Induced membrane technique for the treatment of severe acute tibial bone loss: preliminary experience at medium-term follow-up.

PURPOSE: Management of acute open tibial fractures with critical bone defect remains a challenge in trauma surgery. Few and heterogeneous cases have been reported about the treatment with the induced membrane technique. METHODS: We prospectively evaluated three patients treated with the induced membrane technique for acute Gustilo IIIB tibial fractures with critical bone defect. Success treatment was defined by bone union with patient pain free. Clinical and radiological evaluations were performed regularly until healing, then annually and with a minimum follow-up of five years. RESULTS: In all patients but one, a success was recorded, respectively, at four and six months. These two patients were pain free until the final follow-up, and no graft resorption or secondary complications related to the index surgery were observed. The third case was managed successfully with a bone transport technique. CONCLUSION: The induced membrane technique is an alternative good option for the treatment of these severe lesions.

Bone disorders in children and adolescents with chronic HCV infection.

BACKGROUND AND AIMS: Although several studies have demonstrated a higher incidence of bone disorders in HCV-infected adults, the bone turnover alterations occurring in children and adolescents with chronic hepatitis C has not been thoroughly focused yet. We performed a study on a cohort of 30 HCV infected caucasian children and adolescents to assess the prevalence of osteodystrophy and evaluate a possible prophylactic and therapeutic approach. METHODS: Data regarding biochemical markers of bone metabolism were collected. Moreover, results of ultra-sonographic bone densitometry yearly performed were evaluated in comparison with data obtained from more than 500 healthy children and adolescents. RESULTS: Osteocalcin and telopeptide of the collagen molecule type-1, CTX, appeared higher than normal in 8/30 and in 7/30 cases respectively; the 25OH vitamin D values were normal in 25/28 cases. By densitometry osteoporosis was detected in 2 patients and osteopenia in other 5. After stratification of cases by age groups, the incidence of osteopenia/osteoporosis appeared higher among children than among adolescents. Osteocalcin levels tended to be higher in cases where hepatic fibrosis were not detected. CONCLUSIONS: The higher number of cases of osteopenia/osteoporosis in children than in adolescents is worthy of note, although not statistically significant. Ultrasound densitometry confirmed its important early diagnostic role in asymptomatic HCV infected children; moreover, also the increase in serum levels of osteocalcin may be considered as early marker of osteodystrophy of complementary value. Larger studies will be needed to confirm the efficacy and safety of antiviral and supportive care in these patients.

Ultrasonic Evaluation of the Achilles Tendon in Patients Treated for Congenital Clubfoot: Comparison between Patients Treated with Plaster Alone, Achilles Tenotomy, and Z-Plasty Lengthening.

BACKGROUND: Clubfoot is a common congenital deformity. The Ponseti technique, involving early corrective manipulations followed by applying long leg casts and Achilles tenotomy, is widely accepted as the preferred treatment. Rapid tendon healing after surgery has been documented, but the aspect regarding long-term tendon structure and properties is not known. Three cases of Achilles tendon rupture in adolescents previously treated for clubfoot have been described in the literature. As rupture is a rare event in this age group, a possible correlation with previous surgery has been hypothesized. The primary aim of the study was to compare the ultrasound findings of the Achilles tendon in patients treated for clubfoot, between patients treated with casting alone and with patients who underwent surgery (percutaneous tenotomy or Z-plasty lengthening). METHODS: There were 22 asymptomatic patients (34 feet) with a median age of 12 years, previously treated for clubfoot, that were recruited for this study; the patients underwent an Achilles tendon ultrasound examination during a follow-up outpatient visit. RESULTS: A greater thickness and increased number of structural alterations with the presence of hypoechoic areas of the operated tendons compared with those treated with plaster alone were observed (p-value: 0.0498 and <0.001, respectively). These ultrasound findings were indicative of tendon suffering, as seen in tendinopathies. CONCLUSIONS: The presence of ultrasound alterations in asymptomatic patients operated on for clubfoot requires careful control of the extrinsic factors of tendinopathy in order to reduce the risk of subcutaneous rupture.

Achilles tendon surgery in clubfoot: Are long term sequelae predictable?

Congenital Clubfoot (CCF) treatment involves a surgical procedure on the Achilles tendon most of the time, i.e. tenotomy or, in selected cases, Z-plasty lengthening. Many authors have studied the outcomes of Achilles tenotomy, describing complete clinical and ultrasound tendon fibers integrity restoration 3-6 weeks after surgery. Nevertheless, little is known about the mechanical properties of the operated tendon. Recently, cases of subcutaneous rupture of the Achilles tendon have been described in adolescents who practiced sports and who had undergone Achilles tenotomy for congenital clubfoot in childhood. Authors report two cases of atraumatic Achilles tendon injury (subcutaneous rupture and intratendinous ossification) in adult patients who had been treated for congenital clubfoot in childhood. In both cases, no causes determining the injury were identified; in the medical history there was a Z-plasty lengthening of the Achilles tendon, performed within the first year of life, which could be considered a predisposing factor. The usefulness of long-term monitoring of patients treated for CCF with surgical procedures on the Achilles tendon is therefore hypothesized, in order to promptly identify by symptoms, clinical pictures and ultrasound criteria, tendon suffering that may predispose subcutaneous rupture.

