Fracture liaison service model: project design and accreditation.

Frailty fractures place a significant socioeconomic burden on the health care system. The Italian Society of Orthopaedics and Traumatology (SIOT) is proceeding to fracture liaison service (FLS) model accreditation in several Italian Fracture Units (FUs), which provides a multidisciplinary approach for the management of the fragility fracture patient. INTRODUCTION: Osteoporosis and the resulting fragility fractures, particularly femoral fractures, place significant socioeconomic burdens on the health care system globally. In addition, there is a general lack of awareness of osteoporosis, resulting in underestimation of the associated risks and suboptimal treatment of the disease. The fracture liaison service (FLS) represents an exemplary model of post-fracture care that involves a multidisciplinary approach to the frail patient through the collaboration of multiple specialists. The purpose of this article is to highlight the path undertaken by the Italian Society of Orthopaedics and Traumatology (SIOT) for the purpose of certification of numerous FLS centers throughout Italy. METHODS: SIOT is proceeding with international FLS accreditation in several Italian Fracture Units (FUs), following the creation of a model that provides specific operational and procedural steps for the management of fragility fractures throughout the country. FUs that decide to join the project and implement this model within their facility are then audited by an ACCREDIA-accredited medical certification body. RESULTS: The drafted FLS model, thanks to the active involvement of a panel of experts appointed by SIOT, outlines a reference operational model that describes a fluid and articulated process that identifies the procedure of identification, description of diagnostic framing, and subsequent initiation of appropriate secondary prevention programs for fractures of individuals who have presented with a recent fragility fracture of the femur. CONCLUSION: Accreditation of this prevention model will enable many facilities to take advantage of this dedicated diagnostic-therapeutic pathway for the purpose of fracture prevention and reduction of associated health and social costs.

Nucleus disc arthroplasty with the NUBAC™ device: 2-year clinical experience.

Low back pain (LBP) due to degenerative disc disease (DDD) is a common condition that can be treated along a continuum of care: from conservative therapies to several surgical choices. Nucleus arthroplasty is an emerging technology that could potentially fill part of the gap in the spine continuum of care. The introduction of recent technologies that allow the replacement of the degenerated disc nucleus using prosthetic devices may be considered an additional therapeutic tool that can be used by the surgeon in selected cases of LBP due to DDD. Nucleus arthroplasties are designed to treat early stages of DDD, which are one of the most common spinal disorders in the population under 65 years of age. NUBAC™ is the first articulating nucleus disc prosthesis, designed to optimally respect the lumbar anatomy, kinematics, and biomechanics, constructed in unique two-piece manufactured from polyetheretherketone (PEEK) with an inner ball/socket articulation. The optimal indications for NUBAC™ implantation are: disc height >5 mm, degenerative disc changes at an early stage (Pfirmann 2, 3), single level affection, integrity of posterior facet joints, lack of local anatomical contraindication, failure of conservative treatment for at least 6 months. From December 2006 to January 2009, a total of 39 patients underwent nucleus disc arthroplasty with NUBAC™ device. 22 cases have 2-year follow up. There have been no major intra-operative or post-operative vascular or neurological complications in this series. The data showed that there were significant decreases in both Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) after the procedure, with a meaningful improvement of symptoms in all patients. Although preliminary, the initial results are encouraging. The absence of any major intra-operative and post-operative complications supports the design rationale of the NUBAC™, being less invasive comparing to total disc replacement (TDA) and with a low rate of surgical risk. The effectiveness of data as seen in 2-year follow-up on both VAS and ODI have also suggested that the NUBAC™ could be considered a viable treatment option for patients with LBP caused by DDD.

Percutaneous techniques in the treatment of osteoporotic, traumatic and neoplastic fractures of thoraco-lumbar spine: our institutional experience.

