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This study compares the outcomes of consecutive of patients with Sanders II and III and IV calcaneal fractures that were stabilized by either close reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF). Group I (N = 49) underwent close reduction internal fixation (CRIF). Group II (N = 39) underwent open reduction internal fixation (ORIF). The clinical outcomes included time to operation, operative duration, visual analog score (VAS), length of hospital stay, wound-related complications and AOFAS SF-36 score. Preoperative and postoperative radiographic measures also were compared. The duration of operation in the CRIF group was considerably shorter than in ORIF group (P = 0.0001). Postoperatively, at seventh day, the VAS in the CRIF group (4.2 ± 1.1) was meaningfully lower than those of the ORIF patients group (4.7 ± 1.2, P = 0.04). Totally, the prevalence of wound complications in CRIF group was significantly lower than in ORIF group. In final follow-up visit after one year, AOFAS scores and SF-36 scores between groups were comparable. Comparable radiographic measures were found in both groups. There was no significant difference between groups regarding preoperative radiographic measures (P > 0.05), while in postoperative imaging acceptable calcaneal fracture reduction was found in both groups. We believed that for treatment of various types of calcaneal fracture compared with ORIF the percutaneous reduction and screw fixation may lead to shorter hospital stay, decreased subtalar joint stiffness and earlier weight bearing along with much favorable patients’ satisfaction.

CASE We present a 36-year-old man with L1 burst fracture after a sneeze. He was in follow-up for indolent systemic mastocytosis (ISM), and osteoporosis was treated with bisphosphonate. Owing to neurologic impairment, posterior decompressive laminectomy and thoraco-lumbar fusion with cemented screws were performed. CONCLUSION Vertebral fractures in young patients affected by ISM required a multidisciplinary approach and a careful preoperative planning to achieve acceptable results. These fractures are so rare that even an experienced spine surgeon may not come across them during his whole career. Nevertheless, diagnostic tool improvement makes its diagnosis more frequent, that is why every spine surgeon should know this disease.

Cross-sectional study. To describe oral health and hygiene as a risk factor for surgical site infection (SSI). This cross-sectional study was conducted on patients over 18 years of age who were candidates for elective spinal surgery. The exclusion criteria were immunodeficiency, history of cancer, history of previous infection at the surgical site, cutaneous diseases and long-term use of corticosteroids. Questionnaires were filled out for patients via an interview in order to collect the demographic data of patients. Oral and dental examinations were performed using DMFT (D: decayed, M: missing, F: filled, T: total) and PUFA (P: pulp, U: ulcer, F: fistula, A: abscess) indices. Data were analyzed using Fisher’s exact test and Mann–Whitney test. A total of 78 patients were evaluated. There were 59 females (75.6%) and 19 males (24.6%). Eight patients were positive for SSI. Teeth caries (P = 0.016) and periodontal disease (P = 0.049) were significantly correlated with SSI. No significant association was noted between PUFA and SSI (P > 0.05). Sixty-five patients (83.3%) had a history of dental infection before surgery. Fifty% of patients being positive for SSI had a history of dental abscess (P = 0.023). A significant association exists between SSI and caries, gingivitis/periodontitis and history of dental abscess.

Scheuermann kyphosis is the most common structural kyphosis among adolescence and young people. Surgical treatment may be performed through combined anterior and posterior or posterior-only approaches; to our knowledge, the efficacy of posterior-only approach as less invasive procedure is not well studied in case of severe rigid Scheuermann kyphosis. Eighteen patients with severe rigid Scheuermann kyphosis operated through only posterior approach from 2013 to 2016 were evaluated. All information regarding demographic data, curve size before and after the surgery, surgical time, amount of blood loss, correction loss during follow-up and also complications was collected. There were six females and 12 males. Mean age of the patients was 22.4 years (range 17–38). Mean kyphosis angle before surgery was 87.2° (range 85–105), and that reduced to 47.4° (range 45–55) after the surgery. Mean curve size in hyperextension view was 73.8°. Mean postoperative Cobb angle was 50–55 percent of preoperative curves. Mean hospital admission duration was 3.5 days after the index surgery (range 3–5 days). Mean blood loss during the surgery was 250 ml. Mean surgical duration time was 150 min. Mean follow-up period was 9 months (range 8–48 months). No complication was found among the patients. Posterior-only approach using advanced osteotomy techniques and posterior release is a safe and reliable approach for treatment of patients suffering from severe rigid Scheuermann kyphosis and provides acceptable deformity correction.

