Evaluation of Outcome after Total Hip Arthroplasty for Femoral Neck Fracture: Which Factors Are Relevant for Better Results?

Background: Femoral neck fractures (FNFs) are frequent orthopedic injuries in elderly patients. Despite improvements in clinical monitoring and advances in surgical procedures, 1-year mortality remains between 15% and 30%. The aim of this study is to identify variables that lead to better outcomes in patients treated with total hip arthroplasty (THA) for FNFs. Methods: All patients who underwent cementless THA for FNF from January 2018 to December 2022 were identified. Patients aged more than 80 years old and with other post-traumatic lesions were excluded. Patient data and demographic characteristics were collected. The following data were also registered: time trauma/surgery, surgical approach, operative time, intraoperative complications, surgeon arthroplasty-trained or not, and anesthesia type. In order to search for any predictive factors of better short- and long-term outcomes, we performed different logistic regression analyses. Results: A total of 92 patients were included. From multivariable logistic regression models, we derived that a direct anterior surgical approach and an American Society of Anesthesiologists (ASA) classification < 3 can predict improved short-term outcomes. Moreover, THAs performed by surgeons with specific training in arthroplasty have a lower probability of revision at 1 year. Mortality at 1 year was ultimately influenced by the ASA classification. Conclusions: A direct anterior approach and specific arthroplasty training of the surgeon appear to be able to improve the short- and long-term follow-up of THA after FNF.

Talus dislocation and pereonal malleolar fracture after high-energy trauma: a case report.

Talus dislocation is a rare injury and it is usually the consequence of high energy traumas, despite the anatomical features of the talus which predispose to its dissociation (absence of muscle insertions with over 60% of the surface covered by cartilage). It may be associated with malleolar fractures. Standard treatment of closed talar dislocation is a controversial issue. The most common early complications is avascular necrosis. Authors report a case of a complete talar dislocation associated to displaced lateral malleolar fracture in a 18-years-old male following a high energy trauma treated by closed reduction and fixation of the malleolar fracture.

Proximal fibular stress fracture in adolecent soccer player. A case report.

Fibular fractures are the third most common stress fractures in children and adolescents. Proximal fibular location is a very rare finding, with few reports in the literature and, frequently, careful investigations before a definitive diagnosis could be necessary. The authors report a case of an adolescent 13 years old soccer player with a proximal fibular fracture that was initially underestimated and misdiagnosed and ultimately confirmed as a stress lesion by MRI.

Metacarpophalangeal joint hyperextension in rhizartrosis: is surgical correction necessary?

BACKGROUND AND AIM: Rhizarthrosis represents 10% of all arthritic manifestations and its prevalence increases with age and in women. The hyperextension of the metacarpophalangeal joint (MCPj) is consequent to a progressive dorsoradial subluxation of the trapeziometacarpal joint (TMj) in advanced osteoarthritis. The aim of this retrospective study is to evaluate the clinical and functional results of 32 patients affected by advanced rhizarthrosis who underwent to modified Burton-Pellegrini's trapeziectomy in absence of surgical correction of MCPj hyperextension in order to understand when this last step is really necessary. METHODS: Patients were assessed trough DASH and PRWHE questionnaires; the functionality of the hand was assessed by carrying out specific test (grip strength, key-pinch, kapandji test, reduction of wrist flexion strength) and the degree of MCP joint hyperextension was recorded. RESULTS: Clinical evaluation and individual satisfactory were positive in most cases (mean DASH 19 and mean PRWHE 21.8, with a reduction of 77% of VAS pain score). Kapandji test was excellent in 26 patients and grip strength and key pinch were stackable in operated and non-operated hands. Twenty-five out 32 patients presented a MCP joint hyperextension between 0° and 5°, 5 of 10° and other 2 of 15°. CONCLUSION: Modified Burton-Pellegrini's trapeziectomy is a valid option to treat patient with TMj osteoarthritis. The absence of surgical correction of the MCPj does not affect clinical and functional results in deformities <15°.

Dair approach in 7 infected total hip arthroplasties: our experience and current concepts of the literature.

