Surgically treated acute distal biceps tendon injuries: What results do they have in comparison with the contralateral healthy arm? A systematic review and meta-analysis.

BACKGROUND: Surgical repair of distal biceps tendon injury restores flexion and supination strength, resulting in good functional outcome. There are few studies that consider clinical results of the operated arm compared to the healthy contralateral arm, whereas there are many articles examining the results of different surgical techniques. We carried out a systematic review with meta-analysis of the studies that consider this comparison. The aim was to evaluate if there are significative differences in terms of functional results between the operated arm and the non-injured contralateral arm. In fact, we believe that this comparison is useful for assessing patient true satisfaction. PATIENTS AND METHODS: In accordance with the PRISMA and QUORUM statements, a comprehensive search on PubMed, Scopus, Embase, Cochrane, Google Scholar and Web of Science databases was conducted to identify studies reporting comparative functional results of the operated arm with healthy contralateral arm from January 1985 until November 2022. Criteria for inclusion were acute complete injury of the distal biceps' tendon operated within 30days; range of motion (ROM), isokinetic and isometric strength measurements; minimum patients follow-up of 24months; studies written in English language. Then a DerSimonian and Laird meta-analysis was conducted to compare the functional outcomes of the operated arm to the non-injured arm. RESULTS: Of the 588 initial studies, 18 studies met the inclusion criteria; methodological quality was assessed using the Newcastle-Ottawa scale. A total of 272 surgically treated distal biceps ruptures were included in the study. The mean follow-up time was of 39.6months (24 to 72months). ROM flexion, pronation, and supination of the operated elbows were significantly decreased, with mean differences of -1.24̊ (p=0.004), -7.95̊ (p=0.003), and -9.27̊ (p=0.004) respectively, compared to the non-injured healthy elbows. The difference of ROM extension was not-statistically significant (+0.21̊; p=0.66). The Isokinetic data showed a statistically significant reduction in the flexion strength (-4.56Nm; p=0.0004) and a statistical significative reduction in the supination strength (-1.18 Nm; p=0.02) of the injured operated arm compared with the healthy one. The forest-plot table of the isometric data was not elaborated due to the small number of studies eligible for the meta-analysis. DISCUSSION: This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative treatment of distal biceps tendon ruptures with the contralateral healthy arm. Significant differences in ROM flexion, supination, and pronation and in isokinetic and isometric data were found between the operated and non-operated unaffected arm, demonstrating that, as expected, the unaffected arm performed better than the operated one. However, the functional differences between the data of the operated and healthy arm were slight and lead us to overall consider surgery as good functional result. LEVELS OF EVIDENCE: III.

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.

Partial articular fractures of the radial head: How to understand them using computed tomography.

BACKGROUND: The optimal treatment for different types of displaced partial articular radial head fractures is still debatable. Fractures involving the articulating portion of the radial head can be defined also as bi-articular and are often underestimated. Moreover, the complete loss of periosteal contact between fracture fragments is a marker of instability. Available classifications do not emphasize these aspects. The purpose of the present study is to describe two assessment methods to identify fractures involving the articulating portion of the radial head and complete loss of periosteal contact with the help of 2D-3D CT scan. The second purpose is to propose a classification of the displaced partial articular radial head fractures basing on these two assessment methods. HYPOTHESIS: We hypothesize that the proposed classification is reliable. PATIENTS AND METHODS: By observing the position of the bicipital tuberosity with respect to the ulna in reference to the coronal plane in the 3D-CT scan and by observing the location of the fracture fragment in the 2D axial scan, it is possible to understand if a displaced partial articular fracture involves the articulating portion of the radial head. Also, it is possible to understand the presence or absence of a complete loss of periosteal contact between the two fracture fragments by observing the coronal and sagittal 2D-CT scans. We identified 20 displaced partial articular radial head fractures on a series of 149 patients with radial head fractures. Following the above-described assessment methods, these 20 fractures were classified in three subgroups. Also, seven evaluators were asked to use these assessment methods to classify these 20 fractures in the three subgroups, in order to evaluate inter- and intra-observer agreement. RESULTS: Eight fractures involved the non-articulating portion of the radial head with complete loss of periosteal contact, eight involved the non-articulating portion of the radial head without complete loss of periosteal contact, and four involved the articulating portion of the radial head with or without complete loss of periosteal contact. The kappa for intra-observer reliability ranged from 0.46 to 0.84. The average kappa for inter-observer reliability was 0.570 (range: 0.526 to 0.676). The Kendall's coefficient for inter-observer concordance was 0.673. DISCUSSION: Prognostically, displaced partial fractures of the articulating portion of the radial head could differ from the other types, regardless of whether or not there is a complete loss of periosteal contact. Underestimating this fracture pattern can lead to poor results due to risk of forearm rotation blockage. Moreover, underestimating complete loss of periosteal contact in displaced partial fractures of the non-articulating portion of the radial head could lead to poor results. The described evaluation methods have moderate reliability, but can represent, along with other described methods, a good starting point to better understand and treat these insidious fractures. LEVEL OF EVIDENCE: III; retrospective study.