IntroductionThe outcomes of total hip replacement in patients suffering from residual poliomyelitis are poorly covered in the literature. In this retrospective study we posed the question of whether total hip replacement performed for degenerative hip diseases in limbs with residual poliomyelitis could determine satisfactory mid-term clinical and radiographic results, with a reasonable complication rate.MethodsA retrospective study was carried out to assess the results of 14 total hip replacements performed on 14 patients with residual poliomyelitis on the involved limb from June 1999 to September 2011. Average age at the time of surgery was 51 years (range 26-66 years). Mean duration of follow-up was 92 months (range 52-156 months). Surgery was performed through a direct lateral approach on all hips. All but one were cementless implants.Results2 implants failed, 1 due to traumatic acetabular fracture 6 days after surgery, and 1 due to aseptic cup loosening 13 years after surgery. Surgery was uneventful in all patients except 1 (7%), who experienced a transient sensory sciatic nerve palsy. At the latest follow up Harris Hip Score was 83.3 (range 72-91) with a marked improvement when compared to preoperative score (average 52, range 32-78). No dislocations had occurred.ConclusionsTotal hip replacement can be considered a feasible option for hip osteoarthritis in patients with limbs affected by residual poliomyelitis. Longer follow-up studies are needed to assess the effectiveness of unconstrained total hip replacement in polio patients.

Learning targets • To learn the anatomy and technique of Smith-Peterson anterior cervical spine approach. • To learn anterior cervical discectomy and decompression technique of the cervical spine. • To learn interbody fusion technique using stand-alone cage. • To understand the importance of sagittal segmental alignment and sagittal alignment of the cervical spine restoration.

How to perform a posterior spine fusion and a transforaminal lumbar interbody fusion.

Introduction Cervical degenerative pathology can produce pain and disability and, in case of failure of conservative treatment surgery is indicated. Materials and methods 107 patients affected by single level cervical degenerative pathology were surgically treated by Cloward procedure. On radiographs, the sagittal segmental alignment (SSA) of the affected level and sagittal alignment of the cervical spine were measured. Results Preoperatively, mean SSA was 0.6° and at the last follow-up 1.8°. In particular, adjacent-level degeneration occurred more frequently in Group A than in Group B. Conclusion Lordotic SSA angle can be considered a protective factor against adjacent-level degeneration.

Learning objectives • To explain the pathophysiology of herniated disc. • To show the clinical appearance, physical examination and surgical indication for S1 root radiculopathy. • To learn anatomy and surgical technique related to lumbar discectomy. • To explain surgical tricks when performing an open lumbar discectomy.

Background Congenital hip dysplasia may lead to severe acetabular and femoral abnormalities that can make total hip arthroplasty a challenging procedure. We assessed a series of patients affected by developmental hip dysplasia treated with total hip arthroplasty using cementless tapered stem and here we report the outcomes at long-term follow-up. Materials and methods Twenty-eight patients (24 women and 4 men) aged between 44 and 50 years (mean 47 years) were observed. Clinical evaluation was rated with the Harris Hip Score. Radiographic evaluation consisted in standard anteroposterior and axial view radiographs of the hip. According to Crowe’s classification, 16 hips presented dysplasia grade 1, 14 grade 2, and 4 grade 3. All patients were treated with total hip arthroplasty using a cementless tapered stem (Wagner Cone Prosthesis). Six patients were operated bilaterally, with a totally of 34 hips operated. After surgery, the patients were clinically and radiographically checked at 3, 6, and 12 months and yearly thereafter until an average follow-up of 12 years (range 10–14 years). Results Average Harris Hip Score was 56 ± 9 (range 45–69) preoperatively, 90 ± 9 (range 81–100) 12 months after surgery, and 91 ± 8 (range 83–100) at last follow-up. Radiographic evaluation demonstrated excellent osteointegration of the implants. Signs of bone resorption were present in 6 hips, nevertheless no evidence of loosening was observed and none of the implants has been revised. Conclusions Even in dysplasic femur, the tapered stem allowed adequate stability and orientation of the implant. We consider tapered stem a suitable option for total hip arthroplasty in developmental hip dysplasia, also in case of young patients, thanks to the favourable long-term results.

This study reviewed the medical records of 90 patients with lipomas (47 patients) and atypical lipomatous tumors (ALT)/well-differentiated liposarcomas (WDL) (43 patients) of the extremities treated from 2006 to 2012. All patients had preoperative biopsy and postoperative histologic analysis of the tumors; surgical margins were marginal in all cases. Histologic sections of the tissue blocks from the excised specimens were re-reviewed for all patients; a consensus with postoperative histologic analysis was confirmed. Molecular chromosome analysis was performed on fluorescence in situ hybridization in tissue sections from the tissue blocks in all cases for the purpose of this study; a ratio greater than 2 was considered to represent murine double-minute 2 (MDM2) amplification consistent with a diagnosis of ALT/WDL. Mean follow-up was 52 months (range, 14–96 months). Local recurrence and metastasis rates and the relationship of patient age and sex with tumor size and location were evaluated. None of the patients with lipomas experienced local recurrence compared with 6 patients (13.9%) with ALT/WDL who experienced local recurrence within a mean of 48 months (range, 33–96 months); this difference was statistically significant. None of the patients in either group experienced metastasis prior to the study period. Local recurrence did not correlate statistically with patient age or sex, or with tumor size or location. [ Orthopedics. 2016; 39(4):e610–e614.]

