Although dynamic hip screw (DHS) is considered the treatment of choice for pertrochanteric fractures, we theorized that external fixation would produce clinical outcomes equal to, if not better than, outcomes obtained with conventional treatment. As external fixation is minimally-invasive, we expected a lower rate of morbidity and a reduced need for blood transfusions. We compared fixation with DHS vs. Orthofix pertrochanteric fixator (OPF) in elderly pertrochanteric fracture patients. Forty consecutive pertrochanteric fracture patients were randomized to receive either 135A1 4-hole DHS (Group A) or OPF with 4 HA-coated pins (Group B). Inclusion criteria were: female, age B3 65 years, AO type A1 or A2 and BMD less than −2.5 T score. There were no differences in patient age, fracture type, BMD, ASA, hospital stay or quality of reduction. Operative time was 64 B1 6 minutes in Group A and 34 B1 5 minutes in Group B (p <
0.005). Average number of post-operative blood transfusions was 2.0 B1 0.1 in Group A, and none in Group B (p <
0.0001). Pain was measured 5 days post-operatively and was lower in Group B (p <
0.005). Fracture varization at 6 months was 6 B1 8A1 in Group A and 2 B1 1A1 in Group B (p = 0.002). In Group B, no pin-tract infections occurred. Pin fixation improved over time, as shown by pin extraction torque (2770 B1 1710 N/mm) greater than insertion torque (1967 B1 1254 N/mm), (p= 0.001). Harris hip score at 2 years was 62 B1 20 in Group A and 63 B1 17 in Group B. This study shows that OPF with HA-coated pins is an effective treatment for this patient population. Operative time is brief, blood loss is minimal, fixation is adequate and the reduction is maintained over time.
The purpose of this study is to demonstrate the validity of the autologous chondrocytes transplantation (A.C.T.) technique implemented over the last 6 years in the treatment of osteochondral lesions of the talus. Our case study included 22 patients (12 males and 10 females), with an average age of 27 years affected by osteochondral lesions of the talus surface. All lesions were >
1.5 cm2, monofocal, and post-traumatic in origin. The first 9 patients received ACT (Genzyme technique) and the remaining 13 patients received ACT with an arthroscopic technique. In 6 of the patients, the cartilage harvested from the detached osteochondral fragment was used for culturing, avoiding the first step arthroscopy in the knee. Before surgery, all patients were assessed clinically, radiographically, and using MRIs. For clinical evaluation patients were assessed using the American Foot &
Ankle Society 100 point score. Before surgery the mean score was 48.4 points. 11 patients underwent second-look arthroscopy at one year during which a biopsy was harvested for histologic analysis of the reconstructed cartilage. Of these, 9 patients (Genzyme technique) also had hardware removed. The mean follow-up of the 22 patients was 36 months. At follow-up, all patients but one were satisfied with their results. With regards to the clinical results evaluated using the American Foot and Ankle Society score, an average of 90.5 was obtained at 24 months, while at 36 months the average score (19 patients) was 94.0 (range 54–100). During follow-up arthroscopy, 4 patients had mild fibrosis and 1 patient required regularization of flap overgrowth causing pain. The clinical and histological results have confirmed the validity of the surgical technique utilized with no subjective nor objective complications. An improvement of the symptoms and of articular function has also been observed: laboratory data confirmed the histological appearance of the newly formed hyaline cartilage in all cases evaluated. Immunohistochemistry showed a positive staining for collagen type II located in the extracellular matrix and in the chondrocytes in the healthy and transplanted cartilage biopsies. All the specimens studied were also positive for proteoglycans expression as was the Alcian blue reaction, which highlighted the presence of these fundamental components of a cartilaginous matrix.
Only recently has the mobility of the ankle joint been elucidated. Sliding/rolling of the articular surfaces and slackening/tightening of the ligaments have been explained in terms of a mechanism guided by the isometric rotation of fibres within the calcaneofibular and tibiocalcaneal ligaments. The purpose of this investigation was to design a novel ankle prosthesis able to reproduce this physiological mobility. A four-bar linkage computer-based model was used to calculate the shapes of talar components compatible with concave, flat and convex tibial components and appropriate fully congruous meniscal bearings. Three-component designs were analysed, and full congruence of the articular surfaces, appropriate entrapment of the meniscal bearing and isometry of the two ligaments were required. A convex tibial component with 5 cm arc radius gave a 2 mm entrapment together with a 9.8 mm amount of tibial bone cut, while maintaining ligament elongation within 0.03 % of the original length. The physiological patterns of joint motion and ligament tensioning were replicated. The talar component slid backwards while rolling forwards during dorsiflexion. These movements were accommodated by the forward displacement of the meniscal bearing on the tibial surface under the control of the ligaments. The complementary surfaces provide complete congruence over the entire range of flexion, such that a large contact area is achieved in all positions. To restore the physiological mobility at the ankle joint, not only should the components be designed to be compatible with original ligament pattern of tensioning, but also these should be mounted in the appropriate position. A suitable surgical technique was devised and relevant instrumentation was manufactured. Five below-knee amputated specimens replaced with corresponding prototype components showed good agreement with the model predictions. Current three-component designs using a flat tibial component and physiological talar shapes cannot be compatible with physiological ligament function.
We compared thirty-eight patients from three orthopaedic centres who had external fixation of the femur or the tibia. Patients were randomised to receive standard (tapered 5/6 millimeter) pins (Group A) or OsteoTite (hydroxyapatite coated tapered 5/6 mm) pins (Group B). In Group A there were 18 patients who received 71 pins. Average age of the patients was 49±12 years. Three patients had external fixation in the femur and 15 in the tibia. External fixation was used in three types of treatment: fracture fixation (4), knee osteotomy (12), and bone-transport (2). Two different fixator frames were used: a unilateral fixator was mounted in 15 patients and a circular fixator in three patients. In Group B, 20 patients (average age: ± 48 years) received 86 pins. Four patients had external fixation in the femur and 16 in the tibia. External fixation was used in three types of treatments: fracture fixation in three patients, knee osteotomy in 13 patients, and bone-transport in four patients. Two different fixator frames were used: a unilateral fixator was mounted in 16 patients and a circular fixator in four patients. No significant difference regarding sex, age, external fixation treatment type, external fixation frame, and length of treatment were observed between the two groups. Mean final pin insertion torque was 477 ± 214 Newton cm in Group A and 339 ± 184 in Group B (p<
0.01). Mean pin extraction torque was 205 ± 169 Newton cm in Group A and 532 ± 211 in Group B (p<
0.01). Pin extraction torque was significantly lower compared to the corresponding insertion torque in Group A (p<
0.01). Pin extraction torque was significantly higher compared to the corresponding insertion torque in Group B (p<
0.01). Pin tract infection rate was lower in Group B compared to Group A (p<
0.01). This study shows that hydroxyapatite coating was clinically effective in the improvement of the bone pin interface strength of tapered pins. By using these pins, deterioration of the bone pin interface strength can be avoided and external fixation complications minimised.