Aims

Ganz’s studies made it possible to address joint deformities on both the femoral and acetabular side brought about by Perthes’ disease. Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency, along with periacetabular osteotomy (PAO), which may enhance coverage and containment. The purpose of this study is to show the clinical and morphological outcomes of the technique and the use of an implemented planning approach.

Ganz's studies made it possible to address joint deformities on both femoral and acetabular side brought by the Legg-Calvè-Perthes disease (LCPD). Femoral head reduction osteotomy (FHRO) was developed to improve joint congruency along with periacetabular osteotomy (PAO). The purpose of this study is to show the clinical and morphologic outcomes of the technique, and an implemented planning approach.

From 2015 to 2023, 13 FHROs were performed on 11 patients for LCPD, in two centers. 11 of 13 hips had an associated PAO. A specific CT and MRI-based protocol for virtual simulation of the corrections was developed. Outcomes were assessed with radiographic parameters (sphericity index, extrusion index, integrity of the Shenton's line, LCE angle, Tonnis angle, CCD angle) and clinical parameters (ROM, VAS, Merle d'Aubigné-Postel score, modified-HHS, EQ5D-5L). Early and late complications were reported.

The mean follow-up was 40 months. The mean age at surgery was 11,4 years. No major complications were recorded. One patient required a total hip arthroplasty. Femoral Head Sphericity increased from 45% to 70% (p < 0,001); LCE angle from 18° to 42,8° (p < 0,001); extrusion Index from 36,6 to 8 (p < 0,001); Tonnis Angle from 14,4° to 6,2° (p = 0.1); CCD Angle from 131,7 to 136,5° (p < 0,023). The VAS score improved from 3,25 to 0,75,(p = 0.06); Merle d'Aubigné-Postel score from 14.75 to 16 (p = 0,1); Modified-HHS from 65,6 to 89,05 (p = 0,02). The EQ 5D 5L showed significant improvements. ROM increased especially in abduction and extra-rotation.

FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical and morphologic outcomes in LCPD. The newly introduced simulation and planning algorithm may help to further refine the technique.

Introduction and Purposes

Custom made acetabular prosthesis are a valid option for the reconstruction after the resection of pelvic tumors. They should guarantee a stable and reliable reconstruction for the expected survival of the patient. Nevertheless in many cases periacetabular metastatic lesions have been compared to high grade (IIIA-B) Paprosky defects, but treated with low or intermediate longevity implants. Some complex post-traumatic scenarios or total hip arthroplasty (THA) multiple failures need a reconstruction according to oncologic criteria to fill in the huge defect and to obtain an acceptable function. The aim of the study is to compare 3D custom-made implants for tumors and for THA failures.

Tannast has recently shown that safe hip dislocation (SHD) for femoroacetabular impingement treatment does not result in atrophy and degeneration of periarticular hip muscles. In more complex procedures, such as relative neck lengthening for Perthes disease (PD) or modified Dunn procedure for slipped capital epiphysis (SCFE), minimus gluteus femoral insertion is detached to achieve enough mobility of osteotomized trochanter and to fix the latter more distally. Aim of this study was to evaluate MRI appearance of minimus and medius gluteus after relative neck lengthening.

Patients treated with SHD and relative neck lengthening eventually associated to epiphyseal realignment for PD or SCFE treatment underwent magnetic resonance imaging (MRI) to study gluteus minimus (MI) and medius (ME) muscles. In the axial T1-weighted sequences, cross sectional area (CSA) and signal intensity were evaluated at acetabular roof level. Statistical comparison was made with the opposite healthy side.

Fifteen patients underwent an MRI at an average of 59 months (SD=27.3) after surgery.

Average ratio between gluteus minimus CSA (treated/healthy side) was 0.90 (SD=0.2): this reduction in volume was statistically significant (p=0.04) as well as the signal intensity (p=0.04). CSA and signal intensity of gluteus medius did not differ between two sides (respectively p=0.78 and p=0.30).

In conclusion, gluteus medius appearance was not influenced by distal fixation of the trochanter. The minimus gluteus was reduced in volume as much as 10% in respect to healty side; increased signal intensity in MRI T1-weighted (fatty infiltration) was found in the minimus gluteus.

Aims

Several studies have reported the safety and efficacy of subcapital re-alignment for patients with slipped capital femoral epiphysis (SCFE) using surgical dislocation of the hip and an extended retinacular flap. Instability of the hip and dislocation as a consequence of this surgery has only recently gained attention. We discuss this problem with some illustrative cases.

The management of post-traumatic bone infections relies on antibiotic therapy and surgical debridement. Antibiotic concentration in infected bone is a major determinant of response to medical treatment.

The aim is to assess glycopeptides, fluoroquinolones and carbapenems diffusion in infected human bone, since they are widely used for treating bone infections.

Twenty-four patients with septic pseudoarthrosis undergoing surgical debridement and treated with glycopeptides/fluoroquinolones/carbapenems iv for > 1 week were studied. Plasma and bone specimens were collected intraoperatively at a mean of 4.8h after antibiotic administration. Antibiotic concentrations were measured by the HPLC-UV method.

