Luisella Pedrotti

Nimesulide beta cyclodextrin (nimesulide-betadex) versus nimesulide in the treatment of pain after arthroscopic surgery

Abstract This study examined the efficacy of nimesulide beta cyclodextrin (nimesulide-betadex) in the relief of pain after arthroscopic surgery of the knee. In this double-masked study, 185 patients requiring analgesia after anterior cruciate ligament reconstruction surgery were randomly allocated to receive a single dose of either nimesulide-betadex (n = 93) or nimesulide (n = 92). Patients assessed pain intensity using a 100-mm visual analogue scale (VAS) 15, 30, 45, 60, 75, 90, 120, 150, and 180 minutes after treatment. Both treatments were highly effective in reducing pain intensity. In the nimesulide-betadex group, a statistically significant reduction in pain intensity compared with baseline was observed 15 minutes after treatment, whereas for nimesulide a significant difference was not reached until 30 minutes after treatment. The two treatments were bioequivalent with respect to overall extent of pain relief as measured by the area under the concentration-time curve from 0 to 90 minutes. In both groups the majority of patients (71%) assessed overall efficacy as good or excellent, and more than 76% assessed tolerability as excellent. This study demonstrates that nimesulide-betadex has a more rapid onset of analgesic action than nimesulide, with an equivalent analgesic effect, and may ofer a useful alternative in postoperative cases in which rapid relief of pain is required.

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.

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].

Failure of Union

“Despite the improvement in the understanding of fracture repair and treatment techniques...delayed unions and nonunions occur all too frequently in our violent society...” [1]. Delayed union is a mainly clinical diagnosis, “a clinical entity of a slowly healing fracture” [2]. It is defined as the failure of a fracture to heal in the usual period of time, depending on the type and site of fracture and on the bone and soft tissue damage. Upon physical examination generally some tenderness and mild movement are observed; x-ray findings highlight a certain degree of callus formation but radiolucency at the fracture site. Nonunion is defined as the failure of a fracture to heal in twice the usual period of time (at least 6 months after trauma); the fracture gap is bridged by fibrous tissue or fibrocartilage instead of bone tissue. The main clinical signs are tenderness and presence of micromotion. Radiographic signs include: persistent fracture line, bone end sclerosis, hypertrophic callus formation or atrophic bone resorption, and possibly radiolucency around osteosynthetic devices. Pseudoarthrosis (or synovial pseudoarthrosis) is defined as a fracture that has failed to heal and in which a cleft is observed between the bone ends. This cavity is fluid-filled and lined by a membrane. Radiographic examination very often shows a typical “mortar and pestle” bone configuration.

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.

Non-unions, Pseudoarthroses, and Long-Bone Defects

With rare exceptions, pseudoarthroses are accompanied by the loss of bone tissue, i.e., by an anatomic defect. However, from a practical point of view, a clear definition of both “pseudoarthrosis” and “defect” is of fundamental importance in the correct selection of the extent and tactics of both treatment and rehabilitation measures. A pseudoarthrosis refers to the condition in which it is anticipated that despite medical interventions the achieved degree of union of the bone fragments will not lead to humeral shortening by >8–10 mm, or shortening of one of the forearm bones by >5 mm, or of the femur and leg bones by >10–15 mm.