The use of a standard-length conical tapered stem in hip revision arthroplasty to address Paprosky type I-II femoral defects: a prospective study of 87 patients.

INTRODUCTION: Low-grade femoral defects in revision total hip arthroplasty (rTHA) might be preferably treated with a primary implant. Almost no previous study reported the use of standard-length conical tapered (SLCT) stems in these cases. We analyzed a series of cases using a SLCT stem in rTHA with Paprosky type I-II femoral defects. The purpose of the study was to determine clinical and radiographic outcomes in this series of rTHA. MATERIALS AND METHODS: We prospectively followed 87 patients undergoing a femoral component rTHA: 53 Paprosky type I and 34 type II femoral defects. Patient-reported measures (Oxford Hip Score, EQ-5D, VAS pain during rest and activity) were administered at baseline, 1 and 2 years post-operatively. Radiographic subsidence overtime was scored. Kaplan-Meier curves were used to evaluate the subsidence over time, the complication-free survival, and the implant survivorship with reoperation and stem revision as endpoints. RESULTS: The mean follow-up was 72.5 (SD ± 23.9) months. All PROMs significatively improved over time. The average subsidence was 2.8 (SD ± 3.2), 3.6 (SD ± 4.4), and 4.0 (SD ± 4.9) mm at 4, 12, and 24 months respectively. 6 stems had subsidence > 10 mm. The survival without complication was 0.85 (95% CI 0.94-0.77), while the implant survival without reoperation was 0.83 (95% CI 0.95-0.72). The overall stem survival rate was 93.7% (95% CI 0.91-0.97) at 2 years. CONCLUSION: The use of a SLCT stem in rTHA with Paprosky type I-II femoral defects demonstrated good survival with low subsidence rates during the first 2 years after surgery. Surgeons should consider the use of this primary prosthesis as a potential treatment during stem revision in cases with limited femoral bone loss.

The "Chauffeur Fracture": Historical Origins of an Often-Forgotten Eponym.

This article describes the origin of the term "chauffeur fracture" used to indicate an oblique fracture of the radial styloid process with extension into the wrist joint. This kind of fracture was originally described by the British surgeon Jonathan Hutchinson in 1866. The invention of the automobile increased the incidence of this fracture among chauffeurs and cabdrivers. Indeed, at the beginning of the 20th century, motor vehicles were started by means of a crank-handle connected to the engine, which needed to be turned vigorously clockwise by hand. If the motor started unexpectedly, the crank-handle could jerk back violently and thereby cause a wrist injury due to sudden hyperextension. We retrospectively reviewed the literature and historical articles to better define the historical origins of an often-forgotten eponym. In 1904, the French surgeon Just Lucas-Championnière first evidenced the occupational origin of this fracture, so introducing the term "chauffeur fracture" to identify this injury.

Percutaneous fixation and balloon kyphoplasty for the treatment of A3 thoracolumbar fractures.

BACKGROUND: Despite a long history of descriptive and clinical series, there is still no consensus in the treatment of traumatic thoracolumbar fractures. It is now widely accepted that percutaneous surgery in thoracolumbar spine trauma management can achieve the same results as conventional treatment but less morbidity but it is still not clear which are the best indications for these minimal invasive procedures. METHODS: Thirty-two adult patients with single type A3 thoracolumbar burst fractures without neurologic deficits were included in this retrospective review of clinical and radiological outcomes after surgical management. All patients underwent combined percutaneous kyphoplasty and short fixation with screws in the vertebral pedicles above and below the fracture. Radiographic evaluation of segmental kyphosis and local kyphotic corrections were made preoperatively, 3 days postoperatively, 12 months post-operatively and at the last follow-up (the mean last follow-up was 41 months post-operatively). Clinical outcomes were determined by SF-36® Health Survey and Oswestry Disability Index scores at 3-month and 12-month follow-ups. RESULTS: Clinical assessments suggested good outcomes as early as the third postoperative month. The clinical outcomes were sustained at one year follow-up. At the last follow-up the segmental kyphosis correction and local kyphotic correction were maintained. CONCLUSIONS: Our analysis demonstrates that minimally invasive kyphoplasty and percutaneous short fixation applied to thoracolumbar A3 burst fractures without neurological deficit may achieve results comparable to nonsurgical or open surgical treatment, but with less morbidity and complication, and should be considered as a valid treatment option.

