Fabrizio Rivera

Pure dislocation of the ankle: three case reports and literature review.

Ankle dislocation without fracture is an extremely rare injury. The results of treatment are reported for three patients who had a posteromedial open dislocation, a lateral open dislocation, and a posterior closed dislocation of the ankle. Management consisted of immediate reduction, debridement and capsular suture in the open dislocations, and immobilization with a short leg cast in all patients. At followup no patient had tibiotalar joint instability; a 10 degrees to 15 degrees loss in the range of dorsiflexion was observed in two patients. One patient reported paresthesia in the area of the superficial peroneal nerve. The three patients achieved good long-term functional and radiographic results. Predisposing factors that contribute to the pathogenesis of this lesion are internal malleolus hypoplasia, ligamentous laxity, weakness of the peroneal muscles, and previous ankle sprains. Among the three patients, medial malleolus hypoplasia was present in one patient and previous sprains were seen in the clinical history of another patient.

Peritalar dislocation: three case reports and literature review

Abstract Peritalar dislocation is an uncommon lesion, although its incidence has increased on account of the rise in motor vehicle accidents and improved radiological diagnostic techniques. In our review of the literature, we counted 312 cases described over the past 50 years. Medial dislocation represented the majority of cases (79%), lateral dislocation accounted for 22%, while poster and anterior dislocations seemed to occur rarely. We report the results of the treatment of 3 patients, one with an irreducible lateral dislocation, one with a irreducible medial dislocation, and one with a reducible medial dislocation. The obstruction to closed reduction for lateral dislocation was the interposed posterior tibial tendon. The obstruction to closed reduction for medial dislocation was an osteochondral impact-fracture of the upper medial part of the head of the talus spiking to the lateral corner of the navicular. Management consisted of immediate reduction and application of a short leg cast for 4 weeks. At long-term follow-up, all 3 patients had no complications and had returned to their pre-injury activities.

Risk of stem undersizing with direct anterior approach for total hip arthroplasty

Purpose The direct anterior approach (DAA) for total hip arthroplasty (THA) is claimed to be as effective but less invasive than the conventional posterior approach (PA). However, the higher risk of femoral fracture and soft tissue damage cannot be underestimated. The present authors believe that the difficult femoral exposure and the surgeons knowledge of possible complications related to femoral preparation may result in a higher rate of undersized stems when compared to PA, even when a short femoral component is employed to minimise these risks. Methods A retrospective study was performed to compare the effective adherence of surgical sizing to preoperative planning in a series of 112 short stem THAs, of which 59 were implanted through PA and 53 through DAA without intraoperative imaging, by a single surgeon skilled in both techniques. Results the frequency of stems smaller than expected was 3-times higher with DAA than with PA (54.72% vs 16.95%, p<0.001), while the frequency of stems at least 2 sizes smaller than expected was more than 6-times higher with DAA than with PA (24.53% vs 3.39%, p = 0.001). Conversely, no differences of size discrepancy distribution were found for cups and prosthetic heads. Postoperative x-rays confirmed an inferior mean canal fill in the DAA group, but excluded a different incidence of frontal malalignment between the groups. Conclusions The technical difficulty of femoral preparation and the surgeons knowledge of possible related complications might lead to implant undersized stems more frequently through DAA than through PA, especially if intraoperative imaging controls are not used.

Fractures of the tibial plafond: a comparison of treatment methods

Abstract From 1995 to 1999, 19 patients (13 males and 6 females) were treated for Code 43 (distal segment) tibial fractures according to AO and Orthopaedic Trauma Association classification: there were 5 type A, 4 type B and 10 type C fractures. The mechanisms of injury included motor-vehicle accidents (n = 8), falls from heights (n = 8), a chainsaw injury (n = 1), and crushing injuries (n = 2). Five patients had associated injuries. All open fractures were managed acutely with wound debridement and application of an external fixator. Closed injuries were operated 1–16 days after injury (average, 6 days). The method of treatment depended on fracture comminution and soft tissue condition. Patients were available for follow-up for an average of 14 months. Results were evaluated by means of subjective and objective rating systems. All fractures in the series united with an average time to healing of 12 weeks. Anatomic or good alignment was obtained in all but 1 fracture. There were 7 excellent, 5 good, 5 fair and 2 poor results. Complications occurred in 2 patients (8%) and included 1 deep infection and 1 loss of reduction with malunion. The most important variables affecting the final clinical results were the type of fracture, the method of treatment, and the quality of reduction.

Use of a modified IMHS for unstable intertrochanteric fractures

The treatment of unstable intertrochanteric fractures in elderly osteopenic patients, especially those who cannot follow limited weight bearing instructions, is controversial. Recent publications indicate concern with excessive sliding of telescoping nail or sliding screw devices when used in these unstable intertrochanteric fractures. In our experience with the use of intramedullary hip screw (IMHS) in these fracture patterns, we have observed excessive sliding and collapse of the fracture in some patients. We modified the keyed centering sleeve by threading its internal distal third and substituted the compression screw with a custom bolt to obtain restricted sliding or rigid fixation depending on the gap between the lag screw and custom bolt. We used this modified system in static configuration to treat five patients who had an unstable intertrochanteric fracture of the femur. The length of the involved limb measured at the time of consolidation showed no shortening. In view of these results, intertrochanteric hip fractures that are unstable in patients with poor bone-stock can be fixed using the modified IMHS in a static or controlled sliding configuration.

PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up

INTRODUCTION Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity. MATERIALS AND METHODS We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate. RESULTS Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24-75, 95%CI 34.7-41.4), 67.22 (SD 9.6, range 50-90, 95%CI 64-70.4), 90.54 (SD 6.3, range 75-100, 95%CI 88.4-92.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention. CONCLUSIONS PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention.

Uncemented fully hydroxyapatite-coated hip stem for intracapsular femoral neck fractures in osteoporotic elderly patients: a multicenter study

There is still debate over the limits of age and bone stock quality of patients on whom to use an un-cemented straight stem coated with hydroxyapatite (HA). We studied a group of 244 patients with a displaced intracapsular fracture of the femoral neck who underwent cementless hemiarthroplasty or total hip arthroplasty. 143 patients were reviewed at the two-year follow up. A fully HA-coated stem for intracapsular hip fracture results in a satisfactory return to pre-injury mobility and a low complications rate. The advantage reported in the literature of a low mortality rate with use of an un-cemented implant in elderly patients was shown to be greater still on finding an immediate primary stability and rapid osteointegration of the implant.

A new interlocking dynamic compression nail for tibial shaft fractures

Abstract The Clos tibial nail is a cannulated cylindrical nail that permits static, dynamic as well as incompression mounting by the insertion of locking screws into distal and proximal holes. From September 1998 to March 1999 we treated 16 tibial shaft fractures with CLOS tibial nails. All fractures were managed with calcanear traction, closed reduction, reaming and fixation. Patients were followed for at least 1 year. The mean time to full weight bearing was 11 (10–14) weeks. There were no cases of delayed union or dynamization. All patients returned to their previous activity levels.