A Rare Case of First Metatarsal Extrusion: Results of Treatment After 12 Months.

We present the case of a 21-year-old male with 12 months' follow-up after reimplantation of a completely extruded first metatarsal. The patient had a motorcycle accident involving his right foot and ankle, with multiple lesser metatarsal fractures, lateral malleolus fracture, and a total first metatarsal extrusion (without fracture) through a large dorso-medial forefoot wound. The extruded bone was recovered at the site of the motor vehicle accident and was transported to the hospital with the patient. Before the reimplantation surgery was undertaken, the first metatarsal was immersed in a chlorhexidine solution for 20 minutes and then washed in an antibiotic solution. Metatarsal fixation was performed with Kirschner wires; the lateral malleolus fracture was fixed with plate and screws. An external fixator was then applied. Throughout the 12-month follow-up period, there was no evidence of infection. At the present time, this case suggests that, after antiseptic cleansing and prompt surgery, extruded first metatarsal reimplantation is possible with a reasonable degree of clinical success.

Hallux valgus correction with a new percutaneous distal osteotomy: Surgical technique and medium term outcomes.

BACKGROUND: Many procedures and different osteotomies have been described for percutaneous hallux valgus correction. Percutaneous techniques may lead to reduced morbidity, surgery, and recovery time. The aim of this study is to evaluate the clinical and radiographic outcome of a new percutaneous procedure (PBS-Percutaneous Bianchi System). METHODS: Fifty-eight cases were treated with Percutaneous Bianchi System procedure for correction of mild, moderate or severe hallux valgus deformity. All patients were clinically assessed preoperatively and then followed up by weight-bearing x-rays, AOFAS (American Orthopedic Foot and Ankle Score), VAS (Visual Analog Scale) pain score, and patient satisfaction. RESULTS: AOFAS scores improved from 28.6 at the preoperative assessment to 91.7 at the latest follow-up. The VAS pain score improved from 6.7 before surgery to 0.6 at the latest follow-up. The mean Hallux valgus angle (HVA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) significatively decreased from the preoperative assessment to the latest follow-up. CONCLUSIONS: The PBS technique is a safe, reliable, and effective procedure for the correction of symptomatic mild-to-severe hallux valgus.

Infections in primary total ankle replacement: Anterior approach versus lateral transfibular approach.

BACKGROUND: Total ankle replacement (TAR) represents an alternative to fusion for the treatment of end-stage ankle osteoarthritis. The aim of the present study was to retrospectively assess the frequency of infections between TARs with anterior and lateral transfibular approach at 12-months follow-up. METHODS: 81 TARs through an anterior approach and 69 TARs through a lateral approach were performed between May 2011 and July 2015. We compared surgical time and tourniquet time, as well as superficial and deep infections frequency during the first 12 postoperative months. RESULTS: In the anterior approach group, there were 3 (3.7%) deep infections and 4 (4.9%) superficial wound infections. In the lateral approach group, there were 1 (1.4%) deep infection and 2 superficial wound infections (2.9%). There were not statistically significant differences between the groups. There was a significant difference between anterior approach (115minutes) and lateral approach group (179minutes) in terms of surgical time (P<0.001). CONCLUSIONS: The frequency of superficial and deep periprosthetic infections during the first postoperative year was not significantly different in the lateral approach group compared to the anterior approach group, despite the significantly longer surgical time in the lateral transfibular approach group.

Impaired healing of fragility fractures in type 2 diabetes: clinical and radiographic assessments and serum cytokine levels.

BACKGROUND: Diabetes induces bone alterations accompanied by altered cytokine expression patterns. These alterations lead to modified fracture healing, contributing to musculoskeletal fragility in the elderly. AIMS: We evaluated the inflammatory immune response in diabetic patients during fracture healing relative to clinical and radiographic assessments. METHODS: Fifty patients of both sexes with fragility fractures were studied: 30 diabetics (group A, mean age 73.4 ± 11.2 years) and 20 normoglycemic controls (group B, mean age 75.1 ± 16.9 years). Two subgroups comprised those with hip or wrist fragility fractures (25 and 16 patients, respectively). We evaluated serum concentrations of tumor necrosis factor α, interleukins 4 and 8, monocyte chemotactic protein-1 (MCP-1), vascular endothelial growth factor, and epidermal growth factor (EGF) before and at 4 and 8 weeks after surgery. We also determined the Radiographic Union Score for Hips and the Radius Union Scoring System score and applied the Physical Activity Scale for the Elderly test at the same time points. Each patient underwent bone densitometry. RESULTS: MCP-1 and EGF levels were higher in group A than in group B at 4 weeks after surgery (p > 0.05). Radiographic evaluation showed lower scores in group A (p < 0.05). The main difference between the groups was evident 4 weeks after surgery. Changes in the serum concentrations of chemotactic and angiogenic factors could explain the radiographically proved impaired fracture healing in diabetic patients. CONCLUSIONS: Fragility fracture healing is impaired in diabetic patients. Radiographic and molecular patterns confirmed that the most compromised fracture-healing phase is at 4 weeks after surgery, during callus mineralization.