INTRODUCTION: Periprosthetic joint infection (PJI) is one of the most challenging complications following total hip arthroplasty. In early infection, within four to twelve weeks from surgery, debridement, antibiotics and implant retention (DAIR) can be the initial treatment. The aim of this study is to report our case series and review current concepts reported in the literature about this topic. MATERIALS AND METHODS: This was an observational cohort study that included 7 patients managed with DAIR for PJI following primary total hip replacement (THR) between 2014 and 2020. Inclusion criteria were a primary THR, direct anterior or lateral approach, DAIR procedure, and PJI. Exclusion criteria were a PJI following a revision total hip replacement or hemiarthroplasty, posterolateral approach, 1-stage revision, 2-stage revision, and Girdlestone procedure without prior DAIR. For each patient demographic characteristics, laboratory values, microorganisms involved, antibiotic therapy and outcome at one-year follow-up were registered. RESULTS: The mean duration between THR and DAIR was 19 days. In all cases only one DAIR procedure was performed. Most infections were caused by Staphylococcus aureus (4 cases) [one methicillin resistant (MRSA)]. The other infections were caused by Streptococcus agalactiae, Staphylococcus coagulase negative and Escherichia coli. At the final follow-up, the procedure was considered as successful in 6 out of 7 patients (85%). The one with unsuccessful outcome underwent to a two-stage revision. DISCUSSION: Our results were comparable with those of a recent systematic review of the literature. Factors that have been postulated to influence the outcome of DAIR in the management of PJIs include the timing and numbers of debridement, the exchange of components, the responsible microorganism and the duration of antibiotic treatment. In conclusion, the outcomes following DAIR are better as the indications are refined and risk factors identified. PJI prevention remains the key but the current literature still lacks well documented and effective PJI prevention protocols. (www.actabiomedica.it).

Tibial tubercle avulsion fracture during sport activities in adolescent: a case report.

BACKGROUND AND AIM OF WORK: Tibial tubercle avulsion fractures (TTAF) are uncommon condition in children and adolescents. These lesions may be misdiagnosed and consequently not properly treated. Reduction and fixation is indicated if displacement is higher than 2mm or if the extensor apparatus is damaged. Authors present a case of a TTAF associated with a complete lateral patellar retinaculum lesion in a 13-year-old male adolescent non-professional basketball player. METHODS: Surgery consisted of reduction and fixation with 2 half threaded cancellous and washers; TTA was then basted and reinforced with a non absorbable suture according to Krachow technique and finally the patellar lateral retinaculum through a direct repair with absorbable material. RESULTS: Clinical evaluation after 3 years showed bone healing, a complete resolution of pain, complete range of motion, good strength and complete functionality of the operated limb. CONCLUSIONS: Misdiagnosis or delayed treatment of TTAF can often result in nonunion, functional impairment, and persistent pain. For these reasons, authors believe that a stable and quick fixation associated to specialized rehabilitation are crucial for recovery. (www.actabiomedica.it).

Delirium risk factors analysis post proximal femur fracture surgery in elderly.

BACKGROUND AND AIM: The increase in the average-age and in the percentage of elderly people implies an exponential increase in fractures of the proximal femur. A common consequence of hip fracture in elderly patients is delirium, characterized by cognitive confusion or a lethargic-type condition. Predisposing factors have been identified, but risk factors assessment useful for managing clinical intervention, has not received unanimous consent. This work aims to identify the potential risk factors for delirium in the elderly operated for hip fracture. METHODS: In this prospective observational study, we included 83 patients aged ≥65 years. Patients undergoing osteosynthesis of the femur and hip replacement for fractures were included. Patients already delusional in the pre-operative period were excluded. At the time, deadlines T0 (pre-operative), and T1,T3,T7 post-operative day, delirium, hematic parameters, blood transfusions, were assessed. RESULTS: Level of delirium was assessed obtaining 80% not delusional and 20% delusional. Glycemia and hemoglobin were not found to be risk factors, although they are known to influence cognitive status; we hypothesize they should be considered predisposing factors. Comorbidities such as atrial fibrillation and Chronic Obstructive Pulmonary Disease were found associated with delirium. The most advanced age, anxiolytic drugs, the use of benzodiazepine as anaesthetic, the time surgical waiting, were found significantly associated with delirium. CONCLUSIONS: Taken together, findings of this prospective observational study showed that environmental and metabolic risk factors might contribute to make elderly susceptible to develop postoperative delirium following hip surgery. Thus, these patients should be adequately assessed and monitored. (www.actabiomedica.it).

