Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies.

INTRODUCTION: To date, the management of critical-sized bone defects lacks a universally accepted approach among orthopedic surgeons. Currently, the main options to treat severe bone loss include autologous grafting, free vascularized bone transfer, bone transport and induced-membrane technique. The purpose of this study is to critically compare the outcomes of Masquelet technique and bone transport to provide a higher level of evidence regarding the indexed techniques. MATERIAL AND METHODS: The authors conducted a systematic search on several databases according to the PRISMA guidelines. English-written reports comparing outcomes of the Masquelet technique versus the bone transport technique in patients with critical-sized defects in lower extremities were included. RESULTS: Six observational studies involving 364 patients were included. The systematic review and meta-analysis of pooled data showed no significant difference in most outcomes, except for ASAMI bone outcomes and residual deformity, which showed better results in the bone transport group. The 64% of patients treated with Masquelet technique obtained excellent/good bone ASAMI results compared to 82.8% with bone transport (p = 0.01). Post-operative residual deformity was 1.9% with the bone transport method versus 9.7% with the Masquelet technique (p = 0.02). CONCLUSIONS: Both the Masquelet technique and bone transport showed comparable results for the management of critical-sized bone defects of the lower limb. However, these findings must be carefully interpreted due to the high risk of bias. Further prospective randomized controlled trials are necessary to better clarify the strengths and limitations of these two techniques and to identify the variables affecting the outcomes.

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications.

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety.

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

Overview of fracture liaison services in the UK and Europe: standards, model of care, funding, and challenges.

Fragility fractures represent a growing global problem, including in the United Kingdom and European countries. Reports demonstrate the benefits of national guidance and organized fragility fracture programs through fracture liaison services to deliver care to patients who sustain these injuries. The challenge of assembling multidisciplinary teams, providing routine screening of appropriate patients, and monitoring therapies where there is a known compliance problem, remains an obstacle to the success of fragility fracture treatment programs to all. Efforts should continue to introduce and maintain fracture liaison services through coordinated national approaches and advanced systems.

Third generation Dual Mobility Cups: could be the future in total hip arthroplasty? A five-year experience with dualis.

BACKGROUND: The concept of dual mobility (DM) is currently approved as a valid option for reducing the risk of dislocation, with an incidence ranging from 0% to 4.6%. The principle is to achieve a high joint stability through a large diameter polyethylene (PE) liner, and to reduce cutting forces due to a "low-friction" head-liner coupling mechanism. METHODS: From March 2015 to March 2020, 138 patients were treated with Dualis Cup (Gruppo Bioimpianti-Peschiera Borromeo, MI, Italy) for a total of 141 implants (three cases were bilateral). The average age at the time of the surgery was 77. Patients' clinical and X-ray follow-up was at 1, 3, 6, 12 months and then once a year. RESULTS: Seven patients (4.9%) had complications which required a second surgery, but only one case (0.7%) of intraprosthetic dislocation (which required cup revision), was directly ascribable to the DM cup. CONCLUSIONS: Improvements in design and materials of the third generation DM cups allowed both to reduce the rate of dislocations in high-risk patients (i.e., patients with neuro-muscular diseases and cognitive disorders, patients needing revisions, osteosynthesis failures, femoral neck fractures) and to achieve a survival rate similar to standard cups, ensuring a range of motion (ROM) very close to the physiological one. In our brief experience, Dualis Cups showed results comparable to those reported in the literature for Dual Mobility. If this data is confirmed by long-term studies, the use of DM cups could be extended even for young patients with high functional demands. (www.actabiomedica.it).

Retrospective analysis of outcomes and complications after Korus hemiarthroplasty in elderly patients with neck femur fractures.

