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.

Effect of trochleocapitellar index on adult patient-reported outcomes after noncomminuted intra-articular distal humeral fractures.

BACKGROUND: Anatomic surgical reduction of intra-articular fractures of the distal humerus is important to achieve the best long-term outcomes and prevent post-traumatic arthritis. In this study we compared the radiographic reduction using the trochleocapitellar index. We also correlated the trochleocapitellar index to the functional outcomes next to the comparison of the triceps brachii lifting approach and olecranon osteotomy approach, 2 common approaches for distal humeral fractures. METHODS: From January 2006 to June 2016, patients with elbow fractures were registered in 4 centers. The trochleocapitellar index, a ratio between the angle of the capitellum and the trochlea to the midline of the distal humerus on anterior-posterior radiographs, was calculated for included patients. Functional outcomes were measured using the Oxford Elbow Score and the Mayo Elbow Performance Score. Bone healing was measured using radiographic union scoring. RESULTS: There were 86 patients enrolled: 46 in the olecranon osteotomy group and 40 in the triceps lifting group. Functional outcomes and bone healing did not differ between the approaches. Functional results had a medium correlation with the trochleocapitellar index, which did not differ between the 2 approaches (olecranon osteotomy group, κ = 0.56; triceps lifting group, κ = 0.57; P = .7932). CONCLUSIONS: The trochleocapitellar index has a moderate predictive value on the functional results after 12 months after open reduction and internal fixation of intra-articular distal humeral factures. There is no difference in reduction, as measured by trochlear index and functional outcome scores, between the olecranon osteotomy approach and the triceps brachii lifting approach groups.

Foot Loading and Gait Analysis Evaluation of Nonarticular Tibial Pilon Fracture: A Comparison of Three Surgical Techniques.

The aim of our study was to investigate which technique among hybrid external fixation, plate and screws, and intramedullary nailing produces better outcomes in foot loading when treating type 43.A1, 43.A2, and 43.A3 fractures, according to the AO classification. From November 2011 to December 2014, 34 patients, including 25 (73.5%) males and 9 (26.5%) females with an average age of 32.3 (range 16 to 67) years, with a type A tibia fracture were treated with intramedullary nailing, plate and screws, or hybrid external fixation. The patients were divided into 3 groups: 16 (47%) received hybrid external fixation, 10 (29.4%) received plate and screw fixation, and 8 (23.5%) received intramedullary nailing fixation. The follow-up protocol included clinical and radiologic evaluations performed at 15 days, 1 month, 3 months, 6 months, and 12 months after surgery. The selected outcome parameters for the 3 groups were as follows: visual analog scale for pain of the traumatized tibia, interval from surgery to weightbearing, average time required for fracture recovery, subjective and objective Ovadia-Beals scores, baropodometric examination at 12 months, walking recovery at 12 months, outcomes, and surgical complications. The endpoint assessment was set at 12 months. The results showed that incorrect reduction of a type A tibia fracture can lead to changes in the sagittal balance line for foot loading and pace training. In conclusion, these findings have shown that the experience of the surgeon in the reduction of the fracture and knowledge of the method of synthesis is essential.

Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not?

BACKGROUND: There is a high incidence of blood transfusion following hip fractures in elderly patients. AIM: The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery. MATERIALS AND METHODS: Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer). RESULTS: Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05). CONCLUSION: Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss.

TEN versus external fixator in the management of pediatric diaphyseal femoral fractures: evaluation of the outcomes.

INTRODUCTION: Over the last 20 years, the incidence of pediatric diaphyseal femoral 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, involvement of the soft tissues, and concomitance with other injuries. MATERIALS AND METHODS: From 2000 to 2015, 38 pediatric patients with diaphyseal femoral fractures were surgically treated and enrolled in the study. The average age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN) and the other 16 with external axial fixators. Comparing the two groups, radiographic images were taken to assess the fracture reduction and consolidation. RESULTS: The average follow-up was 14 months. The average time needed to remove the TEN nails was 5 months; while 2.5 months was the time to remove the external fixator. At the final follow-up, there were no differences between two groups in term of significant rotation defects, angulation, growth, and/or nonunion. CONCLUSIONS: This study showed that TENS and external fixation have similar results in term of fracture healing and complication, even if patients treated with TENS are more satisfied.

Comparison of Plate, Nail and External Fixation in the Management of Diaphyseal Fractures of the Humerus.

INTRODUCTION: Humeral shaft fractures are quite common in orthopedics and represent 1-3% of adult fractures. The surgical treatment is the a better choice in order to obtain a reduction and stable alignment and to prevent the complications. The goal of this study was to compare the three techniques (IMN, LCP and EF) in the treatment of diaphyseal fractures of the humerus in the adult patient. MATERIALS AND METHODS: We examined 79 patients with diaphyseal fractures of the humerus. 32 were treated with plaque (LCP), 26 with intramedullary nail (IMN) and 21 with eternal fixer (FE) The clinical and radiographic follow-up was done at 1.3, 6 and 12 months. As rating scales we used the ASES and SF-36. We recorded all the complications. RESULTS: The median follow-up was 11.5 months (9-16). The operative time was significantly smaller in the case of FE (47 ') with a statistically significant difference compared with other techniques. Even the blood loss was lower in the case of FE (60ml), compared to nails (160ml) and LCP (330ml) p <0.05. We had no differences in the duration of hospitalization and the ASES SF-36 score. We had 2 cases of non-union in the LCP group, 1 case in the IMN group and no cases in the FE group. In IMN group we had one case of radial transient paralysis. We did not have any deep infection, in the FE group 8 patients we had superficial secretions from pins. CONCLUSION: From the results of our study, it is clear that the treatment of humeral shaft fractures guarantee overlapping results with the use of plates, of intramedullary nails, or with the external fixator. Consequently, the choice of which technique to use should be determined based on the experience of the operator and patient compliance.

Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: is There a Real Difference in Skin Complication? A Retrospective Study in Three Level I Trauma Center.

INTRODUCTION: Not enough literature is available to evalute the wound complication rate of plates type in distal fibular fractures. AIM: The aim of our study was to compare wound complications of using a third tubular plate compared to LCP distal fibula plate. MATERIAL AND METHODS: This study is a retrospective single-centre study in which was performed plating of fibula in closed ankle fractures. 93 patients were included in our study and assigned in two groups, based on using of different implant : in group A 48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distal fibula plate. There were no significant differences in the baseline characterisctics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evalueted at 1-3-12 months and clinical examination was made at 12 months using AOFAS clinical rating system. Categorical data, grouped into distinct categories, were evalueted using Chi-square test. We considered a p value < 0.05 as statistically significant. RESULTS: The wound complications rate of the overall study group was 7.6%. There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%); plate removal was performed earlier in the locking plate because of wound complications. CONCLUSIONS: Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distal fibula plate and conventional one-third tubular plate. Controversy still exists about the best method for the fracture reduction.

Subtrochanteric femoral shortening osteotomy combined with cementless total hip replacement for Crowe type IV developmental dysplasia: a retrospective study.

BACKGROUND: Total hip replacement for high dislocation of the hip presents some difficulties, considering patients' young ages, the abnormal hip anatomy and the high rate of complications. In this study, we present our experience in terms of clinical and radiological results in the treatment of Crowe type IV hips with subtrochanteric femoral shortening osteotomy and cementless total hip replacement. MATERIALS AND METHODS: We retrospectively reviewed 15 patients with Crowe type IV hip dysplasia (two bilateral cases for a total of 17 hips) treated with cementless total hip replacement associated with shortening subtrochanteric osteotomies (nine transversal and eight Z-shape osteotomies) between March 2000 to February 2006. The mean follow-up was 88 months (range 63-133). Harris hip score, leg length discrepancy, neurological status, union status of the osteotomy and the component stability were the criteria of the evaluation. All complications were noted. RESULTS: The mean HHS improved from 38.3 (range 32-52) to 85.6 (range 69-90). The mean preoperative leg length discrepancy was of 45 mm (range 38-70) and reduced to a mean of 12 mm (range 9-1.6) postoperatively. All osteotomies resulted healed at an average of 12.3 weeks (range 10-15). No cases of delayed union or nonunion were detected. Two patients (11%) showed early symptoms of sciatic nerve palsy which resolved uneventfully in 6 months. There was no migrations and none of the implants required revision. CONCLUSIONS: Cementless THA with shortening subtrochanteric osteotomy is an effective method in the treatment of patients with Crowe type IV development dysplasia of the hip. LEVEL OF EVIDENCE: IV.

The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem?

INTRODUCTION: The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step. MATERIALS AND METHODS: Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months. RESULTS: Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle. CONCLUSIONS: The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion. The return to pre-injury quality of life has to be our main goal.

Grafting and fixation of proximal humeral aseptic non union: a prospective case series.

BACKGROUND: Fractures of the proximal part of the humerus represent almost 4-5% of all fractures. The rate of non union is estimated to be 1.1 to 10%. Non union, displacement, and fixation failure can be hazardous complications for these injuries. The purpose of our study was to evaluate the outcomes of plate and bone strut allograft with bone chips grafting augmentation in the management of proximal humeral aseptic non union. METHODS: We treated 16 aseptic non union proximal humeral fractures by the medial humeral shaft bone strut allograft and lateral plate and screws with bone chips grafting. The patients' ages were between 55 and 70 years. The chosen criteria to evaluate the group during the clinical and radiological follow-up were the quality of life measured by The Short Form (12) Health Survey (SF-12), shoulder function and related quality of life measured by the Constant Shoulder Score (CSS) compared with healthy side, bone healing measured by X-rays, and postoperative complications. The follow-up was perfor med with clinical and radiographic controls at 1, 3, 6 and 12 months. Surgical time and international units of red blood cells transfused were also calculated. The evaluation endpoint was set at 12 months. RESULTS: The X-rays bone healing occurred in our group on average of 126.4 days after surgery. The surgical time and blood loss were consistent with standard surgical procedures. The quality of life and functional recovery were excellent after plate and bone strut allograft. CONCLUSIONS: Surgical techniques that increase mechanical stability, while incorporating bone biology, are effective aids for treating problematic fractural patterns.

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.

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.

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.

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.

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.

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.

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.

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.