Fifty-eight (30 females) patients with a mean age of 55 were treated in our institution with minimal invasive surgery techniques for osteoporotic, traumatic and neoplastic fractures of the thoraco-lumbar spine. All patients completed pre-operatively and post-operatively the VAS score (0-10, 10 being the worst state for pain) as well as the Oswestry low back pain disability questionnaire at 3, 12, 24 and 36 months intervals. Overall the VAS score was reduced from 7.8 points pre-operatively, to 2.1 points at the 36 month follow up. Oswestry disability score improved from a pre-operative severe disability to moderate disability at 3 months up to a minimum disability at 36 months. The minimally invasive surgical techniques can significantly improve clinical outcomes by preventing many of the drawbacks associated with open approaches whilst also allowing to associate other methods such as coblation, vertebroplasty, interbody fusion that can be complementary to vertebral fixation.

Scanning electron microscopic findings of the gliding surface of the A1 pulley in trigger fingers and thumbs.

The gliding surface of the A1 pulley was studied in 20 cases of primary trigger finger by scanning and transmission electron microscope. In 12 normal specimens, the whole deep surface was covered uniformly by an amorphous extracellular matrix. In the pathological samples, there was the same general surface appearance but, also, areas, varying in shape and dimension where loss of the extracellular matrix had exposed the collagen fibres and a few cells of the middle layer of the pulley. There were also changes typical of "chondroid-metaplasia". These data were confirmed by transmission electron microscopy. The fragmented areas are probably the result of altered forces of friction between the pulley and the flexor tendon and may be the "gate" through which the forces of friction cause chondroid-metaplasia in the underlying fibrous tissue, a phenomenon recognised to be one step in the pathogenesis of trigger finger.

Histomorphological study of bone response to hydroxyapatite coating on stainless steel.

Bone response to hydroxyapatite coating on stainless steel has not been so extensively tested in animals as it happened for other metallic substrate, like Ti6Al4V. For this reason, authors performed an in vivo histomorphological electron microscopic study of hydroxyapatite coating on duplex stainless steel cylinders, to gather further evidences on the characters of bone apposition at the interface. Sixteen HA-coated cylinders were implanted in the distal femur of New Zealand White rabbits. Comparison with uncoated controls was made. Retrieval steps were at: 4, 8, 26 and 34 weeks. Specimens were analyzed in a Jeol JSM 6301F scanning electron microscope. The response to HA-coated samples has a morphological character of tight apposition between bone and coating. Osteocytic lacunae may be found few microns close to the coating and newly formed bone is extremely interlocked with it so that even an higher magnification electron-microscopy cannot resolve any discontinuity in between. Pictures of physiological bone-turnover are distinguishable at the bone-coating interface; areas of well preserved coating may be present together with areas where local exfoliation or fragmentation has already completely exposed the metallic substrate. On the opposite in uncoated samples, despite a morphological picture of properly formed bone, the largest area of the metal has no direct apposition with it.

Bone response to polymers based on poly-lactic acid and having different degradation times.

Authors studied two degradable and resorbable polymers derived from lactic acid: poly-L-Lactic acid (PLLA), with a relatively long time of degradation (longer than 6 months, PL10 Purac NL); poly-DL-Lactic acid (PDLLA), with a relatively short time of degradation (shorter than 6 months, PDL Purac NL). The animal species was the young adult New Zealand White rabbit. The in-vivo study was performed by implantation of small cylinders of 10 x 3 mm in size (length x diameter) in the distal metaepiphysis of the femur; 34 cylinders have been implanted. Retrievals of PLLA specimens took place at 3, 6, 9, 12 and 24 months; for PDLLA specimens at 1, 2, 4 months. Polarized light microscopy of undecalcified tissue sections was performed. The analysis for PLLA and PDLLA has shown a favorable response of bone tissue: alterations in the bone repair, growth and remodeling have not been observed. PLLA is persistent at the times studied; there is never a tight apposition between bone and PLLA implant and an intervening fibrous layer has often been observed. PDLLA is not persistent at the times studied and it degrades quite fast; bone repair of the empty implantation's hole occurs by bony growth from the endosteal trabeculae. The newly formed bone covers the hole's walls with an elongation parallel to them. For both polymers, whether the degradation is fast or slow, the material's substitution by newly formed bone never starts from the walls of the implantation hole. Only after the complete disappearance of the polymeric material newly formed bone begins to fill the hole.