BACKGROUND: Femoral neck fractures (FNF) is one of the most common traumatic events in elderly patients: the choice of an appropriate treatment is necessary to decrease the related mortality and to achieve the best possible outcomes. Nowadays, it is still debated whether or not to cement the stem in hemiarthroplasty and above all, which stem to use to best respect the integrity of the elderly bone. METHODS: From January 2017 to December 2019, a bi-centric study utilizing prospectively collected databases of elderly patients with FNF treated with uncemented Korus stem hemiarthroplasty was performed. Patients were preoperatively classified according to ASA score. Patients' clinical and X-ray follow-up was at 1, 3, 6, 12 months. Harris Hip Score (HHS) was used for analysed clinical improvement. On the X-rays, we analysed iatrogenic fractures, osteolysis area and radiolucent lines in the stem region during follow up. RESULTS: 233 patients were identified. Median follow-up was 12 months. Over time, 51 patients died (21.88%). Mean age was 89,56 ± 6,25. 75 patients had ASA score of 2 (32.3%), 102 patients a score of 3 (43.7%), 56 an ASA score of 4 (24,0%). The main Harris hip score was 68,66 ± 8.53 at 1 month of follow-up, 71,74 ± 9.65 after 3 months, 72,50 ± 10.66 at 6 months and 75,61 ± 9.63 at 12 months control. CONCLUSIONS: Hydroxyapatite coated stem with an accurate design guarantee early fixation, good clinical and radiographic results, low rate of re-intervention and mortality rate and a satisfying return to pre-injury activities.

Radiocapitellar plica: a narrative review.

Radiocapitellar plica is a vestigial lateral portion of elbow synovial fold which may cause pain and snap in some cases. Plica is a difficult and misleading diagnosis and it could be easily confused with a common lateral epicondylitis however, they are different conditions. Pathology full understanding and proper diagnosis is essential to achieve patient's pain relief and functional recovery therefore, we reviewed the most relevant literature about radiocapitaller plica. The aim of this study is to provide the best and current concepts about: clinical evaluation, imaging findings and surgical treatments of radiocapitellar plica.

Articular Femoral Head Fracture Management: A Meta-analysis of Literature.

PURPOSE: Articular fractures of the proximal femur are seldom encountered and there are few studies in literature regarding this topic. To date, only a few large series have adequate follow-up and exhaustive description of treatment and outcome, which, however, often result incomplete and do not allow a comparison. Since there are still uncertainties and debates on which the treatment gold standard should be, the goal of the present study is to carry out a meta-analysis on type I and II Pipkin fracture management to establish the best treatment according to EBM. METHODS: Studies regarding acetabular fractures of the femur head were identified from Google Scholar, Cochrane Library, Medline, ScienceDirect and PubMed; gray studies were searched from the included references' literature, and using general search engines and Social media; the query to be temporally extended from 1996 to 2020. Only comparative studies were included; we ruled out case-reports, case series, author's opinion, register databases. RESULTS: Comparing conservative and surgical treatment, we found evidence of a better outcome choosing surgical treatment. We found a significant better outcome with open reduction internal fixation, instead of fragment excision. Comparing failure rate of surgical approaches, we found no statistically significant difference. CONCLUSION: Our study proves that there is evidence in favor of operative treatment rather than conservative in complete or displaced Pipkin fracture Type I + II; open reduction internal fixation should be preferred rather than fragment excision, whenever possible. LEVEL OF EVIDENCE: III. Therapeutic.

Skeletal System Biology and Smoke Damage: From Basic Science to Medical Clinic.

Cigarette smoking has a negative impact on the skeletal system, as it reduces bone mass and increases fracture risk through its direct or indirect effects on bone remodeling. Recent evidence demonstrates that smoking causes an imbalance in bone turnover, making bone vulnerable to osteoporosis and fragility fractures. Moreover, cigarette smoking is known to have deleterious effects on fracture healing, as a positive correlation between the daily number of cigarettes smoked and years of exposure has been shown, even though the underlying mechanisms are not fully understood. It is also well known that smoking causes several medical/surgical complications responsible for longer hospital stays and a consequent increase in the consumption of resources. Smoking cessation is, therefore, highly advisable to prevent the onset of bone metabolic disease. However, even with cessation, some of the consequences appear to continue for decades afterwards. Based on this evidence, the aim of our review was to evaluate the impact of smoking on the skeletal system, especially on bone fractures, and to identify the pathophysiological mechanisms responsible for the impairment of fracture healing. Since smoking is a major public health concern, understanding the association between cigarette smoking and the occurrence of bone disease is necessary in order to identify potential new targets for intervention.

