Discussion

Paltrinieri thought that trophic and reactive alterations of bone tissue occur at the nonunion site. This would explain the not infrequent failure of local treatments, such as bone grafting. Failure risk increases in the management of open or infected fractures, even after the phlogosis ended, because of the latent microbial colonization.

The osteotomy performed at the fracture site has the ideal effect of perfectly interfacing the opposite fragments, anatomically reconstructing the morphology and completely resolving the mechanical aspect of the problem. However, this method fully ignores the biological aspect: it acts on bone tissue that generally is sclerotic and not entirely suitable for undergoing a new regenerative process.

To solve the biological problem, the osteotomy is indicated at a site away from the original fracture. Biologically, the metaphysis offers the best result; here the cortical bone is sharp, with a lot of spongy tissue and the possibility of obtaining wide contact surfaces. The metaphyseal osteotomy, however, has limited indications both in femur and tibia, because it is not suitable from the mechanical point of view.

If the indications for osteotomies at the fracture site and at a distance conflict, the former with the biological factor and the latter with the mechanical factor, it is logical to assume that an osteotomy performed as close as possible to the fracture site would successfully solve the problem. The parafocal osteotomy acts on a normal bone tissue with normal osteogenic capacities and achieves a good correction both aesthetically and mechanically.

As for the convenience of performing the osteotomy proximal or distal to the nonunion site, some biological and mechanical aspects should be considered. Biologically, vascularization by the feeding artery must be considered. The osteotomy must be performed in respect of vascularization proximal or distal to arterial penetration into the diaphysis. From the mechanical point of view, parafocal osteotomy aims to correct angular displacements. The irregular weight distribution on abnormally oriented articular surfaces causes degenerative alterations over time: it is then necessary to ensure that the articular lines are parallel. The closer the osteotomy is to the fracture line, the less difference there will be between the nonunion angle and the osteotomy angle.

Paltrinieri evaluated the possibility of performing a double osteotomy, proximal and distal to the lesion, on the basis of the hypothesis that complete rest at the site of delayed union or nonunion can only be achieved with this solution. The results obtained in his series do not confirm this hypothesis; on the contrary, they failed to show any advantage over the single osteotomy.

Paltrinieri's technique was successfully employed later by other authors [1,4,5-15]. In particular, the stabilization with circular external fixation systems, suggested by Umiarov [4], shows many favorable aspects: stability, assembly modularity, multiplanar control, and the possibility of gradually correcting deformities.

Therefore compression-distraction techniques seem to represent a natural complement to Paltrinieri's technique: the elasticity of these systems allows easy control of mechanical stress, taking away the cut and torsion forces and maintaining and improving the compression and distraction forces at the cor-ticotomy site. This represents a further stimulus to healing and helps improve weight transfer from the fixator to the bone as the consolidation proceeds.

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