Suprapatellar nail removal after suprapatellar nailing of the tibia: it could work!

BACKGROUND AND AIM OF THE WORK: Intramedullary nailing is a fundamental tool for the treatment of meta-diaphyseal tibia fractures. While, in the past, the infrapatellar approach was the only one available, over the last few years, an alternative approach has been developed: the suprapatellar tibial nailing. This technique has shown some advantages over the other one. However, as the most recent method has become increasingly more common, concerns have been put forward about the possibility to remove the nail using only the infrapatellar approach, thus incising the previously unviolated patellar tendon. The aim of our study is to describe the technique and the results of a suprapatellar approach to remove the nail. METHODS: We describe the surgical technique used to remove the tibial nail via the suprapatellar approach. We analyze a small case series of 12 patients who underwent the operation of nail removal, analyzing operation time, intraoperative and/or postoperative complications and clinical outcomes. RESULTS: The mean duration of the operation was 39.8 minutes. The difference between the two values of the Lysholm score (pre- and postoperative) in each patient was not statistically significant, ranging between -2 to +4 points. We did not observe any intraoperative or postoperative complications. CONCLUSIONS: After suprapatellar nailing of the tibia, it is possible to remove the nail using the same suprapatellar approach with a safe, easy and reproducible technique. The clinical results observed in our case series show excellent outcomes in terms of absence of complications and good functional knee score.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures.

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Intramedullary cortical fragment in tibial nailing: push it, remove it or ignore it?

Intramedullary nailing of long bones is a safe procedure, with excellent long-term results. Even in apparently simple fractures, many complications may arise. Incarceration of a cortical fragment in the medullary canal is a fearsome situation, which may lead to severe complications and, consequently, poor outcomes. The surgeon should be aware of this risk and, after careful analysis of the pre-operative imaging, must remove or, at least, disengage the fragment from the medullary canal.

Long head of biceps in proximal fractures of the humerus: an underestimated problem?

BACKGROUND AND AIM OF THE WORK: The long head of biceps (LHB) is one of the tendons of the rotator cuff that runs strictly close to the humeral head. In case of pathology, it can be responsible for pain and shoulder impairment: in such cases, surgical options include tenotomy or tenodesis. The management of LHB along with surgery of the rotator cuff or during shoulder prosthetic replacement has been widely discussed in the literature. Conversely, the possibility of acute impingement and incarceration of LHB in proximal humerus fractures, as well as its role in shoulder pain in outcomes of these fractures, has been poorly considered. METHODS: The following aspects in the literature on LHB and proximal humerus fractures have been analysed: its management during fixation of fractures, the possibility of interference of the tendon with reduction of fractures or dislocations of the shoulder and its possible role in chronic pain after fixation of proximal humerus fractures. RESULTS: LHB can be an obstacle in the reduction of fractures, dislocations and fracture-dislocations. Only a few papers take into account acute surgery to LHB (tenotomy or tenodesis); most of the studies on fixation of proximal humerus fractures simply ignore the problem of LHB. The tendon can be a source of pain and a cause of disability in sequelae of these fractures. CONCLUSIONS: LHB should be taken into consideration both in the acute phase of fractures of the proximal humerus and in the outcomes. Other studies are needed to better understand its optimal management during fracture surgery.

Rotational malalignment in femoral nailing: prevention, diagnosis and surgical correction.

BACKGROUND AND AIM OF THE WORK: to review and discuss the literature about rotational malalignment during and after femoral nailing. METHODS: analysis of the literature on prevention and evaluation of rotation during femoral nailing, clinical and subjective consequences of malrotation and techniques used to correct the deformity, both in the acute and chronic phase. RESULTS: malrotation is very common after femoral nailing. The exact definition of a malrotated femur is controversial, but it is widely agreed that a rotational malalignment <10° is considered normal while >30° is a deformity which requires correction. The complaints of the patients with a malrotated femur can be various and can involve the hip, the knee or below the knee. The ability to compensate for the deformity while standing and walking may decrease the symptoms. Surgical correction is feasible with many techniques and devices: the procedure involving derotation, changing the locking screws and maintaining the nail is safe, reproducible and relatively easy. CONCLUSIONS: prevention of malrotation during femoral nailing is the cornerstone of successful operation outcomes. If rotational malalignment is suspected, prompt diagnosis and adequate surgical treatment are mandatory to overcome this common complication.

Locked posterior fracture-dislocation of the shoulder.