Distal tibial fractures treated with intramedullary nailing: management of associated posterior and medial malleolar injuries.

INTRODUCTION: Articular tibial ankle injuries may occur in association with distal tibial fractures, especially in those characterized by spiral or oblique shape. These lesions are often misdiagnosed and overlooked with significant biomechanical and clinical consequences. The purpose of this study was to evaluate the outcomes of patients affected by posterior and medial malleolar ankle fractures associated with distal tibial fracture who underwent intramedullary nailing at a follow-up of 3 years. Furthermore authors wanted to highlight the correct sequence of diagnosis and fixation in these associated fracture patterns. MATERIALS AND METHODS: All treated patients between 2006 and 2016 (Group 1) were compared with a control group (Group 2) without ankle lesions. Demographic variables and data related to surgical procedure and hospitalization were documented and analyzed. X-rays and computed tomography before operation were reviewed to identify type of fracture; radiographs after surgery and at follow-up were respectively analyzed to study the quality of joint reduction and the development of osteoarthritis. Clinical outcomes were evaluated using OMAS and DRI scores. RESULTS: Thirty-six patients were in group 1 and 36 in group 2. In group 1 longer operating time and hospitalization were documented. Quality of reduction in group 1 was always satisfactory. No signs of osteoartritis were detected at 3 years follow-up. The mean union time was 23.6 weeks for group 1 and 20,4 for group 2 (p=0.111). No differences in clinical scores were documented after 6 months. The full weight-bearing time was longer in group 1 (p=0.017). CONCLUSIONS: Clinical results appeared similar. No osteoarthritis was documented in group 1 as consequence of good articular reduction that is better and more easily executable if malleolar ankle fractures are fixed before intramedullary nailing. In distal tibial fractures CT has always to be performed to recognize associated ankle lesions as it may modify the surgical plan, postoperative management and outcomes.

Femoroacetabular impingement: correlation between imaging parameters, sport activity and chondral damage.

BACKGROUND: Femoroacetabular impingement is characterized by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: pincer-FAI, cam-FAI and cam-pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages. METHODS: Forty-one patients, undergoing arthroscopic chondroartroplasty for cam and cam-pincer mixed form were considered. All patients underwent an X-Ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-Ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge Classification. RESULTS: The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50±0.23 and 0.33±0.19. The α angle predictive for a chondral damage of IV degree was 81.5°. The chondral damage of the patients suffering from cam-FAI and cam-pincer mixed form were respectively 3.53±0.80 and 3.00±1.41. CONCLUSIONS: From the results was possible to: 1) elaborate two tables providing a reliable indirect calculation of the alpha angle; 2) establish an alpha angle cut-off value indicative for a IV degree chondral damage; 3) show that pincer-FAI does not represent an aggravating factor for chondral damage; 4) show that the level of sports activity was related to the severity of chondral damage; and 5) show that a physically demanding occupation was not an aggravating factor for chondral damage.

Involvement of the medial and lateral epicondyles in distal humeral coronal shear fractures: Case series and literature review.

PURPOSE: Epicondyle involvement in capitellar and trochlear fractures is often considered a simple associated lesion that does not substantially change treatment or prognosis. Although theoretically predicted in reviews, case series almost never report elbow prosthesis use in comminuted coronal shear injuries associated with epicondylar fracture in the elderly. The purpose of this study is to focus on this underestimated injury pattern that can be a negative risk factor for treatment and prognosis. METHODS: We retrospectively reviewed all cases with coronal shear fracture of the distal humerus treated from 2016 to 2019. Fractures were classified according to Dubberley. Open reduction and internal fixation (ORIF) were performed when possible. Partial or total elbow replacement was used in severely comminuted fractures with epicondylar involvement in four elderly patients. RESULTS: Nineteen consecutive patients were selected (mean age: 62.4 years), of which 10 had type 3A/3B fractures, and seven had both medial and lateral epicondylar involvement. The mean follow-up duration was 31.78 months. The average Mayo Elbow Performance Index (MEPI) score was 81.05 points, with 7 excellent, 8 good, 1 fair, and 3 poor results. The average MEPI score of Dubberley's type 1 and type 2 was better than that of type 3 (mean: 92 vs. 72, p = 0.02). Further, the results of average range of motion were better in patients who had sustained Dubberley types 1 and 2 lesions than those with Dubberley type 3 lesion (mean: 133° vs. 85°, p = 0.002). Two patients out of three who required intra-operative conversion to total elbow arthroplasty had poor outcomes. CONCLUSIONS: The simultaneous presence of fracture of one or both epicondyles are usually associated with severe joint comminutions and makes ORIF more challenging, especially among elderly women. In these cases, primary total elbow prosthesis implantation could be a valid treatment option.