Fracture healing in elderly patients: new challenges for antiosteoporotic drugs.

Osteoporosis is a major public health concern, characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fracture. Fracture repair progresses through different pathways, striking a balance between bone formation and bone remodeling mechanisms. Conventionally, fracture repair is divided into defined stages, each characterized by a specific set of cellular and molecular events. In postmenopausal women and elderly patients, bone healing rates are conditioned by cellular and molecular alterations to bone tissue that result in a progressive deterioration of fracture healing ability. In addition, in elderly patients, comorbidities and drugs therapies may also affect fracture healing. For this reason, pharmacological research is now focused on the possible use of antiosteoporotic drugs to promote bone healing in frail patients.

A new antiresorptive approach to the treatment of fragility fractures: long-term efficacy and safety of denosumab.

An imbalance of the remodeling process for bone resorption leads to a loss of tissue with consequent microarchitectural damage, evident in conditions such as osteoporosis and related fragility fractures. Currently, pharmacological therapies are able to prevent or slow down bone resorption by inhibiting osteoclast activity. An innovative and targeted anti-resorptive approach is represented by the inhibition of RANK ligand (RANK-L), essential for the proliferation and activity of osteoclastic cells. The human monoclonal antibody against RANK-L (denosumab) has been approved for the treatment of osteoporosis. In clinical trials of patients with osteoporosis, inhibition of RANK-L has reduced bone loss and damage to the microarchitecture and was associated with an increase in mass and resistance at different skeletal sites, with most significant effects than those demonstrated by any other antiresorptive drugs. In addition, after 3 years of treatment, it showed a reduction in vertebral and non-vertebral fracture risk. Denosumab treatment also has not revealed any alteration in the physiological processes of fracture repair, showing no increase in the onset of complications 3 years after the fracture. The data show that denosumab offers an effective alternative therapeutic approach for the treatment of severe osteoporosis, with positive effects on BMD and reduction of fragility fractures risk. So, promising results in terms of therapeutic efficacy and reliability make desirable the wide clinical use of denosumab for the treatment of osteoporotic fractures in the near future.

Osteoporosis and sarcopenia: the connections.

Osteoporosis and sarcopenia are the most frequent musculoskeletal disorders affecting older people. Osteoporosis is a widespread disorder affecting millions of individuals of all ethnic backgrounds worldwide, particularly among older women. It is characterized by reduced bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in the risk of fracture. Sarcopenia is considered to be one of the major factors responsible for functional limitations and motor dependency in elderly persons. In age-related muscle atrophy, a decrease in muscle fiber size and number, and a preferential loss of type II fibers have been reported. A decrease in the circulating levels of specific hormones (e.g., estrogen, testosterone, growth hormone, and insulin-like growth factor-1) has been shown to be associated with sarcopenia and this appears to play an important role in its pathogenesis.

Outcomes of Percutaneous Calcaneoplasty for Insertional Achilles Tendon Problems.

BACKGROUND: Percutaneous procedures have been used recently to treat insertional Achilles tendon problems. The present study reports our results of this treatment approach. METHODS: Patients undergoing percutaneous calcaneoplasty for insertional Achilles tendon problems were retrieved. Patients completed the visual analog scale (VAS) for pain and the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire before the operative procedure and at the last follow-up. At the last follow-up, we asked the patients whether they were completely satisfied, moderately satisfied, or unsatisfied after the procedure. Complications were also recorded. RESULTS: A total of 27 patients were enrolled. The average follow-up was 26.5 months (range 6-68). The mean age of patients was 56.2 years (24-82). The mean VAS score before surgery was 8.1 ± 0.9 decreasing by the last follow-up to 2.4 ± 2.3 (P < .0001). The mean VISA-A score improved from 20.7 ± 5.4 to 75.7 ± 25.5 at last follow-up, an improvement of 55% (P < .0001). At the last follow-up, 84.5% (22 of 27) patients were completely satisfied with the procedure, 7.4% (2 of 27) moderately satisfied, and 11.1% (3 of 27) were not satisfied. These last 3 patients presented recurrence of symptoms, requiring revision surgery. CONCLUSION: For the selected patients, we found percutaneous calcaneoplasty to be an effective treatment for insertional Achilles tendon problems. LEVEL OF EVIDENCE: Level III, retrospective study.

Osteoid osteoma of the proximal phalanx of the hallux: a case report of a challenging diagnosis.

