Dorsally and volarly angulated extra-articular malunions of the distal radius treated with volar corrective osteotomy and volar locking plate fixation. A case series of 19 patients with a long-term follow-up.

BACKGROUND AND AIM: To date, different technique of corrective osteotomy for the treatment of distal radius extra-articular malunions are described. With this study, we present a case series of corrective osteotomy using volar plate fixation to treat volar and dorsal extra-articular malunions aiming to evaluate the effectiveness of corrective osteotomies through volar plate stabilization in these two types of extra-articular malunions. METHODS: Between August 2008 and May 2017 all patients diagnosed with extra-articular malunion were included in the study. An extended volar Orbay approach and two types of dedicated volar locking plate (Medartis AG, Switzerland and Acumed, Hillsboro,OR) were used. Clinical and radiological parameters were evaluated. The DASH and PRWE scores and the VAS scale questionnaires were administered. The results were analyzed through statistical evaluations. RESULTS: A retrospective analysis of 19 patients diagnosed with extra-articular malunion was carried out. Nine had a volar type deformity (group A), while the other 10 had a dorsal type deformity (group B). The active range of motion (aROM), radiographic parameters, grip strength and pinches in both groups were statistically improved, except for radial deviation in both groups, ulnar deviation in group A, and radial inclination in group B.  The grip strength and pinches values were slightly better in group A. DASH, PRWE scores and VAS scale showed a significant improvement. CONCLUSION: Corrective osteotomy through volar fixation is an effective technique to treat both extra-articular dorsally and volarly angulated malunions. Statistically significant benefits are present in both types of deformities, with better outcomes in the group of volar deformities.

Subtalar arthroeresis with peek endorthesis in juvanile flexible flafoot: Short-term results.

A successful and minimally invasive treatment for adolescent flexible flatfoot is subtalar arthroeresis. This study examines the short-term results of subtalar arthroereisis with a new PEEK device (Pit'Stop®); additional research will be required to determine the device's true potential, but the preliminary findings are very encouraging, with a high success rate and a low complication rate (0.08).

Rare shear-type fracture of the talar head in a thirteen-year-old child - Is this a transitional fracture: A case report and review of the literature.

BACKGROUND: Talar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close. CASE SUMMARY: A thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications. CONCLUSION: Injuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.

TRPV4 and TRPM8 as putative targets for chronic low back pain alleviation.

The purpose of this study is to investigate the presence of nervous fibers and expression of TRP channels in samples harvested during decompressive/fusion spine surgeries from patients affected by chronic low back pain (CLBP). The aim was to understand if members of this family of receptors played a role in detection and processing of painful stimuli, to eventually define them as potential targets for CLBP alleviation. Expression of transient receptor potential (TRP) channels (A1, V1, V2, V4, and M8) was evaluated in samples from different periarticular sites of 6 patients affected by CLBP, at both protein and transcript levels. The capsular connective pathological tissue appeared infiltrated by sensitive unmyelinated nervous fibers. An increase in TRP channel mRNAs and proteins was observed in the pathological capsule compared with tissues collected from the non-symptomatic area in five of the six analyzed patients, independently by the location and number of affected sites. In particular, TRPV4 and TRPM8 were consistently upregulated in pathological tissues. Interestingly, the only patient showing a different pattern of expression also had a different clinical history. TRPV4 and TRPM8 channels may play a role in CLBP and warrant further investigations as possible therapeutic targets.

Müller-Weiss disease: Four case reports.

BACKGROUND: Müller-Weiss disease (MWD) is an idiopathic foot condition characterized by spontaneous tarsal "scaphoiditis" in adults. Frequently bilateral and affecting females during the 4th-6th decades of life, the pathogenesis of MWD remains unclear: It has been traditionally considered a spontaneous osteonecrosis of the navicular. The typical presentation of MWD is a long period of subtle discomfort followed by prolonged standing, atraumatic, disabling pain. Currently, there is no gold standard for the treatment of patients with MWD. Most support initial conservative therapy. Operative treatment should be considered for failure of conservative therapies longer than 6 months. The indication for surgery is severity of symptoms rather than severity of deformities. Operative treatment options include core decompression, internal fixation of the tarsal navicular, open or arthroscopic triple fusion, talo-navicular or talo-navicular-cuneiform arthrodesis, and navicular excision with reconstruction of the medial column. CASE SUMMARY: In this study, we report four patients affected by MWD. Clinical and radiographic assessment, follow-up and treatment are reported. CONCLUSION: As it is frequently misdiagnosed, MWD is challenging for orthopedic surgeons. Early diagnosis and effective treatment are mandatory to avoid sequelae.

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients.

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon's experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Arthroscopically assisted and three-dimensionally modeled minimally invasive rim plate osteosynthesis via modified anterolateral approach for posterolateral tibial plateau fractures.

