Pietro Bartolozzi

Percutaneous Distal Metatarsal Osteotomy for Correction of Hallux Valgus

BACKGROUND Distal osteotomy of the first metatarsal is indicated for the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal with use of a percutaneous technique. METHODS From 1996 to 2001, 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed for the treatment of painful mild-to-moderate hallux valgus in eighty-two patients. The patients were assessed with a clinical and radiographic protocol at a mean of 35.9 months postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment. RESULTS The patients were satisfied following 107 (91%) of the 118 procedures. The mean score on the AOFAS scale was 88.2 +/- 12.9 points. The postoperative radiographic assessments showed a significant change (p < 0.05), compared with the preoperative values, in the mean hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle, and sesamoid position. The valgus deformity recurred after three procedures (2.5%), the first metatarsophalangeal joint was stiff but not painful after eight (6.8%), and a deep infection developed after one (0.8%). The infection resolved with antibiotic therapy. CONCLUSIONS The percutaneous technique proved to be reliable for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of a painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable with those obtainable with traditional open techniques, with the additional advantages of a minimally invasive procedure, a substantially shorter operating time, and a reduced risk of complications related to surgical exposure.

Preformed acrylic bone cement spacer loaded with antibiotics: Use of two-stage procedure in 10 patients because of infected hips after total replacement

In 10 patients having deep infection after total hip replacement, we used a two-stage revision procedure involving implantation of a preformed spacer with a cylindrical rod coated with acrylic cement containing antibiotics (Spacer-G). This device, which remained in situ for an average of 5 months, permitted healing of the infection in 8 cases and reimplantation of a new prosthesis (mean follow-up 35 months). During treatment, 1 dislocation occurred. The spacer maintained the gap between both bone segments and allowed a certain degree of joint mobility. Use of Spacer-G improved the quality of life of the patients during treatment and accelerated recovery of function after reimplantation.

Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing

We studied 80 patients (56 females) with an average age of 84 years (range 80-94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55 g/dL and 1.05 g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery.

Long-Term Results of Anti-Protrusio Cage and Massive Allografts for the Management of Periprosthetic Acetabular Bone Loss

From 1992 to 1995, 71 total hip arthroplasties with extensive acetabular bone loss underwent revision using bulk allografts and Burch-Schneider anti-protrusion cages. Twelve patients died of unrelated causes and 3 were lost to follow-up. Fifty-six hips were available for clinical and radiographic follow-up examination at an average of 11.7 years after surgery. The average final Harris hip score was 75. X-ray signs of incorporation of massive bone graft were observed in 49 hips. Two cases developed deep infection that required resection arthroplasty. Aseptic loosening of the acetabular cage occurred in 5 patients, and 2 of them underwent re-revision. With a total survival rate of 87.5%, anti-protrusion cages and structural allografts compare favorably with other techniques in the long-term reconstructive treatment of extensive loss of acetabular bone stock.

Metatarsal lengthening by callotasis during the growth phase

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length.

A Minimum of 10-Year Follow-Up of the Burch-Schneider Cage and Bulk Allografts for the Revision of Pelvic Discontinuity

Eighteen consecutive hips with pelvic discontinuity and associated periprosthetic bone deficiency were treated with bulk allografts and Burch-Schneider antiprotrusio cage. Clinical and radiographic follow-up was performed at an average of 13.5 (range, 10.5-16.6) years. Three cages required re-revision because of infection (1) and aseptic loosening (2). Average Harris hip score improved from 31.9 to 77.0 points (P < .001). A severe resorption of the bone graft occurred in 2 hips. The stability of the cage was detected in 13 cases. The cumulative survival rate at 16.6 years with acetabular revision for any reason, radiographic loosening, or unhealing of the discontinuity as the end point was 72.2%. The use of Burch-Schneider cage and bulk allografts is an effective technique for the treatment of pelvic discontinuity.

One-stage Posterior Decompression-Stabilization and Trans-sacral Interbody Fusion after Partial Reduction for Severe L5-S1 Spondylolisthesis

Study Design. A retrospective clinical study was conducted. Objectives. To evaluate the clinical and radiologic outcomes of one-stage posterior decompression-stabilization after partial reduction and trans-sacral interbody fusion with a titanium cage for severe L5–S1 spondylolisthesis. Summary of the Background Data. Trans-sacral interbody fusion for the management of severe L5–S1 spondylolisthesis with or without partial reduction and pedicular fixation has been previously described. The use of a trans-sacral titanium cage has not been previously reported. Methods. Fifteen patients with severe L5–S1 spondylolisthesis were treated consecutively with posterior decompression, partial reduction, pedicular fixation, and posterior lumbar interbody fusion using a trans-sacral titanium cage. The mean age at the time of surgery was 22.4 years (range, 11–37 years). The mean follow-up period was 31.4 months (range, 12–58 months). Nine patients had severe back pain and six patients radicular pain. Three patients had a partial unilateral L5 motor deficit and two an L5 sensory deficit. Five patients had extremely tight hamstrings. The mean preoperative percentage of slipping was 69.3% (range, 53–91%). Patients were evaluated for complications and fusions, and outcomes were collected using the modified Scoliosis Research Society Outcomes Instrument. Results. At follow-up, all patients, except one with major vascular complications, were extremely or reasonably satisfied with the surgery. All patients showed improvements in radiologic indexes and stable fusion at the final follow-up examination. Conclusions. Posterior decompression and partial reduction followed by circumferential stabilization performed in one stage combining pedicle fixation with trans-sacral titanium cage interbody fusion is an effective and safe technique for the management of severe spondylolisthesis.

Traumatic loss of the talus treated with a talar body prosthesis and total ankle arthroplasty. A case report.

