Intramedullary reaming in the treatment of chronic osteomyelitis of the femur and tibia.

The authors comment on the experience acquired in the treatment of chronic osteomyelitis of the long bones with intramedullary reaming. The procedure is reserved for the femur and tibia with stage I chronic osteomedullary infection according to the Cierny-Mader classification. 2 A total of 36 patients were treated. Surgical treatment consists in reaming of the medullary canal and in its contra-opening with antiseptic solutions. Mean time for lavage is 6 days. Criteria for healing involves the absence of clinical, humoral, and radiologic signs of active medullary sites of infection. The percentage of healing was 83.2%, mean long-term follow-up was 2.9 years.

Subtrochanteric nonunion of the femur.

Nonunion of the subtrochanteric region is usually secondary to incorrect surgical treatment. The main cause of failed osteosynthesis is related to interruption of the medial cortex of the femur. Either a closed method, with intramedullary nailing, or an open method, using cortical osteosynthesis and opposing bone graft, may be used to treat the pathology. Surgery differs depending on the instrumentation used for the initial treatment of the fracture. A total of 8 cases of intra- and subtrochanteric nonunion with intramedullary nailing and cortical osteosynthesis are reported.

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.

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.

Fractures of the humerus treated by elastic nailing.

The Marchetti-Vicenzi elastic nail was used in the osteosynthesis of 15 diaphyseal or metadiaphyseal fractures of the humerus, 14 cases achieved consolidation, 1 resulted in nonunion. Surgical approach was always distal, transtricipital and the nail was always locked distally. In the cases that healed, the mean radiographic consolidation time was 90 days. There were no immediate postoperative complications.

Lumbar disc herniation in the elderly patient.

It was the purpose of this study to clinically follow-up 78 patients affected with lumbar disc herniation, aged from 60 to 81 years (mean 66 years), hospitalized in several wards at the Rizzoli Orthopaedic Hospital between 1987 and 1996, for surgical treatment. A minimum of 24 months after surgery (maximum 61 months), sciatic pain (present in all of the patients prior to surgery) had regressed in 90% of the patients and was reported to occur only occasionally in 10%. Low back lumbar pain was still present in 21%. Results concerning recovery of motor deficit (30%), deficit in reflexes (31%), and sensory deficit (24%) were good. Better results were obtained when the surgical findings were sequestered hernia and expulsed hernia, with excellent results observed in 70% and 60%, respectively (based on the Smiley-Webster scale), as compared to contained hernia, the results for which were excellent in 54% of patients. Complications were observed in 9 cases (11%); 5 of the cases (6%) after a period of time ranging from 20 to 45 days postsurgery required further surgery because of an error in level in 3 and a residual nerve root compression in 2.