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Introduction Diseases related to the lesions of upper or lower motor neurons, such as spina bifida, myopathy, and residual polio, often cause severe deformities of the foot and ankle. The treatment goal is to convert a deformed and rigid foot into a plantigrade foot. Matherial and method We treated 51 neurological feet from 2001 to 2018 with the Ilizarov method. They were polio outcomes in 27 cases, 17 feet were affected by spina bifida, 6 other patients had Charcot-Marie-Tooth disease. Results Results were assessed by comparing appearance and function before and after surgery described by Dimeglio, and modified by Dong Y.L. et al. Before surgery, there were 33 moderate and 28 severe deformities (average preoperative scores, 6.3). The mean time required to correct a deformity was 37.1 days (range, 22–58 days) and the mean time for stabilization was 67.2 days (range, 45–98 days). At latest follow-up (mean 7.42 years, from 13 month to 16 years), clinical outcomes and patient satisfaction were considered acceptable. 28 patients achieved an excellent outcome and 21 patients had a good outcome, two feet were classified as having a poor result. Nearly 86 % of patients (44 patients) were satisfied with their outcomes and replied they would repeat their procedure. Complications include infection in 15 % of K-wire tracts, Dysesthesia in 5 cases, superficial necrosis in 3. One patient developed knee contracture. 2 patients were re-operated with V osteotomy. Conclusions The Ilizarov method represents a great resource in the treatment of severe neurological deformities of the foot.

Introduction The development of new megaprosthesis for the treatment of large bone defects provides important options to orthopaedic oncologic surgeons for the replacement of skeletal segments, such as the long bones of the upper and lower limbs and the relative joints. We implanted megaprosthesis using either a one-step or two-step technique depending on the patient's condition. The aim of this study was to evaluate retrospectively both clinical and radiological outcomes in patients who underwent lower limb megaprosthesis implant. Materials and methods A total of 32 patients were treated with mono- and bi-articular megaprosthesis subdivided as follows: proximal femur, distal femur, proximal tibia and total femur. The mean follow-up of patients was about 18 months (range 3 months to 5 years). Clinical and serial radiographic evaluations were conducted using standard methods (X-ray at 45 days, 3, 6, 12, 18 and 24 months) and blood parameters of inflammation were monitored for at least 2 months. Results Although the mean length of follow-up was only 18 months, the first patients to enter the study were monitored for 5 years and showed encouraging clinical results, with good articulation of the segments, no somato-sensory or motor deficit and acceptable functional recovery. During surgery and, more importantly, in pre-operative planning, much attention should be given to the evaluation of the extensor apparatus, preserving it and, when necessary, reinforcing it with tendon substitutes. Discussion Megaprosthesis in extreme cases of severe bone loss and prosthetic failure is a potential solution for the orthopaedic surgeon. In oncological surgery, the opportunity to restore functionality to the patient (although not ad integrum) is important for both the patient and the surgeon. The high mortality associated with cancer precludes long-term patient follow-up; therefore, there is a lack of certainty about the survival of this type of prosthesis and any medium- to long-term complications that may occur. Nevertheless, patients should be considered as an oncologic patient, not because of the disease, but because of the limited therapeutic options available. Conclusions Megaprosthesis provides a valuable opportunity to restore functionality to patients with highly disabling diseases.

Introduction The recent evolution of prosthesis technology has enabled the surgeon to replace entire limbs. These special prostheses, or megaprostheses, were developed for the treatment of severe oncological bone loss; however, the indications and applications of these devices have expanded to other orthopaedic and trauma situations. For some years, surgeons have been implanting megaprostheses in non-oncological conditions, such as acute trauma in severe bone loss and poor bone quality; post-traumatic failures, both aseptic and septic (represented by complex non-unions and critical size bone defects); major bone loss in prosthetic revision, both aseptic and septic; periprosthetic fractures with component mobilisation and poor bone stock condition. The purpose of this study was to evaluate retrospectively the complications during and after the implantation of megaprosthesis of the lower limb in post-traumatic and prosthetic bone loss, and to propose tips about how to avoid and manage such complications. Materials and methods All the complications and difficulties we have encountered during or after the implantation of megaprosthesis in non-oncology patients were evaluated retrospectively. A total of 72 patients were treated with large resection mono-and bi-articular prostheses between January 2008 and January 2014. Results The main critical problems found in the study were: restoration of the correct length and rotation of the limb; reconstruction of the knee extensor mechanism; trochanteric reconstruction; stability/dislocation of the implant; mobility/range of motion (ROM) of the implant; skin cover; sepsis, and bone quality. Conclusion Megaprosthesis in severe bone loss can be considered as an available solution for the orthopaedic surgeon in extreme, appropriately selected cases. This type of complex surgery must be performed in specialised centres where knowledge and technologies are present. Patients with severe bone loss should not be treated in the same way as oncology patients because life expectancy is definitely longer; therefore, the surgical technique and the system implantation must be extremely rigorous to ensure longevity of the prosthesis. The characteristics of the bone and soft tissue conditions in these patients are very different from those presented by oncology patients, which creates critical problems that the surgeon should be able to manage to avoid serious complications.