The impact of warfarin on operative delay and 1-year mortality in elderly patients with hip fracture: a retrospective observational study.

BACKGROUND: Guidelines underline the importance of early surgery in elderly patients with proximal femoral fractures. However, most of these patients present a high number of comorbidities, some of which require the use of warfarin. Waiting for INR decrease is a cause of surgical delay, and this influences negatively their outcome. METHODS: We retrospectively reviewed all patients with proximal femoral fracture admitted to our unit from March 2013 to March 2017 to determine whether warfarin therapy is associated with reduction of survival, delay of surgery, and increased blood loss. From 1706 patient, a total of 1292 fulfilled the eligibility criteria and were included. Data regarding general information (type of fracture according to AO/OTA classification), pharmacological history regarding anticoagulant therapy pre-admission, surgery (type of surgery and time to surgery), clinical findings (blood loss), and date of exitus were collected. RESULTS: We identified 157 patients with warfarin, 442 with antiplatelet agents (aspirin, clopidogrel, ticlopidin), and 693 in the control group. We observed a significant difference in the warfarin group regarding an increased ASA score, Charlson Comorbidity Index, and blood loss. Patients taking warfarin experience delay to the theater significantly more than the other groups. Patients in warfarin therapy have a 42% higher risk of death within 1 year from their surgery. Patients who underwent surgery after 48 h have 1.5 times higher risk of mortality with respect to the patients who underwent surgery within 48 h. CONCLUSION: Warfarin therapy at the time of proximal femoral fractures is associated with increased time to surgery, blood loss, and mortality.

Below-elbow or above-elbow cast for conservative treatment of extra-articular distal radius fractures with dorsal displacement: a prospective randomized trial.

BACKGROUND: Distal radial fractures are common traumatic injuries, but their management remains controversial also in case of conservative treatment regarding the type of immobilisation. Hence, we conducted a two-arm, parallel-group, prospective randomised trial to compare the capacity of long casts (above-elbow) and short casts (below-elbow) to maintain the reduction of extra-articular distal radius fractures with dorsal displacement (AO/OTA classification: 2R3A2.2). METHODS: Seventy-four eligible patients with AO/OTA 2R3A2.2 fractures treated with closed reduction and cast immobilisation were randomised to the long cast group (n°= 37) or to the short cast group (n°= 37). Baseline radiological parameters, radial inclination (RI), radial height (RH), ulnar variance (UV) and palmar tilt (PT) were taken, and compared with clinical (DASH, Mayo Wrist and Mayo Elbow) and radiological scores taken at 7-10 days, 4 weeks and 12 weeks. Furthermore, to evaluate correlations between radiological parameters and functional outcomes, patients were divided into two groups according to whether or not their radiological parameters at Follow-ups 2 and 3 were acceptable, i.e. within the range 11-12 mm for RH, 16°-28° for RI, - 4-+ 2 mm for UV and 0°-22° for PT. RESULTS: Patient demographic and baseline radiological parameters were similar between groups. At follow-up, there were no statistically significant differences between the two types of cast in terms of RI, RH, UV or PT, or Mayo wrist or DASH scores. Short cast group patients displayed better Mayo elbow score at follow-up 2 (4 weeks), but this difference was no longer statistically significant at follow-up 3 (12 weeks). No statistically significant differences in clinical outcomes were found between patients who presented acceptable radiographic parameters at follow-up and those who did not. CONCLUSION: As there were no significant differences between short casts and long casts in terms of fracture reduction maintenance or clinical outcomes, short casts are an effective method of post-reduction immobilisation in AO/OTA 2R3A2.2 fracture of the radius. Radiological parameters outside the range conventionally considered acceptable do not preclude a satisfactory clinical outcome. TRIAL REGISTRATION: ClinicalTrials.gov PRS, NCT04062110. Registred 20 August 2019.

Rapid Femoral Head Collapse after Removal of a Kuntscher Nail Implanted 35 Years Earlier: A Case Report.

We report the case of a 54-year-old man who developed femoral head collapse after removal of a Kuntscher nail used to fix a shaft femoral fracture that occurred 35 years earlier. The removal of fixation devices implanted several years earlier can be a difficult procedure and can expose patients to several complications. Literature is still controversial regarding the correct timing and indications. It is mandatory to evaluate potential complications and inform the patients before undertaking this procedure when really necessary.

