Dario Capitani

Bone Transport for Postinfectious Segmental Tibial Bone Defects With a Combined Ilizarov/Taylor Spatial Frame Technique

Objective: To assess and compare the results of trifocal (two-level bone lengthening with compression at the nonunion site) and bifocal (one-level bone lengthening with compression at the nonunion site) bone transport using the Taylor Spatial Frame (TSF; Smith and Nephew, Inc, Memphis, TN) for postinfectious segmental tibial bone defects. Design: Retrospective study of 12 patients with atrophic tibial nonunions. These patients were treated with resection of the nonunion followed by bone transport using the TSF for the segmental tibial bone defects. All patients were treated by the same surgeon (F.S.). Setting: Level I trauma center. Patients/Participants: Twelve consecutive patients treated for postinfectious segmental tibial bone defects between November 2004 and September 2007. Intervention: All patients were treated using the TSF for a trifocal or bifocal technique of bone transport along with associated soft tissue reconstructive surgeries. All patients were additionally treated with 45 days of culture-specific antibiotics. Outcome Measurement: All patients were evaluated by the guidelines of the Association for the Study of the Method of Ilizarov. Results and Conclusion: All patients achieved complete union and eradication of infection. The results were evaluated according to Association for the Study of the Method of Ilizarov criteria: 83% were excellent and 17% were good in terms of bony outcomes; functional results were excellent in 50%, good in 42%, and fair in 8%. Combined Ilizarov/TSF trifocal and bifocal techniques for the treatment of segmental tibial bone defects achieve union without malalignment of the mechanical axis.

Alternative fixation method for open femoral fractures from a damage control orthopaedics perspective.

A decision for immediate versus delayed fixation in a polytrauma patient mainly in cases of open femoral fracture depends upon time elapsed since injury, duration of stay in intensive care, soft tissue status, probable intra-operative difficulties and presence of systemic complication. We studied the outcome of the Taylor Spatial Frame (TSF) as a solution in the role of primary and definitive fixator for patients in whom definitive osteosynthesis with intramedullary nailing (IMN) can be associated with higher rate of complications. In view of damage control orthopaedics (DCO), we found that TSF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. According to the Paley and Maars evaluation criteria, 11 patients had an excellent result with clinical and radiological union; the functional result was excellent in three patients, good in five, fair in two and poor in one.

Management of distal tibial intra-articular fractures with circular external fixation

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.

Taylor spatial frame fixation in patients with multiple traumatic injuries: study of 57 long-bone fractures.

Objective: To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of lower limb long-bone fractures in patients with multiple traumatic injuries. Design: Retrospective. Setting: Level I trauma center. Patients: Consecutive series of 52 patients, 57 fractures (25 femoral and 32 tibial), treated between 2005 and 2009. Forty-nine fractures (86%) were open. Injury Severity Score ≥16 for all patients. Intervention: Fifty-four fractures (95%) underwent definitive fixation with the TSF and 3 were treated primarily within 48 hours of injury. In 22 cases (39%), fractures were acutely reduced with the TSF, fixed to bone and the struts in sliding mode without further adjustment, and in 35 cases (61%), the total residual deformity correction program was undertaken. Main Outcome Measure: Clinical and radiological. Results: Complete union was obtained in 52 fractures (91%) without additional surgery at an average of 29 weeks. Four nonunions and 1 delayed union occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 74% excellent, 16% good, 4% fair, and 7% poor for bone outcomes and 35% excellent, 47% good, and 18% fair for functional outcomes. Eighty-eight percent of patients returned to preinjury work activities. Conclusions: Primary and definitive fixation with the TSF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate and range of motion for lower extremity long-bone fractures in patients with multiple traumatic injuries. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of unipedicular baloon kyphoplasty for treatment of multiple myeloma vertebral lesions.

