Michele Bisaccia

Bunionette: Minimally Invasive and Percutaneous Techniques: A Topical Review of the Literature

Purpose. The purpose of this study is to review the most recent literature available on the treatment of bunionette (also named tailor’s bunion) with percutaneous and minimally invasive techniques. Focusing especially on clinical outcomes, studies related to this type of techniques were examined in order to evaluate the success of this practice that is, fusion rate and complications. The hypothesis is that these techniques are safe and successful procedures. Methods. In July 2015, a topical review of the PubMed/MEDLINE, EMBASE, and Google Scholar databases was conducted using the keywords percutaneous (OR mini-invasive OR minimally invasive) AND bunionette (OR tailor’s bunion) AND treatment (OR surgery). Studies reporting the outcomes of the surgical treatment of bunionette were also included in our review. Results. The search yielded a total of 111 publications from PubMed/MEDLINE, EMBASE, and Google Scholar. After evaluating abstracts and full-text reviews, 9 articles were included in this review. Treat...

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon

BACKGROUND To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. METHODS We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. RESULTS Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Mearys angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. CONCLUSIONS Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

Comparison of Plate, Nail and External Fixation in the Management of Diaphyseal Fractures of the Humerus

Introduction: Humeral shaft fractures are quite common in orthopedics and represent 1-3% of adult fractures. The surgical treatment is the a better choice in order to obtain a reduction and stable alignment and to prevent the complications. The goal of this study was to compare the three techniques (IMN, LCP and EF) in the treatment of diaphyseal fractures of the humerus in the adult patient. Materials and Methods: We examined 79 patients with diaphyseal fractures of the humerus. 32 were treated with plaque (LCP), 26 with intramedullary nail (IMN) and 21 with eternal fixer (FE) The clinical and radiographic follow-up was done at 1.3, 6 and 12 months. As rating scales we used the ASES and SF-36. We recorded all the complications. Results: The median follow-up was 11.5 months (9-16). The operative time was significantly smaller in the case of FE (47 ‘) with a statistically significant difference compared with other techniques. Even the blood loss was lower in the case of FE (60ml), compared to nails (160ml) and LCP (330ml) p <0.05. We had no differences in the duration of hospitalization and the ASES SF-36 score. We had 2 cases of non-union in the LCP group, 1 case in the IMN group and no cases in the FE group. In IMN group we had one case of radial transient paralysis. We did not have any deep infection, in the FE group 8 patients we had superficial secretions from pins. Conclusion: From the results of our study, it is clear that the treatment of humeral shaft fractures guarantee overlapping results with the use of plates, of intramedullary nails, or with the external fixator. Consequently, the choice of which technique to use should be determined based on the experience of the operator and patient compliance.

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.

The Advantages of Type III Scaphoid Nonunion Advanced Collapse (SNAC) Treatment With Partial Carpal Arthrodesis in the Dominant Hand: Results of 5-year Follow-up

Introduction: The SNAC wrist (Scaphoid nonunion advanced collapse) is one of the complications following scaphoid fractures treated conservatively and one of the causes of wrist arthritis that the hand surgeon has to face most frequently. In these cases surgical management is usually warranted. Materials and Methods: In the set time frame of 6 years we treated 15 SNAC wrist cases. On average patients underwent surgery five years after the trauma. All patients were treated via dorsal incision with partial carpal arthrodesis and total scaphoidectomy, associated with denervation of the posterior interosseous nerves. A plaster cast was applied to all patients for 3 weeks postoperatively. In the preoperative stage, X-rays of the healthy contralateral limb were taken for the measurement of the normal radiocarpal joint space. Clinical and radiographic follow-ups were conducted at 1,3, 6 and 12 months from the trauma; then every 12 months. Criteria for the evaluation of patients: visual analog pain scale (VAS), average time of radiographic fusion of wrist bones, Active Range of Wrist Motion (WAROM), subjective Mayo Wrist Score (MWS) and The Short Form ( 36) Health Survey (SF-36), return to the main tasks and complications. The evaluation endpoint was set at 60 months. Average time of surgery: 48.3 minutes. Average time of arthrodesis consolidation: 67.8 days. The VAS and WAROM showed a gradual improvement in seriated controls, returning to values almost identical to pre-trauma at a 5-year follow-up. By this time, the MWS and SF-36 scores were similar to pre-trauma. On average, the return to pre-injury daily activities occurred in 12.5 months after surgery. There were no complications. Conclusions: The partial carpal arthrodesis is a safe and effective procedure for the treatment of SNAC wrist cases. Our results show a progressive and significant improvement in ROM, VAS and great satisfaction from the patient.

