Applicazione della metodica di Ilizarov nella ricostruzione dell\u2019arto inferiore dopo rimozione di protesi cementata sostitutiva di ginocchio in esiti di osteosarcoma

La sopravvivenza da osteosarcoma \ue8 notevolmente aumentata nelle ultime decadi, con interventi conservativi di salvataggio dell\u2019arto nella maggior parte dei casi. L\u2019inerente svantaggio \ue8 per\uf2 che a lungo termine le endoprotesi sostitutive vanno incontro a usura, infezione, rottura, causando talvolta metallosi o fenomeni di intolleranza. I pazienti sopravvissuti a lungo termine vanno spesso incontro a numerosi reinterventi chirurgici di revisione protesica e riprotesizzazione. Gli autori descrivono l\u2019esperienza nell\u2019applicazione della metodica di Ilizarov per ricostruzione di arto inferiore in una paziente di 32 anni (G.O.), 20 anni dopo la diagnosi di osteosarcoma teleangiectasico esteso al terzo medio e distale del femore sinistro. La paziente era stata trattata con Cisplatino intra-arterioso, Adriamicina e Metotrexate ad alte dosi, rimozione di 18 cm di femore e 2 cm di tibia con applicazione di protesi sostitutiva cementata di tipo Guepard e ancora trattamento chemioterapico. A 17 anni dall\u2019impianto della protesi, la paziente, presentando infezione periprotesica ed estesa metallosi, nonch\ue9 deficit dell\u2019apparato estensore del ginocchio, veniva sottoposta a rimozione della protesi e dell\u2019abbondante cemento periprotesico con metodica SEG-CES. Le veniva applicato un fissatore esterno trifocale di tipo Ilizarov, praticando due osteotomie della tibia e applicazione di perle antibiotate. La paziente \ue8 stata successivamente sottoposta a interventi per rimozione delle perle di antibiotico, osteotomia del perone, montaggi del piede, allungamento del tendine di Achille, innesti da cresta iliaca per scarso rigenerato tibiale. Dopo trasporto di circa 18 cm di tibia, \ue8 stata praticata fusione del moncone femorale con la tibia, supportata con successo da innesti da cresta iliaca e idrossiapatite porosa. Dopo 32 mesi di trattamento, \ue8 stato rimosso il fissatore e confezionato un gesso poi sostituito da tutore su misura. Il presente caso rappresenta la prima esperienza di ricostruzione dell\u2019arto inferiore con allungamento di 18 cm di tibia e fusione tibiofemorale in esiti di tumore osseo

Plasticity of body representations after surgical arm elongation in an achondroplasic patient

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External versus internal fixation for bicondylar tibial plateau fractures: systematic review and meta-analysis.

BACKGROUND: It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures. MATERIALS AND METHODS: A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses. RESULTS: Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25-5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups. CONCLUSION: Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures

Role of high tibial osteotomy in chronic injuries of posterior cruciate ligament and posterolateral corner

High tibial osteotomy (HTO) is a surgical procedure used to change the mechanical weight-bearing axis and alter the loads carried through the knee. Conventional indications for HTO are medial compartment osteoarthritis and varus malalignment of the knee causing pain and dysfunction. Traditionally, knee instability associated with varus thrust has been considered a contraindication. However, today the indications include patients with chronic ligament deficiencies and malalignment, because an HTO procedure can change not only the coronal but also the sagittal plane of the knee. The sagittal plane has generally been ignored in HTO literature, but its modification has a significant impact on biomechanics and joint stability. Indeed, decreased posterior tibial slope causes posterior tibia translation and helps the anterior cruciate ligament (ACL)-deficient knee. Vice versa, increased tibial slope causes anterior tibia translation and helps the posterior cruciate ligament (PCL)-deficient knee. A review of literature shows that soft tissue procedures alone are often unsatisfactory for chronic posterior instability if alignment is not corrected. Since limb alignment is the most important factor to consider in lower limb reconstructive surgery, diagnosis and treatment of limb malalignment should not be ignored in management of chronic ligamentous instabilities. This paper reviews the effects of chronic posterior instability and tibial slope alteration on knee and soft tissues, in addition to planning and surgical technique for chronic posterior and posterolateral instability with HTO

Ilizarov method to correct limb length discrepancy after limb-sparing hemipelvectomy

Pelvic resection for a sarcoma in young patients is challenging, with significant functional, psychological, and social implications. We report the case of a 26-year-old former Ewing's sarcoma patient in whom the Ilizarov technique was applied to address 6 cm of leg length discrepancy secondary to internal hemipelvectomy with superomedial dislocation of the right femoral head. Fifteen years after the internal hemipelvectomy, the patient underwent distal femoral and bifocal tibial lengthening using circular frames. The results obtained in this patient underline the usefulness of the Ilizarov treatment to increase the quality of life in long-term survivors of pelvic bone cancer

Limb reconstruction in lipofibromatosis

A 6-month-old infant presented with a soft tissue tumor (lipofibromatosis) of the right leg and procurvatum deformity of mid-shafts of tibia and fibula. He underwent deformity correction with Ilizarov fixator. He later had multiple surgeries for limb length difference and angular deformities of the tibia for more than a decade. At 12 years of age, his limb was well aligned with good function. Appearance of the leg was satisfactory despite lack of any surgical interventions for the soft tissue tumor