Study Design A retrospective cohort study. Purpose To analyze differences in between the unipedicular vs. bipedicular balloon kyphoplasty for the treatment of multiple myeloma lesions. Overview of Literature Both vertebroplasty and kyphoplasty are reported to be effective for the treatment of vertebral compression fractures in multiple myeloma patients. Kyphoplasty is often performed with a bipedicular approach while vertebroplasty with a monopedicular approach. Monopedicular kyphoplasty is investigated as a viable surgical technique alternatively in comparison with the bipedicular method. Methods We performed 37 vertebral body augmentation procedures, 18 vertebroplasty (group A) and 19 kyphoplasty, 9 unipedicular approaches (group B1) and 10 bipedicular approaches (group B2), on 14 patients affected by multiple myeloma with a mean clinical and radiographic follow up of more than 12 months. Results Both kyphoplasty techniques lead to a better postoperative improvement of the vertebral height and kyphotic deformity if compared with the vertebroplasty, with a statistical significance for the body height restoration only (p = 0.0066). The unipedicular and the bipedicular kyphoplasty have similar results in term of kyphotic deformity correction and height restoration. The 85.7% (12/14) of the patients had an immediate improvement of the pain and no difference between the vertebroplasty and kyphoplasty groups were observed regarding the pain. We observed a 24.3% of cement leakage in all groups with no clinical symptoms and noticed that the risk of extravasations was higher in multilevel treatment, in bipedicular kyphoplasty procedures and in patients not treated previously with a bone marrow transplant. Conclusions Both vertebroplasty and kyphoplasty are effective in treating vertebral compression fracture due to multiple myeloma. Unipedicular kyphoplasty could give equivalent results as with bipedicular kyphoplasty in multilevel disease, aiming only to restore the sagittal alignment of the spine and the height of the vertebral body especially at the thoracolumbar spinal segment.

Evaluation of an endoscopic procedure for the treatment of docking site nonunion.

Objective: To determine the effectiveness of an endoscopic docking site surgery during the use of a classic bone transport technique for dealing with bone loss. Design: Retrospective comparative study. Setting: Level I trauma center. Patients: Nine patients treated with endoscopic docking site surgery (group 1) were compared with 18 patients treated with standard open grafting of the docking site (group 2). All 27 bone transports with distraction osteogenesis were performed for the treatment of segmental tibial bone defects. Intervention: In group 1, 6 tibial and 3 tibiotalar docking sites were endoscopically treated. Anteromedial (instrumentation) and anterolateral (visualization) portals were used without a tourniquet, using a 30-degree arthroscope and a motorized 5-mm shaver/abrader. Fibrous tissue was removed, bone ends abraded, and the bone canal cleaned with bone grafting. Main Outcome Measure: Clinical and radiographic. Results: Bone transport lengthening was 9.7 and 9.1 cm in groups 1 and 2, respectively. Consolidation at the docking site occurred in 8 patients (89%) in group 1. The docking site consolidation time and index lengthening were lower in group 1 (18 vs. 20 weeks for group 2 and 1.59 vs. 1.82 mo/cm in group 1 vs. group 2). Time in the external fixator was similar between the 2 groups (461 vs. 466 days in group 1 vs. group 2). Normal alignment was observed in both groups. Conclusions: This study provides evidence that minimally invasive endoscopic docking site treatment during bone transport is a safe and viable technique using a common arthroscopic instrumentation. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Protocol-driven approach of bleeding abdominal and pelvic trauma

Control on a priority basis of significant sites of hemorrhage in patients with abdominal trauma and pelvic disruption may be critical for survival. Purpose of this study was to evaluate retrospectively a work-up based on initial pelvic radiograph, abdominal ultrasound (US) and contrast CT (CESCT).

Le fratture complesse dell’omero

Complex humeral fractures represent an exciting challenge in traumatology. Recently, the use of MIPO techniques has been gaining success in traumatology as well. Concerning our experience, we do not recommend the use of these techniques in all fracture types and kinds of patients.