Redento Mora

Isolated fracture-dislocation of the second cuneiform bone

A 61-year-old man had been involved in a head-on car collision. In an attempt to avoid the collision, he had violently jammed his right foot under the brake pedal. On admission, he had a great deal of pain, edema, and deformity of the dorsal aspect of the midfoot. Radiographs revealed a dorsal, isolated fracture-dislocation of the second cuneiform bone (Figure 1). Under local anesthesia, the dislocation was reduced with an audible snap, but the reduction was unstable. A posterior splint was then applied to the right leg, and was allowed to remain until the edema, 1 week later, had subsided. Two days later, then under general anesthesia and fluoroscopic control, a new closed reduction was performed, and two crossed Kirschner wires were used to maintain it. Lastly, a short leg cast was applied. The cast and the wires were removed after 5 weeks; and 4 months after the injury, there was complete recovery.

Two cases of periosteal chondroma.

One of our 2 cases of periosteal chondroma of the tibia recurred three times before definitive cure, and required extensive radiographic and histologic evaluation to avoid overinterpreting the malignancy. Our experience confirms that marginal excision should be employed.

Treatment of infected nonunions

The first three types of the classification outlined in Table 1 are the “infected variety” of the three corresponding types of noninfected nonunion, whose morphologic and functional features and whose principles of treatment have already been discussed. Their treatment is similar to that of the noninfected variety, but commences after accurate debridement and adequate specific antibiotic therapy. Only on rare occasions does “infection burn on the fire of the bone regenerate”, as Ilizarov mentioned with a sort of optimism Table 1. Classification of infected nonunions and principles of treatment according to Umiarov [1]

Revision of 120 tibial infected non-unions with bone and soft tissue loss treated with epidermato-fascial osteoplasty according to Umiarov

Treatment of tibial infected non-unions with bone and soft tissue loss has to solve three problems: infection, lack of bone continuity and lack of skin coverage. The aims of treatment are infection healing, bone consolidation with preservation of limb length and soft tissue reconstruction. The most important stage in the planning is an accurate débridement. Soft tissue reconstruction can be achieved using plastic surgery, and bone reconstruction is accomplished with bone grafts or induced membrane technique, but these methods may present disadvantages and risks. Epidermato-fascial osteoplasty is a modified procedure of compression-distraction osteosynthesis that was first described by Umiarov in 1982. This procedure offers the advantages of exactly classifying the phases of simultaneous bone and soft tissue regeneration, and of eliminating large tissue losses without previous closure of soft tissues or use of grafts, because the transported fragment takes fascia and skin along during the transport and closes the edges of the soft tissue gap until the epidermic and fascial reconstruction is complete. A total of 120 patients underwent this kind of surgery between 1986 and 2010 and were followed up for 2-26 years. Average age was 34 years (range 21-57 years). Cultures were positive for Staphylococcus in all cases, and for Pseudomonas in 27 cases. Adequate antibiotic therapy was administered in collaboration with the Infectious Diseases Specialist. Tibial bone resection was from 6 to 18cm (average 9.5cm). The Ilizarov apparatus was used with the oblique wire technique for bone transport in all patients. No intraoperative complications were observed. One patient died 40 days after the operation because of pulmonary embolism. The duration of treatment for the remaining 119 patients was 7-18 months. In all cases, infection eradication, healing of regenerate bone, consolidation at the docking site (with the aid of an autoplastic bone graft in only 11 patients), and epidermic and fascial reconstruction were observed, and functional results were very good. These techniques are particularly demanding for the patient and for the surgical team, but our results demonstrate that they can provide excellent outcomes in the management of difficult cases of infected non-unions.

Compression-Distraction Systems

There are a few basic elements of circular external fixation systems, as underlined by Kalnberz [1]. They can be summed up as: bone fixation elements, rings which encircle the bone segment, rods connecting the rings, connecting elements between rods and rings, and connecting elements between rings and bone fixation elements. Many other elements can be added (Fig. 1). However, they differ in importance and number from system to system, and their effectiveness is often questionable.