Osteoid osteoma is a benign bone lesion that accounts for approximately 10% to 12% of all benign bone tumors. More than 80% of lesions occur in patients between 5 to 25 years old; males are more commonly affected with a ratio of 3:1. The foot is rarely involved: its involvement is less than 4% in the foot and of 1.7% in the metatarsals. In this paper we discuss the case of a 27-years-old woman with a 12 months follow-up, presented with an osteoid osteoma of the proximal phalanx of the great toe that underwent an en-bloc excision of the lesion and subsequent filling with cancellous autograft from the ipsilateral calcaneus.

Fracture healing: from basic science to role of nutrition.

Fracture healing is a complex event that involves the coordination of different processes: initial inflammatory response, soft and hard callus formation, initial bony union and bone remodeling. This well-orchestrated series of biological events follows a specific temporal and spatial sequence that can be affected by biological factors, such as age and bone quality. There is some evidence that increased age is a considerable factor in the inhibition of fracture repair in human subjects. During aging there is an accumulation of damage that depends on the activation of inflammation processes and on changes in the circulating levels of inflammatory cytokines. In addition to the physiological slow down in the repair process, other conditions such as multiple comorbidities leading to polymedication are a frequent occurrence in elderly patients and can have an influence on this process. A further factor that affects bone metabolism is nutrition: bone quality, fragility fractures risk and fracture healing process are all influenced by the nutritional status. This review provides a summary of the immunological aspects of physiological fracture healing and of those nutritional factors which might play an important role in this process.

Ten years of hip fractures in Italy: For the first time a decreasing trend in elderly women.

AIM: To evaluate the hospitalization rate of femoral neck fractures in the elderly Italian population over ten years. METHODS: We analyzed national hospitalizations records collected at central level by the Ministry of Health from 2000 to 2009. Age- and sex-specific rates of fractures occurred at femoral neck in people ≥ 65 years old. We performed a sub-analysis over a three-year period (2007-2009), presenting data per five-year age groups, in order to evaluate the incidence of the hip fracture in the oldest population. RESULTS: We estimated a total of 839008 hospitalizations due to femoral neck fractures between 2000 and 2009 in people ≥ 65, with an overall increase of 29.8% over 10 years. The incidence per 10000 inhabitants remarkably increased in people ≥ 75, passing from 158.5 to 166.8 (+5.2%) and from 72.6 to 77.5 (+6.8%) over the ten-year period in women and men, respectively. The oldest age group (people > 85 years old) accounted for more than 42% of total hospital admissions in 2009 (n = 39000), despite representing only 2.5% of the Italian population. Particularly, women aged > 85 accounted for 30.8% of total fractures, although they represented just 1.8% of the general population. The results of this analysis indicate that the incidence of hip fractures progressively increased from 2000 to 2009, but a reduction can be observed for the first time in women ≤ 75 (-7.9% between 2004 and 2009). CONCLUSION: Incidence of hip fractures in Italy are continuously increasing, although women aged 65-74 years old started showing a decreasing trend.

Acetabular fragility fractures in elderly patients.

The incidence of acetabular fractures in the elderly is recently becoming common. Acetabular fractures in this age range are more demanding, regarding fracture patterns, poor bone quality, patient status and potential comorbidities. Therefore it is necessary to determine the ideal treatment that should allow patients to obtain early mobilization and prevention of common complications. Different treatment options include conservative management, percutaneous minimally invasive procedures, open reduction and fixation (ORIF) and primary total hip arthroplasty (THA). The purpose of this paper is to review these options in fractured elderly patients.

Role of the orthopaedic in fragility fracture and in the prevention of a new fracture: SIOT 2009 recommendations.

The progressive aging of the population inevitably leads to an increase in all age-related diseases, with osteoporosis arising as a health and social priority. Fragility fractures, resulting by Osteoporosis, may have important consequences such as hospitalizations with long periods of immobility, need of surgery, increased risk of disability and partial or complete loss of autonomy in the ordinary activities of daily life and related economical burden. It is therefore essential to implement immediately a tertiary prevention to reduce the risk of further fractures through a diagnostic-therapeutic evidence-based pathway. So, starting from the fracture, the orthopaedic surgeon is meant to play an essential role in the management of osteoporotic patients, both to reduce the risk of further fractures and improve long-term outcome in these people, thus lowering the health and life quality downward spiral that often results in fractures in the elderly.

Bone healing and osteoporosis.

A correct fracture healing depends on the synergy between biomechanical, molecular and cellular factors. Focusing on different stages, fracture hematoma represents the starting point of the inflammatory process, with a critical role in triggering the process of fracture healing. The essential factors for bone repair are the activation of mesenchymal stem cells and the release of growth and regulatory factors. Moreover, the efficacy of fracture healing is determined by three ideal conditions: adequate blood supply, good contact between bone fragments and good stability. It is remarkable how the implant choice influences fracture healing after surgical treatment. In osteoporosis, bone quality adversely affects the tissue structural competence, increasing the risk of a complicated fracture healing. The qualitative and quantitative alterations established at the cellular level during osteoporosis explain the progressive deterioration of bone tissue healing ability.