Gabriele Falzarano

Non-operative vs. percutaneous stabilization in Magerl’s A1 or A2 thoracolumbar spine fracture in adults: is it really advantageous for a good alignment of the spine? Preliminary data from a prospective study

PurposePercutaneous and non-operative stabilization are very controversial choices in the management of Magerl’s A1 or A2 thoracolumbar spine fractures in adults. Our purpose is to figure out which of the two treatments is more suitable for the management and outcomes of these injuries.MethodsFrom 12/01/2011 to 06/30/2014 at the AO Orthopedics and Traumatology, Gaetano Rummo in Benevento, Italy, we treated 39 adult patients with thoracolumbar spinal fractures according to Magerl’s A1 and A2. Twenty-four patients were treated with a 3-point orthopedic corset, and 15 patients were treated with percutaneous posterior stabilization without augmentation. The patients decided on treatment after extensive explanation of the pros and cons of the two treatments. The endpoint evaluation was set at the 6-month follow-up through the evaluation of the Visual Analogue Scale, Angle’s Regional Kyphosis, Oswestry Low Back Pain Disability Questionnaire, and Denis work scale.ResultsThe preliminary results of this prospective study show that there is a considerable advantage in functionality and pain in treating adults suffering from thoracolumbar fractures with Percutaneous technique at the expense of the bust with three points.ConclusionsAlthough the data are preliminary and based on data available in the literature, we can say that the Percutaneous posterior stabilization of thoracolumbar fractures in Magerl’s A1 and A2 in adults is the ideal method for a good and functional alignment of the spine.

The orthopedic damage control in pelvic ring fractures: when and why-a multicenter experience of 10 years' treatment

Abstract Objectives To report our experience of regional referral center for the pelvis. Methods We treated 526 pelvic fractures from January 2004 to December 2014 in three regional reference centers for pelvic trauma. Men were 480 and women were 46 and ages ranged from 16 to 93 years old. Car (65%) and farm (20%) crashes were the most frequent causes of pelvis fractures. Injury severity scores ranged from 9.0 to 75.0, with a mean of 37.5. A defined algorithm for fracture management has been in place and employed to assure adequate resuscitation and fracture care. Results There were 24 deaths in total (4.56%). Sixty three (11.98%) patients underwent angio-embolization for control of bleeding (12 deaths). The average amount of blood transfused was 8.3 IU. Hospital lengths of stay ranged between 1-35 days. Among the 502 alive patients, 55.98% were able to be discharged at home while the remaining 44.02% being transferred to various rehabilitation facilities or extended care facilities. Conclusions The goal of initial management is to restore vital indicators, urinary excretion function and protect the patient from infectious complications. An emergency decisional algorithm helps manage hemodynamic instability. Initial bone and ligament procedures should reduce displacement and make it possible for the patient to wait until his condition is stable enough for definitive surgical fixation.

Le fratture esposte d’avambraccio

Open fractures of the forearm represent an urgent/emergency orthopaedic condition. They are not free of complications, which can lead to upper limb disabling outcomes or amputation. The traumatologist’s goal is to carry out a correct and anatomic osteosynthesis bearing in mind the type of lesion, the instruments used for the synthesis and the consequences of his therapeutic choices. The authors of this articles describe the state of the art of open forearm fractures.

Long-term outcome of grade III and IV chondral injuries of the knee treated with Steadman microfracture technique

INTRODUCTION The aim of our study is to demonstrate the effectiveness of Steadman microfracture technique in the management of high-grade chondral defects at the level of the knee by clinical follow-ups at eleven years. MATERIALS AND METHODS This is a study conducted on fifteen patients suffering from Outerbridge grade III and IV chondral lesions of the knee, who underwent Steadman microfracture surgery between 2003 and 2004. Selective exclusion criteria to prevent that other treatments or comorbidities could invalidate the results were used. Patients were clinically evaluated with Lysholm and IKDC scale scores before surgery and at follow-ups at eleven years. RESULTS There has been an improvement in the Lysholm scores (59.33 ± 18.2 at time zero vs 82.13 ± 14.16 at time t; p value: 0.0342) and in the IKDC scores (45.13 ± 17.07 at time zero vs 68.66 ± 21.47 at time t; p value: 0.04) that appears statistically significant. DISCUSSION Currently microfracture surgery is not indicated in patients with high-grade chondral defects, but at the same time, it is a technique of easy execution, low cost and good results. The clinical improvement observed appears statistically significant, but we have also noticed a slight clinical worsening in two patients, possibly caused by: improper treatment, new trauma, incorrect rehabilitation and age at time of surgery. CONCLUSIONS The study has shown significant clinical improvements in patients, despite the fact that indications to the use of microfracture are still very limited and selective. Its essential to underline the importance of the single patient assessment process, taking into account a variety of aspects including the site, the number and extent of the lesion, the degree of functionality, activity level, age and previous trauma. This shows the importance of a comprehensive assessment of the patient in order to choose the most suitable surgical option, which not necessarily has to strictly adhere to standard practice.