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).

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.

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.

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.

Simple and stable elbow dislocations: results after conservative treatment.

BACKGROUND AND AIM OF THE WORK: In adults, elbow dislocations are second in frequency after shoulder dislocations. They are often the result of a trauma due to accidental falls on the palm of the hand with the elbow flexed. In most cases this mechanism produces a posterior dislocation of the radius and ulna with respect to the humerus. The therapeutic approach was usually conservative in the past and it was characterized by manual reduction and plaster immobilization. More recently, as consequence of biomechanic and pathophysiology studies, the management of these injuries has gradually changed. The current trend is to immobilize the elbow only for few days and to evaluate its stability several times. In case of instability surgery may be indicated. The aim of this study was to assess the outcomes of simple stable elbow dislocations treated conservatively between january 2012 and december 2018. METHODS: Twenty-six patients were included. All subjects underwent to a follow-up visit, in which clinical functional tests were performed in order to evaluate any stiffness in flexion-extension, prono-supination and instability in varus-valgus. In addition, patients were asked to complete three questionnaires (DASH, MEPS, SF-36) to evaluate how much the pathology interfered with ADL's. RESULTS: Outcomes showed that prolonged immobilization increased stiffness in flexion and extension with the need of longer reabilithation. The recovery of prono-supination was instead always optimal. ADL's migth be influenced by the traumatic event and its management. CONCLUSIONS: Results of conservative treatment of simple elbow dislocation are generally satisfactory. A precise flow-chart of the patient management after trauma is essential in order to detect unstable lesions and.

Subtrocantheric nonunion following fracture of an arthrodesed hip: a case report.

In recent years in the era of successful of total hip replacement, hip arthrodesis is rarely performed. The anatomy and biomechanics of an arthrodesed hip is altered, thus influencing the treatments strategies in case of fracture or nonunions. This case report describes the management and therapeutic solution for the treatment of subtrochanteric nonunion in a patient with hip arthrodesis. Satisfactory outcomes were finally obtained after a double surgical procedure.

Distal femur nonunion treated with retrograde intramedullary nailing and RIA: a case report.

The current treatment of distal femur fractures includes locking plating and retrograde intramedullary nailing. These fractures are difficult to manage also for experienced surgeons, with results not always satisfactory. Reported nonunion rates now range from 0 to 34%. Factors associated with nonunion include comorbidities, such as obesity and diabetes, as well as the presence of open fractures, medial bone defects and comminuted fractures. This case report summarizes all of these assumptions and it concerns a 58 years old patient who underwent to 6 surgical procedures before to arrive to bone healing.

Monteggia-like lesions: preliminary reports and mid-term results of a single center.

