Acetabular fractures.

Over the last few years an increased percentage of work-related and car accidents has led to a higher percentage of acetabular fractures. These injuries are among the most difficult to treat in orthopaedic surgery because of their anatomy and because of the consequent difficulty in surgical exposure. It was the purpose of this study to reveal the diagnostic and the therapeutic paths related to the treatment of these kinds of fractures, based on our experience. A total of 517 acetabular fractures were treated over 16 years; at present, better results are obtained with surgical treatment than with non-surgical treatment.

Sister chromatid exchanges and ion release in patients wearing fracture fixation devices.

The quantification of sister chromatid exchange (SCE) during mitosis is a useful index for evaluating genotoxic effects in subjects occupationally or incidentally exposed to potentially toxic substances. The authors investigated the hypothesis that ions released by corrosion from prosthetic components of fracture fixation devices are associated with change in SCE incidence. In the present study, ten patients with implants were examined, and fifteen subjects with no implants were used as controls. SCE and high frequency cell (HFC) numbers were evaluated in circulating lymphocytes. In addition, nickel (Ni) and chromium (Cr) ion values in the serum were measured because, after iron, these metals are major components of stainless steel. A significant increase in SCE numbers was observed in patients compared to the control population (4.9 +/- 1.3 vs. 3.5 +/- 1.4). Ni concentration was 1.71 +/- 1.49 ng/mL in patients and 0.72 +/- 0.52 ng/mL in control subjects; Cr concentration was, respectively, 1.01 +/- 0.77 ng/mL and 0.19 +/- 0. 27 ng/mL. The increase of serum Cr and Ni was statistically significant. No correlation was found between the increased Cr concentrations and SCE number while Cr ion levels were found to be significantly correlated to HFC. An inverse correlation between Ni level and SCE numbers was observed. Our findings suggest that Cr release by stainless steel implants could have a genotoxic effect; thus it would be useful to carefully monitor implanted subjects with regard to serum ion dosage, SCE analysis, and HFC evaluation. In any case, it would be appropriate to remove the implant when fracture fixation is reached.

The surgical treatment of nonunion of the proximal metaphysis of the femur.

Nonunion of the proximal femur is a severe pathology, often provoked by the inopportune or improper use of a therapeutic aid: nonsurgical (primary nonunion), surgical (secondary nonunion). Surgical treatment of this nonunion may thus be characterized by different degrees of difficulty, depending on whether or not it is the sequela of surgery or of nonsurgical treatment. In lax nonunion, with atrophy of the segments and regions of necrotic bone interposed, modeling resection is required to correct the functional axes. The condylar blade-plate may be opposed by a cortical graft--to improve stability of the assembly--protecting the medial wall and providing the screws with excellent hold.

Aseptic nonunion of the humeral shaft.

A total of 78 cases of aseptic nonunion of the humeral shaft treated at the third division of the Rizzoli Orthopaedic Institute between 1980 and 1997 were evaluated. There was a mean time of 19 months between trauma and definitive treatment. Surgical treatment consisted in osteosynthesis with a plate and bone grafting in 75 cases, and synthesis with screwed bone grafting alone in 3 cases. Consolidation was obtained in 96% of cases. The bone graft used (homo- or autoplastic) encountered complete osteointegration in a maximum time of 8 months. Postoperative motility of the shoulder and elbow were comparable to the preoperative findings.

Dislocation of the proximal femoral epiphysis in acetabular fractures.

Acetabular fractures are often associated with dislocation of the proximal femoral epiphysis. The dislocation may be of three types, based on the type of fracture to which it is associated: anterior, central, posterior. In anterior and in central dislocation epiphyseal necrosis of the proximal femur has never been observed, while in posterior dislocation necrosis has been observed in 23% of cases. Diagnosis of posterior dislocation is of essential importance so that it may be reduced immediately, decreasing the risk of necrosis. The authors report a review of 192 fractures of the acetabulum to which dislocation of the femoral epiphysis was associated, treated between 1980 and 1996 at the IIIrd Division of the Rizzoli Orthopaedic Institute.