Five patients received vancomycin: mean bone concentrations were 2.4mg/L in cortical and 7.1mg/L in cancellous bone, with a bone/plasma extraction of 12% and 36%, respectively.

Nine patients were treated with teicoplanin: bone concentrations were 2.5mg/L for cortical and 8.3mg/L for cancellous bone (14% and 46% of plasma levels).

Five patients received a fluoroquinolone. Ciprofloxacin concentrations were 1.8mg/L in cortical bone and 30.2mg/L in cancellous and newly formed bone (respective bone/plasma ratios 1.06 and 8.4). Levofloxacin concentrations were 0.3 and 2.69mg/L in cortical and cancellous bone, with diffusion rates of 12% and 108%, respectively.

Five patients received a carbapenem. Imipenem diffusion rates were respectively 7.5% and 58.3% for cortical and cancellous bone (bone concentrations 0.09 mg/L and 0.7 mg/L). Meropenem levels were 1.2 mg/L and 5.2 mg/L in cortical and cancellous bone, with respective diffusion rates of 3.6% and 15%.

Both glycopeptides provided concentrations exceeding the MIC of infecting agents, with satisfactory bone diffusion. Fluoroquinolones, especially ciprofloxacin, displayed excellent diffusion. Ciprofloxacin concentrations in cancellous and new bone were far higher than in plasma, suggesting accumulation into highly vascularized tissue. Imipenem had better diffusion than meropenem, but bone levels were under the MIC of susceptible agents. Glicopeptides and fluoroquinolones appear excellent options for bone infections, while carbapenems should be a second choice treatment.

Antibiotic concentration in infected bone is a major determinant of clinical response. As glycopeptides and fluoroquinolones are widely used for the treatment of bone infections, aim of our study was to assess their diffusion in infected human bone. Patients with a posttraumatic septic pseudoarthrosis undergoing debridement of infected tissue, who received a glycopeptide or a fluoroquinolone for > 1 week, were studied. Plasma and bone specimens were collected intraoperatively for phamacokinetic and microbiologic assays at a mean of 4.1h after antibiotic administration. Bone samples were crushed and concentrations were measured by HPLC-UV method. Overall plasma exposure was also determined with daily sampling. 16 patients were studied. 6 patients received iv vancomycin 1 g bid over a 1-hr infusion Bone cultures grew E. faecalis, MRSA and MRSE (MIC < 2 mg/L). Mean plasma concentration of vancomycin at time of osteotomy was 19.8 mg/L. Mean bone concentrations were 2.4 mg/L in cortical and 7.1 mg/L in cancellous bone, with a mean bone extraction of 12 % and 36 %, respectively. 4 patients were treated with iv teicoplanin 10/mg/Kg for MRSA infection (MIC < 2 mg/L). Mean bone concentrations were 8.9 mg/L and 37 mg/l respectively for cortical and cancellous bone, respectively corresponding to 6% and 25% of plasma levels. Six patients were treated with a fluoroquinolone. 3 patients received iv ciprofloxacin 400mg bid and E. coli grew from bone samples(MIC = 0.5 mg/L). Mean Plasma concentration of ciprofloxacin at the time of osteotomy was 3.6 mcg/mL. Mean bone concentrations were 1.7 mg/L in cortical bone and 30.2 mg/L in cancellous and newly formed bone, with respective bone/ plasma ratios of 0.5 and 8.4. 3 patients were administered iv levofloxacin 500mg qd and Enterobacter spp. were isolated (MIC = 1 mg/L). Mean plasma concentration at the time of surgery was 2.5 mcg/mL. Mean bone concentrations were 0.3 and 2.69 mcg/mL in cortical and cancellous bone, respectively. To our knowledge this is the first study that compares different antibiotic’s concentration in infected bone with the same dosing procedure. Both vancomycin and teicoplanin provided mean bone concentrations exceeding the susceptibility breakpoint of the infecting agents. Higher and constant glycopeptides plasma levels may be required for preventing recurrencies in bone infections. Only ciprofloxacin provided cortical bone concentrations higher than the susceptibility breakpoint of the infecting agent, and similar to those reported in non-infected bone. Ciprofloxacin concentration in cancellous bone and in bony callus were far higher than those detected in plasma, which may be related to an augmented vascularization and/or selective accumulation of fluoroquinolones into regenerating bone, as observed in children’s cartilage growth plate. Ciprofloxacin may be therefore preferred to levofloxacin.

In amputation or amputation-like injuries of lower limbs, only in a few cases reconstructive treatment with microsurgery is encouraged, according to evaluation of lesion by Mangled Extremity Severity Score (MESS). Replantation cases may require substantial bone shortening, as consequence to seriousness of the trauma or a deliberate choice to enable primary vessel and nerve repair. Callus distraction technique by external fixation, circular or axial, is a common method for recover lengthening in these cases of replanted or revascularized extremities.

We report six cases of lower limb replantation or revascularisation, with primary bone shortening from 3 to 7 cm and secondary lengthening by callus distraction.

It was always obtained equalization of lower extremities, with successful rehabilitation of the patients and low onset of complications during treatment.