Massimiliano Carrozzo

Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study

We investigated whether a proximal femoral nail can be implanted without a distal locking screw in AO/OTA 31-A1 and 31-A2 pertrochanteric stable femur fractures. A multicentre, randomised study was conducted in six level-two trauma centres in our area (Puglia, Italy). A total of 333 patients received their allocated intervention (162 in the locking group [LG] and 171 in the unlocking group [UG]) and 266 patients were included in the final analysis at 1year. Our data showed no statistically significant difference between the two groups at 1-year follow-up for ability to walk, SF-36 questionnaire results, residual pain (visual analogue scale [VAS] score) and level of overall satisfaction. There were also no statistically significant differences between groups for mortality and length of hospital stay. Conversely, the UG was associated with shorter operation and fluoroscopy times, shorter surgical incision length, and less blood loss and residual thigh pain. Pertrochanteric stable fractures (31-A1, 31-A2) can be treated successfully with intramedullary nails without distal locking, reducing patient and clinical personnel radiation exposure and sanitary costs (surgery time and screws costs).

Volar locking plate vs epibloc system for distal radius fractures in the elderly

PURPOSE To compare clinical outcomes of ORIF with volar locking plates and the Epibloc system (ES) in the treatment of distal radius fractures (DRFs) in patients aged over 65 years. METHODS We retrospectively examined a consecutive series of 100 patients with intra-articular or extra-articular DRF who were admitted to our Department of Orthopaedics and Traumatology between January 2007 and January 2013. Fifty patients were treated using the Epibloc System; and the other 50 patients using ORIF with volar locking plates. In all patients, functional evaluation (wrist range of motion [ROM], grip strength and Disability of the Arm, Shoulder and Hand [DASH] Score) and radiographic assessment (radial inclination, volar tilt, ulnar variance and articular congruity) were performed at 2 and 6 weeks, and 3, 6 and 12 months postoperatively; then every 12 months thereafter. RESULTS ORIF with volar locking plates was associated with better outcome than ES in the intra-articular and extra-articular DRF groups, generating higher average ROM, DASH and visual analogue scale (VAS) scores. Grip strength mean values, however, were quantified over the minimum level for a functional wrist (>60%) in both groups. There were no differences between the two techniques in X-ray parameters, and no further correlation was found with functional outcome and ROM. CONCLUSIONS In a low-functioning patient with multiple medical comorbidities, minimally-invasive surgery with the ES is a safe option, enables early mobilisation of the wrist and is likely to produce acceptable clinical outcomes.

Correlation between fixation systems elasticity and bone tunnel widening after ACL reconstruction.

BACKGROUND Femoral and tibial tunnel widening (TW) after ACL reconstruction is a phenomenon increasing talk in the literature. It is underlying biological and mechanical causes. OBJECTIVE The aim of this study was to evaluate the relationship between bone tunnel enlargement and two different ACL fixation systems. PATIENTS AND METHODS 40 patient underwent ACL reconstruction with hamstring; randomly divided into group A with 20 patients treated with stiff systems (femoral Rigidfix and tibial interference screw), and into group B, with 20 patients treated with morel elastic system (femoral and tibial Tight-rope). Evaluated postoperatively with knee MRI at 40 days, 3 months, 6 months to measure bone tunnel diameters widening. RESULTS At 40 days tunnel widening between two groups shows no statistically difference. At 3 months postoperatively, femoral bone tunnel widening amounted on average to 1.84 mm in middle of tunnel and 1 mm at the mouth in joint in group A, and respectively 3.2 mm and 2.5 mm in group B (p<0.05). Tibial tunnel widening was 1.24 mm at the mouth in joint and 1.3 mm in middle in group A and respectively 2.26 mm and 2.43 mm in group B (p<0.05). At 6 months femoral tunnel widening amounted on average to 2.45 mm in middle and 1.35 mm at the mouth in joint in group A and respectively 3.5 mm and 2.7 mm in group B (p<0.01). Tibial tunnel widening amounted on average to 1.27 at mouth in joint and 1 mm in middle of tunnel in group A and respectively 2.6 mm and 2.3 mm in group B (p<0.01). CONCLUSIONS This study results suggest elastic fixation system increases bone tunnel enlargement after ACL reconstruction with hamstring without correlation with worse clinical performance. LEVEL OF EVIDENCE IV.

