Cannulated screws fixation for nondisplaced femoral neck fractures: early versus late weight-bearing-a prospective analysis.

PURPOSE: Nondisplaced intracapsular fractures (Garden I/II) are predominantly treated with an internal fixation technique. The purpose of the study is to identify the best rehabilitation protocol after internal fixation with 3 parallel cannulated screws. METHODS: All patients operated on from 2016 to 2021 for femoral neck fractures by internal fixation with 3 cannulated screws were enrolled into this prospective study. The population was divided into two groups: Group A (n = 34) who followed a postoperative rehabilitation protocol involving full and immediate loading, and Group B (n = 22) who followed a postoperative rehabilitation protocol involving late full loading (after 30 days). The two groups were compared with each other by mortality rate, postoperative complications and need for re-interventions. Functional outcome and quality of life were assessed at the minimum follow-up of 1 year using the modified Harris Hip Score (HHS) and the Short form health survey (SF-12) questionnaire. RESULTS: Group A showed a lower complication rate (2.9% vs. 18.2%), a lower 1-year mortality rate (5.9% vs. 9.1%), a better perception of mental health status (SF12-MCS 56.2 vs. 51.4, p = 0.03) but a worse perception of one's physical health status (SF12-PCS 48.1 vs. 56.7, p < 0.01). The two groups were also statistically overlapping in terms of the functional outcome achieved after the intervention (HHS was 90.94 in Group A vs. 93.15 in Group B, p = 0.32). CONCLUSION: Postoperative complications, mortality and revision rate were higher in patients who followed a late-loaded rather than early loaded rehabilitation protocol. Functional outcome at 1-year survival is not significantly different. In nondisplaced intracapsular hip fractures treated with cannulated screws, an immediate full load should be preferred. Query.

Treatment of avascular osteonecrosis of femoral head by core decompression and platelet-rich plasma: a prospective not controlled study.

PURPOSE: Core decompression is a surgical option since the 1960s for hip osteonecrosis treatment. This technique promotes bone repair by reducing intramedullary pressure, but this is not often enough to stop the progression of necrosis. The aim of this study was to associate core decompression with the regenerative stimulus provided by platelet-rich plasma (PRP) and compare our results with other regenerative techniques. METHODS: Femoral head osteonecrosis was prospectively evaluated in 30 hips (22 patients, 15-60 years) treated by core decompression and PRP graft. Patients presented monolateral or bilateral osteonecrosis in stage I-IIA-IIB according to Arlet and Ficat classification. The outcome was assessed by changes in Harris Hip Score (HHS) and the need for total hip replacement (THA). RESULTS: The mean preoperative HHS was 64 points, at two years from surgery was roughly 84 points. Sixteen of 30 hips showed osteonecrosis progression of the femoral head and were converted to THA. At the five year follow-up, the survival rate was 100% for patients at stage I, 67% for stage IIA, and 0% for stage IIB and was 68% and 32% for idiopathic and secondary osteonecrosis, respectively. CONCLUSION: Core decompression combined with PRP could be indicated as a treatment for the I and IIA stages of osteonecrosis, as it significantly reduces joint pain and delays THA. This procedure should be avoided in AVNFH related to cortisone therapy because only a few benefits have been proven. It also has the advantage of being technically simple, minimally invasive, and free from complications.

Percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fractures in children.

PURPOSE: To describe clinical and radiographic outcomes after surgical management of angulated radial neck fracture in children. METHODS: Twenty children (aged 2-11 years) with angulated radial neck fracture with more than 30° angulations (Judet type III and IV fractures) were retrospectively reviewed. All the enrolled patients were surgically treated with percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation. Clinical outcomes were evaluated using Tibone and Stoltz score and the Mayo Elbow Performance Score (MEPS). Radiographic outcomes were evaluated with Métaizeau score. Complications were also evaluated. RESULTS: At a mean follow-up of 20 months, no patients showed axial deformity of the upper limb or instability of the elbow. The mean value of the MEPS was 99.2, and excellent clinical results were achieved in 14 patients (73.7%) at Tibone and Stoltz score. The final X-rays showed fracture healing in all patients; furthermore, 75% of patients showed excellent reduction at Métaizeau score. No patient developed complication. There were no iatrogenic nerve injuries or pin infections. CONCLUSIONS: The results demonstrate that percutaneous k-wire leverage reduction and retrograde transphyseal k-wire fixation of angulated radial neck fracture treatment is a simple, effective, rapid and inexpensive procedure. LEVEL OF EVIDENCE: IV (case series and systematic review of level IV studies).

