Total hip arthroplasty monobloc stem neck rupture in patient with massive heterotopic ossifications: a case report and literature review.

BACKGROUND AND AIM OF THE WORK: Fractures of the femoral stem neck are a rare complication in hip prosthetic surgery, especially in non-modular components. The authors report a case associated with massive heterotopic ossifications, with the purpose to analyze risk factors and specific characteristics. METHODS: A case of femoral monobloc stem neck rupture is described. A non-systematic literature review regarding risk factors for femoral stem neck fracture was conducted in the PubMed database. RESULTS: We report the case of a 61-year-old male who underwent surgery to remove calcifications four years after THA. Four months later the patient reported acute pain in the left hip, arising after a combined movement of external rotation and axial load while standing on the left foot, in the absence of any prodromic symptom. On radiographs, a displaced fracture of the neck of the hip prosthesis was revealed, together with massive heterotopic ossifications. After THA revision the patient's symptoms were resolved. CONCLUSIONS: Prosthetic femoral neck fractures are a rare complication. We suggest that this case represents a unique type of fatigue rupture, where neck length and the presence of massive heterotopic calcifications contributed to flexion forces, resulting in failure in the midpoint of the neck.

Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk.

BACKGROUND AND AIM: Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF). There are many factors related to the risk of developing AVN, with fracture complexity being one of the most relevant. Aim of the present study is to evaluate the correlation between different classification systems and the risk of post-operative AVN in patients treated with locking plate fixation for Neer 3 and 4-part PHFs. METHODS: The study population included 44 patients (F:M 2:1, mean age 62) treated between December 2014 and April 2019. Fractures were classified according to Neer, Russo and Lego classifications and Hertel's criteria. AVN was established on postoperative radiographs after a minimum follow-up of 6 months. The odds ratio (OR) for AVN for each classification subtype was calculated. RESULTS: The incidence of necrosis was 11%. Significant association with AVN was found for Neer 4 part (OR=8), Russo IVB (OR=4), Lego pattern 12 (OR=8) and in presence of 3 mayor Hertel's criteria (OR=15,5). CONCLUSIONS: There is a significant association between AVN and Neer 4 part, Russo type IVB and Lego pattern 12 fractures. AVN risk is also significantly higher in presence of 3 major Hertel's criteria.

Early weight bearing in tibial plateau fractures treated with ORIF: a systematic review of literature.

BACKGROUND: To review the current clinical evidence on advantages and risks of early weight bearing (EWB) after internal fixation for tibial plateau fracture. METHODS: Data source: PubMed and Google Scholar from inception of database to 20 August 2021, using PRISMA guidelines. The included studies were randomized controlled trials, prospective and retrospective observational studies, case reports. Data extraction was performed independently by 2 reviewers. Collected data were compared to verify agreement. Statistical analysis was not performed in this study. RESULTS: The literature search produced 174 papers from PubMed and 186 from Google Scholar, with a total amount of 360 papers. The two reviewers excluded 301 papers by title or duplicates. Of the 59 remaining, 33 were excluded after reading the abstract, and 17 by reading the full text. Thus, 9 papers were finally included in the review. CONCLUSIONS: EWB can be considered safe and effective in selected cases after internal fixation for tibial plateau fractures. Level of evidence Therapeutic Level III.

Mechanobiology of indirect bone fracture healing under conditions of relative stability: a narrative review for the practicing clinician.

BACKGROUND AND AIM: Mechanical influence on secondary fracture healing remains an incompletely understood phenomenon. This is of special importance in biological osteosynthesis, where stability is sacrificed for the sake of an optimal biological fracture environment. Under condition of relative stability, a wide range of biomechanical conditions can be achieved. Mechanobiology, which studies mechanical influences on biological systems has become a large, interdisciplinary field. The aim of this article is to present a comprehensive synthesis of the literature for the practicing clinician, with insights relevant to their practice of fracture care. METHODS: The MEDLINE online database (Pubmed) was searched in September 2021 for relevant articles Results: The search provided 816 results, which were scanned by the first author by the title and abstract. With relevance to the research topic, 59 articles were chosen and read in detail. Another 70 articles were added by screening the references of relevant articles. A total of 129 articles were read and analysed Conclusions: Mechanical environment plays a crucial role in the fracture healing process. The definition of an optimal mechanical environment still evades us, due to the complexity of the problem. Computational models could replicate the complex mechanical environment of bone healing in humans but require detailed knowledge of mechano-transduction and material properties of healing tissues. The literature reminds us of the importance of adequate stiffness of constructs used under conditions of relative stability. Hopefully, further research in this field will result in not only empirical but more accurate and evidence-based assessments of osteosynthesis fixations.

