest and debate among orthopaedic surgeons in recent years. The background of this manuscript is a description of biceps tenodesis which ensure continual dynamic action of the tendon which depresses the head and impedes lateral translation. A new technique has been developed in order to treat LHB tendon irreversible structural abnormalities associated with cuff rotator lesions. This technique entails the construction of a biological anchor between the LHB and supraspinatus and/or infraspinatus tendons according to arthroscopic findings. The rationale, although not supported by biomechanical studies is to obtain a triple, biomechanical effect. The first of these biomechanical effects which we try to promote through the procedure of transposition is the elimination of the deviation and oblique angle which occurs as the LHB completes its intra-articular course prior to reaching the bicipital groove. Furthermore, we have found this technique extremely useful in the presence of large ruptures of the rotator cuff with muscle retraction. The most common complication associated to this particular method, observed in less than 3%, is failed biological fixation which manifests as subsidence of the tenodesis and consequent descent of the tendon with evident aesthetic deformity.

Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience.

Calcific tendinitis of the rotator cuff is a relatively frequent pathology and at times, in some phases, it is a disabling one: for this reason, numerous therapeutic options have been proposed. The authors propose an algorithm for the classification and treatment of calcific tendinitis and report their experience with arthroscopic treatment over a three-year period from 2001 to 2004. Based on the algorithm proposed, out of a total of 126 shoulders affected with calcific tendinitis of the rotator cuff for which debridement was indicated, 106 us-guided percutaneous surgeries (EPT), and only 20 arthroscopies were performed. Arthroscopy is indicated, on the basis of the algorithm that we followed, in patients affected by chronic and persistent calcific tendinitis who did not benefit from the execution of previous types of non-surgical treatment for a period of at least 6 to 12 months. Shoulder instability was found to be present in 8 patients out of 20 treated arthroscopically. After arthroscopy, short- and medium-term results were always positive with the exception of one case that evolved into adhesive capsulitis. Based on an analysis of this series, we were able to confirm the usefulness and clinical applicability of an algorithm to classify and treat calcific tendinitis of the rotator cuff; we also confirmed the role of arthroscopic treatment that in cases which did not respond to conservative procedures proved to be effective in resolving symptoms.

Comparative and experimental study on different tendinous grasping techniques in rotator cuff repair: a new reinforced stitch.

Arthroscopic repair of wide rotator cuff ruptures is burdened by a percentage of recurrences that is greater than the repair carried out when an open technique is used. One of the main reasons for this difference can be searched for in the minor hold of stitching on the tendinous aspect obtained with arthroscopic repair. In fact, when an open technique is used, good hold can be guaranteed by using reinforced stitches such as the modified Mason-Allen. Thus, arthroscopic repair technique on the tendinous aspect, particularly in wide and massive injuries, must be improved. It was the purpose of this study to compare a new reinforced stitch that can easily be obtained in arthroscopy (simple stitch that orthogonally crosses a horizontal stitch previously knotted on the tendon: SS-HL), with traditional stitches (simple stitch, mattress-stitch and modified Mason-Allen stitch). Tests were carried out on sheep infraspinatus tendons in order to evaluate the resistance of pull-out. The SS-HL stitch showed resistance to loading that was similar to that when the modified Mason-Allen was used, but it was greater than that shown by the simple stitch (+48%) and the mattress stitch (+35%).

Conjoined fracture-dislocation of the forearm at the elbow.

Conjoined fracture-dislocation of the elbow were first described by Marotte in 1982. In this study, a total of 41 patients treated between 1975 and 1995 at the Rizzoli Orthopaedic Institute and 4 patients treated between 1997 and 2000 at the Division of Orthopaedics at the Maggiore Hospital are evaluated. Based on the Marotte classification, the patients are divided into 4 groups, by site of dislocation of the radial capitellum and amount of comminution of the fracture of the ulna. A clinical and radiographic evaluation was made after a mean follow-up of 5.3 years based on Anderson criteria. The results obtained were excellent in 17 patients (37.8%) satisfactory in 13 (28.9%), dissatisfactory in 12 (26.7%); 3 patients were considered to be failures (6.7%), the best results were obtained in type I anterior dislocations.

Dislocation of the proximal femoral epiphysis in acetabular fractures.

Acetabular fractures are often associated with dislocation of the proximal femoral epiphysis. The dislocation may be of three types, based on the type of fracture to which it is associated: anterior, central, posterior. In anterior and in central dislocation epiphyseal necrosis of the proximal femur has never been observed, while in posterior dislocation necrosis has been observed in 23% of cases. Diagnosis of posterior dislocation is of essential importance so that it may be reduced immediately, decreasing the risk of necrosis. The authors report a review of 192 fractures of the acetabulum to which dislocation of the femoral epiphysis was associated, treated between 1980 and 1996 at the IIIrd Division of the Rizzoli Orthopaedic Institute.