Congenital Dislocation of the Patella - Surgical Treatment Rationale and Literature Review.

INTRODUCTION: Congenital dislocation of the patella (CDP) is a rare condition and its treatment is not well defined. In CDP, patella is dislocated on the lateral aspect of the distal femur, laterally from the trochlear groove, it cannot be reduced manually and it is almost always associated with genu valgum, lateral torsion of the proximal tibia, and flexion contracture of the knee. This condition is present at birth, but the clinical findings can be subtle at birth due to the size and character of the structures being examined; early diagnosis is essential, but it may be delayed to late childhood or adulthood. If CDP is not promptly treated, the disability increases during growth, so surgical correction should be planned as soon as the diagnosis is confirmed. CASE REPORT: We report a case of bilateral CDP associated with bilateral proximal radioulnar joint stiffness; the patient at the age of diagnosis was 11 years old and underwent a bilateral delayed surgical procedure; the 4-year follow-up results are satisfactory. Surgical treatment rationale and literature are reviewed. CONCLUSION: Surgical correction for CDP is generally recommended, but there is no agreement in literature on the ideal treatment and in some cases, with mild impairment of the knee function, observation alone has been suggested. The decision about a surgical treatment can be difficult and depends on the degree of disability of the patient.

Transient femoral nerve palsy in spica cast treatment for developmental dysplasia of the hip.

A 4 months and half female child come to our attention for congenital dislocation of the left hip, previously treated in another hospital with abduction bracing, without satisfactory results. After progressive longitudinal bilateral traction, closed reduction under general anesthesia was performed and a spica cast was applied in the so-called human position. The patients remained in the spica cast for 6 weeks and then the plaster cast was renewed in narcosis for another 6 weeks. Once the second cast has been removed left femoral nerve palsy was detected. Orthopaedic treatment was interrupted and in 3 months the nerve completely recovered, while the hip was still stable. We followed the child regularly since then, she is now five years old, she is totally asymptomatic, X-rays shows a residual acetabular dysplasia, with no sign of avascular necrosis.

Pseudoarthrosis of second metatarsal fracture.

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

Revision of 120 tibial infected non-unions with bone and soft tissue loss treated with epidermato-fascial osteoplasty according to Umiarov.

Treatment of tibial infected non-unions with bone and soft tissue loss has to solve three problems: infection, lack of bone continuity and lack of skin coverage. The aims of treatment are infection healing, bone consolidation with preservation of limb length and soft tissue reconstruction. The most important stage in the planning is an accurate débridement. Soft tissue reconstruction can be achieved using plastic surgery, and bone reconstruction is accomplished with bone grafts or induced membrane technique, but these methods may present disadvantages and risks. Epidermato-fascial osteoplasty is a modified procedure of compression-distraction osteosynthesis that was first described by Umiarov in 1982. This procedure offers the advantages of exactly classifying the phases of simultaneous bone and soft tissue regeneration, and of eliminating large tissue losses without previous closure of soft tissues or use of grafts, because the transported fragment takes fascia and skin along during the transport and closes the edges of the soft tissue gap until the epidermic and fascial reconstruction is complete. A total of 120 patients underwent this kind of surgery between 1986 and 2010 and were followed up for 2-26 years. Average age was 34 years (range 21-57 years). Cultures were positive for Staphylococcus in all cases, and for Pseudomonas in 27 cases. Adequate antibiotic therapy was administered in collaboration with the Infectious Diseases Specialist. Tibial bone resection was from 6 to 18cm (average 9.5cm). The Ilizarov apparatus was used with the oblique wire technique for bone transport in all patients. No intraoperative complications were observed. One patient died 40 days after the operation because of pulmonary embolism. The duration of treatment for the remaining 119 patients was 7-18 months. In all cases, infection eradication, healing of regenerate bone, consolidation at the docking site (with the aid of an autoplastic bone graft in only 11 patients), and epidermic and fascial reconstruction were observed, and functional results were very good. These techniques are particularly demanding for the patient and for the surgical team, but our results demonstrate that they can provide excellent outcomes in the management of difficult cases of infected non-unions.

O tratamento das deformidades complexas dos membros com o emprego dos aparelhos de compressäo-distraçäo / Treatment of complex extremity deformities using compression-distraction apparatuses

Os resultados favoráveis obtidos no tratamento de 50 pacientes com deformidades complexas dos membros através da correçäo gradual com aparelhos de compressäo-distraçao confirmam as vantagens dessa técnica. A possibilidade de corrigir e alongar em qualquer ponto da circunferência óssea simplifica a recuperaçäo, permitindo carga imediata. Entre os aparelhos utilizados - Volkov-Oganesian, Ilizarov, Kalnberz - este último mostrou-se bastante eficaz, além de apresentar particularidades como anéis de fibra de vidro radiotransparentes e hastes de titânio flexíveis ou rígidas.