Treatment of Noninfected Nonunions: Parafocal Osteotomy

Osteotomies performed in the management of nonunions can be classified into three types [1]: Intrafocal osteotomy (performed at the nonunion site: it consists essentially of the resection of the entire area around the nonunion); Transfocal osteotomy (performed through the nonunion site to reshape the bone ends: it is indicated for nonunions with a longitudinal or oblique fracture line); Parafocal osteotomy (Paltrinieri’s osteotomy, performed some centimeters from the nonunion site). In this chapter the original idea by Paltrinieri (parafocal osteotomy) and the indications for this technique are described and discussed.

Assessment of fracture healing.

Markel and Chao [1] underlined that long bone fractures consolidate without complications in most patients. Moreover, in patients in whom the use of complex monitoring techniques of fracture healing was indicated, these techniques were often in an experimental stage and hardly available, and their use was limited to the study of some selected bone segments. For these reasons the techniques most commonly employed to assess fracture repair until a few years ago included: subjective criteria (patient’s evaluation of pain), objective criteria (manual examination of the fracture stability), temporal criteria (simple passage of time), and instrumental criteria (radiographic evidence of consolidation). In brief, if bone healing conditions are normal, traditional methods of monitoring are considered adequate. In particular, radiographic investigation is the most important method because it is the simplest, it provides continuous information, and it is easily used for iterative interpretations [2].

Failure of Union

“Despite the improvement in the understanding of fracture repair and treatment techniques...delayed unions and nonunions occur all too frequently in our violent society...” [1]. Delayed union is a mainly clinical diagnosis, “a clinical entity of a slowly healing fracture” [2]. It is defined as the failure of a fracture to heal in the usual period of time, depending on the type and site of fracture and on the bone and soft tissue damage. Upon physical examination generally some tenderness and mild movement are observed; x-ray findings highlight a certain degree of callus formation but radiolucency at the fracture site. Nonunion is defined as the failure of a fracture to heal in twice the usual period of time (at least 6 months after trauma); the fracture gap is bridged by fibrous tissue or fibrocartilage instead of bone tissue. The main clinical signs are tenderness and presence of micromotion. Radiographic signs include: persistent fracture line, bone end sclerosis, hypertrophic callus formation or atrophic bone resorption, and possibly radiolucency around osteosynthetic devices. Pseudoarthrosis (or synovial pseudoarthrosis) is defined as a fracture that has failed to heal and in which a cleft is observed between the bone ends. This cavity is fluid-filled and lined by a membrane. Radiographic examination very often shows a typical “mortar and pestle” bone configuration.

Treatment of Noninfected Nonunions: Normotrophic Nonunions

In normotrophic nonunions (the intermediate category between hypertrophic and atrophic nonunions), vascularization at the nonunion site is poor but exists, and on the bone scan detection of the tracer is poor. The biological activity of the connective tissue in the interfragmentary gap is low but not absent. Therefore, the aim of the treatment is to increase this capability and enhance the osteogenic properties of the tissue.

Reaction to methylmethacrylate in bone metastases treated by surgical curetting and filling with acrylic cement

SummaryA femur bone metastasis from breast carcinoma was treated by curetting and filling with acrylic cement and osteosynthesis.The histological study of the resected proximal third of the femur five months after surgery shows a thin layer of connective tissue between bone and cement.There are no neoplastic cells in this connective tissue nor in the spongious bone of the proximal femur.Instead the diaphyseal channel is fully invaded with neoplastic cells.Pathogenesis and validity of surgical treatment by the emptying and filling with acrylic cement of bone metastases are discussed.ZusammenfassungEine, von einem Mammacarcinom ausgehende, solitäre, osteolytische Skelettmetastase im Femur führte zur pathologischen Fraktur. Die Osteolysezone wurde auskürettiert, mit autopolymerisierendem Methylmethacrylat aufgefüllt und die Fraktur durch eine zusätzliche Osteosynthese stabilisiert. Fünf Monate nach diesem Eingriff mußte das proximale Femurende wegen Bruches der Osteosyntheseplatte reseziert werden. Die histologische Untersuchung des Resektates ergab eine dünne Schicht von Bindegewebe zwischen Knochenzement und Knochen. Weder in diesem Bindegewebe noch im spongiösen Knochen des proximalen Teiles des Femur fanden sich neoplastische Zellen. Dagegen war der Femurdiaphysenkanal vollkommen von Tumorgewebe ausgefüllt. Die Pathogenese der Knochenmetastase und die Wirksamkeit der chirurgischen Behandlung durch Kürettage und Füllung mit Knochenzement werden diskutiert.