Rigid fixation with plate and bone graft in failures of intramedullary osteosynthesis for the treatment of diaphyseal nonunion of the femur.

Fractures and diaphyseal nonunion of the femur are normally treated by intramedullary nailing. In cases in which nailing fails, nonunion is treated by reaming of the canal and substitution of the nail with one of a more adequate caliber. Rarely, however, due to unfavorable mechanical conditions or in cases of atrophic nonunion or with scarce vascularization the biological conditions for healing are absent. In cases such as these, nonunion must be treated by rigid internal fixation with a plate, aided by the use of cortical graft on the opposite side. The authors present 7 cases of diaphyseal nonunion of the femur treated between 1994 and 1996 using rigid fixation (plate and graft) as a salvage method, as a result of numerous previous failures in surgery. The results were favorable in all of the cases without complications.

Osteosynthesis with percutaneous wiring in fractures of the proximal humerus.

The authors report the preliminary results of osteosynthesis with percutaneous wiring in the treatment of fractures of the proximal humerus. This method which is still described in very few cases, is characterized by several advantages such as its minor invasiveness, and respect for vascularization of the fragments that guarantee good functional results. The application of threaded pins or pins of large diameter guarantees excellent hold with a low incidence of loosening secondary to loss of reduction. The use of a traction device applied to the surgical table simplifies reduction maneuvers and osteosynthesis.

Inveterate fractures of the acetabulum.

The authors reviewed 44 inveterate fractures of the acetabulum treated surgically by internal osteosynthesis. The definition of inveterate fracture concerns lesions that are treated from 21 to 90 days after trauma. Based on an analysis of this series several features of a prognostic and therapeutic nature may be determined. In particular, it may be observed just how difficult it is to standardize therapeutic strategies in relation to polymorphism and anatomopathologic progression of the lesions.

Traumatic lesions of the acetabular triradiate cartilage (presentation of four cases and considerations on treatment).

Four cases of fracture of the triradiate cartilage (TC) are reported, all of which may be classified as epiphyseal detachments. Two of the patients were submitted to osteosynthesis of the posterior column: results were very satisfactory in one of the cases for which long-term follow-up was obtained. The other two cases, treated non-surgically, developed meta-traumatic actabular dysplasia probably due to association with crushing phenomena (Salter-Harris V) in the germinative area of TC. Despite the favorable results obtained in the case that was submitted to surgery, the authors believe that conservative treatment is best in this type of lesion, and that surgical reduction should be performed only in cases of instability and severe displacement, once surgical reduction has failed.

A technical report reviewing the use of the 11-mm Gamma nail: interoperative femur fracture incidence.

Two years after the first large series on the Gamma nail, the authors analyze 119 surgical procedures for proximal femur fractures performed using the 11 mm Gamma nail. The study was performed by 24 surgeons (from six orthopedics departments) at different levels of learning, as in the previous study. The small-sized nail allows an easier surgical procedure and a manual introduction of the nail even in small femurs, as suggested by the previous experience. A careful operative technique and a 2 mm overreaming, which was almost always adopted, explains the decrease in interoperative and postoperative complications (evaluated in 88 cases), compared to the last case report published in 1991. No interoperative shaft fractures occurred in 119 nailings.

Revision of the femoral prosthetic component according to the Wagner technique.

The authors report the preliminary results they obtained using the Wagner technique for revision of the prosthetic stem by transfemoral access. Between January 1992 and June 1993 a total of 20 patients were treated by reimplantation of the prosthetic stem according to the Wagner technique. At minimum 12-month follow-up, based on the Harris Score System, results were excellent, good and fair in 16 cases. Results were not satisfactory in 4 cases after sinking of the prosthesis exceeding 2 cm or due to mid-distal pain with loading.

Lesions of the sciatic nerve in fractures of the acetabulum.

Between 1982 and 1992 a total of 211 fractures of the acetabulum were operated. There was lesion of the sciatic nerve in 21 cases, the pathogenesis and evolution of which were studied. Clinical follow-up was obtained at least 2 years after occurrence of neurological deficit and supported in 13 cases by electromyography. Based on an analysis of the literature and of these series it is observed how spontaneous recovery of paralysis is not rare, even if it requires a long period of time. The presence of various levels of lesion, which are not easily diagnosed, and which are not easily attacked surgically, calls for a prudent attitude with regard to neurolysis.

Internal fixation in unstable fractures of the pelvis. Preliminary notes.

