The use of TightRope fixation for ankle syndesmosis injuries: our experience.

PURPOSE: Ten percentage of all ankle fractures sustain an associated syndesmotic injury. TightRope is a relatively new technique for syndesmosis fixation, characterized by a non-absorbable FibreWire held tight between two cortical metal buttons. The purpose of this study was to evaluate the results obtained with the use of this device. METHODS: From January 2011 to December 2015, 54 patients with ankle diastases were treated. Eighteen patients were excluded from the study. Fractures of the fibula or tibia requiring fixation were internally fixed using standard AO techniques. Preoperative and the most recent postoperative ankle radiographs were reassessed for measurements of the tibiofibular clear space (TFCS), medial clear space (MCS) and tibiofibular overlap (TFO). Clinical outcomes were assessed at the time of follow-up using the American Orthopaedic Foot and Ankle Society (AOFAS) score, a self-administered Foot and Ankle Disability Index (FADI) score and patients satisfaction. RESULTS: The mean follow-up was 28, 64 months. Mean values for MCS, TFCS and TFO were 1.51-1.53 and 0.25 cm, respectively. The mean AOFAS score was 93.11, and the mean FADI score was 130.11. Twenty-nine (80.6 %) patients reported their outcome as excellent or very good. CONCLUSIONS: TightRope technique can achieve flexible fixation of the syndesmosis and permit full range of motion of the tibiofibular joint. Patients can start rehabilitation exercise at an early stage after operation. The results of this study indicate that TightRope fixation is a valid option for syndesmotic injuries.

Hinged external fixation for complex fracture-dislocation of the elbow in elderly people.

The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.

The treatment of stable and unstable proximal femoral fractures with a new trochanteric nail: results of a multicentre study with the Veronail.

The incidence of hip fractures continues to rise. This study is the first evaluation of a new intramedullary implant, the Veronail, that provides double axis fixation into the femoral head and allows the surgeon to choose whether to use sliding or fixed locked proximal screw fixation for trochanteric femoral fractures. The fractures were classified according to the AO classification, and function was assessed with the Modified Harris Hip Score. 111 patients with trochanteric fractures were evaluated in eight Italian hospitals. The stable 31.A1 fractures were treated with sliding proximal screws, the subtrochanteric 31.A3 fractures with converging proximal screws, and the unstable 31.A2 fractures were treated with both types of proximal fixation. The unstable fractures treated with locked converging screws had the same function at one year as those treated with sliding screws. This study suggests a possible new method of treating unstable trochanteric femoral fractures. This may be the solution to prevent excessive collapse of the fracture with the resultant poor function and persisting pain noted in the literature. Two converging locked proximal screws seem to provide stable fixation in 31.A2 femoral fractures and produce as good a result as the use of traditional sliding screws. The role of converging locked proximal screws in unstable trochanteric fractures requires further evaluation.

CT-guided percutaneous vertebroplasty: personal experience in the treatment of osteoporotic fractures and dorsolumbar metastases.

PURPOSE: This study was performed to evaluate the results and complications of percutaneous vertebroplasty (PVP) performed under CT guidance. MATERIALS AND METHODS: We treated 106 patients (182 PVP): 67 for osteoporotic vertebral compression fracture, and 39 for osteolytic metastases. The first 78 patients were treated using computed tomography (CT) combined with conventional fluoroscopy as an imaging guide (135 PVP). In 28 patients, the procedure was performed with multislice CT fluoroscopy (47 PVP). RESULTS: Partial or complete pain relief was obtained in 98% of patients within 24 h from the treatment; significant results were also obtained with regard to improvement in functional mobility and reduction of analgesic use. CT allowed the detection of cement leakage in 43.9%. Severe complications were one case of pneumothorax and two cases of symptomatic cement leakage. Mild complications included two cases of cement pulmonary embolism. During the follow-up, eight osteoporotic patients presented a new vertebral fracture, and new vertebral metastases appeared in two oncological patients. CONCLUSIONS: Our personal experience confirms the efficacy of PVP treatment for both osteoporotic and oncological patients. The use of CT guidance reduces the risk of complications in comparison with conventional fluoroscopy alone, as well as facilitates the detection of small cement leakages.

