Pietro Maniscalco

Titanium anchors for the repair of distal Achilles tendon ruptures: preliminary report of a new surgical technique.

From January 1995 to July 1996, the authors used Mitek GIV titanium anchors to treat seven patients with acute rupture of the Achilles tendon (four men, three women; average age 52.42 years; range, 33-62 years). All subjects had a total rupture of the most distal aspect of the tendon; none had an avulsion fracture. After dissection down to the paratenon, the reinsertion site was selected and a 2 to 3-cm-long trough carved through the cortex. Three holes were drilled at a distance of 0.5 cm one from the other and 1 cm parallel and distal to the trough. The anchors were then threaded, inserted into the holes, and engaged. Surgery was completed by resection of the frayed ends, reparation of the tendon, and insertion of the terminal end into the trough. At 6 months postoperative, a modified Mandelbaum and Pavanini clinical assessment indicated five excellent and two good outcomes. There were no cases of deep of superficial wound infection or skin necrosis. Despite the small number of patients and the short follow-up period, the authors believe this technique shows promise and that in selected cases the use of titanium anchors can facilitate the task of the surgeon and enable patients to return to normal and sports activities within 5 months after surgery.

IMHS clinical experience in the treatment of peritrochanteric fractures: The results of a multicentric Italian study of 981 cases

This retrospective study evaluates the results obtained in five Italian departments of traumatology in the treatment of peritrochanteric (pertrochanteric and subtrochanteric) fractures by the intramedullary hip screw (IMHS; Smith & Nephew Richards, Memphis, TN, USA) nail. One thousand two hundred and seventy-three patients were treated with the IMHS nail between March 1992 and February 2000. The results of these operations were evaluated clinically and radiological in 981 patients. The 90.3% of patients could walk unaided or with simple support. Because of the low complication rate requiring re-operation (postoperative shaft fractures, screw penetrated the acetabulum, cut out and non-union) (1.7%), we think that this device is an advance in the treatment of peritrochanteric fractures.

Peritalar dislocation: three case reports and literature review

Abstract Peritalar dislocation is an uncommon lesion, although its incidence has increased on account of the rise in motor vehicle accidents and improved radiological diagnostic techniques. In our review of the literature, we counted 312 cases described over the past 50 years. Medial dislocation represented the majority of cases (79%), lateral dislocation accounted for 22%, while poster and anterior dislocations seemed to occur rarely. We report the results of the treatment of 3 patients, one with an irreducible lateral dislocation, one with a irreducible medial dislocation, and one with a reducible medial dislocation. The obstruction to closed reduction for lateral dislocation was the interposed posterior tibial tendon. The obstruction to closed reduction for medial dislocation was an osteochondral impact-fracture of the upper medial part of the head of the talus spiking to the lateral corner of the navicular. Management consisted of immediate reduction and application of a short leg cast for 4 weeks. At long-term follow-up, all 3 patients had no complications and had returned to their pre-injury activities.

Titanium anchors for the repair of rotator cuff tears: preliminary report of a surgical technique

Summary: We used titanium anchors for the surgical repair of rotator cuff tears in 34 selected patients, all of whom were <60 years of age, had good bone quality, and had no known metabolic bone diseases. Nine tears were repaired within 6 months, 15 within 6-12 months, and 10 later than 12 months after injury. Tear size was graded as small (10 patients), medium (15 patients), and large (nine patients) during open operation. After 6-24 months of follow-up, 30 patients reported satisfactory pain relief, function, active forward flexion, and muscle strength [18 excellent and 12 good results based on the University of California at Los Angeles rating system (UCLA scores)] there were no implant failures (p<0.001). Two patients had unsatisfactory function but good relief of pain, whereas two patients were dissatisfied with their overall result (four poor results based on UCLA scores). Although trans-bone suturing is presently the most common and successful surgical technique for rotator cuff tears, we found that use of titanium anchors shortens operative time and has results comparable with the traditional technique. Titanium anchors should not be used when bone quality is poor or good patient compliance is doubtful. They are also contraindicated, as our four poor results indicate, when the tear is old (>6 months) and large (diameter >5 cm with significant tissue degeneration)

Apixaban Versus Enoxaparin in Elective Major Orthopedic Surgery A Clinical Review

Despite current guidelines recommendations about anticoagulant prophylaxis, many studies have shown an high venous thromboembolism (VTE) incidence in patients undergoing total hip and knee arthroplasty. A number of anticoagulants are currently available, but they have some limitations that affect their applicability and consequently their effectiveness. Several new oral anticoagulants (NOACs) have been developed in an attempt to overcome these limitations. Apixaban is a NOAC that selectively inhibits the coagulation factor Xa; it is approved for the prevention of VTE after total hip replacement and total knee replacement surgery. This review examines the results of main trials designed to test efficacy and safety of apixaban in major elective orthopedic surgery.