Background and aim of the work Monteggia-like lesions are complex and rare elbow injuries. A detailed classification and a proper surgical treatment can provide quite good functional and radiological outcomes. The aim of this retrospective study was to evaluate the mid-term results of Monteggia-like lesions surgical treatment. The other purpose was to investigate whether the complexity of ulna and radius fractures could be prognostic factors of insufficient functional results. Methods Seven women and five men, with a mean age of 59,25 years who had sustained a Monteggia-like lesion were followed up clinically and radiologically after surgical treatment. The Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QUICK-DASH) score were used for evaluation at a mean of 17,5 months postoperatively (12-26). The range of movement (ROM), patients' satisfaction and neurological symptoms were also investigated. Osteolysis, implant loosening and heterotopic ossification were graded. Pearson's test was used to correlate the different classification systems used (AO/OTA, Bado and Jupiter, PURCCS, Mason) with MEPS and QUICK-DASH score. Results The mean MEPS was 84,92 (65 to 100). The mean QUICK-DASH score was 18,75 (0 to 34,1). The mean active pronation and supination was 72,5° and 59,17°, respectively. The mean active ROM of the elbow was 101,43°. Heterotopic ossifications were absent in six cases but were found in six. No statistically significant correlation was found between the analyzed variables. Conclusions Quite good functional results can be obtained in Monteggia-like lesions if injury pattern is recognized and each component of the injury is addressed. Further studies are needed to determine any prognostic factors.

Survival and outcome of total elbow arthroplasty for distal humeral fracture at long term follow-up.

Background Total elbow arthroplasty is an accepted procedure for the treatment of acute comminuted distal humeral fractures in elderly. Few long-term outcomes are available. The purpose of this study was to examine long-term clinical and radiological outcomes of prosthesis performed (January 2002-June 2015) for complex intra- fractures of the distal humerus (AO/C) in patients older than 65 years with low functional demands. Materials and Methods Further inclusion criteria were: the availability of a clinical and radiological follow-up of minimum 5 years and pattern of closed fracture. Demographic data and characteristics of patients were collected. All patients were clinically and radiographically assessed after 2 and 5 years from surgery. Results Twelve patients were included with complete available data. The mean follow-up was 7.6 years. Five patients reported a worsening of the elbow functionality through the follow-ups. Five subjects had complications. There were no cases of revision surgery. The quality of fixation showed a progressive worsening with increase of radiolucency both on humeral and ulnar side. The recorded MEPS showed no correlation with the grade of periprosthetic osteolysis. Polyethylene bushing wear was scored of grade 2 in one subject who had showed type 4 Morrey radiolucency. Discussion and Conclusions Total elbow arthroplasty is an effective and reliable procedure for comminuted fractures of the distal humerus in elderly, although the incidence of complications can not be considered as negligible. For the majority of these patients, a well-performed implant will give them a well-functioning elbow for their remaining life.

Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years.

BACKGROUND AND AIM OF THE WORK: Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis. METHODS: 183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication. RESULTS: The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis. DISCUSSION AND CONCLUSIONS: Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Is there a relation between clinical scores and serum ion levels after MoM-THA? One year results in 383 implants.

BACKGROUND AND AIM OF THE WORK: Adverse reaction to metal debris is the major cause of the high revision rates of metal on metal hip implants with femoral head size ≥ 36mm. Health authorities recommend regular surveillance even for asymptomatic individuals. The main investigations used are Co+ and Cr+ serum levels, x-rays and, eventually, ultrasound and MARS-MRI. Clinic is also assessed. The aim of this study is to identify if there is a relation between  ion levels and the clinical scores  in order to evaluate the outcome and  plan the correct management after this type of implant. METHODS: 383 subjects were included and divided in 3 groups (serum ion levels >, <  and >60 µg/L). Co+, Cr+, HHS and OHS results of 1 2017 were analysed in order to show a correlation between ion levels and clinical scores . RESULTS: Clinical scores were similar in group 1 and 2. Differences were observed comparing the group 1 and 2 with group 3 for both variables. DISCUSSION AND CONCLUSIONS: Surveillance algorithms have been introduced by health  authorities. Nevertheless, the indication to revision surgery is not simple especially in those cases in which a discrepancy between clinic and investigations is present. In this study clinical scores seem to be less important than ion levels in the evaluation of outcomes and in order to plan the correct management in the majority of cases. Larger studies are needed to highlight the real importance of clinical scores in the decision making after these type of implants.