A B S T R A C T Introduction: Non-union of long bones is a significant consequence of fracture treatment. The ideal classification for non-union of long bones would give sufficient significant information to the orthopaedic surgeon to enable good management of the treatment required and to facilitate the creation of comparable study groups for research purposes. The Non-Union Scoring System (NUSS) is a new scoring system to assist surgeons in the choice of the correct treatment in non-union surgery. The aim of this study was to determine the evidence supporting the use of the NUSS classification in the treatment of non-unions of long bones and to validate the treatment algorithm suggested by this scoring system. Materials and methods: A total of 300 patients with non-union of the long bones were included in the clinical study. Results: A radiographic and clinical healing was reached in 60 of 69 non-unions (86%) in group 1 (0-25 points), in 102 of 117 non-unions (87%) in group 2 (26-50 points), and in 69 of 84 (82%) in group 3 (51-75 points). The mean time to clinical healing was 7.17 1.85 months in group 1, 7.30 1.72 months in group 2 and 7.60 1.49 months in group 3. The mean time to radiographic healing was 8.78 2.04 months in group 1, 9.02 1.84 months in group 2 and 9.53 1.40 months in group 3. Discussion: There are few articles in the scientific literature that examine the classification systems for non-union. Conclusions: A statistical analysis of the first results we have obtained with the use of NUSS showed significant rates of union in all the evaluated groups. This indicates that NUSS could be an appropriate scoring system to classify and stratify non-unions and to enable the surgeon to choose the correct treatment.

Clinical management of non-union of long bone fractures and segmental bone defect is a challenge for orthopaedic surgeons. The use of autologous bone graft (ABG) is always considered the gold standard treatment. Traditional techniques for harvesting ABG from iliac crest usually involve several complications, particularly at the donor site. The Reamer-Irrigator-Aspirator (RIA) is an intramedullary reaming system that generates a large volume of cancellous bone material in a single-step reaming process; this bone material can be collected and potentially used as an ABG source. Our interest is to compare the complications associated with the standard technique of harvesting from iliac crest with those of the innovative RIA harvesting device.A database of 70 patients with long bone non-unions was studied. The patients were divided into two groups according to the surgical harvesting technique used: RIA system ABG (35 patients) and iliac crest ABG (35 patients).At the 12-month follow-up, pain at the donor site was reported in no patients in the RIA system ABG group and five of 35 patients (14.28%) in the iliac crest ABG group. Local infections at the donor site were found in no patients in the RIA system ABG group compared with five patients (14.28%) in the iliac crest ABG group. There were no fractures in the RIA system ABG group and one case (2.85%) of anterior superior iliac spine (ASIS) dislocation in the iliac crest ABG group. No systemic infections were detected in either group.We analysed the scientific literature on the use of RIA technique to collect ABG for use in patients with anthropic-oligotrophic non-unions, with a focus on the complications associated with this technique.RIA bone graft for the treatment of non-unions and segmental bone defect of long bones seems to be a safe and efficient procedure with low donor site morbidity.

The long bone nonunions and critical bone defects are two of the more difficult complications to treat. We treated a 59 years old patient that came to our attention through the ambulatory of nonunion of our institute with a diagnosis of distal femoral nonunion on the left side: the patient had undergone previous osteosynthesis with plate and screws. At admission the NUSS score of the patient was calculated in order to orientate on the therapeutic strategy to be adopted. It was decided to follow the principles of monotherapy, proceeding with the resection of necrotic bone and the subsequent installation of bone morphogenetic proteins (BMP-7). The postoperative course was smooth; it took a long motory rehabilitation period but, a year after surgery, the patient has achieved a good functional recovery, reaching a good quality of life.