The authors report the preliminary results of the surgical treatment of unstable fractures of the pelvic ring. Between 1989 and 1993 a total of 12 unstable fractures were treated by internal fixation. Short-term radiographic and functional results were satisfactory. The authors attribute an essential role to preoperative planning by conventional radiographic assessment and CT scan with multiplanar reconstructions, associated with carefully performed internal osteosynthesis.

The results of a multicenter Italian study on the use of the Gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases.

A total of 1147 pertrochanteric and subtrochanteric fractures, 10 delays in consolidation and non-union, 24 pathologic fractures and osteolysis with the risk of fracture, treated with a gamma nail in 17 Italian departments of traumatology, were collected. In 70% of the patients weight-bearing was allowed during the first week postsurgery; 77% of the patients followed-up recovered the same ability to walk that had preceded trauma. Complications included intraoperative (1.8%) and postoperative (1.1%) diaphyseal fractures, cephalic screw cut out (2.2%), and breakage of the nail (0.4%). There were two cases of infection (0.3%). Most of the complications were related to errors in technique. The safest procedure is constituted by the choice of a nail with a thinner caliber, 2 mm diaphyseal over-reaming, insertion of the nail without the use of a hammer, and distal locking; the cephalic screw must always be inserted in the lower portion of the femoral head.

The role of magnetic resonance in necrosis of the femoral epiphysis as the sequelae of acetabular fracture (preliminary results).

Eleven patients surgically treated for fracture of the acetabulum were examined postoperatively by MRI in order to reveal any signs of necrosis of the femoral head at an early stage. The means of osteosynthesis used underwent preliminary testing in order to exclude magnetic or thermal phenomena. The study confirmed the usefulness of this test in the early diagnosis of this serious complication. In 3 cases the presence of the means of osteosynthesis obstructed a correct interpretation of the images.

The "Tour Eiffel" double Rush nail in the treatment of fractures of the lower limb.

The authors reviewed 73 patients treated by delayed osteosynthesis with a "Tour Eiffel" double Rush nail. The cases involved fracture of the lower third of the femur in 20 patients, fracture of the proximal third of the tibia in 24 cases, and fracture of the distal third of the tibia in 29. The results indicate the effectiveness of the method, despite the fact that its use was reduced as a result of the introduction of the Grosse-Kempf nail. This is however the method of choice for tibial meta-diaphyseal fractures associated with fracture of the tibial plateaux and complex and comminuted fractures of the distal fourth of the tibia. Moreover, this method must be used three-six weeks after the fracture, when the callus formation is in progress.

The role of magnetic resonance imaging in lumbar disc disease.

The authors analyze 30 cases of herniated lumbar disc, comparing the clinical features with the magnetic resonance images and the intraoperative findings. In 10 cases it was possible to compare MRI with computerized tomography as well. This paper confirms, in agreement with the international literature, the great diagnostic value of this new imaging study. While MRI is non-invasive and does not expose the patient to ionizing radiation, it provides an amount of information that could previously be obtained only by combining CT with myelography and discography.

Results of the multicentric Italian experience on the Gamma nail: a report on 648 cases.

In a multicentric study, the data of 628 trochanteric fractures, two non-unions, and 18 pathologic or impending fractures treated by Gamma nail in 13 Italian traumatology services were collected and analyzed. In 70% of the patients weight bearing was allowed in the first postoperative week and 78% of the controlled patients returned to their pretrauma walking ability. Complications included intraoperative (1.4%) and postoperative (1.2%) shaft fractures, "cut out" of the lag screw (2.6%), and nail failure (0.5%). There were no cases of infection. An analysis of complications showed that most of them were due to technical mistakes. The safest procedure is 2 mm diaphyseal overreaming, introduction of the nail without hammering, and distal locking; the lag screw should be placed in the lower part of the head of the femur.

Complex fractures of the tibial plateau.

Out of 142 consecutive cases of fracture of the tibial plateau 48 cases (34%) of complex fractures are taken into consideration. Surgical treatment is based on two types of osteosynthesis: 1) osteosynthesis "of election" with interfragmentary plates and screws, which was used in most of the cases; 2) minimal osteosynthesis with Barr or lag screws, when there are lesions of the soft tissue and capsuloligamentous lesions. A total of 69% of the results were satisfactory (good and excellent). The most unfavorable prognostic factors are comminution of the fracture and residual widening of the tibial plateau.

Osteosynthesis in fractures of the femoral neck in the young adult.

The authors report 21 cases of fracture of the femoral neck in the young adult followed-up after a minimum of 2 years, which is a sufficient amount of time to be able to evaluate cephalic necrosis. The results obtained with the various methods of osteosynthesis were: excellent: 38%; good: 33.5%; fair: 9.5%; poor: 19%. Emphasis is made on the effectiveness of the Garden classification system for prognosis and treatment, and several aspects of the method used are discussed.