Open fracture-dislocation of the knee associated with nonunion of the medial femoral condyle and chronic tendon patellar rupture.

BACKGROUND AND AIM OF WORK: The incidence of coronal fractures of the femoral condyle, Hoffa fractures, ranges from 8.7% to 13% of all fractures of the distal femur and are often observed in polytraumas. Hoffa fractures may be misdiagnosed and consequently not properly treated. Reduction and synthesis of this type of fracture should be achieved to avoid complications such as nonunion, pain, functional impairment. The authors present a case of a 5 year old nonunion of a Hoffa fracture of the medial condyle with chronic patellar tendon rupture.   Methods: Revision surgery consisted of reduction and fixation of the Hoffa fracture with screws associated with bone grafting from the iliac crest. Distalization of the patella by Z-plasty and reconstruction of the patellar tendon with Achille's allograft were also performed.   Results: Clinical evaluation after 10 months following the end of the treatment showed a complete resolution of pain, almost complete range of motion, good strength and almost complete functionality of the operated limb.   Conclusions Mistakes in the diagnosis or treatment of Hoffa fracture can often result nonunion, functional impairment, and persistent pain. To avoid these, the senior authors of this text believe that the correct treatment of acute Hoffa fracture and its potential associated injuries are crucial, according to the concept of early damage control and later synthesis with soft tissue reconstruction.

Long-term results after modified Burton-Pellegrini's technique in 24 cases affected by advanced rhizarthrosis.

BACKGROUND AND AIM: Rhizarthrosis common in elderly and represents 10% of all artrhitic manifestations. Trapeziectomy with ligament reconstruction and tendon interposition remains the gold standard for stages II to IV according to Eaton and Littler. This retrospective study aimed to evaluate the results of 24 patients affected by advanced rhizarthrosis who underwent to modified Burton-Pellegrini's trapeziectomy with ligamentoplasty using the entire flexor carpi radialis tendon. METHODS: Patients were assessed through DASH and PRWHE questionnaires; the examination focused also on pain symptoms (VAS score) and the results obtained in carrying out specific tests to evaluate the trapezius-metacarpal functionality (key-pinch, grip strength, Kapandji test, reduction of wrist flexion). Furthermore, postoperative complications were evaluated. RESULTS: Clinical evaluation and individual satisfaction were positive in most cases (mean DASH 18,8 and mean PRWHE 21,7). VAS pain score reduced of 76.7%, grip strength and key pinch were similar to those of the non-operated hand and Kapandji test was excellent in 20 patients.  One superficial wound infection was encountered which resolved by specific antibiotic therapy. CONCLUSIONS: The choice of the most appropriate treatment depends on clinical conditions and socio-occupational factors of the patient (age, sex and functional needs), the degree of osteoarthritis and the presence of deformaties of the first metacarpophalangeal joint. Surgery aims to relief pain and to improve joint function and strength. According to the results observed this surgical technique has to be considered a valid option for the treatment of advanced rhizarthrosis as it provides pain relief, stability and mobility of the thumb.

Grice subtalar arthrodesis of bilateral adult flatfoot in a professional dancer: a case report.

BACKGROUND AND AIM: Adult acquired flatfoot deformity (AAFD) is a common pathology and an important cause of pain and disability. This deformity causes a progressive flattening of the foot arch which has traditionally been associated with posterior tibialis tendon (PTT) dysfunction. Operative treatment is indicated after the failure of conservative management aiming to achieve proper alignment of the hindfoot and to maintain as much flexibility as possible. If subtalar osteoarthritis is present, subtalar arthrodesis is usually the best therapeutic option. Grice-Green subtalar arthrodesis is a widely used procedure. METHODS: This report describes a case of bilateral painful AAFD in a 39-years old female professional dancer treated with Grice-Green subtalar arthrodesis with an autologous corticocancellous graft harvested from the ipsilateral proximal tibia. Surgeries were performed 3 years apart from each other. RESULTS: The patient followed had good clinical and radiological outcomes. She returned to dance 4 months after surgery with no referred pain or limitations.  Conclusions: Due to its versatility and capability to restore the shape and thickness of the hindfoot Grice-Green procedure is a simple and effective technique for the treatment of AAFD with subtalar osteoarthritis and a valid option to solve professional disabilities as it happened in this case with a professional dancer.

Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts.

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.

Acute radial head replacement with bipolar prostheses: midterm results.

In irreparable radial head fractures, especially if primary stabilizers of the elbow are damaged, the prosthetic replacement prevents instability and stiffness. Concerns have arisen over the use of bipolar press-fit prostheses due to the frequent finding of osteolysis and the risk of instability if compared to monopolar implants. Our aim was to assess midterm clinical and radiological outcomes of bipolar implants and the influence of osteolysis on proximal pain. Seventeen patients with irreparable fractures of the radial head, treated in acute with the same prosthetic model (rHEAD recon SBI/Stryker) between January 2015 and December 2018, were enrolled. Clinical assessment was performed using MEPS and DASH scores; a radiographic study was done to identify heterotopic ossifications and periprosthetic osteolysis. Outcomes at the last follow-up, according to MEPS, were excellent in 10 cases, good in 5 and fair in 2; none of the patients had severe pain or instability. In 3 cases, it was necessary to remove the implant, mainly because of early loosening. Radiological findings of osteolysis were detected in 9 cases, but no statistical correlation was found with MEPS and proximal pain. The use of bipolar implants is reliable if an accurate repair of ligament tears is performed and provides a good stability. Nevertheless, the risk of early aseptic loosening in uncemented implants is not negligible, and the follow-up of the patient must be strict. Late osteolysis does not seem to have clinical relevance, but further prospective studies are necessary to clarify this topic.

Neck modularity in total hip arthroplasty: a retrospective study of nine hundred twenty-eight titanium neck implants with a maximum follow-up of eighteen years.

PURPOSE: Neck modularity was introduced to improve total hip arthroplasty (THA) accuracy, but it has been associated with early breakages and corrosion issues. In our hospital, modular necks have been in clinical use since the 1990s. We retrospectively analysed the occurrence of these sequelae in implants placed between January 2000 and December 2014. METHODS: Survival data from patients operated on in our hospital were obtained from the regional arthroplasty registry (Registro dell'Impiantologia Protesica Ortopedica, RIPO). The cohort comprised 928 THAs on 908 patients. The average patient age was 67.8 years. Main indications were primary osteoarthritis (71.4%), fracture (9.2%), congenital dysplasia or congenital luxation (7.8%), and idiopathic osteonecrosis (6.4%). All femoral stems were cementless, with 318 anatomically shaped (34.3%), 579 straight (62.4%), and 31 short stems (3.3%). All necks used were made of titanium alloy. The average follow-up time was 9.6 years (range, 4-18 years). RESULTS: In total, 66 revisions were reported. The main revision causes were periprosthetic fractures (33.3%), aseptic stem loosening (19.7%), luxation (18.2%), and implant breakage (12.1%). Five modular neck breakages were recorded. The overall survival rate was 87.7% at 17 years. We did not observe any component corrosion. The neck breakage rate was 0.5%, and the luxation rate was 1.3%. CONCLUSIONS: Our experience suggests that neck modularity is a safe, effective way to reconstruct the proximal femur in THA patients. We attribute the absence of corrosion to the exclusive use of titanium necks.

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.

Arthroscopically-assisted Reduction and Internal Fixation (ARIF) of tibial plateau fractures: clinical and radiographic medium-term follow-up.

