Gabriella Tuvo

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: Normotrophic Nonunions

In normotrophic nonunions (the intermediate category between hypertrophic and atrophic nonunions), vascularization at the nonunion site is poor but exists, and on the bone scan detection of the tracer is poor. The biological activity of the connective tissue in the interfragmentary gap is low but not absent. Therefore, the aim of the treatment is to increase this capability and enhance the osteogenic properties of the tissue.

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.

Nonunions: Treatment Objectives and Options

The main objective in the management of nonunions is fracture healing; the second objective is restoration of the limb function, either by correcting any shortening or angular, rotational, translational deformity or by eliminating the stiffness of the adjacent joints. Joint stiffness can be treated by using the most appropriate nonoperative techniques (physiotherapy, CPM, or hinged braces) or operative methods (arthrotomy, arthrolysis, or myolysis). In the particular case of infected nonunions, the treatment aim is nonunion healing and eradication of infection and to gain a functional limb. To accomplish these objectives, considerable time is needed and multiple operative procedures are often required. In selected patients in whom many previous procedures have failed and who have extensive bone and soft tissue loss and neurovascular damage, amputation can be considered.

Prevention of Venous Thromboembolism

Patients should be assessed individually, both considering any existing risk factors for VTE, and their risk of bleeding (ie may be already at lower risk of DVT). A decision can then be made as to whether VTE prevention should be offered and, if so, whether this should be pharmacological or mechanical. For patients with increased risk, the balance of risk versus benefits of treatment should be reassessed at regular intervals. For patients in hospital this should be 24 hours after admission or whenever there is a change in the clinical situation.