Quantification of surgical trauma: comparison of conventional and minimally invasive surgical techniques for pertrochanteric fracture surgery based on markers of inflammation (interleukins).

BACKGROUND: Fixation of pertrochanteric fracture is undoubtedly an additional trauma after the fracture itself. In elderly patients, it might have an important impact on the whole organism. In the literature we find various techniques to perform this type of surgery. Up to now, there are no parameters validated for quantification of the invasiveness of a surgical procedure; it is therefore still not demonstrated that any method is less invasive than any other. In an effort to find a way to quantify the invasiveness of a surgical procedure, inflammatory markers were collected in patients undergoing fixation of trochanteric fracture with gliding hip screw [dynamic hip screw (DHS)] using either a conventional (DHS conv) or minimally invasive (DHS MIO) technique. METHOD: Two groups of patients were investigated prospectively; 36 of them were treated with conventional DHS technique and 32 with minimally invasive technique. Mean age was 84.7 ± 7.20 and 82.78 ± 7.71 years, respectively. Fracture type was classified according to the AO classification. Interleukin (IL)-6, IL-10, IL-8, and tumor necrosis factor (TNF)-α were measured 1 h before and 1 h after surgery. Student's t test, chi-square test, and multivariate logistic regression were used for statistical analysis. RESULTS: Preoperative levels of interleukins showed no significant differences between the two groups. In contrast, the postoperative blood level of IL-6 in patients operated with DHS conv technique (78.41 ± 67.04 pg/ml) was on average higher than in patients operated by DHS MIO technique (39.02 ± 37.36 pg/ml), the mean difference being 39.39 pg/ml [95 % confidence interval (CI) 12.65-66.13 pg/ml; p = 0.0045]. Multivariate logistic regression (backward method with limit of significance 0.05) confirmed that patients operated by conventional technique were significantly more likely to have increased IL-6 after surgery than those operated by MIO technique. IL-8 was measured in only 36 patients (20 for DHS conv, 16 for DHS MIO). No significant differences were found between the two groups; however, there was a drastic decrease postoperatively (p < 0.0001) regardless of the type of surgery performed. IL-10 and TNF-α were tested in all subjects, but did not show significant differences between the two groups. Average length of incision was significantly different (4.61 cm, 95 % CI 3.50-5.71 cm; p < 0.001) between the two groups, being 11.65 ± 2.64 cm for DHS conv and 7.05 ± 1.77 cm for DHS MIO. Similarly, average units of red blood cells (RBCs) transfused [performed for hemoglobin (Hb) <9 g/dl and/or hematocrit (HCT) <27 %] was higher (2.22 ± 0.99) in the DHS conv group compared with the DHS MIO group (1.09 ± 1.20), with average difference of 1.13 (95 % CI 0.59-1.66; p < 0.001). CONCLUSIONS: This attempt to quantify the invasiveness of internal fixation for trochanteric fracture comparing two techniques (DHS conv versus DHS MIO) based on inflammatory markers (IL-6) has given encouraging results. Measurement of systemic inflammatory response to local tissue damage caused by osteosynthesis using IL-6 as marker seems to confirm the lower invasiveness of MIO techniques. These results for trauma cases seem in line with those published for hip prosthesis. Ongoing further studies analyzing the effect of nailing will confirm or invalidate these preliminary results.

Antibiotic-coated nails in orthopedic and trauma surgery: state of the art.

Optimal management of deep infections in orthopedic and trauma surgery is often challenging. Traditional prophylactic and treatment approaches are based on the systemic administration of relatively high doses of antibiotics, which may result in a number of side effects. Furthermore, systemically administered antimicrobials may not reach adequate concentration at the desired site. Finally, traditional approaches are based on two-step protocols, thus delaying definite fixation. In recent years, antibiotic-coated intramedullary nails (ACINs) have been introduced, which offer the advantage of delivering antibiotics locally, thus increasing their local concentrations and length of action. In addition, ACINs offer the great advantage of combining antimicrobial prophylaxis/treatment and stabilization in a single step. Preliminary evidence by small clinical studies appears to support the effectiveness of ACINs in the management of chronic osteomyelitis and infected non-unions, with high rates of infection eradication and bone union. However, randomized clinical trials are needed to definitely establish ACINs ' effectiveness and safety.

Resection of parosteal osteosarcoma of the distal part of the femur: an original reconstruction technique with cement and plate.

Parosteal osteosarcoma is a low-grade malignant bone tumor arising from the distal femur and tibia. Wide resection of a parosteal osteosarcoma usually prevents local recurrence. In literature, hemicortical resections of low-grade malignant bone tumors and allograft reconstruction are described. We describe a new method of resection and reconstruction of parosteal osteosarcoma located in the popliteal paraosseous space of the distal part of the femur using cement and plate (LISS-SYNTHES) through dual medial and lateral incisions. The patient did not present infections and fractures and the functional results were good. After one year, no metastases developed and there were no local recurrences.

Cervical cord compression due to atypical primary neuroectodermal tumor (PNET): one-stage removal and combined cervical spine stabilization. Case report.

INTRODUCTION: The neuroectodermal tumor of bone constitutes a recently isolated neoplasm, which morphologically resembles the peripheral neuroepithelioma of soft tissue. The diagnosis is made by excluding readily classified small round cell neoplasms and then demonstrating the neural origin of the tumor by means of ultrastructural or immunocytochemical studies. CLINICAL CASE: We report a case of a primary neuroectodermal tumor (PNET) with atypical findings (primary cervical location, massive vertebral body infiltration and isolated neurological symptomatology). Total tumor removal was achieved by means of a one-stage three-level laminectomy (partial C5, total C6-C7), C6 somatectomy, and combined anterior and posterior cervical spinal instrumentation and fusion. CONCLUSIONS: Our case presents three peculiar features: 1) isolated myelopathic symptomatology (first case described); 2) primary isolated massive vertebral cervical involvement with intraspinal epidural extension (first case described); 3) one-stage tumor resection, fusion and instrumentation. Since radiation therapy causes tumor shrinkage but is not curative, radical removal is mandatory even with complex instrumentation procedures.

Massive osteolysis induced by high molecular weight polyethylene wear debris.

We investigated the mechanism by which particulate wear debris of polyethylene may induce bone resorption using an in vivo model. Two uncemented total hip prostheses, in which the socket was directly in contact with acetabular bone, were selected because there was massive bone loss around the implant. A thick synovium-like layer was found at the polyethylene-bone interface during revision operations. Samples were examined by transmitted and polarised light microscopy, and by transmission electron microscopy. This study demonstrates that polyethylene wear products alone can cause massive osteolysis by triggering the formation of foreign body granuloma at the bone-implant interface.

Percutaneous elastic fixation of proximal humeral fractures: operative indications, techniques, results and complications.

We present a technique of osteosynthesis of proximal humeral fractures using Kirschner wires, assembled in an elastic manner. We report 29 patients (mean age, 68 years) with types II, III and V fractures, according to Neer's classification, treated with closed or open (seldom) reduction and percutaneous pinning. The pin placement was antegrade: the wires started on the epiphysis and aimed at the diaphysis, with the proximal ends fixed with an external clamp and the distal ends crossed and laying on the endosteal surface. Patients were evaluated with the Constant-Murley scale at the end of treatment. Radiological and clinical outcome was satisfactory in all but one patient, in whom the closed reduction was insufficient. Percutaneous elastic pinning is an effective treatment of proximal humeral fractures. If necessary, it should be associated with open reduction.