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Many authors consider the Ilizarov method as the best choice for correction of complex multiplanar foot deformities. Fifty-one patients, for a total of 55 feet, underwent V or Y osteotomy (respectively 32 and 23), 12 were due to congenital clubfoot outcomes, 11 were from post-traumatic pathologies, 9 from hemimelia, 7 from Charcot-Marie-Tooth, 5 from poliomyelitis, 3 from spina bifida, 2 from myopathy, 2 from poly-epiphyseal dysplasia, 1 from achondroplasia, 1 from arthrogryposis, 1 patient from Charcot's foot and 1 rheumatoid arthritis. All patients were contacted to undergo AOFAS and EQ-5D-5L questionnaire. The mean distraction time was 74.0 days (±25.3) and it was longer for V osteotomy (63.1 ± 21.1 vs 81.8 ± 25.4 days for Y and V respectively, p = .006). The average fixation time was 97.9 days (± 61.2), 90 days in the Y and 103 days in the V osteotomy groups. The mean preoperative foot length was longer in the group of Y osteotomy patients (158.7 ± 21.3 mm vs 133.5 ± 21.6 mm, p.001). The mean length postoperatively was substantially the same (Y group 164.0 mm vs V group 167.4 mm, p.562). The V osteotomy produces an elongation ratio of 440% with respect to that produced from the Y osteotomy (ratio length/distraction V/Y 0.44/0.1), with only 19% more in the distraction days. (81.8 V group vs 63.1 Y group). While the V osteotomy allows a lengthening of about 27%, the Y osteotomy, despite having correction potential superimposable to the V osteotomy, minimizes the elongation component.

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.

Abbiamo trattato un paziente di 47 anni giunto alla nostra osservazione tramite il Servizio Traumatologico d’Urgenza del nostro Istituto con diagnosi di frattura di trochine dalla testa omerale destra in paziente sottoposto a stabilizzazione della spalla omolaterale con tecnica secondo Letarjet nel 1993. Il paziente pertanto e stato sottoposto a intervento chirurgico di osteosintesi a cielo aperto mediante ancorette. Il decorso post-operatorio e stato regolare e il recupero funzionale buono con grande soddisfazione del paziente.

Introduzione Lo sviluppo di nuove megaprotesi per il trattamento di grandi difetti ossei ha offerto importanti opportunita ai chirurghi ortopedici oncologi per la sostituzione di grandi segmenti scheletrici, come le ossa lunghe degli arti superiori e inferiori e le relative articolazioni. La nostra esperienza clinica nel trattamento di pseudoartrosi e grave perdita di tessuto osseo ci ha portato, a volte, a confrontarci con la realta di alcuni fallimenti chirurgici dopo tentativi infruttuosi di ricostruzione. Di fronte a certe situazioni cliniche o radiologiche drastiche abbiamo voluto applicare i principi della Camera Biologica in associazione con soluzioni di sostituzione megaprostesica. Abbiamo impiantato megaprostesi sia con tecnica a 1 o 2 step (precedentemente trattati con spaziatore antibiotato) a seconda delle condizioni del paziente. Lo scopo di questo studio e quello di valutare retrospettivamente i risultati clinici e radiologici in pazienti sottoposti a megaprotesizzazione di arto inferiore e di registrare le complicanze.

Introduzione L’innesto osseo autologo e stato a lungo considerato il gold standard per il ripristino dei difetti ossei. Tuttavia questa procedura si associa nel tempo allo sviluppo di un alto tasso di complicazioni senza, peraltro, garantire benefici clinici assoluti. Per questo motivo la ricerca si e concentrata negli ultimi anni sullo sviluppo di sostituti ossei alternativi (biologici e sintetici).

Bone regeneration presents a unique challenge to both clinicians and scientists. Recently, a vast amount of knowledge has been attained with regard to the molecular mediators, cell populations and the overall cascade of events participating in the bone repair processes. For the treatment of bone non-unions or bone defects, the ‘Diamond Concept’ for biological enhancement supports the associated implantation of mesenchymal stem cells, a scaffold and growth factors. Prior to the implantation of any or all of these materials however, the surgeon must develop the ideal biological environment where molecular and physiological processes will evolve facilitating an early and successful osteogenesis leading to bone continuity. This privileged environment is the “Biological Chamber” that can create the best conditions promoting the regeneratiion and thus optimizing the results. A “bioreactor” is crated in order to reproduce ideal laboratory conditions. The “Biological Chamber” must be asteptic, vascularized and protected, that means not completely isolated but surrounded selectively in order to mantain the proper contacts with the surrounding tissues.The notion of creating the optimum ‘biological chamber’ represents the centre of the highest biological activity and in a sense the heart of the “Diamond Concept”.

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.