BACKGROUND AND AIM OF THE WORK: Tibial plateau fractures include a wide spectrum of lesions with potentially disabling sequelae. Arthroscopically-assisted Reduction and Internal Fixation (ARIF) is an alternative to traditional ORIF. The aim of this retrospective single centre study is to evaluate medium-term clinical and radiographic outcomes achieved in a consecutive series of patients treated with ARIF. METHODS: 21 patients, with a mean age of 52.2 ± 13.4 years at surgery, were included. According to Schatzker classification, there were 9 type II, 10 type III, 2 type IV fractures. Associated intra-articular injuries (meniscal tears, tibial spine fractures, chondral lesions) were detected in 8 patients. At follow up, patients were clinically and radiographically evaluated according to knee ROM, KOOS, OKS and Rasmussen Clinical and Radiological Scores. RESULTS: At an average follow-up of 84 ± 22.5 months, 18 patients were evaluated. Mean values recorded were the following: knee ROM 1° - 135°, OKS 41.6 / 48 ± 8.18, subscale KOOS scores ranged from 75% ± 25.4 (Quality of Life) to 91.1% ± 11.2 (Pain), Rasmussen Clinical e Radiological 27.2 ± 2.64 (14 excellent, 3 good, 1 fair) and 9.1 ± 0.64 (15 excellent, 3 good) respectively. Worse results were observed in 5 patients with pre-existing degenerative chondropathy. CONCLUSIONS: ARIF revealed to be an effective technique for surgical treatment of unicondylar tibial plateau fractures. Our findings support the favourable results reported by other authors. ARIF is not a simple technique and requiresspecific experience in knee arthroscopy and a steep learning curve.(www.actabiomedica.it).

Translation, cross-cultural adaptation, reliability, and validation of the italian version of the Foot and Ankle Disability Index (FADI).

BACKGROUND AND AIM OF THE WORK: Foot-and-Ankle-Disability-Index (FADI) is one of the most widely used evaluation questionnaires for this anatomical district, but an italian validated version lacks and is necessary to properly evaluate italian people. In fact a correct interpretation of the items by patients is essential to obtain a precise subjective response, making the questionnaire valid to evaluate patients' satisfaction and wellness. Our purpose was to translate and culturally adapt into Italian the FADI questionnaire, and to check its reproducibility and validity. MATERIALS AND METHODS: The original english version of FADI questionnaire was translated into Italian and checked for medical part coherence. It was submitted to 10 italian randomized patients to verify a correct cultural adaptation, and then to other 50 randomized patients operated at their ankle or hallux to assess intra- and inter-observer reproducibility by the Pearson's-Correlation-Coefficient (PCC) and the Intra-Class-Correlation (ICC) coefficient. Moreover, Short-Form-36 (SF36) questionnaire for Quality-of-Life and Visual-Analogue-Scale (VAS) for pain were also administered to the same 60 people and compared to italian-FADI to perform validation analysis by PCC and ICC coefficient. RESULTS: Cultural adaptation of the translated version of the scale resulted good in terms of understandability by patients. An optimal correlation of the inter- and intra-observer reproducibility was obtained. The correlation obtained between FADI and SF-36 as well as between FADI and VAS indicates success in the validation process. CONCLUSIONS: Validation of the FADI italian version has been performed successfully, its use can be considered appropriate and is indicated in italian clinical practice. (www.actabiomedica.it).

Antegrade intramedullary nailing in proximal humeral fractures: results of 23 cases.

INTRODUCTION: the metaepiphyseal fractures of the proximal humerus represent 5% of all fractures and mainly affect elderly patients. The type of treatment remain controversial. This retrospective study aimed to evaluate the clinic and radiographic results of 23 patients affected by two or three fragments fractures of the proximal humerus with or without metaphyseal extension treated with antegrade intramedullary nailing. MATERIALS AND METHODS: all patients were clinically evaluated using the "Constant score" (CS) and individual satisfaction was assessed with a visual scale (VS). Moreover, the fracture's healing process and the neck shaft angle (NSA) were assessed radiographically. RESULTS: the mean follow-up was 72 months (24-120). Clinical evaluation and individual satisfaction were positive in most cases (mean CS 79,39 and VS 3,17). Worse results were observed in patients over 65 years. DISCUSSION: among the different surgical options intramedullary nailing ensures good fracture stability and high consolidation rate. The entry point through the rotator cuff is of main importance as well as proximal nail positioning and choice of the locking screws length. In this study the functional results of the shoulder are worse in the elderly, who are supposed to have already a degenerated rotator cuff. CONCLUSIONS: antegrade intramedullary nailing should be considered a valid therapeutic option in this type of fractures. The surgical technique may influence functional results, as consequence of iatrogenic damage of the rotator cuff.