L’osteosintesi nelle fratture periprotesiche di ginocchio: una chirurgia difficile

The incidence of periprosthetic fractures after total knee arthroplasty appears to be on the rise as a result of the increasing longevity of patients with knee prosthetic implants. The most common pattern involves the supracondylar area of the distal femur above a well-fixed prosthesis. If a periprosthetic fracture occurs, an appropriate treatment method should be selected considering different factors.

TEMPORARY REMOVAL: Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis’ injuries in Weber B and C type fractures

BACKGROUND This study compared clinical and radiographic results of patients who underwent stabilization of syndesmosis with one tricortical syndesmotic screw divided into three different groups: Group A without preoperative fractured ankle computed tomography (CT) scan, Group B with preoperative fractured CT scan, and Group C with preoperative bilateral ankle CT analysis. METHODS Between June 2016 and May 2017, fifty-one patients with fracture type AO/OTA 44 B and C were analyzed. Of those, 14 (27.45%) were assigned to Group A, 19 (37.25%) to Group B, and 18 (35.30%) to Group C. Clinical outcomes with AOFAS score at 3, 6 and 12 months were recorded. Seven measurements on axial CT scan images were confronted between the injured and uninjured ankle to check the accuracy of reduction. RESULTS At three months of follow up the median AOFAS score was 70.86 ± 2.98 with no significative difference between groups (p = 0.105). At 12 months of follow up the median AOFAS score was higher in group C (93.44 ± 3.01) compared to Group B and Group C. The seven variables measured at the CT scan after syndesmotic reduction were statistically different between groups. We found a better restoration of the tibiofibular distances and the correct ankle anatomy in Group C respect to Group A and Group B. CONCLUSIONS Use of the pre-operative CT scan of the injured and uninjured ankle give to the surgeons the more and accurate information for the reduction and help him intraoperative in the correct maneuvers. The accuracy of the syndesmosis reduction determines better clinical outcomes.

Il ruolo della fissazione esterna come trattamento definitivo delle fratture sovracondiloidee di femore

The treatment of distal femoral fractures has evolved with the introduction of the LISS and MIPO techniques. Unfortunely, these fractures remain difficult to treat with an unpredictable prognosis. Over the years, many different strategies have been used with varying success. The role of external fixation in the management of these fractures is discussed. Holding the surgical skill factor constant, we conclude that external fixation provide excellent bone healing capability, especially in case of open fractures, and guarantee satisfactory outcomes in selected cases.

Clavicle aseptic nonunion: is there a place for cortical allogenic strut graft?

We investigated functional and radiological outcome in 57 cases of midshaft clavicle nonunion treated with open reduction and internal fixation with plate and screws over a 13 year-period. Intercalary bone graft was used in 42 patients; opposite autologous strut graft was used in 31 cases to provide mechanical support to the host bone. Patients were analysed using chart and radiological review and assessed with DASH questionnaire obtained at the latest follow-up. 37 patients were male while 20 were females, with a mean age of 35 years (63-17). All cases were of nonunion, 35 atrophic and 22 hypertrophic. The dominant side was injured in 32 cases and the non dominant in 25 cases. Primarily, 43 cases were treated conservatively with a figure of eight bandage. Time between fracture and our operative treatment was on average 44 months (13-72 months). Only those patients who were symptomatic were included in this study. We used straight reconstruction LCP and low profile precontoured plates. By reviewing patients charts all the cases but one of nonunion progressed to osseous healing at a mean time of 14 weeks (range 12-16). The patient with non-union refused further surgery. 49 patients were available for a final follow up. DASH score was 16.7 at an average of 42 months. Open surgery and internal fixation, using plate and screws in a compression construct is the treatment of choice for symptomatic clavicular non-unions. Intercalary autologous or allograft bone graft should be used especially in patient with significant bone loss; autologous cortical strut graft provides optimum mechanical stability, thus assuring optimal screw purchase and allowing immediate limb movement.