KNEE PERIPROSTHETIC FRACTURES IN THE ELDERLY: CURRENT CONCEPT.

Periprosthetic fractures around total knee arthroplasty in elderly represent an emerging cause of implant revision and their incidence seems destined to further increase in the upcoming years, considering the ever-increasing number of implanted prostheses. These are complex injuries with very high complication rates. It has been estimated that the incidence of femoral periprosthetic fractures after T.K.A. ranged between 0,3 to 2,5%, but increases up to 38% when considering revision T.K.A. Patient-related risk factors for T.K.A. periprosthetic fracture (T.K.A.P.F.) include osteoporosis, age, female sex, revision arthroplasty and peri-implant osteolysis. The grate debate concerns the choice of the most appropriate fixation device for T.K.A.P.F.: closed or open reduction with internal fixation with either locked plate or intramedullary nail is the most commonly used for treating these fractures. Success of these methods depends on the fracture pattern, the stability of implants, and the patient's bone quality which is often poor in elderly, thus resulting in high complication rates. Conversely, a revision of T.K.A. (R.T.K.A.) should be considered in case of prosthetic component instability, severe comminution or metaphyseal extension of the fracture (that precludes a good fixation), previous treatments failure and severe malalignment of T.K.A. Instead megaprosthesis and allograft-prosthesis composite are necessary in case of sever bone loss. Considering the variability of the clinical scenario of T.K.A.P.F., this complex injury requires and experienced and comprehensive approach based on both facture fixation and/or revision arthroplasty.

Analysis of early and late clinical and radiologic complications of proximal humeral fractures using open reduction, internal fixation, and intramedullary titanium cage augmentation.

BACKGROUND: An intramedullary augmentation technique using a titanium cage with different types of hardware can be considered a new option in the management of proximal humeral fractures. This study aimed to report the perioperative, early, and late complications of proximal humeral fractures using the intramedullary augmentation technique. METHODS: From 2005 to 2017, 142 displaced proximal humeral fractures were treated in the same unit by the aforementioned technique. Perioperative, early, and late complications were evaluated in all patients. Clinical evaluation was performed according to the Constant and Disabilities of the Arm, Shoulder and Hand scores. Only 115 patient records could be considered to have long-term follow-up (7-12 years). RESULTS: Extra-articular migrations of K-wires, plate cutout, and screw penetration were not observed. A transitory axillary nerve palsy with inferior humeral head subluxation was observed in 41 patients (29.8%). Of the 142 patients, 2 (1.4%) manifested early signs of infection, and 1 underwent a reoperation after 30 days. Complete bone healing was obtained at a mean of 3.5 months in 140 of 142 shoulders (98.6%). We achieved long-term follow-up on only 115 patients because 14 had died, 6 lived abroad, and 7 could not participate due to illness. The results were good or excellent in 99 patients (86%), fair in 12 (10.4%), and poor in 4 (3.4%). K-wires were removed in 15 of 79 patients (11.5%). Nonunion or malunion occurred in 1 patient (0.8%). Asymptomatic avascular necrosis developed in 8 patients (6.9%) after 5 years, and secondary glenohumeral osteoarthritis occurred in 6 (5.2%). CONCLUSIONS: Intraoperative and postoperative analyses with short-, medium-, and long-term outcomes show that the intramedullary augmentation technique improves fracture treatment with significantly good anatomic reconstruction in complex and unstable cases. The bone healing rate is significantly high, and the technique is associated with a significantly low percentage of complications.

Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy.

BACKGROUND: From February 20 to April 2020, the coronavirus SARS (severe acute respiratory syndrome)-CoV-2 spread in northern Italy, drastically challenging the care capacities of the national health care system. Unprepared for this emergency, hospitals have quickly reformulated paths of assistance in an effort to guarantee treatment for infected patients. Orthopaedic departments have been focused on elderly traumatology, especially the treatment of femoral neck fractures in patients with coronavirus disease-2019 (COVID-19). The purpose of the present study was to evaluate the orthopaedic management strategy for femoral fragility fractures in COVID-19-positive patients with the hypothesis that operative treatment may contribute to the overall stability of the patient. METHODS: Sixteen patients affected by proximal femoral fracture and a recent history of fever, shortness of breath, and desaturation were admitted to the emergency room. Thoracic computed tomography (CT) and oropharyngeal swabs confirmed that they were positive for COVID-19, requiring hospitalization and prophylaxis with low-molecular-weight heparin. RESULTS: Three patients died before surgery because of severe respiratory insufficiency and multiple-organ-failure syndrome. Ten patients underwent surgery on the day after admission, whereas 3 patients had suspended their use of direct thrombin inhibitors and needed surgery to be delayed until the third day after admission. In all patients except 1, we noted an improvement in terms of O2 saturation and assisted respiration. In 9 patients, hemodynamic and respiratory stability was observed at an average of 7 days postoperatively. Four patients who underwent surgical treatment died of respiratory failure on the first day after surgery (1 patient), the third day after surgery (2 patients), or the seventh day after surgery (1 patient). CONCLUSIONS: We noted a stabilization of respiratory parameters in 12 COVID-19-positive patients who underwent surgery treatment of proximal femoral fractures. We believe that in elderly patients with COVID-19 who have proximal femoral fractures, surgery may contribute to the overall stability of the patient, seated mobilization, improvement in physiological ventilation, and general patient comfort in bed. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.