Effects of metal ions on white blood cells of patients with failed total joint arthroplasties.

In this study twenty-two patients who had revision surgery for aseptic loosening of joint prostheses were examined. The concentration in serum of soluble products of corrosion from the implant, that is, chromium (Cr), cobalt (Co), and nickel (Ni) ions, and the number of white blood cells (leucocytes, myeloid cells, lymphocyte subpopulations) were measured. Twenty patients with no implants were used as controls. The patients who had revision surgery showed normal Ni concentration whereas by statistical analysis that same patient group was shown to have serum Cr and Co levels significantly higher than those of the control. By flow cytometry, a significant decrease of leucocytes, myeloid cells, lymphocytes, and CD16 populations as found in patients versus controls whereas CD3, CD4, CD8, and CD20 positive cells were decreased, but not significantly. In the arthroplasty patients the Cr concentrations were inversely correlated with some of the immunologic parameters while no significant correlation was found between Co levels and decreased lymphocyte subpopulations. Only in revision surgery patients with high Cr concentrations did we find a significant decrease of lymphocytes, namely of CD4 and CD16 positive cells; revision surgery patients with normal Cr concentrations did not show a significant decrease of lymphocyte subpopulations. These data suggest that the presence of metal ions, especially chromium, released from prosthesis components could be associated with changes of lymphocyte subpopulations in patients with loosening of joint prostheses.

Cytokine release in mononuclear cells of patients with Co-Cr hip prosthesis.

The aim of this study was the evaluation of the release of bone-resorbing cytokines in peripheral blood mononuclear cells (PBMC) of patients with aseptic loosening of Co-Cr hip prostheses. TNF-alpha, IL-6, and GM-CSF were measured in both unstimulated and PHA-stimulated PBMC, and in PBMC cultured in the presence of chromium and cobalt extracts. Blood samples from healthy donors were used as controls. Serum samples of both patients and healthy donors were tested to determine the concentration of metal ions. The proportion of lymphocyte, monocyte and lympocyte subpopulation in cultured PBMC did not differ in patients and the control group. In unstimulated PBMC the release of TNF was significantly higher in patients than in the control group, while IL-6 was significantly decreased and no change was observed for GM-CSF. When the PBMC were challenged with chromium extract, all the 'index of cytokine release' resulted higher in patients than in the control group; cobalt extract increased both the TNF and GM-CSF index, but not the index of IL-6 release. Metal concentrations in serum from patients were significantly increased and correlated with the TNF release in PBMC stimulated with both metal extract. Our results suggest that a CoCr-implant releases a large amount of metal ions which could mediate the priming or the renewal of a cell-mediated hypersensitivity reaction. The prevalence of circulating lymphocytes responsible for the delayed hypersensitivity, namely Thl, would justify both the significant increase of TNF and the significant decrease of IL6 in unstimulated PBMC of patients, as well as the significant increase of the 'index of cytokine release' after the challenge with metal ions.

Intra- and extra-pelvic lesions associated with unstable fractures of the pelvic ring.

Fracture of the pelvis is often caused by high-energy trauma, and for this reason it is frequently associated with fractures in other regions, hemorrhages, or severe lesions of the organs. Based on an analysis of the results, obtained by a review of 68 cases of unstable fracture of the pelvis treated at the IIIrd Division of the Rizzoli Orthopaedic Institute between 1980 and 1995, the authors make several suggestions concerning diagnosis and therapy for the evaluation and treatment of these patients.

Valgus-lateralization osteotomy: notes on surgery.

There are specific forms of nonunion secondary to per-inter-subtrochanteric fractures that make surgical planning a critical phase. In cases such as these, it may be useful to transform the center of the nonunion into an osteotomy plane. Because of the anatomotopographical features, course and progression of the lesion, cases such as these constitute a pathology that is difficult to define in terms of a therapeutic protocol. The authors report the surgical technique used in 4 cases of nonunion of the proximal metaphysis of the femur.

Rigid fixation with plate and bone graft in failures of intramedullary osteosynthesis for the treatment of diaphyseal nonunion of the femur.