Resorbable magnesium screws for fixation of medial epicondyle avulsion fractures in skeletally immature patients: A comparison with Kirschner wires.

Background: Displaced medial epicondyle fractures are treated with open reduction and internal fixation with K-wires or screws. Rates of implant prominence, failure, or non-union reported are considerable. Magnesium screws have demonstrated biocompatibility, osteoconductivity, and high pull-out strength. The aim of this study was to compare surgical fixation of medial epicondyle fracture using resorbable magnesium Herbert screws to K-wires, in skeletally immature patients. Methods: A retrospective analysis was performed from January 2015 to April 2020. Inclusion criteria were as follows displaced medial epicondyle fracture, <15 years, and absence of concomitant ipsilateral upper limb fractures. Two consecutive cohorts based on fixation device were made: Group A (wires) and Group B (magnesium screws). Alignment, pain, range of motion, Mayo Elbow Performance Score, and radiological healing were assessed. Results: A total of 27 patients were included: 15 in Group A and 12 in Group B. Groups were comparable for age and sex. Mean follow-up was higher in Group A (38.73 ± 3.15 vs 26.18 ± 4.85 months; p < 0.001). No significant differences were observed regarding range of motion, alignment, pain, and Mayo Elbow Performance Score, with excellent results in both groups. Two patients in Group A developed a deep wound pin site infection requiring antibiotics. X-rays revealed three cases of non-union in Group A and one in Group B, all of them asymptomatic. No patient required a second surgical procedure. Conclusion: Open reduction and internal fixation of medial epicondyle fractures with magnesium screws showed comparable results to a widely accepted procedure such as the use of K-wires, potentially with a lower incidence of non-union and infection. No adverse reactions were recorded. Level of evidence: level III.

The use of 3D printed models for the pre-operative planning of surgical correction of pediatric hip deformities: a case series and concise review of the literature.

BACKGROUND AND AIM: Three-dimensional (3D) printing is prevailing in surgical planning of complex cases. The aim of this study is to describe the use of 3D printed models during the surgical planning for the treatment of four pediatric hip deformity cases. Moreover, pediatric pelvic deformities analyzed by 3D printed models have been object of a concise review. METHODS: All treated patients were females, with an average age of 5 years old. Patients' dysplastic pelvises were 3D-printed in real scale using processed files from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). Data about 3D printing, surgery time, blood loss and fluoroscopy have been recorded. RESULTS: The Zanoli-Pemberton or Ganz-Paley osteotomies were performed on the four 3D printed models, then the real surgery was performed in the operating room. Time and costs to produce 3D printed models were respectively on average 17:26 h and 34.66 €. The surgical duration took about 87.5 min while the blood loss average was 1.9 ml/dl. Fluoroscopy time was 21 sec. MRI model resulted inaccurate and more difficult to produce. 10 papers have been selected for the concise literature review. CONCLUSIONS: 3D printed models have proved themselves useful in the reduction of surgery time, blood loss and ionizing radiation, as well as they have improved surgical outcomes. 3D printed model is a valid tool to deepen the complex anatomy and orientate surgical choices by allowing surgeons to carefully plan the surgery.

Pediatric trans-olecranon fracture dislocation of the elbow associated with fracture of the radial head and with medial collateral ligament lesion: A case report and review of the literature.

