Michele Francesco Surace

Clinical applications of growth factors in bone injuries: Experience with BMPs

The management of open fractures and delayed or non unions continue to be complicated by high rates of treatment failure and significant patient disability and dissatisfaction. The use of bone morphogenetic proteins (BMPs) in the treatment of these injuries has been assessed by several authors. BMPs induce the process of bone healing by recruiting bone-forming cells to the area of lesion. The use of BMP currently has two FDA-approved indications: treatment of open tibial fractures treated with intramedullary fixation and treatment of tibia long bone non-union. Despite this limited target, off-label BMP use continues to push the spectrum for new applications. This review describes the current evidence for the use of BMPs in open fractures and non-unions.

Complex Articular Fractures of the Distal Radius: The Role of Closed Reduction and External Fixation

Twenty-two patients underwent surgery for 23 complex articular fractures of the distal radius of C.3 type, according to the AO classification. The surgical treatment consisted, in all cases, of a closed, or limited-open, reduction and external fixation. The functional and radiographic results were analysed at a mean follow-up of 40 months. This retrospective study confirms that satisfactory functional results where obtained in 12 out of the 15 wrists where all the intra and extra-articular parameters of the Fernandez’ criteria where respected. For those wrists where keeping with Fernandez’ criteria for intra-articular parameters and ulnar variance was not possible, four of eight had satisfactory results. As far as the acceptability criteria for radial inclination and dorsal tilt are concerned, the functional results seem to suggest that a little wider tolerance than proposed in the literature could be accepted.

The "Double-Pulley" Technique for Arthroscopic Fixation of Partial Articular-Side Bony Avulsion of the Supraspinatus Tendon: A Rare Case of Bony PASTA Lesion.

We report the use of the double-pulley technique for arthroscopic fixation of the bony PASTA (partial articular surface tendon avulsion) lesion. Arthroscopic examination documented a 15-mm-long and 8-mm-wide comminuted bony avulsion with 2 main fragments. Two double-loaded suture anchors were placed with a transtendinous technique at the anterior and posterior edges of the lesion respecting the tendon insertion to the avulsed fragment. The medial sutures were retrieved through the intact supraspinatus tendon medially to the fracture. The sutures were initially coupled in a double-pulley configuration generating 2 sutures oriented from anterior to posterior; then a simple suture for each anchor oriented from medial to lateral was obtained. At the end of the procedure, the adequacy of reduction and stability of the fragments were confirmed. At 2 months from surgery, radiographic healing of the fracture was noted and integrity of the supraspinatus tendon insertion to the footprint was confirmed by arthro-magnetic resonance imaging, with full recovery of daily activities and complete active range of motion confirmed at 6 and 12 months. The double-pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures. Moreover, it creates a waterproof reduction of the fragments, protecting the fracture site from synovial fluid.

Age-Related Outcome of Mobile-Bearing Total Ankle Replacement

The aim of this study was to investigate clinical and radiographic outcomes in patients 50 years and younger vs patients older than 50 years undergoing total ankle replacement. Seventy consecutive patients who underwent primary total ankle replacement were included in this retrospective study. Patients were assessed clinically and radiographically. There was a statistically significant difference between the 2 groups for the American Orthopaedic Foot & Ankle Society score at final follow-up. The younger group had significantly greater improvement compared with the older group. Total ankle arthroplasty is an effective treatment for young, active patients with symptomatic end-stage ankle arthritis. [Orthopedics. 2017; 40(3):e567-e573.].

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intra-articular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient’s goal and expectations, and surgeon’s experience with the technique.

Femoral Bone Plug in Total Knee Replacement

The intramedullary alignment guides used in total knee replacement disrupt the intramedullary vessels, resulting in greater postoperative blood loss. The use of an autologous bone plug to seal the intramedullary femoral canal has been shown to be effective in reducing postoperative bleeding. The authors present a simple technique to create a bone plug from the anterior chamfer femoral cut to perfectly seal the intramedullary canal of the femur.

Mid- and long-term results of open discectomy: a clinical study with three to twelve years of follow-up

Long-term studies on the results of open discectomy (OD) for the treatment of lumbar disc herniation have shown a high percentage of patients complaining of low back or leg pain and obtaining a permanent disability allowance. We evaluated the clinical results of OD in a consecutive series of patients with 3–12 years of follow-up. A standard questionnaire, containing the Oswestry disability questionnaire (ODQ), was administered to 94 patients who had undergone OD at our institute between 1991 and 1999. A total of 85 patients (55.2%) gave complete information for the study; their mean follow-up was 85.9 months. Forty patients (25.9%) consented to a second clinical examination. The overall mean Oswestry disability index (ODI) was 17.43. At clinical follow-up, 29 of 40 patients (72.5%) suffered low back pain (LBP) with a mean ODI of 21.56. The presence of LBP correlated positively with a higher ODI score. Re-operation was performed in 11 of 85 patients: a 2nd OD procedure was done for recurrent disc herniation in 6 cases and posterior lumbar interbody fusion (PLIF) with posterior instrumentation was performed in 5 patients with disabling LBP. ODI scores in these two groups were respectively 37.33 and 13.2 with a significant difference. Long-term studies on OD have shown a deterioration of the clinical results with time. LBP is the complaint most responsible for a patient’s disability. Our study shows that at the mid- to long-term follow-up, OD still provides good clinical results, but also reveals a high percentage of LBP that is related to the onset of a symptomatic insufficiency of the operated disc. These data seem to be confirmed by the significant improvement of ODI after PLIF.

Femoral revision with special stems

None.

Anterior Longitudinal Osteotomy of the Greater Trochanter in Total Hip Arthroplasty.

The extra-articular impingement of the greater trochanter against the ileum is an underrated cause of early dislocation in total hip arthroplasty. In this preliminary study, the authors assess the effectiveness of an anterior longitudinal osteotomy of the greater trochanter for preventing dislocation. A total of 115 patients underwent a total hip arthroplasty through a posterolateral approach. All patients underwent clinical and radiological follow-up at 1, 3, and 6 months. No dislocation was reported. All patients demonstrated fast recovery of range of motion and walking. No trochanter fractures were observed. The osteotomy of the greater trochanter is an effective surgical technique that decreases anterior impingement and consequently lowers the dislocation rate in primary total hip arthroplasty. [Orthopedics. 2015; 38(8):490-493.].

Fracture of a polyethylene post in a 9-year-old posterior-stabilized knee prosthesis: light microscopy and SEM evaluation

Preoperative planning for revision hip arthroplasty is different form and more complex than planning for primary hip replacement. The surgeon has to keep in mind a variety of issues, including existing implants, techniques of removal implant, bone quality, evidence of infection, soft tissue healing, neurovascular injuries, leg-length discrepancy. A special equipment, implants or bone graft required should be anticipated. Revision of a femoral stem and acetabular component can be a complex and technically demanding procedure due to poor bone stock, periprosthetic fracture, infection and complexities in cement or removal implant. It is mandatory to have clear management strategies with a variety of techniques available. Surgical intervention should be performed only when there is clear evidence of loosening or sepsis. Exploratory procedures without documentation of loosening or sepsis are rarely productive. In aseptic cases with no evidence of loosening, observation is prudent and not harmful.