Total talar dislocation is a rare injury1-6 that usually occurs as a result of a high-energy continuation of extreme supination forces causing lateral subtalar dislocation or extreme pronation forces causing medial subtalar dislocation7. Most of these injuries are open and are associated with a high rate of postreduction complications, such as persistent infection (reported in up to 89% of patients2), shearing osteochondral fractures (45%3), osteonecrosis (33% to 50%1,8,9), and severe degenerative arthritis5,6. Prompt closed or open reduction of the talus, when possible, is the recommended treatment, in combination with soft-tissue debridement of open injuries3,10. However, the high rate of complications has led many authors to suggest that primary excision of the talus or tibiocalcaneal arthrodesis1,2,4,5,11 should be performed instead. Tibiotalar or pantalar arthrodesis has been recommended for any cases of osteonecrosis or arthritis that develop later. Primary open dislocation with loss of the talus (“missing talus”)2, however, necessitates the performance of either a tibiocalcaneal arthrodesis or a resection arthroplasty, which is difficult to create and maintain. Both procedures often produce unwanted effects on the foot, particularly in young patients, because of loss of function of the peritalar joints3,12-14. To avoid the necessity of performing these procedures and to preserve ankle function, the implantation of a talar body prosthesis has been proposed15. Because the long-term survival of such an implant, especially in active individuals, is not known, a total ankle arthroplasty coupled with a talar prosthesis fixed to the calcaneus and the navicular may be an alternative solution. We describe the case of a forty-five-year-old man in whom total ankle arthroplasty and …

Minimally invasive retrocapital osteotomy of the first metatarsal in hallux valgus deformity.

ObjectivePercutaneous retrocapital distal osteotomy of the first metatarsal for surgical treatment of hallux valgus.IndicationsMild to moderate hallux valgus deformity in both juveniles and adults.Recurrent hallux valgus deformity after previous surgery.ContraindicationsSevere degenerative changes of the first metatarsophalangeal joint (hallux valgus et rigidus).Previous Kellers procedure.Surgical TechniqueA percutaneous distal linear osteotomy of the first metatarsal is performed and stabilized with a Kirschner wire. The surgical technique follows these steps: distal Kirschner wire insertion; skin incision; sparse periosteal detachment; distal retrocapital osteotomy of the first metatarsal; correction of the first intermetatarsal angle by lateral displacement of the capital fragment; stabilization with Kischner wire insertion into the proximal metatarsal; postoperative taping.ResultsThe patients were satisfied following 107 (91%) of 118 consecutive percutaneous procedures with a follow-up of 35.9 months (range 24–78 months). According to the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale for the clinical assessment, a mean score of 88.2 ± 12.9 was obtained at follow-up. The clinical results can be compared to those obtained with open techniques, with the advantages of a minimally invasive procedure.ZusammenfassungOperationszielPerkutane retrokapitale distale Osteotomie des ersten Mittelfußknochens zur chirurgischen Behandlung des Hallux valgus.IndikationenLeichte bis mittelschwere Hallux-valgus-Deformität bei Jugendlichen und Erwachsenen.Wiederauftretende Hallux-valgus-Deformität nach vorangegangener Operation.KontraindikationenSchwere degenerative Veränderungen des ersten Metatarsophalangealgelenks (Hallux valgus et rigidus).Vorheriges Keller-Verfahren.OperationstechnikEine perkutane distale lineare Osteotomie des ersten Mittelfußknochens wird durchgeführt und mit einem Kirschner-Draht stabilisiert. Die Operationstechnik umfasst folgende Schritte: distale Einführung des Kirschner-Drahts; Hautschnitt; sparsame Ablösung der Knochenhaut; distale retrokapitale Osteotomie des ersten Mittelfußknochens; Korrektur des ersten intermetatarsalen Winkels durch seitliche Verschiebung des Kopffragments; Stabilisation durch Einführung des Kirschner-Drahts in den proximalen Mittelfußknochen; postoperativer Verband.ErgebnisseNach 118 konsekutiven perkutanen Verfahren mit einer Nachuntersuchungszeit von durchschnittlich 35,9 Monaten (24–78 Monate) waren 107 (91%) der Patienten mit dem Ergebnis zufrieden. Auf der „hallux metatarsophalangealinterphalangeal“-Skala der American Orthopaedic Foot and Ankle Society (AOFAS) zur klinischen Beurteilung wurde bei den Nachuntersuchungen ein durchschnittliches Ergebnis von 88,2 ± 12,9 erreicht. Die klinischen Ergebnisse können mit denen der offenen Techniken verglichen werden, haben aber den Vorteil eines minimalinvasiven Verfahrens.

Three-Dimensional Matrix-Induced Autologous Chondrocytes Implantation for Osteochondral Lesions of the Talus: Midterm Results

Introduction. We evaluate the midterm results of thirty patients who underwent autologous chondrocytes implantation for talus osteochondral lesions treatment. Materials and Methods. From 2002 to 2009, 30 ankles with a mean lesion size of 2,36 cm2 were treated. We evaluated patients using American Orthopaedic Foot and Ankle Surgery and Coughlin score, Van Dijk scale, recovering time, and Musculoskeletal Outcomes Data Evaluation and Management System. Results. The mean AOFAS score varied from 36.9 to 83.9 at follow-up. Average of Van Dijk scale was 141.1. Coughlin score was excellent/good in 24 patients. MOCART score varied from 6.3 to 3.8. Discussion. This matrix is easy to handle conformable to the lesion and apply by arthroscopy. No correlation between MRI imaging and clinical results is found. Conclusions. Our results, compared with those reported in literature with other surgical procedures, show no superiority evidence for our technique compared to the others regarding the size of the lesions.