Reliability of S.A.R.A. (sterilization and reimplantation autograft) technique in long bone open fractures

The reimplantation of small or large extruded bone segments is one of the most complex clinical management scenarios in the treatment of open fractures. No consensus exists regarding the efficiency of this technique. The aim of the study was to analyse the clinical and radiological outcomes of Sterilization and Reimplantation Autograft (S.A.R.A.) technique in open fractures. Therefore, fifteen skeletally mature patients with Gustilo-Anderson -IIIB type fractures treated with autograft reimplantation, were included in this study. The sample size was divided in two groups: patients with a loss of small segments (Group A - less than 5 cm) and those with large segments (Group B - greater than 5 cm). Eight patients belonged to Group A and seven to Group B. The treatment of contaminated bone may be performed by the following protocols: saline rinse, povidone-iodine scrub and saline rinse, retain periosteum, immersion in antibiotic solution (clindamycin and gentamicin and metronidazole), washing with physiological solution, acute reimplantation in Group A or reimplantation after 21 days in Group B after a bone freezing at -80°C. The Radiographic Union Score (RUS), pain visual analogic score (VAS), patient satisfaction and return to work were assessed at a mean follow-up of 24 months. No cases of superficial or deep infection were reported at 2-year follow-up. The fractures achieved a complete union in 14 patients; one patient belonging to Group A had a malabsorption of the replanted bone. Furthermore, povidone-iodine scrub, antibiotic solution immersion, and washing with physiological solution preserved the articular surface morphology. This study suggests that reimplantation of extruded short or long segments may represent a reliable alternative to amputation in open long bone fractures. Further studies are needed to define the most efficient technique for sterilizing the bone autograft to reduce the complication rate.

Bone grafiting combined with Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union

Distal radius fractures are the most common type of upper limb fractures in adults. Non-union after distal radius fracture is rare, serious and unpredictable. The aim of our paper is to analyse the clinical and radiological outcomes of bone grafting and Sauvé-Kapandji Procedures for the treatment of aseptic distal radius non-union. We enrolled 13 patients with distal radius aseptic non-union. The following parameters were evaluated: The surgical time, elbow, forearm and wrist range of motion, the subjective quality of life and the wrist function measured by Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Pain Visual Analogic Score (VAS) and the complication rate. Bone union was measured using the radiographic union score as described by Radiographic Union Score (RUS). The evaluation endpoint was set at 24 months after surgery. All patients achieved fracture union. Grip strength improved by 12.4 kg. There was also improvement in wrist flexion, in wrist extension, and forearm pronosupination. These ranges of motion and grip strength improvements were statistically significant. Only 6 patients returned to full activity. This surgical technique represents a reliable alternative for treatment of distal radius aseptic non-unions. Further studies are needed to assess the long-term clinical results of this surgical procedure.

Allograft versus autograft in forearm aseptic non-union treatment

Non-union in forearm fractures is an uncommon challenging clinical condition for orthopaedic surgeons. The complex anatomy and biomechanics of the upper limb make this surgery very demanding. The accurate restoration of the normal anatomy is mandatory to obtain bone healing. Infections and important bone loss further reduce the therapeutic success. The use of bone graft in atrophic non-union may significantly reduce the bone healing time with good clinical results. The aim of the study was to compare fresh-frozen bone (FFB) allograft and autograft in the treatment of forearm aseptic non-union. Inclusion criteria were patients aged between 18 to 75 years old with forearm aseptic shaft non-union treated with plating and bone grafting. The Authors retrospectively evaluated minimum 12-month follow-up with standard X-rays and clinical outcomes. All non-unions were classified according Association for the Study and Application of the Method of Ilizarov (ASAMI) classification for long bones. The sample size was divided in two groups: patients treated with FFB allograft (Allograft Group) and patients treated with iliac crest autograft (Autograft Group). The mean patient age was 33.58±16.72 (18-75) years old in Allograft Group and 33.28±17.24 (18-75) in Autograft Group. The mean follow-up was 62.6 months (±12.3, range 12-160) in Allograft Group and 64.4 (±12.4; 12-160) in Autograft Group. The mean bone union time after the surgery was 101.6 (±14.6; 82 -156) days in Allograft while 117.6 (±14.6; 90 -180) days for autograft. The Radiographic Union Score was 26.8 (±2.2; range 24.3-30) in Allograft while 26.9 (±2.8; range 24.1-30) in Autograft. A correlation between clinical and radiographic outcomes was found (Cohen κ: 0.86±0.11 in Allograft Group; Cohen κ: 0.85±0.10 in Autograft Group, p=0.051). The preoperative surgical planning is essential to apply this technique: the adequate cortical graft length is the key point to gain adequate implant stability. A meticulous surgical technique is mandatory to obtain good clinical and radiological outcomes. The study reported a good reliability of FFB allograft for large non-union bone defects. This technique may represent a feasible alternative to bone transport or amputation, as it allows the return to daily life activities. Further studies are needed to assess the long-term clinical results of this surgical procedure.