Fractures of the tibial plafond: a comparison of treatment methods

Abstract From 1995 to 1999, 19 patients (13 males and 6 females) were treated for Code 43 (distal segment) tibial fractures according to AO and Orthopaedic Trauma Association classification: there were 5 type A, 4 type B and 10 type C fractures. The mechanisms of injury included motor-vehicle accidents (n = 8), falls from heights (n = 8), a chainsaw injury (n = 1), and crushing injuries (n = 2). Five patients had associated injuries. All open fractures were managed acutely with wound debridement and application of an external fixator. Closed injuries were operated 1–16 days after injury (average, 6 days). The method of treatment depended on fracture comminution and soft tissue condition. Patients were available for follow-up for an average of 14 months. Results were evaluated by means of subjective and objective rating systems. All fractures in the series united with an average time to healing of 12 weeks. Anatomic or good alignment was obtained in all but 1 fracture. There were 7 excellent, 5 good, 5 fair and 2 poor results. Complications occurred in 2 patients (8%) and included 1 deep infection and 1 loss of reduction with malunion. The most important variables affecting the final clinical results were the type of fracture, the method of treatment, and the quality of reduction.

Use of a modified IMHS for unstable intertrochanteric fractures

The treatment of unstable intertrochanteric fractures in elderly osteopenic patients, especially those who cannot follow limited weight bearing instructions, is controversial. Recent publications indicate concern with excessive sliding of telescoping nail or sliding screw devices when used in these unstable intertrochanteric fractures. In our experience with the use of intramedullary hip screw (IMHS) in these fracture patterns, we have observed excessive sliding and collapse of the fracture in some patients. We modified the keyed centering sleeve by threading its internal distal third and substituted the compression screw with a custom bolt to obtain restricted sliding or rigid fixation depending on the gap between the lag screw and custom bolt. We used this modified system in static configuration to treat five patients who had an unstable intertrochanteric fracture of the femur. The length of the involved limb measured at the time of consolidation showed no shortening. In view of these results, intertrochanteric hip fractures that are unstable in patients with poor bone-stock can be fixed using the modified IMHS in a static or controlled sliding configuration.

The importance of early rehabilitation in proximal humeral fracture: A clinical trial of efficacy and safety of a new endomedullary nail

BACKGROUND The aim of the surgical treatment in proximal humeral fractures is to maintain bone alignment facilitating an early shoulder mobilization. This can be obtained with the use of an endomedullary nail with specific characteristics: a proximal angular multiplanar stability and the possibility to place proximal screws in the calcar region. The objective of this randomized controlled trial is to investigate the effects of an early rehabilitation program in 3-part proximal humeral fractures treated with endomedullary nailing. MATERIALS AND METHODS 126 patients treated with the Diphos Proximal Humeral Nail (PHN), followed with an Intensive Rehabilitation Program (IRP) started in the second postoperative day, were compared to 62 patients with a Standard Rehabilitation Program (SRP) where shoulder mobilization started after 3 weeks. The age of patients was under 65 years. Main Outcome measures were improvement of shoulder function based on Constant Score and quality of life on DASH questionnaire at 1, 3, 6 and 12 months after surgery. Safety outcome was no loss of radiological reduction at any follow-up control. RESULTS A difference considered statistically significant (95% confidence interval) was demonstrated by Constant scores at 3 and 6 months and by DASH questionnaire scores at 1 month after surgery between IRP and SRP groups, however without loss of radiological reduction and maintaining the full fracture healing at the same mean period of 1,8 ± 0,7 months. DISCUSSION This experience allows to highlight essential features of this new kind of endomedullary humeral nail, by its mechanical properties, in proximal humeral fractures in order to permit an early rehabilitation without creating displaced or consolidation delay. LEVEL OF EVIDENCE III, randomized clinical-case-control study.

PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up

INTRODUCTION Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity. MATERIALS AND METHODS We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate. RESULTS Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24-75, 95%CI 34.7-41.4), 67.22 (SD 9.6, range 50-90, 95%CI 64-70.4), 90.54 (SD 6.3, range 75-100, 95%CI 88.4-92.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention. CONCLUSIONS PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention.

Uncemented fully hydroxyapatite-coated hip stem for intracapsular femoral neck fractures in osteoporotic elderly patients: a multicenter study

There is still debate over the limits of age and bone stock quality of patients on whom to use an un-cemented straight stem coated with hydroxyapatite (HA). We studied a group of 244 patients with a displaced intracapsular fracture of the femoral neck who underwent cementless hemiarthroplasty or total hip arthroplasty. 143 patients were reviewed at the two-year follow up. A fully HA-coated stem for intracapsular hip fracture results in a satisfactory return to pre-injury mobility and a low complications rate. The advantage reported in the literature of a low mortality rate with use of an un-cemented implant in elderly patients was shown to be greater still on finding an immediate primary stability and rapid osteointegration of the implant.