AIM: The aim of this study was to describe a new, closed, arthroscopically-assisted reduction of posterolateral tibial plateau fractures with minimally invasive plate osteosynthesis using a plate pre-contoured over a 3D-model based on a CT-scan of the injured tibial plateau and positioned by using a minimal anterolateral approach. METHODS: A five to six centimeter long curvilinear incision was made over the Gerdy's tubercle. After subcutaneous dissection, the fascia was incised, the ileo-tibial band was split, and the dissection was extended posteriorly. The knee was flexed to 90° and the space between the fibular collateral ligament and the posterolateral plateau rim (para-FCL space) was created. A variable-angle locking compression plate contoured on a 3D-model was inserted flush to the tibial plateau rim. Two cortical screws were placed to ensure support under the area of depression as far posteriorly as possible. Two additional screws were implanted, and a cortical screw was used for the most anterior screw hole. The custom pre-contoured plate based on a person-specific 3D-model, associated with arthroscopy reduction, provides a supporting and containing effect to the posterolateral periarticular fragments and allows a minimally invasive plate osteosynthesis fixation to be performed. This guarantees a proper reduction and fixation without the described limitations and risks associated with the classic approaches. CONCLUSIONS: This approach should be considered to treat fractures of the posterolateral plateau, isolated or associated with medial tibial plateau fractures, as it could improve the outcome in terms of lower associated risks, better reduction and fixation, and faster and improved patient recovery.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

BACKGROUND: Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs. METHODS: The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded. RESULTS AND CONCLUSION: Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Synovial chondromatosis of the foot: Two case reports and literature review.

BACKGROUND: Primary synovial chondromatosis (PSC) is a rare arthropathy of the synovial joints characterized by the formation of cartilaginous nodules, which may detach and become loose bodies within the joint and may undergo secondary proliferation. PSC of the foot and ankle is exceedingly rare, with only a few cases reported in the literature. The diagnosis may be difficult and delayed until operative treatment, when it is confirmed by histological assessment. PSC may degenerate into chondrosarcoma. Operative treatment is the gold standard aiming to minimize pain, improve function, prevent or limit progression of arthritis. Surgical treatment consists in debridement by arthrotomic or arthroscopic management, but there is no consensus in the literature about timing of surgery and surgical technique. Thus, the aim of this study is to report the outcomes of the surgical treatment of two cases, together with a literature review. CASE SUMMARY: We report two cases of patients affected by PSC of the foot in stage III, according to the Milgram classification: the former PSC localized in the ankle that underwent open surgery consisted of loose bodies removal; the latter in the subtalar joint, and the choice of treatment was the arthrotomy and debridement from loose bodies, in addition to the subtalar arthrodesis. Both patients returned to complete daily and working life after surgery. CONCLUSION: Synovial chondromatosis is a rare benign pathology, even rarer in the ankle joint and especially in the foot. Surgery should be minimal in patients with ankle PSC, choosing the correct timing, waiting if possible until stage III. More aggressive and early surgery should be performed in patients with PSC of the foot, particularly the subtalar joint, due to the high risk of arthritic evolution.

Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis of Risk Factors at 7 to 10 Years Follow-up.

BACKGROUND: Dislocation of primary THA (total hip arthroplasty) is one of the most undesirable complications with an incidence ranging from 2% to 5%. Several risk factors are described, related to the patient, surgery, or prosthetic design. The aim of the study was to assess risk factors and their potential influence on dislocation. MATERIALS AND METHODS: 387 primary THA were performed between September 2005 to December 2008 at our institute (Varese, Italy) through a modified posterior-lateral approach. Clinical evaluation was based on range of motion (ROM) and Harris Hip Score; femoral offset, acetabular inclination, and anteversion were measured on plain radiograms. Data were analyzed by SPSS software (SPSS, Inc., Chicago, Illinois). RESULTS: Excellent ROM and Harris Hip Scores were achieved in more than 95% of patients (p<0.05). The offset was restored in all patients. Most of the cases had their cup positioned in the "safe zone" (both inclination and anteversion). Six dislocations (1.87%) occurred: significant correlation was found between dislocation and preoperative diagnosis of femoral neck fracture. CONCLUSIONS: THA dislocation rate appears not to be related to patient biometric parameters and prosthesis design. Femoral neck fracture is reported as the major risk factor for this complication, probably caused by higher preoperative activity and lesser compliance of the patient.

The Use of an Electronic System for Soft Tissue Balancing in Primary Total Knee Arthroplasties: Clinical and Radiological Evaluation.

The eLibra® Dynamic Knee Balancing System (Synvasive Technology, Zimmer, Warsaw, IN) is an instrument designed to address the flexion stability during a TKA. It provides an objective measurement of the soft-tissue forces in the two compartments before the final cuts are made, allowing to obtain patient-specific rotational orientation of the femoral component. Between March 2010 and March 2012, the eLibra® system was used during the implantation of 75 TKAs in 75 patients at the author's institution. Preoperative and postoperative clinical assessment were evaluated using the Knee Society Score (KSS) and the Visual Analogical Scale (VAS). Radiographic evaluation was performed with weight-bearing radiographs in antero-posterior and lateral views in order to study the presence of radiolucencies. In a sample of 20 patients, representative of the population studied, the rotation of the femoral component was measured by two independent observers using the C-arm Cone Beam CT scan (XperCT/Allura FD20 angiography system; Philips, Best, Netherlands). At a mean follow-up of 42.3 months (29-54 months), three patients died from causes not related to the surgery. We had one case of aseptic loosening three years after surgery. None of the patients reported complications peri- or postoperatively. Clinical evaluation showed an improvement in KSS scoring, from preoperative means of 48.35 and 47.53 points for clinical and functional aspects, respectively, to postoperative means of 88.03 and 91.2 points, respectively (p<0.001 for both aspects). The current study demonstrates that the use of the eLibra® device is simple and reproducible. It could help surgeons objectively quantify ligament balance and perform soft tissue-guided resection in a reproducible way, resulting in better post-operative stability and reduced complications. The use of the postoperative cone beam computed tomography (CBCT), in a representative sample of patients, revealed a specific and optimal orientation of the femoral component with a mean of 2.18° of external rotation.