Effect of trochleocapitellar index on adult patient-reported outcomes after noncomminuted intra-articular distal humeral fractures

BACKGROUND Anatomic surgical reduction of intra-articular fractures of the distal humerus is important to achieve the best long-term outcomes and prevent post-traumatic arthritis. In this study we compared the radiographic reduction using the trochleocapitellar index. We also correlated the trochleocapitellar index to the functional outcomes next to the comparison of the triceps brachii lifting approach and olecranon osteotomy approach, 2 common approaches for distal humeral fractures. METHODS From January 2006 to June 2016, patients with elbow fractures were registered in 4 centers. The trochleocapitellar index, a ratio between the angle of the capitellum and the trochlea to the midline of the distal humerus on anterior-posterior radiographs, was calculated for included patients. Functional outcomes were measured using the Oxford Elbow Score and the Mayo Elbow Performance Score. Bone healing was measured using radiographic union scoring. RESULTS There were 86 patients enrolled: 46 in the olecranon osteotomy group and 40 in the triceps lifting group. Functional outcomes and bone healing did not differ between the approaches. Functional results had a medium correlation with the trochleocapitellar index, which did not differ between the 2 approaches (olecranon osteotomy group, κ = 0.56; triceps lifting group, κ = 0.57; P = .7932). CONCLUSIONS The trochleocapitellar index has a moderate predictive value on the functional results after 12 months after open reduction and internal fixation of intra-articular distal humeral factures. There is no difference in reduction, as measured by trochlear index and functional outcome scores, between the olecranon osteotomy approach and the triceps brachii lifting approach groups.

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

Tranexamic Acid in Pertrochanteric Femoral Fracture: Is it a Safe Drug or Not?

Abstract Background: There is a high incidence of blood transfusion following hip fractures in elderly patients. Aim: The aim of this study is to evaluate the effectiveness and complications of use of tranexamic acid in proximal femur nailing surgery. Materials and methods: Our sample group consisted of 90 patients suffering from pertrochanteric fractures surgically treated with osteosynthesis with SupernailGT(LimaCorporate). The classification system AO/OTA was used to divide the fractures into 31A1 (n=45) and 31A2 (n=45). The patients were divided into two groups: 47 patients were administered 15 mg of tranexamic acid per kg (group A) and 43 patients were administered placebo (group B). Blood counts were monitored daily to evaluate the rate of anemia. As a safety criterion, we monitored the possible occurrence of vascular events, symptomatic or not, over the 8 weeks post-surgery. Markers predicting mortality and deep venous thrombosis (DVE) were also monitored (fibrinogen D-dimer). Results: Blood loss occurring post-surgery can be influenced by numerous factors that are not linked to the use or non-use of tranexamic acid. While closely monitoring hemoglobin levels daily, we observed that 42% of the patients in group A required blood transfusion as opposed to 60% in group B. The results of the markers predicting mortality (alpha1-acid glycoprotein; albumin LDL) and those of DVE were not statistically significant between the two groups in this study (p>0.05). Conclusion: Based on this study, the use of tranexamic acid was statistically significant in reducing post-surgery blood loss.

Breakage in Two Points of a Short and Undersized “Affixus” Cephalomedullary Nail in a Very Active Elderly Female: A Case Report and Review of the Literature

Introduction Trochanteric fractures of the femur are common in elderly individuals with osteoporosis. The use of cephalomedullary nails is increasing, and they are now the most commonly used fixation devices, especially for the treatment of unstable trochanteric fractures. The nail breakage is not the most common complication of intramedullary nailing. Many scientific papers report nail breakage in a specific location: through the lag screw hole, the nail shaft, or the distal locking hole. Materials and Methods We present a case of an 84-year-old patient treated with modular revision hip arthroplasty due to the breakage in two points of a cephalomedullary nail implanted 3 years earlier for a subtrochanteric fracture. Results After modular revision hip arthroplasty, the functional results and quality of life have been excellent. Conclusions As far as we could determine, this appears to be the first case of a breakage of a cephalomedullary nail in two points after nonunion in a very active elderly female.