BACKGROUND AND AIM OF THE WORK: To describe a valid option for the treatment of locked posterior fracture-dislocation of the shoulder (LPFDS) and to compare it to the literature about this topic. METHODS: We present a small case series (3 patients), with a medium follow up at 4 years and 5 months. We accurately describe our surgical strategies, underlining the choice of approach, reduction and fixation. RESULTS: The three patients showed excellent functional and radiological results at the follow up examinations, with a full range of shoulder movements and complete regain of pre-trauma activities. A lateral approach (standard or minimally invasive), a reduction technique with a Shantz pin in the head and in the humeral shaft, and fixation with a locking plate were used in the three patients. CONCLUSION: LPFDS is a challenging lesion, hard to recognize and to treat. Our suggested method of treatment is highly reproducible and has revealed itself to be very effective in achieving good results.

Can Clinical and Surgical Parameters Be Combined to Predict How Long It Will Take a Tibia Fracture to Heal? A Prospective Multicentre Observational Study: The FRACTING Study.

BACKGROUND: Healing of tibia fractures occurs over a wide time range of months, with a number of risk factors contributing to prolonged healing. In this prospective, multicentre, observational study, we investigated the capability of FRACTING (tibia FRACTure prediction healING days) score, calculated soon after tibia fracture treatment, to predict healing time. METHODS: The study included 363 patients. Information on patient health, fracture morphology, and surgical treatment adopted were combined to calculate the FRACTING score. Fractures were considered healed when the patient was able to fully weight-bear without pain. RESULTS: 319 fractures (88%) healed within 12 months from treatment. Forty-four fractures healed after 12 months or underwent a second surgery. FRACTING score positively correlated with days to healing: r = 0.63 (p < 0.0001). Average score value was 7.3 ± 2.5; ROC analysis showed strong reliability of the score in separating patients healing before versus after 6 months: AUC = 0.823. CONCLUSIONS: This study shows that the FRACTING score can be employed both to predict months needed for fracture healing and to identify immediately after treatment patients at risk of prolonged healing. In patients with high score values, new pharmacological and nonpharmacological treatments to enhance osteogenesis could be tested selectively, which may finally result in reduced disability time and health cost savings.

Scapulothoracic dissociation: a devastating "floating shoulder" injury.

Background and aim of the work The term "floating shoulder" was used in a previous paper to describe lesions of at least two components of the SSSC (superior shoulder suspensory complex), a bony-ligamentous structure of the shoulder girdle. Following this article other types of floating shoulder were described, including scapulothoracic dissociation (STD), a rare lesion with potentially devastating consequences, with detachment of the scapular body from the thoracic wall, with following lateralization of the scapula,  fracture of the clavicle or injury of the adiacent sterno-clavear or acromion-clavicular joints. Prognosis and outcome are also negatively influenced by secondary vascular and neurologic injuries.  Methods We review the literature on this lesion and we describe two patients with STD, their treatment and outcome.  Results Reviewing the literature and analysing our cases, we point out that the STD is often associated with serious general lesions and is indicative of an high-energy trauma. The consequences can be disabling for the upper limb (20% amputation, 50% flail limb) or for the general status of the patient (10% mortality).  Conclusions STD must be timely recognized and subsequently properly treated, to avoid the associated general and local injuries (vascular) and subsequently the musculoskeletal lesions.

Patient-reported outcome measures for non-specific neck pain validated in the Italian-language: a systematic review.

BACKGROUND: Patient-reported outcome measures can improve the management of patients with non-specific neck pain. The choice of measure greatly depends on its content and psychometric properties. Most questionnaires were developed for English-speaking people, and need to undergo cross-cultural validation for use in different language contexts. To help Italian clinicians select the most appropriate tool, we systematically reviewed the validated Italian-language outcome measures for non-specific neck pain, and analyzed their psychometric properties and clinical utility. METHODS: The search was performed in MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and Cochrane Library. All articles published in English or Italian regarding the development, translation, or validation of patient-reported outcome measures available in the Italian language were included. Two reviewers independently selected the studies, extracted data, and assessed methodological quality using the COSMIN checklist. RESULTS: Out of 4891articles screened, 66 were eligible. Overall, they were of poor or fair methodological quality. Four instruments measuring function and disability (Neck Disability Index, Neck Pain and Disability Scale, Neck Bournemouth Questionnaire, and Core Outcome Measures Index), and one measuring activity-related fear of movement (NeckPix©) were identified. Each scale showed some psychometric weaknesses or problems with functioning, and none emerged as a gold standard. CONCLUSIONS: Several patient-reported outcome measures are now available for assessing Italian people with non-specific neck pain. While the Neck Disability Index is the one most widely used, the Neck Bournemouth Questionnaire appears the most promising tool from a psychometric point of view.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe.

BACKGROUND: The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA). METHODS: Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05). RESULTS: Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values. CONCLUSIONS: Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.