Arthroscopic-assisted latissimus dorsi transfer for massive rotator cuff tear: a systematic review.

Introduction: This systematic review provides a comprehensive description of different surgical techniques for massive rotator cuff tears (MRCTs) using arthroscopic-assisted latissimus dorsi transfer (A-LDT), reporting clinical outcomes and complications. Sources of data: We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'latissimus dorsi', 'tendon', 'transfer', 'rotator cuff tears', 'shoulder' and 'arthroscopy' to identify articles published in English, Spanish, French and Italian. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed for the manuscript selection. Areas of agreement: Ten studies (five retrospective and five prospective investigations), all published between 2014 and 2018, fulfilled our inclusion criteria, dealing with 348 (55.7% male) patients, with a mean age of 61.6 years (range 31-83). Areas of controversy: A-LDT is a technical demanding procedure. When compared with the open technique, it does not seem to provide significant subjective and objective clinical outcome improvements. Growing points: A-LDT seems to yield lesser surgical complications and post-operative stiffness. Sparing the deltoid muscle belly could result in a more effective shoulder post-surgery function. Areas timely for developing research: Further comparative randomized controlled trials with longer follow-up are needed to clarify the potentially promising superiority of A-LDT.

Minimally invasive fixation techniques for thoracolumbar fractures: comparison between percutaneous pedicle screw with intermediate screw (PPSIS) and percutaneous pedicle screw with kyphoplasty (PPSK).

PURPOSE: To assess and compare the efficacy of two minimally invasive techniques (percutaneous pedicle screw with intermediate screw vs. percutaneous pedicle screw with kyphoplasty) for spinal fracture fixation by comparing the segmental kyphosis and vertebral kyphosis angles after trauma before surgery, after surgery, and at 4-month and 12-month follow-up. METHODS: Data from 49 patients without neurological deficit treated by either percutaneous pedicle screw with intermediate screw or percutaneous pedicle screw with kyphoplasty were retrospectively analysed. The segmental kyphosis and vertebral kyphosis angles over time were calculated and correlated with the type of procedure, AO classification, lumbar or thoracic site and the age and sex of the patients. RESULTS: After surgery, both techniques were found to be efficacious means of bringing about a significant correction of the segmental kyphosis angle (p = 0.002) and a just significant correction of the vertebral kyphosis angle (p = 0.06), although less effectively in thoracic fractures (p = 0.004). At follow-up, the vertebral kyphosis angle was stable in both groups, while there was a significant loss of segmental kyphosis angle stability in the percutaneous pedicle screw with kyphoplasty group at 1 year (p = 0.004); fractured thoracic vertebrae maintained a greater vertebral kyphosis angle (p = 0.06) and segmental kyphosis angle (p < 0.001), than the lumbar. CONCLUSION: At 1 year after surgery, the use of intermediate screws in fractured vertebrae seemed to maintain a more efficacious correction with respect to kyphoplasty, although thoracic fracture sites appear to be associated with greater post-traumatic segmental kyphosis and lesser stability in the long term after both percutaneous surgical techniques.

Spinal Deformities in Romantic Operas.

: The librettos of several of the most famous Romantic operas contain references to disease. These operas can serve as valuable sources of information regarding how spinal deformities were understood during the nineteenth century by physicians and lay persons alike. Original librettos of the operas "Rigoletto" (1851) by Giuseppe Verdi (1813-1901) and "La Esmeralda" (1836) by Louise Bertin (1805-1877) were analyzed. In both operas, spinal deformities of Rigoletto and Quasimodo are a central issue. In detail, Quasimodo could suffer from von Recklinghausen's neurofibromatosis, while Rigoletto could be affected by severe adolescent idiopathic scoliosis. The plays are an expression of the nineteenth century attitude toward deformity: the hunchbacks are ridiculed and excluded from the society due to their deformity. Thus, they are forced by society to act as ugly and evil beings. Although both Rigoletto and Quasimodo show an intense love, at the end of each opera, they are defeated by loss of this love. This is an evident sign that, despite its willingness to tackle the subject, nineteenth-century society was not still ready to attribute success or human value to people affected by disabilities.Level of Evidence: 5.

Surgical treatment of periprosthetic femoral fractures: a retrospective study with functional and radiological outcomes from 2010 to 2016.