INTRODUCTION: We report what is, to the best of our knowledge, the first case of pediatric trans-olecranon fracture dislocation of the elbow associated with a radial head fracture and with a medial collateral ligament disruption. CASE PRESENTATION: A 7-year-old girl presented to the emergency department after a fell on his right elbow while playful activity at home. The elbow X-ray showed acute trans-olecranon fracture dislocation of the elbow associated with a radial head fracture. A pre-operative 3D TC scans confirmed and clarified the injury pattern. However, stress radiographs performed in the operating room under anesthesia revealed an associated severe valgus instability caused by medial collateral ligament disruption. The olecranon fracture was fixed with two crossing 1.5 mm K-wires and the angulated radial neck fracture was fixed with a retrograde 1.5 mm K-wire by S.E.R.I. technique. CONCLUSION: Although trans-olecranon fracture dislocation of the elbow is well recognized and clearly described in adults, it is uncommon in children. A pre-operative 3D TC scans are recommended to enable a more accurate diagnosis and surgical planning. Medial collateral ligament has a central role in elbow stability and is very important to repair it during surgery.

Remodeling of distal radius fractures in children: preliminary retrospective cost/analysis in level II pediatric trauma center.

BACKGROUND AND AIM: Children displaced distal radius fractures (DRFs) are commonly treated by reduction. Yet, their excellent remodeling ability provides good clinical-radiographic outcomes even in case of non-anatomical reduction. The reduction under analgesia or sedation involves hospitalizations, greater risks, and higher hospital costs. The aim of this preliminary study is to demonstrate the accountability and conveniency of non-anatomical reduction. METHODS: The study involved all 0-8 years-old children who were affected by a closed overriding DRF from February 2017 to December 2018 and were managed non-operatively by a long arm cast without reduction, analgesia, or sedation treatments. We retrospectively evaluated their clinical-radiographic outcomes and healing time. The costs of no-reduction treatments were compared with those of the two main approaches to DRFs, that is: closed reduction under sedation and application of a long arm cast; closed reduction under anesthesia, percutaneous pinning, and application of a long arm cast. The comparison was based on the Diagnosis Related Group system. RESULTS: We treated 11 children with an average initial radial shortening of 5±3 mm and average initial sagittal and coronal angulations of 4.0° and 3.5°, respectively. Average casting duration was 40 days. All patients achieved a full range of wrist motion without deformities. The procedure was respectively 7 times less expensive than closed reduction in emergency room under sedation and application of a long arm cast, and 64 times less expensive than closed reduction in the operating room under anesthesia, percutaneous pinning, and application of a long arm cast. CONCLUSIONS: In children aged 0-8 years, non-operative treatment of closed overriding DRFs with a long arm cast without reduction is a simple and cost-effective procedure with both clinical and radiographic medium-term excellent outcomes.

Traumatic hip fracture-dislocation: A middle-term follow up study and a proposal of new classification system of hip joint associated injury.

Traumatic hip fracture dislocation is a rare injury associated with high-energy trauma. Most of these injuries should be surgically treated. Hip dislocation is an orthopaedic emergency and reduction must be performed within 6-8 hours of trauma. We performed a retrospective analysis of 69 patients with "hip joint associated injuries", treated between January 2002 and December 2016. 33 patients were assessed at a mean follow-up of 36.9 months (range 18-132) after surgery. We propose a new classification system in which, different patterns of fracture (head and/or neck and/or acetabular) are described according to different types of hip dislocation. This anatomical-descriptive classification system is based on the concept of hip as a complex anatomical district and contains all possible traumatic injuries associated with hip dislocation. It includes isolated hip dislocation, hip dislocation with femoral head or neck fracture or hip dislocation with acetabular fracture and femoral head fracture. There are 4 groups: Each one of the previous groups is composed by different subgroups. Post-traumatic osteoarthritis is the most common complication of these hip injuries, followed by avascular necrosis of femoral head and heterotopic ossification. The bad prognosis depends on the type of trauma rather than surgical treatment.