Fractures and diaphyseal nonunion of the femur are normally treated by intramedullary nailing. In cases in which nailing fails, nonunion is treated by reaming of the canal and substitution of the nail with one of a more adequate caliber. Rarely, however, due to unfavorable mechanical conditions or in cases of atrophic nonunion or with scarce vascularization the biological conditions for healing are absent. In cases such as these, nonunion must be treated by rigid internal fixation with a plate, aided by the use of cortical graft on the opposite side. The authors present 7 cases of diaphyseal nonunion of the femur treated between 1994 and 1996 using rigid fixation (plate and graft) as a salvage method, as a result of numerous previous failures in surgery. The results were favorable in all of the cases without complications.

Bone-resorbing cytokines in serum of patients with aseptic loosening of hip prostheses.

Our aim was to determine if the serum levels of bone-resorbing cytokines (IL-1beta, TNF-alpha, IL-6, GM-CSF) are altered in patients with aseptic loosening of a total hip prosthesis, and if such levels are influenced by the type of implant. We determined cytokine levels in sera from 35 patients before revision for failed total hip arthroplasty and compared them with those in 25 healthy donors. We also assessed the soluble receptor of interleukin-2 (sIL-2r) in serum as an indication of a specific immune reaction against the implant. Our findings showed that the sIL-2r and TNF-alpha serum level did not change. The IL-6 level was not significantly altered, but was higher in patients with TiAIV prostheses than in those with a CrCoMo implant and in patients with cemented prostheses. The IL-1beta level was found to be higher in those with a TiAIV cemented prosthesis than in the control group (p=0.0001) and other groups of patients (p=0.003 v uncemented TiAIV, p=0.01 v cemented CrCoMo, p=0.001 v uncemented CrCoMo). The GM-CSF level significantly increased in patients compared with healthy subjects (p=0.008), and it was higher in those with cemented than with uncemented implants (p=0.01). Only patients with cementless CrCoMo prostheses had levels of GM-CSF similar to those of the control group. The highest GM-CSF concentrations were observed in patients treated with non-steroidal anti-inflammatory drugs (NSAIDs) in the last months before revision (p=0.04). In addition, when massive osteolysis was observed, the level of GM-CSF tended to decrease to that of the control group.

Inveterate fractures of the acetabulum.

The authors reviewed 44 inveterate fractures of the acetabulum treated surgically by internal osteosynthesis. The definition of inveterate fracture concerns lesions that are treated from 21 to 90 days after trauma. Based on an analysis of this series several features of a prognostic and therapeutic nature may be determined. In particular, it may be observed just how difficult it is to standardize therapeutic strategies in relation to polymorphism and anatomopathologic progression of the lesions.

The opportunity of rehabilitation treatment in acetabular fractures treated by osteosynthesis.

Two groups of 24 patients each who had been submitted to osteosynthesis for the treatment of fracture of the acetabulum were evaluated. The first group was submitted to rehabilitation treatment according to the protocol used in the Division of Physiotherapy at the Rizzoli Institute; the second group did not use this protocol. Clinical-radiographic follow-ups were obtained after 1 month, 3 months, 6 months, and 1 year postsurgery. The results of the evaluations carried out showed the usefulness of specific physiokinesitherapy in obtaining more rapid and best possible functional recovery.

Surgical treatment of isolated forearm non-union with segmental bone loss.

Twenty-four isolated radius and ulna non-unions with segmental bone loss were operated on. Nine non-unions were in the radius, 15 in the ulna. The surgical technique consisted of removal of the necrotic bone, filling of the bone defect with an intercalary bone graft and internal fixation with a cortical bone graft fixed opposite to a plate. The average length of bone defect after freshening of the bone ends was 3.6 cm (range 2-10.5 cm). The average length of follow-up was 90 months. In 23 cases union was achieved. In three cases a postoperative infection developed. Resolution of the infection after surgical debridement was achieved in two of these patients, while recurrent infection caused failure of the treatment in the third patient. Statistical analysis revealed a shorter healing time (p = 0.031) in the ulna non-unions (12.5 +/- 3.0 weeks) compared with the radius non-unions (16.4 +/- 4.2 weeks). Functional results were classed as excellent in 10 patients, satisfactory in six, unsatisfactory in seven and failure in one.

