Barbara Bertani

Treatment of infected nonunions

The first three types of the classification outlined in Table 1 are the “infected variety” of the three corresponding types of noninfected nonunion, whose morphologic and functional features and whose principles of treatment have already been discussed. Their treatment is similar to that of the noninfected variety, but commences after accurate debridement and adequate specific antibiotic therapy. Only on rare occasions does “infection burn on the fire of the bone regenerate”, as Ilizarov mentioned with a sort of optimism Table 1. Classification of infected nonunions and principles of treatment according to Umiarov [1]

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.

Compression-Distraction Systems

There are a few basic elements of circular external fixation systems, as underlined by Kalnberz [1]. They can be summed up as: bone fixation elements, rings which encircle the bone segment, rods connecting the rings, connecting elements between rods and rings, and connecting elements between rings and bone fixation elements. Many other elements can be added (Fig. 1). However, they differ in importance and number from system to system, and their effectiveness is often questionable.

Treatment of Noninfected Nonunions: Parafocal Osteotomy

Osteotomies performed in the management of nonunions can be classified into three types [1]: Intrafocal osteotomy (performed at the nonunion site: it consists essentially of the resection of the entire area around the nonunion); Transfocal osteotomy (performed through the nonunion site to reshape the bone ends: it is indicated for nonunions with a longitudinal or oblique fracture line); Parafocal osteotomy (Paltrinieri’s osteotomy, performed some centimeters from the nonunion site). In this chapter the original idea by Paltrinieri (parafocal osteotomy) and the indications for this technique are described and discussed.

Assessment of fracture healing.

Markel and Chao [1] underlined that long bone fractures consolidate without complications in most patients. Moreover, in patients in whom the use of complex monitoring techniques of fracture healing was indicated, these techniques were often in an experimental stage and hardly available, and their use was limited to the study of some selected bone segments. For these reasons the techniques most commonly employed to assess fracture repair until a few years ago included: subjective criteria (patient’s evaluation of pain), objective criteria (manual examination of the fracture stability), temporal criteria (simple passage of time), and instrumental criteria (radiographic evidence of consolidation). In brief, if bone healing conditions are normal, traditional methods of monitoring are considered adequate. In particular, radiographic investigation is the most important method because it is the simplest, it provides continuous information, and it is easily used for iterative interpretations [2].

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.

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.

Le fratture diafisarie delle ossa lunghe. Correzione delle deformità post-traumatiche

Long bone deformities as a result of trauma may lead to complications such as chronic pain, abnormal functional loading, cosmetic abnormality, joint arthritis and, if located at the lower limbs, difficult walking. The introduction of the typical circular external fixation played a prominent role in improving the management of these deformities, and second-generation circular devices (hexapod systems connected to computer planning software), which allow for simultaneous correction of all kinds of deformities in adults and children, further improved versatility, patient tolerability and nursing.

Treatment of noninfected nonunions: techniques other than compression- distraction methods.

Techniques for the management of infected nonunions of the long bones aim to solve three problems: infection, lack of bone continuity, and lack of skin coverage. These problems are always related to varying degrees: the lack of skin coverage can allow a superinfection; the persistence of infection damages the surrounding soft tissues; the lack of consolidation and the persistence of abnormal mobility improves infection [1]. Conventional treatment combines, in several operative stages, debridement, stabilization, and reconstruction. Debridement, associated with antibiotic therapy, attempts to sterilize the nonunion site. Stabilization aims to allow consolidation and to fight infection more effectively. Skin and bone grafts can be used for reconstruction. Concerning bone grafts, there are two possibilities: corticocancellous bone grafting with skin coverage (the use of corticocancellous graft requires skin closing since the cortical bone suffers from air exposure) and cancellous bone grafting without skin coverage (Papineau method).