Surgical treatment of multifragmentary segmental femur shaft fractures with ORIF and bone graft versus MIPO: a prospective control-group study.

Aim Multifragmentary segmental femoral shaft fracture is a high energy injury frequently associated with life-threatening conditions. The aim of this study was to compare the use of bio metallic open reduction internal fixation (ORIF) (plate with allograft bone strut) with minimally invasive plate osteosynthesis (MIPO) fixation for the treatment of multi-segmental femoral shaft fracture in terms of outcomes, bone healing and complications. Methods Forty patients with segmental femoral shaft fractures were included and divided into two groups: 20 patients treated with ORIF+, 20 with MIPO. All fractures were classified according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) and Winquist and Hansen Classification. Evaluation criteria were: duration of follow up and surgery, Non-Union Scoring System, Pain Visual Analogic Scale (VAS), objective quality of life and hip function, subjective quality of life and knee function, quality of life the Short Form-12 Survey Questionnaires (SF-12), bone healing and femoral alignment (radiographs), Radiographic Union Score for Hip (RUSH). Results Better results of ORIF in terms of complication rate, RUSH, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients' outcomes (Cohen k) were obtained, and similar results for the length of follow up, surgery duration, perioperative blood transfusion, wound healing. No statistical difference for Harris Hip Score (HHS), Knee Society Score (KSS), quality of life (SF-12). Conclusions The ORIF and bone strut allograft technique had better results compared to the MIPO technique with regards to complication rate, RUSH, VAS, regression between RUSH and VAS, and average correlation clinical-radiographic results and patients' outcomes (Cohen k) in the surgical treatment of multifragmentary segmental femoral shaft fractures.

Grafting and fixation after aseptic non-union of the humeral shaft: A case series.

PURPOSE: Non-unions after humeral shaft fractures are seen frequently in clinical practice at about 2-10% after conservative management and 30% after surgical treatment. Non-union, displacement of structures and fixation failure can be hazardous complications. The purpose of our study was to evaluate the outcomes of an on-lay bone graft strut construction with bone chips as grafting augmentation in the management of aseptic non-unions of the humeral shaft. METHODS: From 124 eligible patients with a humeral shaft non-union, we included 48 patients. In all cases an anterolateral humeral approach was used, with an on-lay bone graft using an allograft strut construction and with bone substitute augmentation in the non-union gap. To assess the bone healing on radiographs, we used the non-union scoring system according to Whelan. Patients were followed with objective and subjective scores. RESULTS: In all 48 patients we achieved full bone healing without major complications. The average period of union was 124 days. In 40 cases after healing the alignment was neutral, valgus deformation occurred in 6 cases a varus deformation in 2 cases. At twelve months after surgery, all patients recovered with satisfactory range of motion of shoulder and elbow and a good quality of life, without any radial nerve palsies or other major complications. CONCLUSION: Given the satisfactory results of full bone healing, recovery of the range of motion and the lack of major complications as seen in this study, we find that plating with supporting allograft as a good choice of treatment in the cases of aseptic non-union of the humeral shaft.

The challenge of nonunion and malunion in distal femur surgical revision.

Aim To demonstrate validity of a bio-metallic solution in bone healing combined with the quadriceps safe approach in the treatment of nonunions of distal femur while malunions were treated by metallic solution. Methods We treated 57 patients with nonunion or malunion of distal femur at the Orthopaedics and Traumatology Department of a single orthopaedic trauma centre (Italy). A total of 57 patients were divided in two groups: the first (NU) group was composed of 35 patients affected; the second group (MU) was composed of 22 patients affected by malunion of distal femur. Criteria chosen to evaluate the two groups during a clinical and radiological followup were: the quality of life measured by the Short Form (12) Health Survey, the knee function and quality of life related to it measured by the Knee Injury and Osteoarthritis Outcome Score KOOS and the Knee Society Score, bone healing measured by modified Radiographic Union Score by X-rays during the follow-up and CT at one year after the surgery, the difference of the limbs length before and after the revision surgery, and postoperative complications. The evaluation endpoint was set at 12 months. Results There were no statistical differences between the two groups. Conclusion The role of bio-metallic solution in the treatment of nonunions and malunions is to recreate the knee anatomy and functionality compatible with a satisfactory quality of life.

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.

Ibandronate and cementless total hip arthroplasty: densitometric measurement of periprosthetic bone mass and new therapeutic approach to the prevention of aseptic loosening.

Studies of the mechanisms of periprosthetic bone loss have led to the development of pharmacologic strategies intended to enhance bone mass recovery after surgery and consequently prevent aseptic loosening and prolong the implant survival. Bisphosphonates, potent anti-resorptive drugs widely used in the treatment of osteoporosis and other disorders of bone metabolism, were shown to be particularly effective in reducing periprosthetic bone resorption in the first year after hip and knee arthroplasty, both cemented and cementless. Based on these results, we investigated the inhibitory effects of ibandronate on periprosthetic bone loss in a 2-year study of postmenopausal women that underwent cementless total hip arthroplasty. In the first 6 months both groups (A, treated with ibandronate 3 mg i.v. within five days after surgery and then with oral ibandronate 150 mg/month, plus calcium and vitamin D supplementation; and B, treated with calcium and vitamin D supplementation only) experienced bone loss, though to a lesser extent in group A. After 12 months, group A showed a remarkable BMD recovery, that was statistically significant versus baseline values (about +1, 74% of global BMD) and most evident in region R1 (+3, 81%) and R2 (+4, 12%); in group B, on the contrary, BMD values were unchanged compared with those at 6 months post-surgery. Quality of life scores also showed a greater improvement in group A, both at 6 and 12 months after surgery, likely because of the pain-reducing effects of ibandronate treatment.

Ibandronate and periprosthetic bone mass: new therapeutic approach in periprosthetic loosening prevention.

A prosthetic implant modifies the physiological transmission of loads to the bone, initiating a remodeling process.Studies of the mechanisms responsible for periprosthetic bone loss contributed to the definition of new pharmacological strategies that may prevent aseptic implant loosening. Bisphosphonates are a class of drugs useful to this purpose, and have been shown to be effective in reducing periprosthetic resorption during the first year after the implant. We aimed to assess the inhibitory effect on periprosthetic osteolysis of ibandronate, a highly potent aminobisphosphonate, administered orally and IV with an extended interval between doses and optimal treatment adherence. In view of the fact that periprosthetic remodeling takes place during the first 6-12 months after surgery and is ultimately responsible for prosthesis longevity, we may conclude that the administration of high dosage ibandronate postsurgery by IV bolus and subsequently as cyclic oral treatment reduced cortical osteopenia in the metaphyseal region, and in the calcar region of the proximal femur. This therapy might therefore be used as preventive measure against postsurgical osteopenia and probably also against aseptic loosening.