Aseptic nonunion of the tibia treated by intramedullary osteosynthesis.

The authors report 52 cases of aseptic nonunion of the tibia treated by intramedullary osteosynthesis. The means of synthesis used were the Küntscher nail, the Eiffel Tower Rush nail, and the Grosse-Kempf nail. Which means of synthesis was used depended on the site and the features of the nonunion. Healing occurred in all of the cases after an average of 5 months. Mean follow-up was 4.5 years.

Revision of the femoral prosthetic component according to the Wagner technique.

The authors report the preliminary results they obtained using the Wagner technique for revision of the prosthetic stem by transfemoral access. Between January 1992 and June 1993 a total of 20 patients were treated by reimplantation of the prosthetic stem according to the Wagner technique. At minimum 12-month follow-up, based on the Harris Score System, results were excellent, good and fair in 16 cases. Results were not satisfactory in 4 cases after sinking of the prosthesis exceeding 2 cm or due to mid-distal pain with loading.

Lesions of the sciatic nerve in fractures of the acetabulum.

Between 1982 and 1992 a total of 211 fractures of the acetabulum were operated. There was lesion of the sciatic nerve in 21 cases, the pathogenesis and evolution of which were studied. Clinical follow-up was obtained at least 2 years after occurrence of neurological deficit and supported in 13 cases by electromyography. Based on an analysis of the literature and of these series it is observed how spontaneous recovery of paralysis is not rare, even if it requires a long period of time. The presence of various levels of lesion, which are not easily diagnosed, and which are not easily attacked surgically, calls for a prudent attitude with regard to neurolysis.

Internal fixation in unstable fractures of the pelvis. Preliminary notes.

The authors report the preliminary results of the surgical treatment of unstable fractures of the pelvic ring. Between 1989 and 1993 a total of 12 unstable fractures were treated by internal fixation. Short-term radiographic and functional results were satisfactory. The authors attribute an essential role to preoperative planning by conventional radiographic assessment and CT scan with multiplanar reconstructions, associated with carefully performed internal osteosynthesis.

Surgical treatment of both-column fractures by staged combined ilioinguinal and Kocher-Langenbeck approaches.

Between 1981 and 1989, 18 patients affected by both-column acetabular fractures were operated on by staged combined ilioinguinal and Kocher-Langenbeck approaches. Postoperative reduction quality and long-term radiographic results were evaluated according to the Matta radiological systems. The Harris hip scoring system was used for the functional results. Average follow-up was 53.2 months, ranging from 24 to 132 months. Reduction was anatomical in five cases (27.8 per cent), satisfactory in 11 (67.1 per cent), and non-anatomical in two cases (11.1 per cent). Radiographic long-term results were excellent in nine cases (50 per cent), good in five (27.8 per cent), fair in two (11.1 per cent) and poor in two (11.1 per cent). The Harris score was more than 90 in eight patients (44.4 per cent), between 80 and 90 in seven (38.8 per cent), between 80 and 70 in one (5.5 per cent), and less than 70 in two (11.1 per cent).

Composite bone grafting and plate fixation for the treatment of nonunions of the forearm with segmental bone loss: a report of eight cases.

Between June 1986 and December 1991, eight aseptic isolated severe forearm segmental bone losses were treated. The average age of the patients was 26 years. Three cases involved the radius and five the ulna. The average time between the onset of trauma and the final surgical intervention was 9 months. The surgical technique consisted of complete removal of necrotic bone, filling of the bone defect with an intercalary autogenous bone graft, and stable internal fixation, which required combining a plate and an opposite cortical bone allograft. The average bone loss length after freshening the bone ends was 7 cm (range 4-11). The average follow-up was 48 months (range 24-80). In all eight cases union and recovery of forearm function was achieved. The proposed surgical technique proved to be effective in obtaining results with no major complications.