A new scoring system is proposed in order to assist surgeons with the complex analysis associated with non-union surgery. Patients with non-union are rarely easily compared with one another and this has frustrated research in this field. We have therefore attributed values to clinical features based on clinical experience and research evidence, so that patients of similar complexity can be compared with one another. When greater experience with this scoring system has been gained it will be further refined and validated. We propose that surgeons with a subspecialist interest in non-union surgery use this system in reporting results, and that non-specialist surgeons use it to inform their decision to treat the fracture themselves, or refer to a subspecialist.

Studies have estimated that 5–10% of all fractures are associated with impaired healing, resulting in delayed union or non-union. Bone defects can result from a high-energy traumatic event, from large bone resection for different pathologies such as tumours or infections or from the treatment of complex non-unions. A large bone defect represents a challenge for the orthopaedic surgeon. This clinical condition is considered critical in relation to the skeletal segment involved: 3 cm for the forearm, 5 cm in the femur and tibia, 6 cm in the humerus. Excluding the traditional surgical techinques (distraction osteogenesis, autologous bone grafts or arthrodesis), the use of biotechnology can be very useful. We treated a 42 years old patient, that came to our observation through the ambulatory of nonunion of our Institute with a diagnosis of “humeral large bone septic defect”; this patient had in his history multiple previous osteosynthesis surgeries. The patient therefore underwent corrective surgery according to the Masquelet’s technique in two surgical times. The postoperative course was uneventful; during the follow-up the patient showed a good functional recovery with great satisfaction.

Avascular necrosis of the femoral head (AVN) is a common cause of hip disability that, if left untreated, may cause collapse of femoral head and secondary hip osteoarthritis in up to 80% of patients. Osteonecrosis of the femoral head typically affects patients in their third-to-fifth decades of life and often, in 50% of these patients, the disease will develop on both sides.

Fragility fractures, and in particular those of the femoral neck, vertebrae, wrist and proximal humerus, are increasing, with a socio-economic impact strong enough to suggest modifications in their current management. These fractures are characterized by their time of event, clinical approach and functional results, which are also influenced by co-morbidity of the patient. However, in Italy, it was recently shown that patients hospitalized for hip fracture, as well as having an average age over 75, are averagely in their fourth fracturative episode. The high mortality rate usually associated to this type of fracture is significantly decreased when an anti-osteoporosis therapy is initiated. Given the increase of the elderly population in the coming years, and especially the octogenarians, it is necessary to implement a multidisciplinary therapeutic approach suitable to the recovery of a quality of life of the same level to the period preceding the fragility fracture. Therefore, during the first fragility fracture, the orthopedist is essential to implement an adjuvant drug therapy that promotes healing and begins to improve bone quality, with the aim of reducing the risk of further fractures.

In orthopaedic practice, periprothesic fractures are gaining relevance. Their incidence after first implantation is 1.5% and they increase to 6% in revisions. However, their etiology is still uncertain, as evidenced by the present case report of a femoral periprosthetic re-fracture. A female 83-years-old patient, admitted to another hospital for a femoral subcapital fracture and treated with the implantation of an endoprosthesis, was discharged for a long rehabilitative period. After some time the patient had a new periprosthetic fracture, followed by prolonged bed rest due to a synthesis with long plate. Less than one year later she had her third femoral fracture of Vancouver type B1 involving the diaphysis between hip stem of the endoprosthesis and the plate implanted in the two previous occasions. During hospitalization at our institute bone turnover markers and vertebral DEXA revealed a severe poromalacic status characterized by high bone resorption and vitamin D3 deficiency related to secondary hyperparathyroidism. After surgery, in view of 3 months of wheel-chair and no weight-bearing, she started teriparatide, a bone anabolic agent, with daily calcium carbonate and vitamin D3 supplementation; 5 months after the intervention she walked on weight-bearing with crutches. At 2 years f.u. she is free from new fractures and lives and walks in autonomy with one crutch.