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.

Fragility Fractures of the Acetabulum: Current Concepts for Improving Patients' Outcomes.

The incidence of fragility fractures of the acetabulum (FFA) is constantly increasing. Generally, these fractures are related to a fall on the greater trochanter involving the anterior column. The management of FFA is extremely difficult considering both patients' comorbidities and poor bone quality. Both non-operative and several operative treatment protocols are available, and the choice among them is still ambiguous. The proposed surgical techniques for FFA [namely open reduction and internal fixation (ORIF), percutaneous fixation and total hip arthroplasty (THA)] are associated with a high complication rate. The treatment with the higher early mortality is the ORIF + THA, while the one with the lowest is the non-operative. However, at longer follow-up, this difference dreadfully change is becoming the opposite. Frequently ORIF, percutaneous fixation, and non-operative treatment need a subsequent re-operation through a THA. This latter could be extremely difficult, because of poor bone quality, acetabular mal union/non-union, bone gaps and hardware retention. However, the outcomes of each of the proposed treatment are mostly poor and controverted; therefore, a comprehensive patient evaluation and an accurate fracture description are required to appropriately manage acetabular fracture in the elderly.

Extracapsular femoral neck fractures treated with total hip arthroplasty: identification of a population with better outcomes.

Background: Femoral neck fractures (FNF) are associated to patient's disability, reduced quality of life and mortality. None of the fixation devices commonly used for extracapsular (EC) FNF (i.e., dynamic hip screws (DHS) and intramedullary nails (IN)) is clearly superior to the other, especially in case of unstable fractures (31.A2 and 31.A3 according to AO/OTA classification). The aim of our study was to identify a sub-population of patients with EC fractures in which better outcomes could be obtainable using total hip arthroplasty (THA). Methods: All patients with EC unstable fractures treated with THA were included in the present study. Demographic data, American Society of Anesthesiologists (ASA) score, hospitalization length, transfusion rate, implant-related complications and mortality rate were collected. Clinical outcomes were evaluated using the Oxford Hip Score (OHS), while patients' general health status through the 12 Item Short Form questionnaires (SF-12). Results: 30 patients (7 male; 23 female) with a mean age of 78.8 years were included. The 1-year mortality rate was 13.3%. The mean OHS was 27.5, while the mean SF-12 were 45.84 for the mental item and 41.6 for the physical one. Age was the only factor associated with the OHS and patients older than 75 years presented a 12- fold higher risk of developing bad outcomes. Conclusions: THA seems to be a viable option for unstable EC fractures, with good clinical outcomes, especially in patients younger than 75 years of age. The mortality rate associated with THA in EC fractures is low and anyway comparable with IN.

Fractures around Trochanteric Nails: The "Vergilius Classification System".

INTRODUCTION: The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures. MATERIALS AND METHODS: A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.

Correlation Between Serum Activity of Muscle Enzymes and Stage of the Estrous Cycle in Italian Standardbred Horses Susceptible to Exertional Rhabdomyolysis.

Equine exertional rhabdomyolysis (ER) is a well-recognized clinical syndrome affecting racehorses. Prevalence analysis of ER showed that female sex was a significant risk factor. The aim of this research was to evaluate the differences and correlations in the serum activity of muscle enzymes and the stage of the estrous cycle in ER-susceptible and control (C) mares. Serum muscle enzyme activity before and after exercise and sex hormones were analyzed in the two groups of mares. Ten cyclic ER and 10 cyclic C mares were examined weekly for 4 weeks. During diestrus, ER horses had significantly higher resting and postexercise aspartate aminotransferase (AST) activity, but not creatine kinase (CK) activity, compared with controls; only postexercise AST activity was significantly higher during estrus compared with activity levels in controls. During estrus, 17ß-estradiol and AST activity were significantly negatively correlated in the control but not ER mares. Based on our results, further studies should be performed to characterize the presumptive different roles played by sexual hormones in horses susceptible to ER compared with healthy mares.

Bilateral fractures of acetabulum in a young girl with osteogenesis imperfecta and epilepsy.

We report a case of bilateral displaced acetabular fractures including both columns fractures with protrusio acetabuli in a female patient, aged 15 years, with osteogenesis imperfecta (OI) (Sillence Type I), epilepsy, blue sclera and bilateral ipoacusia. Since OI is a rare genetic disorder characterized by an increased propensity to osteopenia, intraoperative fracture risks and hemorrhagic diathesis, we opted for the open reduction and internal fixation of the acetabula in two surgical steps and using two different approaches. Although the clinical outcomes are not excellent in this report (HHS 45/100), the authors suggest that chances of a good outcome with reconstruction of the acetabulum must be balanced against the benefits of early or late total hip arthroplasty. The goal was to delay a joint replacement as long as possible due to the patient's young age. Level of evidence: V, case report.