A rare case of complicated pure posterior sternoclavicular dislocation in a young athlete.

Sternoclavicular joint dislocation (SCJD) is a rare injury, generally classified in anterior and posterior. The posterior SCJD is very infrequent yet potentially associated with life-threatening complications. In patients with unfused medial clavicle physis, SCJD can be associated with fracture-dislocation (Salter type I or II). We hereby present the case of a 12- year-old basketball player with severe pain in sternoclavicular region and arising dysphagia after a fall and tackle by another player. A SCJ injury was hypothesised and the CT scan detected the presence of a true posterior SCJD with no associated fracture, which was also confirmed during open reduction. As the patient complained dysphagia, it was also necessary to study other possible mediastinal compressions by a contrast medium CT scan of the great vessels. The CT scanned brachiocephalic vein compression without additional clinical evidence or signs. Twenty hours after the trauma the patient underwent an unsuccessful closed reduction; for this reason, surgical treatment with open reduction and fixation was mandatory. After 12 weeks of therapy she returned to her previous sport activity.

Pelvic ring fractures: what about timing?

BACKGROUND AND AIM: Pelvic ring fractures represent a challenge for orthopaedic surgeon. Their management depends on patient's condition, pattern of fracture and associated injuries. Optimal timing for synthesis is not yet clear. The aim of this study was to define if surgical timing influenced clinic and radiographic outcomes following open reduction and internal fixation for Tile B and C fractures. MATERIALS AND METHODS: 38 patients were included. Patients underwent a clinical examination with the Majeed Score, Iowa Pelvic Score and Orlando Pelvic Score. The radiographic assessment was performed according to Matta Pelvic Score. A statistical analysis of the data compared patients who were operated within 3 weeks (group 1) and those operated later (group 2). RESULTS: Both clinical and radiological outcomes were influenced by timing of surgery. CONCLUSION: Pelvic ring fractures interest many polytrauma patients and, therefore, their surgical orthopedic approach is frequently delayed as consequence of the severity of the associated clinical conditions. An early surgery of pelvic rong fractures allows a better quality of reduction and osteosynthesis.

When is indicated fibular fixation in extra-articular fractures of the distal tibia?

BACKGROUND AND AIM OF THE WORK: There is no consensus about indications for fibular osteosynthesis in extra-articular fractures of the distal tibia (DTF). This study analyses patients affected by DTF associated to fibular fracture and has the aim to define whether the level of fibular fracture has an influence on bone healing and consequently when its fixation is indicated. METHODS: Eighty-seven patients were operated from January 2005 to December 2016. Inclusion criteria were: the presence of skeletal maturity, the absence of physical limitations before trauma and a type 43-A AO closed fracture. Clinical outcomes were evaluated using Olerud-Molander Ankle Score (OMAS) and the Disability Rating Index (DRI). Malrotation was also assessed as well as incidence of nonunion and malalignment through x-rays. RESULTS: No differences in clinical scores were reported at follow-up between patients in which fibular fixation was performed (Group 1) in comparison with those in which this procedure was not executed (Group 2).  Nonunions were registered in 8 cases: four in Group 1 and four in Group 2. A statistically significant difference in incidence of external malrotation and valgus malalignment between the groups was documented, with a higher risk in patients of the second group. CONCLUSIONS: The level of fibular fracture is important to determine when the fixation of this bone is indicated. In supra-syndesmotic fractures osteosynthesis leads to a higher incidence of nonunions. Fibular osteosynthesis could prevent malrotation and malalignment and is advisable in distal metaphyseal fracture of this bone (trans- or infrasyndesmotic lesion) with syndesmotic injury.