Energy dispersive analysis (EDX) of a degradable bioactive-glass coating on Ti6Al4V in-vivo.

The bioactive-glass coating of metallic substrates provides a gradually degrading interface which can be used to favor the bony integration of the implant by the physiologic processes of bone turn-over and remodeling. Twelve New Zealand White rabbits, about 2700 g of weight, were operated by the sagittal insertion of a bioactive-glass coated plate of Ti6Al4V. Retrievals were performed at 4, 8 and 12 weeks. Undecalcified specimens were embedded in methyl-metacrylate and sectioned at 100 microns of thickness. Blocks were grinded and had an electroconductive coating to be examined by scanning electron microscopy (SEM), back scattering electron microscopy (BSEM) and X-ray energy dispersive spectroscopy microanalysis (EDX). EDX allows to evaluate quantitatively the gradual process of coating degradation. Areas of 200 microns in square were analyzed at the interface between bone and coating to determine their elemental composition. Silicon was the key marker for the presence of the glass. Morphological analysis confirms that a tight apposition with bone can be obtained by utilizing the bioactive glass coating of metal. Results of energy dispersive analysis support the mechanism of a gradual degradation of the bioactive glass coating and its integration with bone, since the presence of silicon can be documented within the newly formed bone after the coating has disappeared.

The effectiveness of the circular external fixator in the treatment of post-traumatic of the tibia nonunion.

Authors report the results they obtained when the Ilizarov circular external fixator was used for the treatment of post-traumatic nonunion of the tibia. A total of 20 patients were treated. Of these 12 had been submitted to treatment elsewhere and using other methods; 9 presented with septic nonunion; 10 revealed radiographic findings of atrophic nonunion, and 10 were hypertrophic. There was axial deviation in 18 patients. The results of treatment were always: healing of the nonunion; functional recovery of the limb; correction of leg length discrepancy; recovery of the mechanical axis. The mean stabilization time (days between the application and the removal of the fixator) was 138 days. The Ilizarov method thus proved that it was effective in the treatment of post-traumatic nonunion of the tibia where other types of treatment had failed.

Autosomal dominant transmission of bilateral "opposable" triphalangeal thumb.

Triphalangeal thumb occurs in two functional types: opposable and non-opposable. The opposable type presents a rudimentary middle phalanx and the thumb is frequently angulated. The non-opposable type presents a finger-like thumb (five-fingered hand). Triphalangeal thumb often occurs in syndromes where other anomalies are present, so its pattern of inheritance has often been described jointly with the syndrome itself, then conflicting patterns of inheritance have been reported in literature. The present study reports upon the character of "bilateral opposable triphalangeal thumb" occurring isolated, without association of other anomalies. Authors studied the phenotype distribution in a family over five generations. They found that this character is transmitted with an autosomal dominant pattern of inheritance, and affected individuals are heterozygotes.

Treatment of the sequelae of primary pathology of the hip by correction osteotomy and femoral lengthening using a combined external fixator.

It is not an exceptional event to observe the sequelae of primary pathology of the hip in young patients that, as such, are not of the ideal age for replacement surgery. Moreover, one must not overlook the difficulties involved in replacement surgery for the treatment of inveterate modifications in the normal hip anatomy. Often, among the sequelae of primary pathology of the hip, deformities of the lower limb must also be included, associated or consequent, which also need treatment. For these reasons, the authors, in three selected cases, used a combined external fixator (circular and lateral) by means of which they were at the same time able to correct the axial deformity (with a support osteotomy), and the residual hypometria (with femoral lengthening). Osteotomy plus lengthening, using an external fixator, avoid hypometria of the limb and deformity in valgus of the knee, and allow for results which would otherwise not be obtained with replacement surgery alone.

Response to polyetherimide based composite materials implanted in muscle and in bone.

