Lateral Humeral Condyle Fracture in Childhood: Results of a New Surgical Technique.

Fractures of the lateral condyle of the humerus are one of the most common fractures in children, accounting for between 10% and 20% of fractures involving the elbow, with a peak incidence at 6 years of age. Treatment is often surgical for displaced fractures > 2 mm, according to Milch and Jakob classification. There is no consensus in the literature about the appropriate surgical management of these fractures. Objectives: The aim of this study is to describe, propose, and evaluate outcomes and complications of the surgical technique of reduction and osteosynthesis using trans-bone suture with resorbable threads. Methods: Patients with lateral condyle fractures treated with this surgical technique from 2015 to 2019 were included in this retrospective study, with a minimum follow-up of 24 months. For clinical and functional assessment of the elbow, Mayo Elbow Scores were recorded; we assessed the time of fracture healing, carrying angles, and Baumann angle of the affected limb compared to the healthy contralateral elbow for radiographic data. Complications have also been described. Results: We achieved satisfactory results; 36 patients with lateral condyle fractures were included in this study. Radiological healing was achieved in all cases. There was only one complication. No cases required additional surgical procedures. Almost all patients achieved a complete flexion of 110 degrees or more and complete extension. Conclusions: This surgical technique has good functional outcomes and fracture healing, a lower incidence of complications when compared to other surgical techniques, and no mechanical failure with good clinical and radiological results.

Evaluation of Gartland Classification, Baumann Angle and Anterior Humeral Line in Paediatrics Supracondylar Fractures: An Inter and Intra-Observer Reliability Study.

Supracondylar fractures of the humerus are frequent paediatric injuries. The aims of this study were to evaluate the applicability and reproducibility of the Gartland and Wilkins classification, the Baumann angle (BA) and the Anterior Humeral Line (AHL). This retrospective monocentric observational study was conducted on 217 patients. Four observers assessed the pre-operative radiographs by applying the Gartland and Wilkins classification and the post-operative X-rays by measuring the BA and AHL. The kappa coefficient (K) and the Cohen's kappa were used for the reliability of the Gartland classification; the Intraclass Correlation Coefficient (ICC) for that of the BA. The AHL was evaluated in a double manner by using first the K and the Cohen's kappa and then the ICC. A total of 186 patients were eligible. Inter-observer reliability for the Gartland classification was K = 0.73-0.61 for type III, 0.65-0.61 for type Ia and 0.43-0.26 for type IIb. The Baumann angle mean value in the first data collection was 73.5 ± 6.85 (inter-observer ICC 0.74) and 72.9 ± 6.83 (inter-observer ICC 0.77) for the second data collection; AHL: inter-observer ICC 0.87 for the first evaluation and 0.80 for the second one. Gartland's classification modified by Wilkins has a high degree of reliability. BA and AHL appear reproducible and reliable.

Femoral neck fracture: the reliability of radiologic classifications.

BACKGROUND: Femoral neck fractures (FNF) are one of the most common injury in the elderly. A valid radiographic classification system is mandatory to perform the correct treatment and to allow surgeons to facilitate communication. This study aims to evaluate reliability of 2018 AO/OTA Classification, AO/OTA simplified and Garden classification. METHODS: Six Orthopaedic surgeons, divided in three groups based on trauma experience, evaluated 150 blinded antero-posterior and latero-lateral radiography of FNF using Garden classification, 2018 AO/OTA and simplified AO/OTA classification. One month later, the radiographs were renumbered and then each observer performed a second evaluation of the radiographs. The Kappa statistical analysis was used to determine the reliability of the classifications. Cohen's Kappa was calculated to determine intra and inter observer reliability. Fleiss' Kappa was used to determine multi-rater agreement. RESULTS: The k values of interobserver reliability for Garden classification was from 0,28 to 0,73 with an average of 0,49. AO classification showed reliability from 0,2 to 0,42, with average of 0,30. Simplified AO/OTA classification showed a reliability from 0,38 to 0,58 with an average of 0,48. The values of intra observer reliability for Garden classification was from 0,48 to 0,79 with an average of 0,63. AO classification showed reliability from 0,2 to 0,64 with an average of 0,5. Simplified AO/OTA classification showed a reliability from 0,4 to 0,75 with an average of 0,61. CONCLUSION: The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. The simplified AO/OTA classification show a reliability similar to Garden classification, with a moderate interobserver reliability. The experience of the surgeons seems not to improve reliability. No classification has been shown to be superior in terms of reliability.

Limb lengthening with PRECICE magnetic nail in pediatric patients: A systematic review.