Should age be a factor in treatment choice of periprosthetic Vancouver B2-B3 proximal femur fractures? A retrospective analysis of mortality and functional outcomes in elderly patients.

Background and aim of the work Revision Arthroplasty (RA) is considered the treatment of choice for periprosthetic femur fractures (PFF) presenting with a loose stem. In the elderly RA may be associated with high post-operative mortality and complications. The aim of this study is to compare mortality and functional outcomes of open reduction internal fixation (ORIF) and RA for B2-B3 PFF in the elderly. Methods The study population included 29 patients (>65 years) surgically treated for B2-B3 PFF at the Orthopedic and Traumatology Unit of Cattinara University Hospital in Trieste (Italy) between January 2015 and December 2019. 16 patients were treated with ORIF and 13 with RA. Mortality and functional outcomes were analyzed. Results In-hospital (6,25% vs 7,69%) and 3 months (6,25 vs 15,38%) mortality was higher in the RA group. Mortality rates were particularly high in the > 85-year-old patients within four months from RA treatment. One year (38,46% and 16,67%) and overall mortality (69,22% and 25%) was higher after ORIF. Average time to weight-bearing and ambulation was 2.6 and 5.25 months for ORIF patients and 1.3 and 2.4 months for RA. A correlation was found between delayed weight-bearing and overall mortality. Conclusions Age is a risk factor for short term mortality following RA. Patients >85 years of age could benefit from a less invasive procedure such as ORIF. Long term outcomes are generally better for patients who undergo RA but further studies are necessary to evaluate the risk-benefit ratio of RA treatment compared to ORIF in elderly patients.

Epidemiology and risk factors for contralateral proximal femur fracture: a single center retrospective cohort study on 1022 patients.

Summary. BACKGROUND AND AIM OF THE WORK: Given the high impact of proximal femur fractures (PFFs) on elderly patients and healthcare systems, the burden of contralateral PFFs might be overlooked. Aim of the study is to analyze the epidemiology and risk factors of contralateral proximal femur fractures. Secondary aim is to detect mortality rate differences in first and contralateral PPF. METHODS: A population of 1022 patients admitted for proximal femur fractures in a single center was studied. Prevalence at admission as well as incidence of contralateral PFF during a 18 to 36 months follow-up was recorded. Epidemiology of contralateral PFF was studied recording number of events, time to second fracture and fracture type. Mortality at 1-year was recorded for all patients and compared between first and second PFF patients. Comorbidities, pharmacotherapy, BMI, MNA and SPMSQ were studied as possible risk factors. RESULTS: Prevalence and incidence of contralateral PFFs were 9.4% and 6.5% respectively. Median time to second fracture was 12 months. One-year mortality of contralateral PFFs was significantly lower (20.5% vs 25.1%, p 0.003) than first PFF. Contralateral fracture patients had a significantly lower BMI and a significantly lower proportion of malnourished patients. CONCLUSIONS: The incidence and prevalence of contralateral PFFs is relevant. Mortality of contralateral PFFs results to be lower than first PFF. Patients with higher BMI and malnourished patients have a lower risk of contralateral PFF.

Predictive value of valgus head-shaft angle in identifying Neer 4-part proximal humerus fractures. A radiographic and CT-scan analysis of 120 cases.

BACKGROUND AND AIM OF THE WORK: Understanding the fracture morphology and its relation to the expected outcome and risk of complications is fundamental for proximal humerus fractures (PHFs) management. Most Neer 3- and 4-part fractures may deserve surgical treatment. Unfortunately, plain x-rays may not be able to differentiate between a 3- or 4-part fractures unless an axillary or analogue projection is carried out. Aim of the present study is to evaluate whether a high valgus head-shaft angle degree is predictive of a Neer 4-part rather than a 3-part fracture. METHODS: The study included 120 3-(75 cases) and 4-(45 cases) part PHFs (valgus displaced in 98 cases), M:F ratio = 1:2.6, mean age 65.7 years, classified on CT scan images. The humeral head shaft angle was calculated on AP x-rays and statistically correlated with 3 and 4-part fractures to identify values predictive of 4-part fracture. RESULTS: Valgus head/shaft angle was significantly higher in 4-part fractures, especially in the valgus displaced group (p < 0.001). A cutoff value of 168.5° was identified as predictive of a 4-part fracture with a sensibility of 74% and specificity of 78%. Increasing by 1 degree the humeral head-shaft angle, the chance to have a 4-part fracture increases of 3% in the whole population and of 11% in the valgus sub-group. CONCLUSION: The severity of PHF can be predicted analysing valgus head shaft angle on AP x-rays with a sensibility of 74% and specificity of 78% in identifying a 4-part fracture with a cutoff value of 168.5°.