One-stage procedure for open tibial fractures: feasible without orthoplastic surgery?

BACKGROUND: Open tibial fractures are mostly the result of high-energy traumas and often involve severe injuries with extensive bone and soft tissue loss, damage of muscles and neurovascular structures. Over recent- years, - the growth of Ortho-Plastic teams, as a well-coordinated bone, joint and soft tissue treatment, contributed to change the approach to these fractures and to achieve higher successful results in lower limb salvage. Unfortunately, many hospitals cannot benefit of a combined team in emergency, and the orthopedic surgeon is forced to manage personally these kinds of traumas. METHODS: We retrospectively reviewed all the open tibial fractures treated at our Orthopaedic Department over the last 10 years, in order to assess the treatments performed (one-stage fixation with Intramedullary Nailing or Open Reduction Internal Fixation - ORIF, versus two/multiple-stage fixation with temporary External Fixation followed by nailing or ORIF) and the differences in the outcome between the different methods. PURPOSE: Based on our experience and review of the literature, the purpose of this paper is to define what cases can be managed by a single-stage orthopaedic approach, and when the orthopaedist should lay down his arms in favor of other specialties.

Internal fixation of acetabular quadrilateral plate fractures in elderly patients: Could the fracture reduction quality affect their functional recovery?

BACKGROUND: Osteoporotic acetabular fractures frequently involve the quadrilateral plate (QP), a flat and thin bone constituting the medial wall of the acetabulum. This study aims to assess the impact of the quality of osteoporotic QP fractures reduction on the patients' functional recovery, at 24 months follow-up. METHODS: Patients referring with osteoporotic QP fractures to our Level I trauma centre were prospectively recruited. INCLUSION CRITERIA: patients aged 60 years old or older; osteoporosis, defined as Dual-energy X-ray Absorptiometry (DXA) T-score ≤ - 2.5; acute acetabular fracture; anatomic or good fracture reduction according to Matta on postoperative CT. EXCLUSION CRITERIA: moderate cognitive impairment (defined as Mini-Mental State Examination < 19); a history of malignant neoplasm; concomitant fractures in other sites; traumatic head injury; lower limb joint prostheses; patient not able to walk independently before trauma; poor fracture reduction, according to Matta, on postoperative CT. All the QP fractures were surgically managed. After surgery, the reduction of each QP fracture was classified as anatomical (displacement 0-1 mm), good (displacement 2-3 mm) and poor (displacement > 3 mm) on postoperative CT. Based on this classification: patients with a poor fracture reduction were excluded from this study, patients with an anatomical reduction were recruited in Group-A and patients with a good reduction in Group-B. All the patients underwent a clinical and radiographic 24-months follow-up. RESULTS: 68 patients (males 38; females 30; mean age 68.6 years old; range 60-79) were finally included in in the study. No cases of open fractures or concomitant pelvic ring fractures were observed. Based on the post-operative CT, 39 patients showed an anatomic fracture reduction (Group-A) while the remaining 29 patients revealed a good fracture reduction (Group-B). Complication rates and mean clinical scores showed no significant differences between groups, at 24-months follow-up. CONCLUSIONS: In this study, the functional recovery at 24 months follow-up showed no significant differences in elderly patients with QP fracture undergoing anatomical reconstruction (displacement 0-1 mm) compared to patients receiving a good QP fracture reconstruction (displacement ≤ 3 mm).

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war.

BACKGROUND: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed. METHODS: The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). RESULTS: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. CONCLUSIONS: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Neglected complete bilateral achilles tendon rupture. clinical case presentation, treatment and follow-up.