BACKGROUND: Limb lengthening techniques play an increasingly important role in the pediatric orthopedic field. The principles of the osteogenesis distraction bonded traditionally with external fixators; however, the recent deployment of fully implantable systems has been able to overcome severities related to external fixators. The PRECICE® is an implantable limb lengthening intramedullary nail system that is remotely controlled and magnetically driven. AIM: To review the current literature available on this matter in order to assess the PRECICE clinical and radiological outcomes and its possible complications in a population of pediatric patients undergoing limb lengthening. METHODS: Only five studies met the inclusion criteria and were consequently included in the review for a total of 131 patients and 135 femurs. The clinical and radiological outcomes of interest were: the main lengthening obtained, the distraction rate, the period of time to full weight bearing, the consolidation index, and the Association for the Study and Application of Methods of Ilizarov score. RESULTS: In conclusion, data collected from the articles under investigation were comparable with the exception of the consolidation index. Unfortunately, the study population was too small and the patients' follow-up was too short to make definitive conclusions. CONCLUSION: This review shows that the PRECICE Nail System is still a therapeutic challenge in limb lengthening for pediatric orthopedic surgeons; however, careful pre-operative planning and an accurate surgical technique could allow the correction of more complex deformities with a low rate of complications.

The stiff elbow: Current concepts.

Elbow stiffness is defined as any loss of movement that is greater than 30° in extension and less than 120° in flexion. Causes of elbow stiffness can be classified as traumatic or atraumatic and as congenital or acquired. Any alteration affecting the stability elements of the elbow can lead to a reduction in the arc of movement. The classification is based on the specific structures involved (Kay's classification), anatomical location (Morrey's classification), or on the degree of severity of rigidity (Vidal's classification). Diagnosis is the result of a combination of medical history, physical examination (evaluating both active and passive movements), and imaging. The loss of soft tissue elasticity could be the result of bleeding, edema, granulation tissue formation, and fibrosis. Preventive measures include immobilization in extension, use of post-surgical drain, elastic compression bandage and continuous passive motion. Conservative treatment is used when elbow stiffness has been present for less than six months and consists of the use of serial casts, static or dynamic splints, CPM, physical therapy, manipulations and functional re-education. If conservative treatment fails or is not indicated, surgery is performed. Extrinsic rigidity cases are usually managed with an open or arthroscopic release, while those that are due to intrinsic causes can be managed with arthroplasties. The elbow is a joint that is particularly prone to developing stiffness due to its anatomical and biomechanical complexity, therefore the treatment of this pathology represents a challenge for the physiotherapist and the surgeon alike.

Arthrodesis in the Charcot foot: a systematic review.

The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Locking plate fixation in pediatric femur fracture: evaluation of the outcomes in our experience.

BACKGROUND AND AIM: Femoral shaft fracture is a common traumatic musculoskeletal injures in pediatric population. The treatment of diaphyseal femoral fractures depends on age patient and pattern fracture. We present our record about the use of locking plate fixation and their outcomes. METHOD: We conduct a retrospective analysis in 22 patients, surgically treated for 26 diaphyseal femur fracture between 2008 and 2013. The mean age was 13 years. All the patients underwent a clinical and radiological follow-up for two years. We recorded time to weight bearing, time to union, complication (malalignment, dysmetria, infection), time to resumption to sport, plate removal, parents' satisfaction. RESULTS: All the patients had a minimal clinical e radiological follow-up of 24 months. The average fracture healing time was of 7.4 weeks. All the patients had a full hip and knee range of movements. Fifteen patients developed minor malalignment (varovalgus or procurvatum femur) without clinical effects. No cases of infections. The mean time to a full weight bearing was 12 weeks and the return to sportive activity was 24 weeks. Four patients required a plate and screws removal. The average result of parents' satisfaction was 8/10. CONCLUSIONS: Locking plate fixation is to be considered a successful way of treatment for pediatric femur fractures, especially in patients older than 6 years, head-injured or in the treatment of polytrauma. The anatomic and functional outcomes are comparable to those of other fixation techniques for this kind of fracture.

Etiopathogenesis of Traumatic Spinal Epidural Hematoma.

Spinal epidural hematoma (SEH) is a rare cause of nerve root or cord compression; its pathogenesis is not always clearly recognizable. The aim of this paper was to investigate possible etiopathological factors in a consecutive series of patients affected by traumatic SEH treated at our institution. Seven patients with neurologic impairment due to traumatic SEH were retrospectively analyzed after diagnosis and surgical treatment. Thoracic localization was found in 5 cases, and lumbar and cervical localization were found in 1 patient each. One patient was affected by ankylosing spondylitis and one by diffuse idiopathic skeletal hyperostosis. SEH was associated with spine fractures in 6 cases. Only 2 cases of traumatic SEH resulted from high-energy trauma. All patients underwent surgical decompression within 24 hours after admittance to the hospital. Three patients recovered completely, 3 remained paraplegic, and 1 remained monoplegic. Several concomitant conditions are suggested to be predisposing factors for the development of SEH, although its inherent mechanism is still unknown. Two patients in the present series were affected by rheumatologic disorders, confirming the elevated incidence of hematomas in such patients compared to the normal population. Three very unusual cases of SEH occurred in senile patients affected by osteoporotic fractures. Early diagnosis and urgent decompression of the hematoma remain mandatory.