Treatment of non-union of the humerus using the Orthofix external fixator.

An Orthofix monolateral axial external fixator was used to treat 31 patients with non-union of the humeral shaft, 30 of whom had been previously treated surgically. In seven cases the non-union was hypertrophic and one of these cases had been treated by simple fixation anol compression, the others by fixation, bone grafting and decortication; in 20 cases the non-union was hypotrophic and had been treated by fixation and decortication with bone grafting. The remaining four cases had septic non-union, treated by debridement of the focus of infection and fixation, followed in three cases by a bone graft and osteomuscular decortication once the infection had been eradicated. The fracture site consolidated in all patients in a mean time of 4.9 months. Five patients required further surgery: three in the group with infected non-union and two who had had a new bone graft and application of the external fixator, one because of a refracture (the patient was receiving chronic treatment with antimitotic agents) and one because of persistent non-union. There were no major complications (e.g. radial nerve palsy, joint stiffness, deep infection), and only six cases of pin track infection (5% of the screws implanted). The authors believe that this method is reliable, effective and low risk provided that the patient is cooperative; furthermore, the monolateral axial external fixator is tolerated well and allows movement of the shoulder and elbow throughout the period of treatment.

The use of external fixation in fractures of the tibial pilon.

The authors report the results of a review of 25 cases of fracture of the tibial pilon, treated by external fixation and minimal internal synthesis. Fractures were classified according to Rüedi and Allgower; they were: type 2: 11 (of which one exposed); type 3: 4 (of which 6 exposed). Complications observed during treatment were: pseudarthrosis: 1; osteomyelitis: 2; healing in valgus at 10 degrees: 2; osteolysis of the distal screws of the fixator: 4; these were all resolved with further surgery, except for an osteomyelitis that required amputation. Follow-up ranged from 3 to 10 years and clinical and functional evaluation, based on the Olerud and Molander score system revealed 80% good (56%) and excellent (24%) results.

Psychologic, vascular, and physiologic aspects of lower limb lengthening in achondroplastics.

Achondroplastic patients having lengthening surgery of the lower limbs were preoperatively evaluated from psychologic, functional, vascular, and endocrinometabolic points of view. Long-term research is required to determine effects of surgical correction of achondroplasia from both psychologic and various physical points of view.

Lengthening in the congenital short femur.

The fundamental concepts underlying lengthening surgery for the congenital short femur were gained from experience in treating 35 cases by means of chondrodiatasis and callotasis.

The callotasis method of limb lengthening.

Callotasis is a lengthening technique that involves slow, controlled distraction after subperiosteal-submetaphyseal osteotomy. The technique and its advantages over other methods are described. Results of lengthenings involving 270 operated bone segments (146 femurs and 124 tibias) in 140 patients are reviewed. Ninety-five patients had limb-length inequality and 45 had hypochondroplasia or achondroplasia. On average, 6.6 cm, or 24.6% of initial length, was gained. The mean healing index was 39; the complication rate was 13.3%.

Lengthening of the lower limbs in achondroplastic patients. A comparative study of four techniques.

We report our experience of lengthening by over 30% a total of 117 lower limbs in achondroplastic patients. We have compared four methods: transverse osteotomy, oblique osteotomy, callotasis of the shaft and chondrodiatasis of the epiphysis. Chrondrodiatasis of the femur and callotasis of the tibia are the techniques which gave fewest complications.

Limb lengthening by callus distraction (callotasis).

Callotasis is a new technique of limb lengthening involving slow distraction of the callus formed in response to a proximal submetaphyseal corticotomy. Using a dynamic axial fixator with telescoping capabilities, distraction begins after 2 weeks. When the required length is attained, the fixator is held in the rigid mode until radiographic evidence of callus is observed. The locking screw is then released, and dynamic axial loading is instituted to promote corticalization. One hundred bony segments have been lengthened; 50 patients had limb length inequality, and 23 had achondroplasia. The mean lengthening achieved was 22% (maximum, 58%). There were 14 complications (14%).