BACKGROUND: The treatment of periprosthetic femoral fractures is a great challenge for the orthopedic surgeon and requires a knowledge of bone fracture fixation as well as skills and experience in revision surgery. The aim of this retrospective study was to evaluate the functional and radiological outcomes of periprosthetic femoral fractures surgically treated in our department from 2010 to 2016. MATERIALS AND METHODS: This study involved 73 patients with a periprosthetic femoral fracture after total hip arthroplasty or hemiarthroplasty. Periprosthetic femoral fractures were classified using the Vancouver system. Functional outcomes were assessed using Harris hip score, Palmer Parker score, SF-36 score and ambulatory status. Radiological findings were classified using Beals and Tower's criteria. RESULTS: The mean age of patients was 79.6 years old. Local risks factors were identified in 67% of the patients, principally osteoporosis (63.0%), followed by osteolysis (26.0%) and loosening of the stem (8.2%). According to the Vancouver classification, there were 10 type A, 49 type B and 14 type C fractures. Of the type B fractures, 26 were B1, 17 were B2 and 6 were B3. Applying Beals and Tower's criteria, radiological results were excellent in 24 patients (32.9%), good in 35 (47.9%) and poor in 14 (19.2%). The mean Harris hip score post-operatively was 72.5. CONCLUSIONS: These kinds of fractures should be assessed individually and the optimal treatment plan should be made in accordance with the bone stock quality, stem stability, location of the fracture and patient expectations.

Transtendon repair in partial articular supraspinatus tendon tear.

Introduction: Partial thickness rotator cuff tears (PTRCTs) are common, with an incidence between 17% and 37%, and a high prevalence in throwing athletes. Different surgical procedures are suggested when partial tears involve the articular portion of the rotator cuff, including arthroscopic debridement of the tear, debridement with acromioplasty, tear completion and repair, and lately transtendon repair. This systematic review describes the transtendon repair and examines indications, contraindications, complications and clinical outcome. Source of data: We identified clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English and Italian concerning the clinical outcomes following treatment of partial articular supraspinatus tendon tear using transtendon surgical repair. Areas of agreement: Eighteen studies fulfilled our inclusion criteria. All were published between 2005 and 2016, three were retrospective, and 15 prospective. The total number of patients was 507 with a mean age of 50.8 years. Areas of controversy: Tear completion and repair and transtendon repair alone produce similar results. Growing points: Transtendon surgical repair allows to obtain good-excellent results in the treatment of partial articular supraspinatus tendon tears. Areas timely for developing research: Further studies are needed to produce clear guidelines in the treatment of partial articular supraspinatus tendon tears. Level of evidence: IV.

Can TAD and CalTAD predict cut-out after extra-medullary fixation with new generation devices of proximal femoral fractures? A retrospective study.

BACKGROUND: Intramedullary and extramedullary strategies of pertrochanteric fracture fixation are still controversial, but new percutaneous devices may give advantages regarding operative time, blood loss and rate of cardiovascular complications. We retrospectively analyze our cases regarding Anteversa® plate (Intrauma, Turin, Italy) fixation of pertrochanteric femoral fractures, focusing on the correlation between two radiographical parameters (tip-apex distance "TAD" and calcar referenced tip-apex distance "CalTAD") and the occurrence of cut-out. The purpose of this study was to determine if these predicting factors of cut-out are reliable in the treatment of proximal femoral fractures with the Anteversa plate. METHODS: A series of 77 patients with 53 31-A1 fracture types and 24-A2 fractures completed a 12-month-follow-up. Clinical outcomes were evaluated according to Parker-Palmer Mobility Score at the final follow-up. TAD and CalTAD were considered to determine their correlation with cut-out events. RESULTS: The mean Parker-Palmer Score was 6.94 in A1 group and 7.41 in A2 group (p = 0.47). Mean value of TAD index was 29.58, 29.81 in the A1 group and 29.08 in the A2 group, and mean value of CalTAD index was 30.87, 31.03 in the A1 group and 30.50 in the A2 group. We observed 3 cases of implant cut-out. We shared our sample in two groups, one group with TAD and CalTAD indices lower than 25 mm and another group higher than 25 mm to evaluate how the Palmer Parker score changed and no statistical differences were found between the two groups. CONCLUSIONS: Taking into consideration that good clinical results were obtained for TAD and CalTAD values superior to 25 mm, the prognostic value of 25 mm of TAD and CalTAD indices might not be appropriate to this new percutaneous plate.