Purpose of the study: Adequate treatment of forearm nonunion should achieve both biological stimulation of the bone and mechanical stability. The use of bone graft could enhance the healing of a nonunion providing osteogenic, osteoconductive and osteoinductive stimulation and an optimal stability of the fixation. We retrospectively reviewed two cohorts of patients affected by forearm nonunion and treated with plate and opposite bone graft to determine whether the use of autograft versus allograft differs in terms of (1) rate of healing of the nonunion and (2) time of healing. Materials and methods: Thirty-four patients were treated for aseptic forearm nonunion with cortical graft strut with opposite plate and intercalary graft in case of segmental bone defect. In 20 patients an autograft harvest from the fibula (group A) and in 14 (group B) an allograft provided by the bone bank of our institution were used. Results: All the nonunions healed in a mean of four months in both groups, ranging from two to 12 months in group A and from three to ten months in group B. At the latest follow up forearm function and pain were satisfactory in both groups. Conclusion: The use of plate and opposite bone graft demonstrated to be effective in promoting the healing of forearm nonunions, without significant differences in terms of rate and time of healing in the two groups. Considering the higher surgical time and the comorbidity of the donor site, if a bone bank is available, we suggest to use homologous cortical bone strut graft with opposite plate and screw fixation for the treatment of aseptic forearm nonunion rather than autograft.

To analyze the role of spine alignment in post-traumatic paraplegic patient as a potential cause of late Charcot spine disease (CSD). A retrospective review of three cases in which the disease appeared more than 15 years after a spinal cord injury treated by posterior fusion. A review of the literature concerning spine balance in sitting position, especially referred to paraplegic patients, is done to validate this hypothesis. Lumbar kyphosis in paraplegic patients during the sitting position may increase the mechanical load on disks and ligament below the previously fused area. This phenomenon, in combination with lack of protective mechanism because of poor muscular support and lack of sensitivity can speed up and amplify the normal degenerative changes in the disk and ligaments. More investigations are required to fully understand all the mechanisms underlying CSD pathogenesis to prevent it. Until then, a systematic long-term clinical and radiological follow-up in all post-trauma paraplegic patients is suggested. Combined anterior and posterior fusion, when feasible, can restore the sagittal balance providing a better quality of life in these patients.

BACKGROUND: In an effort to avoid the morbidity associated with autogenous bone graft harvesting, cervical cages in combination with allograft bone are used to achieve fusion. The goal of the current study was to assess the reliability and efficacy of anterior cervical discectomy and interbody fusion (ACDF) using a PEEK anatomical cervical cage in the treatment of patients affected by single-level cervical degenerative disease. METHODS AND MATERIALS: Twenty-five patients affected by single-level cervical degenerative pathology between C4 and C7 were enrolled in this study. The clinical findings were assessed using the Neck Disability Index and the Visual Analog Scale. Surgical outcomes were rated according to Odom's criteria at last follow-up. Fusion was graded as poor, average, good or excellent by assessing the radiographs. Cervical spine alignment was evaluated by sagittal segmental alignment and sagittal alignment of the whole cervical spine preoperatively, 6 months postoperatively and at the last follow-up. RESULTS: Twenty-five patients underwent ACDF using a PEEK anatomical cervical cage. All patients had a minimum 2 years of follow-up. The operative levels were C4-C5 in 5 patients, C5-C6 in 12 patients and C6-C7 in 8 patients. Preoperatively, average NDI was 34, 13 at 6 months, and 10 at latest follow-up. The mean preoperative VAS was 7; the mean postoperative VAS at latest follow-up was 3. Good or excellent fusion was achieved in all patients within 10 months (mean 5 months). Preoperatively, average sagittal segmental alignment (SSA) was 0.2° and average sagittal alignment of the cervical spine (SACS) 15.8°. Six months after surgery, average SSA was 1.8° and average SACS 20.9°, and at last follow-up, average SSA was 1.6° and average SACS 18.5°. CONCLUSION: Anterior cervical discectomy and interbody fusion using PEEK anatomical cervical cages can be considered a safe and effective technique to cure cervical disc herniation with intractable pain or neural deficit in cases where conservative treatment failed.

The dyaphyseal nonunion of forearm bones is a complication that changes the normal interaction between radius and ulna, which may lead to forearm malfunction. We reviewed 14 patients treated by surgical technique included a homologous bone graft in combination with a plate. The mean age was 31 years (range, 18–45 years) at the time of surgery. Minimum follow-up was 2 years (mean, 5 years; range, 2–13 years). There were no intraoperative or postoperative complications. At last follow-up, all forearm bones had remodelled. The mean visual analogue pain scale was 1 (range, 0–4). There was a high success rate regarding forearm alignment and functional results; all patients recovered daily and working activities quickly. This surgical technique in treatment of aseptic forearm nonunion by combining homologous bone graft with a plate led to bone healing, improved forearm function, and a durable outcome with long-term follow-up.