Nail or plate in the management of distal extra-articular tibial fracture, what is better? Valutation of outcomes

Introduction: Distal tibial fractures are the most common long bone fractures. Several studies focusing on the methods of treatment of displaced distal tibial fractures have been published. To date, locked plates, intramedullary nails and external fixation are the three most used techniques. The aim of our study was to compare intramedullary nail (IMN) and locked plate (LP) for treatment of this kind of fracture. Materials and methods: We collected data on 81 patients with distal tibial fractures (distance from the joint between 40 and 100 mm) and we divided into two groups: IMN and LP. We compared in the 2 groups the mean operation time, the mean union time, the infection rate the rate of malunion and nonunion, the full weight bearing time. Results: No patient in the two groups developed a nonunion. None of the patients obtained a fair or poor outcome. Overall 52 patients obtained an excellent result (69.3%) and 23 obtained a good result (30.6%). Discussion: Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.

Foot Loading and Gait Analysis Evaluation of Nonarticular Tibial Pilon Fracture: A Comparison of Three Surgical Techniques

Abstract The aim of our study was to investigate which technique among hybrid external fixation, plate and screws, and intramedullary nailing produces better outcomes in foot loading when treating type 43.A1, 43.A2, and 43.A3 fractures, according to the AO classification. From November 2011 to December 2014, 34 patients, including 25 (73.5%) males and 9 (26.5%) females with an average age of 32.3 (range 16 to 67) years, with a type A tibia fracture were treated with intramedullary nailing, plate and screws, or hybrid external fixation. The patients were divided into 3 groups: 16 (47%) received hybrid external fixation, 10 (29.4%) received plate and screw fixation, and 8 (23.5%) received intramedullary nailing fixation. The follow‐up protocol included clinical and radiologic evaluations performed at 15 days, 1 month, 3 months, 6 months, and 12 months after surgery. The selected outcome parameters for the 3 groups were as follows: visual analog scale for pain of the traumatized tibia, interval from surgery to weightbearing, average time required for fracture recovery, subjective and objective Ovadia–Beals scores, baropodometric examination at 12 months, walking recovery at 12 months, outcomes, and surgical complications. The endpoint assessment was set at 12 months. The results showed that incorrect reduction of a type A tibia fracture can lead to changes in the sagittal balance line for foot loading and pace training. In conclusion, these findings have shown that the experience of the surgeon in the reduction of the fracture and knowledge of the method of synthesis is essential. &NA; Level of Clinical Evidence: 3

Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: is There a Real Difference in Skin Complication? A Retrospective Study in Three Level I Trauma Center

Introduction: Not enough literature is available to evalute the wound complication rate of plates type in distal fibular fractures. Aim: The aim of our study was to compare wound complications of using a third tubular plate compared to LCP distal fibula plate. Material and Methods: This study is a retrospective single-centre study in which was performed plating of fibula in closed ankle fractures. 93 patients were included in our study and assigned in two groups, based on using of different implant : in group A 48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distal fibula plate. There were no significant differences in the baseline characterisctics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evalueted at 1-3-12 months and clinical examination was made at 12 months using AOFAS clinical rating system. Categorical data, grouped into distinct categories, were evalueted using Chi-square test. We considered a p value < 0.05 as statistically significant. Results: The wound complications rate of the overall study group was 7.6%. There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%); plate removal was performed earlier in the locking plate because of wound complications. Conclusions: Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distal fibula plate and conventional one-third tubular plate. Controversy still exists about the best method for the fracture reduction.

Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes

OBJECTIVE This case-control study was designed to test the hypothesis whether carpal tunnel release (CTR) during fixation of distal radius 23-C2 AO fractures improves outcomes. METHODS Thirty-five consecutive patients who sustained distal radius fractures of the dominant hand participated in this study. Patients were allocated into two groups: (a) The ORIF + CTR (16 patients (11 males and 5 females)); (b) the ORIF and NOT CTR 19 patients (12 males and 7 females). Patient assessment included visual analogic scale of pain (VAS), the subjective Mayo Wrist Score (MWS), electromyograms (EMG) at 3 month and 6 months from the day of injury and complications. All patients had the same physiotherapy treatment algorithm following surgery. Patient follow up took place at 1 month, 3, 6, and 12 months. RESULTS A the T12 month follow up point the VAS average was 0.8 (range 0-3) in ORIF + CTR group compared to 1.2 (range 0-3) in the ORIF and NOT CTR. The MWS average was 98.7 (range 95-100) in ORIF + CTR group versus 97.6 (range 95-100) in ORIF no CTR group. There was no statistical significance (p > 0.5) between the two groups during the follow up period. Patients in the sixth month of ORIF + CTR had no suffering of the median nerve, while 31.58% of patients in ORIF and no CTR found to have carpal tunnel syndrome. CONCLUSIONS Routine release of the transverse carpal ligament at the time of fracture fixation may reduce the incidence of postoperative median nerve dysfunction.

Use of Common Inflammatory Markers in the Long-Term Screening of Total Hip Arthroprosthesis Infections: Our Experience

Orthopedic implants have become essential components of modern medicine. The risk of infection of total hip arthroplasty (THA) is 1.5%−2%. Are the C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) good markers for THA infection screenings? From February 2009 to December 2012 at our Department of Orthopedics and Traumatology, 1248 patients were treated with THA. No prosthesis was cemented. All patients received antibiotic prophylaxis. All patients were discharged approximately 7.4 days after surgery with this clinical and radiographic follow-up program at 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. Blood samples to determine ESR, CRP, and PCT values were taken at 1 hour before surgery and 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. During follow-ups there were 22 cases of THA infections; according the Widmer classification, infections are hematogenous ones in 16 cases, late chronic ones in 5 cases, and early postoperative ones in 1 case. In all cases the three markers were considered positive; in 6 cases there were no radiological signs of septic loosening. ESR, CRP, and PCT proved to have a greater diagnostic accuracy than X-rays in predicting late chronic and early postoperative infections. These markers are valuable support for the surgeon in monitoring the prosthetic implant lifespan.

IS BASELINE STRAIN INDEX A PROGNOSTIC FACTOR FOR SMALL UNILATERAL SUPRASPINATUS TENDON TEARS? A PROSPECTIVE STUDY

Purpose: From prospectively report the 2-year follow-up clinical and real-time sonoelastography (RTSE) outcomes of a group of patients affected by small unilateral supraspinatus tendon tears. Our hypothesis was that patients with lower baseline strain indexes would have worst outcomes at follow-up. Methods: We recruited patients suffering by a unilateral rotator cuff tear. All patients have prospectively scrutinized. Patients were initially managed non-operatively, after at least 3 months of failed conservative treatment patients went under surgery. Our clinical evaluation and follow up was done by: complete physical examination; VAS for pain; Quick DASH; Constant–Murley score; Simple Shoulder Test; ASES score and UCLA score. The mechanical properties of tissues were evalutated by Conventional ultrasounds and RTSE and they were estimated uging the Strain index. Results: Forty-three patients were available for evaluation at 2 years. Fifteen had undergone surgery (operative group), while 28 recovered from pain and dysfunction with conservative management andhad not required surgery (non-operative group). Patients in both groups significantly improved at follow-up, and no differences were found in all considered clinical outcomes. The biomechanical properties of repaired tendons were maintained, while non-operatively treated tendons softened over time. Baseline and follow-up strain indexes were linearly correlated with clinical outcomes at 2 years. Conclusions: Baselinestrain index could be associated with post-operative functional outcomes at 2-year follow-up. The biomechanical properties of surgically repaired tendons were maintained, while non-operatively treated tendons softened over time. At least in this cohort of patients, baseline strain index did not suggest who could be managed conservatively and who will need surgery.