Treatment of humeral shaft aseptic nonunions in elderly patients with opposite structural allograft, BMP-7, and mesenchymal stem cells.

Humeral shaft aseptic nonunions occur in 2% to 10% of patients managed conservatively and 10% to 15% of patients treated surgically. The complex muscular and neurovascular anatomy of the upper limb makes the surgical approach to the fracture site demanding and risky, especially when previous surgeries have been attempted. The clinical consequence of atrophic humeral shaft nonunions is a severe functional limitation that may significantly affect activities of daily living, especially in the elderly. The surgical treatment of humeral shaft nonunions is challenging for orthopedic surgeons. Patients with atrophic nonunions require both a stable fixation and enhancement of the biologic response because of the weak biologic reaction observed at the fracture site. The gold standard of treatment in elderly patients has not been described. Nonetheless, older age and comorbidities are associated with potentially malignant nonunions. This study reports the authors' experience using opposite cortical allograft combined with bone morphogenetic protein 7 and mesenchymal stem cells to treat humeral shaft atrophic nonunions in 2 elderly patients. The nonunion site healed at 4 months (patient 1) and 8 months (patient 2) postoperatively, with full return to activities of daily living and no pain. Neither patient reported complications of the radial nerve, which is at high risk of injury during this type of surgery. The only reported complication (patient 2) was an intraoperative longitudinal partial distal humeral fracture, probably caused by compression screw overtightening. The use of a locking plate and opposite cortical allograft, combined with BMP-7 and mesenchymal stem cells, represents a safe and effective treatment for malignant nonunions in older patients.

Clinical applications of growth factors in bone injuries: experience with BMPs.

The management of open fractures and delayed or non unions continue to be complicated by high rates of treatment failure and significant patient disability and dissatisfaction. The use of bone morphogenetic proteins (BMPs) in the treatment of these injuries has been assessed by several authors. BMPs induce the process of bone healing by recruiting bone-forming cells to the area of lesion. The use of BMP currently has two FDA-approved indications: treatment of open tibial fractures treated with intramedullary fixation and treatment of tibia long bone non-union. Despite this limited target, off-label BMP use continues to push the spectrum for new applications. This review describes the current evidence for the use of BMPs in open fractures and non-unions.

The use of cementless acetabular component in revision surgery without pelvic discontinuity.

Reconstruction of the failed acetabular component in total hip arthroplasty (THA) can be challenging. Although there are multiple reconstructive options available, a cementless acetabular component inserted with screws has been shown to have good intermediate-term results and is the reconstructive method of choice for the majority of acetabular revisions This reconstruction is feasible provided at least 50% of the implant contacts host bone. When such contact is not possible, and there is adequate medial and peripheral bone, techniques using alternative uncemented implants can be used for acetabular reconstruction. An uncemented cup can be placed at a "high hip center." Alternatively, the acetabular cavity can be progressively reamed to accommodate extra-large cups. Oblong cups, which take advantage of the oval-shaped cavity resulting from many failed acetabular components, can also be used. The success of these cementless techniques depends on the degree and location of bone loss. The correct indication to revision and the choice of the correct implant is the keystone for the success of this type of surgery and follows an accurate preoperative planning in order to understand the specific pathologic scenario. The aim of this paper is to review some technical options for the revision of the acetabular component also taking into account our personal experiences and series.

Femoral revision with taper stems: results at ten years follow-up.

In the case of extensively damaged meta-diaphyseal femoral bone with cortices thinning and widened femoral canal, tapered stems allow a good primary fixation and early weight-bearing. A retrospective review was conducted to evaluate long-term results of modular revision taper stems implanted from March 1999 to December 2002. Sixty-five consecutive hip revision surgeries were performed, mostly for aseptic loosening (75% of the cases). Femoral bone stock defects were classified according to AAOS's criteria and consisted mainly in type II (cavitary defects, 44.6%) and type III (combined defects, 33.9%). A trochanteric osteotomy was performed in 25 cases (38%) to remove primary implants that were cemented in 35 cases (54%). The mean postoperative follow-up was 109 months (range, 76 to 131 months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 42 points preoperatively to 81 points postoperatively, while the x-ray examination did show a satisfactory distal integration of the stem in all cases and satisfactory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was less than one millimeter. According to data analysis, a leg-length discrepancy exceeding 15 millimeters caused significantly worse functional outcome and pain.