Limb lengthening by distraction of the epiphyseal plate. A comparison of two techniques in the rabbit.

We have compared, in rabbits, two techniques of limb lengthening by distraction of the epiphyseal plate using a unilateral external fixation frame. In all cases, 14 mm of symmetrical lengthening without deviation was achieved. With rapid distraction at rates of 1 mm per day (distractional epiphyseolysis) separation of the epiphysis from the metaphysis occurred by day 7, and by day 70 almost complete ossification of the cartilage and the elongated segment was evident. In contrast, slow distraction at 0.25 mm every 12 hours (chondrodiatasis) produced hyperplasia of growth cartilage without any evidence of detachment at 28 days, the end of the distraction period. By day 70 the epiphyseal plate had returned to normal thickness with normal cellular morphology, while the lengthened segment was occupied by ossified tissue. The significance of these findings is discussed.

Chondrodiatasis-controlled symmetrical distraction of the epiphyseal plate. Limb lengthening in children.

We describe a technique for slow, progressive, symmetrical distraction of the growth plate using a lightweight dynamic axial fixation system. Results are given for the elongation of 40 bony segments in children with limb-length discrepancies and 60 segments in children with achondroplasia or hypochondroplasia. Increases in limb length of up to 36% were obtained in non-achondroplastic and up to 64.5% in achondroplastic patients. There were no nerve or vascular lesions or bony infections and no case required a bone graft. Pin-track complications occurred in only 1.5%.

Dynamic axial fixation. A rational alternative for the external fixation of fractures.

Conventional external fixation systems neither inhibit motion at the fracture site sufficiently to permit primary bone healing, nor do they allow sufficient motion to encourage adequate external callus formation. Healing with such systems is therefore prolonged. These methods are usually reserved for the most severe fractures when internal fixation may be contraindicated. A unilateral, dynamic axial fixation system (Orthofix - registered trademark) is described which allows for simple conversion from a rigid to a dynamic mode, and so can be readily adapted to the changing physiological patterns of fracture repair. In 288 fresh fractures a success rate of 94% was achieved, with an average time to healing of 4.4 months. The incidence of pin-track infection was only 0.6%. The contribution which the mechanical and design features of the apparatus make to the results obtained is discussed. It is suggested that the system is capable of extending the range of indications for an externally mounted system to include many cases which would formerly have been treated by internal fixation, plaster cast or traction.

Dynamic axial fixation : A rational alternative for the external fixation of fractures.

Conventional external fixation systems neither inhibit motion at the fracture site sufficiently to permit primary bone healing, nor do they allow sufficient motion to encourage adequate external callus formation. Healing with such systems is therefore prolonged. These methods are usually reserved for the most severe fractures when internal fixation may be contraindicated. A unilateral, dynamic axial fixation system (Orthofix - registered trademark) is described which allows for simple conversion from a rigid to a dynamic mode, and so can be readily adapted to the changing physiological patterns of fracture repair.In 288 fresh fractures a success rate of 94% was achieved, with an average time to healing of 4.4 months. The incidence of pin-track infection was only 0.6%. The contribution which the mechanical and design features of the apparatus make to the results obtained is discussed.It is suggested that the system is capable of extending the range of indications for an externally mounted system to include many cases which would formerly have been treated by internal fixation, plaster cast or traction.

The treatment of fractures with a dynamic axial fixator.

The results obtained with a lightweight dynamic axial fixator in the treatment of fractures are reported. The apparatus comprises a single bar with articulating ends which clamp self-tapping screws and can be locked at an angle appropriate for axial alignment. A telescopic facility allows ready conversion from rigid to dynamic fixation once periosteal callus formation has commenced. Reduction and controlled distraction or compression are achieved by means of a detachable compressor unit. We treated 288 patients with fresh fractures and 50 with ununited fractures. The success rate for fresh fractures was 94%, with average healing times ranging from 3.4 to 6.5 months. In ununited fractures also, the success rate was 94% with average healing times ranging from 4.7 to 6.5 months. Complications were minimal. The device is versatile and can be applied in an average of 15 minutes. It permits ambulatory fracture care without sacrificing a sound anatomical result.