Numerous growth factors, together with bone morphogenetic proteins (BMP), are involved in the biological mechanism of bone induction. BMP 7 combined with collagen type 1 has shown to be effective in triggering the osteoinductive mechanism in the presence of bone defects as an alternative to bone graft. The aim of the present study is to present the experience gained at the Orthopaedic Clinic of Catania with BMP in lower limb non-union or pseudoarthrosis with bone defect after skeletal stabilisation.

From December 2003 to May 2004 at the Orthopaedic Clinic Of Catania four patients were treated using OP 1. The study group comprised three women and one man with a mean age at the time of operation of 27 years (range 23– 32 years). One subject presented with non-union, two patients with normotrophic pseudoarthrosis and one with atrophic pseudoarthrosis. In all cases the bone defect was localised at the tibia. All patients were treated surgically with skeletal stabilisation (one with a monolateral external fixator, one with a T2 intramedullary nail and two with a Gross-Kempf nail) always after decortication of Judet.

Three patients healed with a mean follow-up of 5 months. One subject is still under treatment. None of the patients have any pain and demonstrate complete weight bearing and functional capacity. X-rays showed good consolidation of bone defect.

Clinical and radiographic results obtained at this point are more than fair. Healing time was short without any side effects. It is important to verify whether, in the treatment of lower limb non-union and or pseudoarthrosis, the osteoinductive capacity of the OP 1 could provide the same valid results without good reduction and skeletal stabilisation. The use of OP 1 is extremely interesting for many reasons. However, it would be extremely important to test whether the biological effect is not exclusively related to an optimal mechanical stability.

The arthritic varus knee (AVK), charaterised by an overloaded medial compartment of the joint, shows different clinical patterns with corresponding distinctive pathological signs. The surgical approach with opening wedge high tibial osteotomy is indicated in less demanding cases. Transferring the stress in the cartilage and bone of lateral compartment it may represent a definitive solution for both the deformity and the mechanical axis.

Between 1995 and 2003 we treated 52 patients, 60 knees, with distractional osteogenesis using external fixators. The mean age was 51 years (range 45 to 68 years). Radiographic findings showed a third-degree condition according to the Ahlback classification, while pathologically the condition was considered second degree according to the Outerbridge classification. The mean initial varus angle was 8.2°. We analysed the clinical results using the Hospital for Special Surgery score scale and the radiographic result by standing standard X-rays and Rosemberg X-rays.

We followed 38 of 52 patients for 3, 6, 9 and 12 months and then conducted a yearly control with a mean follow up of 4.2 years. The clinical score was 78.5 versus 45.5 in the pre-operative evaluation. At the follow-up radiographic evaluation shows a valgus angle of 2.98° even if there was less of initial correction (mean angle at 6 month 3.53°).

The technique used, moving the weight to the normal compartment of the knee, gives a definitive solution to varus of the femoral-tibial joint, correcting both the deformity and the mechanical axis. The treatment showed several advantages for possible new correction in the late post-operative period and and a minimally invasive operation, even though patient compliance is not good. The best results were obtained thanks to rigorously following the indication for this treatment. In these patients we consider distractional osteogenesis using external fixators a definitive treatment for AVK and not only a way to gain time and to postpone total knee replacement, which is always possible after an osteotomy.

Aims: Severe proximal tibia fractures, which include intra- and extraarticular fractures with metaphyseal-diaphyseal dissociation, pose a difþcult treatment problem for the surgeon with signiþcant complication rates. The aim of this study is to report the experience with a series of consecutive severe proximal tibial fractures treated with hybrid external þxators. Methods: Between 1997 and 2001, we treated 118 cases of proximal tibia fractures of which 52 were treated with hybrid external þxation. Inclusion criteria for hybrid treatment was severe soft-tissue injury, intra-articular displacement, and unstable fracture patterns involvment. In addition to routine demographic data, objective data collected included healing, deformity, complications, and motion. Patient were also evaluated with an SF-36 12 months after healing. Results: All proximal tibial fractures healed without additional procedures. Most patients demonstrated healing by 16 weeks. Accuracy of redution was 0–1mm in 28 patients, 2–3 mm in 19 patients, and 4–5 mm in 4 patients and greater than 5 mm in one patient. Only 5 (10%) of the 52 patients had an angular malunion greater than 6û. One case had a loss of reduction. Four patients developed a mild varus deformity. Radiographic and clinical evidence of degenerative arthritis was seen in 12/52 (23%) patients 18 months after healing. The SF-36 proþlese were health state/rate, daily activity, work activity, emotional problems, pain. Conclusion: We found that hybrid external þxation is a good alternative method for treatment of meta- and/or epiphiseal fractures. The technique and post-op management we describe respects soft-tissue and bone biology and allows early articular mobilization.

Aims: There has been recent interest in the use of external þxation for the treatment of distal peri-articular fractures. The current study was undertaken to evaluate the role of the hybrid external þxation system in the treatment of the distal tibial fractures. Methods: We treated 137 fractures of the distal tibia, of which 46 were treated with hybrid external þxation. The indication for this method of treatment was in the presence of an unstable extra-articular fracture and/or a severe comminution of the distal tibia, as well as an associated severe soft-tissue injury. Routine demographic data, clinical and radiographic þndings as well as reduction, outcomes and complications were recorded. Patients were evaluated with outcome scale of Ovadia and Beals. Results: There were 17 closed fractures and 29 open. Twenty-one extra -and 25 intrarticular fractures were managed with a Hybrid Fixator. All fractures achieved complete healing. Reductions of C-type fractures were within 0-2 mm in 16 and 3–5mm in 56 and > 5mm in 3 patients. The Hybrid External þxator was removed at an average of 17.5 weeks. Full weight bearing was achieved at a mean of 7.8 weeks. There were no intraoperative injuries to nerves or major vessels. Using the outcome scale of Ovadia and Beals, good-excellent results were achieved in 67% (n=31) subjectively and 72% (n=33) objectively. Two poor results occurred in patients with a varus malunion. Conclusion: External þxation is a satisfactory method of treatment for fractures of the distal tibia and is associated with fewer complications than internal þxation, because it limits the amount of soft tissue.

Aims: Various techniques for the þxation of the posterior pelvis have been used, each demonstrating drawbacks speciþc to the technique. In this study, a new protocol was described and evaluated, involving the placement of posterior pelvic screws in the computed tomography (CT) room. Methods: Between September 2001 and September 2002, sixteen patients with unstable pelvic ring injuries were stabilized with iliosacral screws under the CT guided technique, using only local anesthesia and conscious sedation. Patients with displaced fractures initially had their anterior lesion addressed with ORIF or external þxation. The posterior lesion was assessed again and if satisfactorily reduced was treated with the CT guided procedure. In addition to routine demographic data, we evaluated patient pain using an analog scale (0–10), time required per screw, radiation dosage, amount of local anesthesia and sedation required, complications, adequacy of fracture reduction and healing, and accuracy of screw placement. Results: In 16 patients we used 22 screws. The time for the procedure averaged 36 minutes per screw. There were no technical difþculties, logistical problems, or misplaced screws in any patient. There were no infections or non-unions. During ofþce follow up, all patients stated that they would choose to have the CT scan procedure again versus an operating room procedure requiring general anesthesia. Conclusion: CT guided placement of iliosacral screws is a safe, feasible, and alternative to ßuoroscopy guided placement in the operating room in selected cases.