The in-vivo response to a composite material obtained with polyetherimide (PEI) reinforced with carbon/glass fibers was investigated by histological methods by implanting cylinders in muscle and in bone of the New Zealand White rabbit. A common metallic alloy, widely used in orthopaedic surgery, was used as control (Stellite). The aim of the study was to analyze the biological response towards the surface of the material. Composite implants and metallic implants did not induce adverse or inflammatory reactions. The morphological picture produced was similar, in muscle and in bone, for both materials. In muscle, cylinders were confined by an extremely thin fibrous layer and the overall appearance of the muscular tissue was normal. In bone, cylinders were confined by a nearly annular rim of newly formed bone. From these data it is possible to derive that the response to PEI-based composite material is comparable with the response to metallic substrate and, then, the material can be suitable for clinical application.

Biocompatibility and osteogenetic characteristics of new biocompatible glasses.

A fibre-shaped glass with qualities of biocompatibility and biodegradation could be promising for reconstructive bone surgery in orthopaedics and neurosurgery. New highly biocompatible glasses, originally made by the Italian Group of Study on Biocompatible Glass, are obtained both in cylinder and fibre shapes due to their original chemical composition (Glassfiber). This is the only glass which is also available as a continuous filament. Hydrolytic in vitro and in vivo tests demonstrate that these glasses present both good biocompatibility and adjustable biodegradation in relation to their chemical composition. The advantages of bioactive glass also being available as a continuous filament are suggested.

[Post-traumatic deformities of the lower limbs. Pathogenetic and treatment considerations]. / Le deformità post-traumatiche degli arti inferiori. Considerazioni patogenetiche e trattamento.

The authors studied post-traumatic deformities of the lower limbs, outlining the main pathological features. Furthermore they describe the different progression of the pathology in adults and children, due to their different capability for adaptation. Finally, they report in detail on their two-years experience in using the Ilizarov external fixator.

Congenital hip dysplasia treated by the Salter osteotomy. Long-term review of 18 patients.

Between 1965 and 1974 at the Orthopaedic Clinic of the University of Perugia, 20 osteotomies of the innominate bone were performed on 18 patients aged between 18 months and 10 years. All the patients were followed up for 10 to 19 years (average 15 years) after operation. The results were evaluated both clinically and radiographically (according to the Severin and MacFarland methods). The data were later submitted to computer analysis, using a semiautomatic aquisition programme which allowed for evaluation of the geometry of the hip. The most important parameters for evaluation of the results were the Wiberg CE angle, the acetabular angle, the minimum joint space, and the horizontal component of the resultant force. Clinically and radiographically there was an 80% success rate according to Severin's method of evaluation. There was also good correlation with the computerized analysis. Biomechanically, there was almost normal recovery of the load distribution. The clinical, radiographic and biomechanical parameters worsened slightly with age, particularly during puberty.

An experimental study of retrograde axonal plasmatic flow in the peripheral nerves of rats.

Retrograde axonal flow (R.A.F.) in the sciatic nerve of Sprague Dowley rats was studied by injecting horseradish peroxidase (H.R.P.) peripherally and identifying its appearance in the related segment of the spinal cord. This called for a precise identification of the vertebro-medullary topography, the afferant root levels of the sciatic nerve, and the transport velocity of the H.R.P. Our study revealed a clear difference of neuromuscular end plate permeability as between new-born and adult animals. The vertebral column of the rat consists of 8 cervical metameres, 13 dorsal, 6 lumbar, 4 sacral, and 3 coccygeal. The sciatic nerve is derived principally from the roots L4, L5, L6 and in part from L3 and S1. The injection of H.R.P. in the sural triceps of the new-born rat produced granules in the anterior horn cells as early as 12 hours later. In similar experiments with adult rats H.R.P. in the motorneurons was never detected. In our experimental model the transport velocity of H.R.P. from the point of injection to the anterior horn cells was approximately 68 mm per day. These findings provide a foundation on which to base future studies of retrograde flows in conditions of induced pathology.

Corrosion of the Harrington's instrumentation and biological behaviour of the rod-human spine system.

Corrosion and histopathological modifications in tissues surrounding the rod in a stainless steel Harrington's system, are reported. These phenomena occur soon after implantation and are very evident. Therefore in contrast to Harrington's thesis, the authors are convinced that it is necessary to remove the system after the consolidation of bone grafts.