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 Meary's 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.

Tantalum in type IV and V Paprosky periprosthetic acetabular fractures surgery in Paprosky type IV and V periprosthetic acetabular fractures surgery

PURPOSE

Periprosthetic acetabular fractures represent a growing and serious complication of total hip arthroplasty (THA). The purpose of the study is to report our experience in the use of tantalum for the treatment of Paprosky type IV and V periprosthetic acetabular fractures.

METHOD

We analyzed 24 patients with type IV and V periprosthetic acetabular fractures. Patients were treated with a revision surgery using tantalum components, in some cases in association with posterior plating. Outcomes were evaluated using VAS, Harris hip score and considering the average time of integration of the acetabulum and the number of complications. The endpoint evaluation was established at 24 months.

RESULT

Results show that the average time of integration of the neoacetabulum in tantalum was 12.3 months (range 6-18 months). The average VAS pain is 8.7/10 cm at time 0 and gradually returns to basic pre-injury values in the following months. The average value of HHS at time 0 is 13.5 points. This value tends to increase progressively until reaching a mean score of 89.3 points at 24 months, higher than the average pre-trauma value of 84.3 points.

CONCLUSION

Periprosthetic fractures of the acetabulum with bone loss are a rare but potentially disastrous complication of total hip prostheses. Their management and therapeutic choice will test the ability of the orthopedic surgeon. It is important to determine the type of fracture and characteristics in order to pursue an adequate therapeutic strategy. The modern biomaterials, such as porous tantalum, offer a greater potential in replacing bone loss, promoting bone regrowth and obtaining a stable implant.

Lung function in beta-thalassemia patients: a longitudinal study

Patients with beta-thalassemia often present with a restrictive pattern at pulmonary function tests (PFTs) due to several pathogenetic factors. However, the long-term evolution is unknown. We performed a longitudinal study of pulmonary function in asymptomatic, non-smoking patients with beta-thalassemia major and intermedia. We looked for temporal changes in lung function and characteristics that would predict the development of PFT abnormalities. In 1996, 18 patients with major beta-thalassemia (9 males and 9 females; age range: 18-35 years) and 11 patients with intermediate beta-thalassemia (5 males and 6 females; age range: 25-51 years) underwent clinical assessment and PFT, including body plethysmography and gas transfer study (carbon monoxide diffusion capacity, DL(CO)). Patients were reassessed in 2003. An echocardiographic evaluation was also obtained to exclude pulmonary hypertension. In 55.5% of major and 45.4% of intermediate beta-thalassemia patients, a restrictive pattern was found in 1996; in 2003 only 38.8 and 27.2% of patients, respectively, exhibited total lung capacities below the predicted values. DL(CO) was unchanged in both groups of patients, being reduced in 5 thalassemia major patients and within the normal range in intermediate patients. We conclude that asymptomatic patients with beta-thalassemia have a high prevalence of PFT abnormalities, but without significant increases over time. An improvement may be observed when good control of the iron balance is reached with optimal chelation therapy.