BACKGROUND AND AIM OF THE WORK: subcutaneous Achilles tendon lesions are common degenerative tendon tears, often related to sport activities, multiple pharmacotherapies and internal medical comorbidities. Neglect an Achilles tendon lesion can affect walk ability, while neglect a bilateral lesion could really lead to a serious limitation of self-sufficiency in daily living. We report a case of chronic bilateral Achilles tendon lesion successful treated with LARS augmentation, along with some clinical considerations concerning the clinical outcome. METHODS: we report a case of a chronic bilateral Achilles tendon lesion in an elderly man with multiple comorbidities, successful treated with LARS reconstruction, along with some considerations concerning possible intraoperative issues and the clinical outcome. RESULTS: good functional result was obtained as documented with pre and postoperative American Orthopedic Foot And Ankle Society Scale and the "Foot And Ankle Disability Index", without complications. CONCLUSIONS: a bilateral Achilles tendon rupture is a very disabling pathology, that needs prompt diagnosis and treatment to prevent further complications. LARS reconstruction could be an effective method in selected patients to avoid some intraoperative issues related to patient comorbidities and ability to follow complex postoperative rehabilitation protocols. (www.actabiomedica.it).

A 2-free-end flexor carpi radialis tendon graft for treating a complex index finger extensor tendon injury.

BACKGROUND: Volar plating has increasingly become the most used technique for the treatment of unstable distal radius fractures due to the low soft-tissue disturbance and its biomechanical reliability, which allows the early mobilization of the wrist. One of the main goals of the volar locking compression plates design is to avoid those soft tissue complications historically associated to the dorsal plating. However, extensor tendon complications can not be completely excluded. METHOD: The authors report the case of a patient with a complete rupture of the index finger extensor tendons after volar plate fixation of the distal radius. Due to the presence of a severe tendons retraction with a 4-centimeter gap and the neighbouring soft tissues damage, it was decided to fill the gap with a 2-free-end autograft harvested from the Flexor Carpi Radialis (FCR) tendon, using the volar surgical approach performed to remove the plate. RESULTS: At the 2-month follow-up, the patient showed the complete recovery of the flexion-extension movements. CONCLUSIONS: Even though the 2-free-end FCR tendon graft is not commonly reported for the reconstruction of extensor tendons defects, we assume it deserves to be considered as an adequate technique whenever the neighbouring tendons are critically compromised.

Factors associated with positive outcomes of platelet-rich plasma therapy in Achilles tendinopathy.

BACKGROUND: The efficacy of platelet-rich plasma in the treatment for Achilles tendinopathy is debated. Therefore, it is important to know which factors, related to the subjects and/or the disease, are associated with positive or negative outcomes. Aim of this study was to evaluate in a large cohort of patients with Achilles mid-portion tendinopathy which variables were independently associated with a positive outcome after platelet-rich plasma treatment. MATERIAL AND METHODS: Eighty-four subjects with Achilles tendinopathy were evaluated by means of VISA-A score and ultrasound and treated with a single platelet-rich plasma injection once a week for 3 weeks. Afterward, a rehabilitation program, based on eccentric training, was implemented. At 3 and 6 months, the relationship between the mean VISA-A score and the following putative predictors was evaluated: sex, age, physical activity, sport, smoking, metabolic risk factors, BMI, symptoms duration, tendon damage, neovessels, adherence to eccentric training. Finally, the percentage of clinically evident positive outcomes (defined as an increase in VISA-A score ≥ 20 points) related to each variable was computed. RESULTS: At final follow-up, using the General Linear Model for Repeated Measures procedure, male sex (0.02), age ≤ 40 (0.05) and adequate eccentric training (0.02) were found to be independently associated with a significant increase in the mean VISA-A score. Moreover, the clinically evident positive outcomes, as previously defined, were significantly associated with male sex (0.01), age ≤ 40 (0.000), BMI ≤ 25 (0.001), symptoms duration ≤ 12 months (0.02) and good adherence to eccentric training (0.004). CONCLUSION: Younger age, male sex and good adherence to eccentric training can be considered predictors of better results after platelet-rich plasma therapy in Achilles tendinopathy.

Hip fracture systems-European experience.

European countries have established health care systems but are struggling with the increasing rise of fragility fractures in their aging population. In trying to address this significant burden, countries are establishing national guidelines and standards, focusing on hip fractures, which represent the significant cost for this patient group. This has evolved with the establishment of national audits and guidelines. Reports from 4 European countries (England, Italy, Netherlands, and Spain) are presented. All nations have identified both deficiencies in their systems, and protocols to improve these deficiences. When standards are introduced, there has been evidence of improved results. Significantly more work is needed to understand the key components of the systems and pathways, and efforts to study and standardize care are ongoing.

Injury of the brachial artery accompanying simple closed elbow dislocation: a case report.

BACKGROUND: Elbow dislocation is the second common dislocation in adults, after the shoulder. The anatomical proximity to the joint of the brachial artery could lead to concomitant vascular injuries, even if their occurrence remains very rare. METHOD: It is reported the case of a right-hand-dominant  42-year-old man who sustained a simple closed  posterior elbow dislocation of  his left elbow, associated to a complete brachial artery rupture. He urgently underwent the reduction of the joint dislocation and an artery-repairing surgical procedure using a graft from ipsilateral saphenous vein. RESULTS: The full functional capacity of the elbow was obtained. CONCLUSIONS: The abundance of the brachial artery collateral network may hide the presence of a vascular injury,  potentially associated to a closed elbow dislocation. Therefore, a high index of suspicious should be maintained. The Emergency Team plays a crucial role in its early diagnosis, which is essential to avoid irreversible ischemia related damages. A prompt reduction of the joint dislocation and the vascular injury surgical repair are required. Regarding the treatment of the concomitant collateral ligaments and capsular injuries, the indication to proceed to the simultaneous ligaments reconstruction is still controversial in literature.

An unusual two-stage infection following a scolopendra bite.

BACKGROUND: Scolopendrae represent the best-known genus of centipedes. They are nocturnal general feeders with strong mandibles and venomous fangs which leave visible puncture marks at the bite site. The bite accidents occur during the warm rainy season and mostly take place on the extremities. Following the bite, the most common symptoms are mild: limited localized erythema, pain, swelling, local itching and burning sensation. However, more severe local and systemic sequelae can not be excluded. METHOD: we report the case of a 63-year-old man with fever and a widespread edema of the right hand and forearm, happened as a consequence of a Scolopendra Subspinipes bite. During the weeks following the bite, he developed a severe unusual superinfection via hematogenous dissemination, which  required a double surgical debridement and a targeted intravenous antibiotic therapy. RESULTS: the complete clinical recovery took over two month. CONCLUSIONS: Many victims of Scolopendra envenomation do not seek medical attention since most symptoms will resolve spontaneously. The case presented falls within the spectrum of those rare cases which escalate due to bacterial superinfection.

Ceramic on ceramic total hip arthroplasty and liner fracture. Two case reports and review of literature.

BACKGROUND AND AIM OF THE WORK: Ceramic on ceramic bearing surfaces in total hip arthroplasty are rising in number with the purpose of reducing debris osteolysis in young patients. New generation ceramics drastically reduced the well known problem of liner's fracture associated with this material but this still represents a complication. METHODS: We present the only two cases of acetabular liner fracture we had in our department, on a total of 252 patients, since we use CoC bearing surfaces in THR (2005-2019) analyzing symptoms and causes of this complication. Review of recent literature focused on symptoms and causes of liners fracture, well matched our cases. RESULTS: In line with the analysis of literature, the major cause of liner fracture is neck-cup impingement resulting in the "edge-loading" effect, followed by other factors like prosthesis design, traumas and patient weight. From data also emerge the role of acoustic phenomena (e.g. squeaking) and CT scan in the diagnostic process. CONCLUSIONS: Last generation ceramics should be used in CoC THR, implant malposition and prosthesis design have a dominant role in liner fracture, squeaking should always be investigated. CT scan have an important role in diagnosis. Implant revision with substitution of the bearing surfaces is mandatory in case of fracture or impending fracture signs.