Pseudotumor from ceramic-on-ceramic total hip arthroplasty.

INTRODUCTION AND IMPORTANCE: Total hip arthroplasty is one of the most performed surgical interventions in the world. Adverse local tissue reactions and pseudotumors are infrequent but dangerous eventualities, which are often related with metal-on-metal or metal-on-polyethylene implants. This study wants to highlight how adverse local tissue reactions and pseudotumors must be taken into consideration during the diagnostic process. CASE PRESENTATION: We report the case of a patient with ceramic-on-ceramic modular total hip arthroplasty with titanium neck. 12 years after surgery, he complained of pain and swelling on the hip. Diagnostic tests revealed the presence of a bulky pseudotumor. During the revision surgery biopsy samples were taken and microscopical analysis revealed the presence of fibrous tissue, fibrin hemorrhagic collections, histiocytes and chronic inflammation due to foreign body, with dark refractive material of an exogenous nature. CLINICAL DISCUSSION: The possible formation of pseudotumor and metallosis reactions in hip prostheses with metal-on-metal coupling or in couplings with polyethylene is known. Many cases of pseudotumor are reported after revision of prostheses due to the breakage of ceramic components, but we did not observe any damage or corrosion of the prosthetic elements; on the other hand, we noticed an excessive retroversion of the femoral neck. It may be possible that an accurate microscopic analysis could clarify the failure of this implant. CONCLUSION: To date ceramic-ceramic coupling remains the gold standard in terms of resistance and durability for hip arthroplasty but there is still a gap of knowledge in the field of tribology and individual immune response mechanisms.

Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report.

Thoracic duct (TD) is the largest lymphatic vessel in the body and drains the lymph at the junction between the left subclavian and jugular veins. Chylothorax (CTX) represents an accumulation of lymphatic fluid in the pleural space. We present a case of a 65 years-old man with an histologically diagnosed mediastinal type B non-Hodgkin Lymphoma, treated with chemo-immunotherapy. CT scan during follow up showed significant left side pleural effusion, amounting to 2.8 litres after drainage. Conservative treatment with low fat parenteral nutrition was started without reduction of drainage output, then lymphangiography (LP) with Lipiodol was performed demonstrating a leak in the distal TD. CTX increased in the following days, and a further LP was performed. Using transvenous retrograde access we catheterized TD at the left subclavian jugular veins using a microcatheter. The leak was treated with multiple conventional and controlled delivery microcroils and cyanoacrylate, obtaining complete embolization without residual leak.

DIPHOS® nail for proximal humeral fractures: our experience with more than 190 procedures and surgical tips.

AIM: evaluate the outcome of proximal  humeral nailing over 5 years follow-up, focusing  on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure. MATERIALS AND METHODS: the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject. RESULTS: mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded "very good" / "good" results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails).  Second surgery was performed in 8.2% (16/194) of cases. CONCLUSION: intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support.

Spyglass percutaneous transhepatic lithotripsy of symptomatic recurrent lithiasis of the intrahepatic bile duct with distal stenosis.

In patients with symptomatic intrahepatic biliary lithiasis, the treatment is usually discussed by a multidisciplinary team. Although hepatectomy is considered as definitive treatment, when lobar atrophy is absent, endoscopic procedures are frequently proposed as first-line treatment due the low invasiveness and for sparing liver parenchyma. Percutaneous route is used in case of peroral approach failure. We present a case of recurrent symptomatic intrahepatic biliary lithiasis of the right posterior hepatic duct, sustained by downstream biliary stenosis. Peroral cholangioscopy failed to visualize the stone for the accompanying stenosis. Thus, the patient was successfully treated with percutaneous transhepatic lithotripsy performed with Spyglass direct visualization system II (Boston Scientific Inc., Natick, Massachusetts, USA). During the procedure, the biopsy of the biliary stenosis revealed fibrosis, which was treated by cholangioplasty with cutting balloon. After 15 months, the patient is asymptomatic, with moderate residual stenosis in absence of calculi at follow-up magnetic resonance cholangiography.

Gartland type III supracondylar fracture in children: is open reduction really a dangerous choice?

BACKGROUND: Type III supracondylar fractures represent a difficult injury to treat and there is no universal consensus regarding the best treatment. The purpose of this study is to assess the incidence of complication associated with open reduction and compare open reduction vs closed reduction, in order to determine which treatment lead to better clinical and radiological outcomes. Is open reduction really associated with a higher number of iatrogenic complication and worse clinical outcomes in comparison to closed reduction? METHODS: A total of 55 patients, affected by type III supracondylar humerus fracture, were retrospectively selected and divided into two groups according to which type of treatment they received (open reduction or closed reduction). Major complications correlated with surgical procedure, such as infections, neurovascular iatrogenic lesions, elbow stiffness and painful scarring were assessed. The treatment outcomes and clinical features were compared among the two groups. A statistical analysis to find association between the type of reduction, the restored elbow anatomy and the clinical outcomes were performed. The follow-up varies between 1 year and 7 years. RESULTS: No major complications occurred in our series of patients. Excellent and good outcomes were reported among all 26 patients that underwent an open reduction surgery and in 23 out of the 29 patients who received a closed reduction surgery. A higher number of patients in the open reduction group presented angles with normal values; moreover 3 out of the 6 patients with unsatisfactory outcomes presented with angles not in range, underlying the presence of a connection between the restored elbow anatomy and the clinical outcomes. There were no differences among the two groups regarding the presence of complications. DISCUSSION: Open reduction should not be considered as a first line option of treatment in any pediatric patient with a type III supracondylar humerus fracture, but in several cases open surgery must be viewed as the choice with the best outcomes not only in presence of neurovascular lesion but also in case of irreducible fracture.

Iron overload and Hepcidin overexpression could play a key role in COVID infection, and may explain vulnerability in elderly, diabetics, and obese patients.

BACKGROUND: The COVID epidemic hit like a tsunami worldwide. At the time of its arrival in Italy, available literary data were meager, and most of them concerned its epidemiology. World Health Organization proposed guidelines in march 2020, a strategy of treatment has been developed, and a significant number of subsequent articles have been published to understand, prevent, and cure COVID patients. METHODS: From the observation of two patients, we performed a careful analysis of scientific literature to unearth the relation between COVID infection, clinical manifestations as pneumonia and thrombosis, and to find out why it frequently affects obese, diabetics, and elderly patients. RESULTS: The analysis shows that hepcidin could represent one of such correlating factors. Hepcidin is most elevated in older age, in non-insulin diabetics patients and in obese people. It is the final target therapy of many medicaments frequently used. Viral disease, and in particular SARS-CoV19, could induce activation of the hepcidin pathway, which in turn is responsible for an increase in the iron load. Excess of iron can lead to cell death by ferroptosis and release into the bloodstream, such as free iron, which in turn has toxic and pro-coagulative effects. CONCLUSIONS: Overexpression of hepcidin and iron overload might play a crucial role in COVID infection, becoming potential targets for treatment. Hepcidin could also be considered as a biomarker to measure the effectiveness of our treatments and the restoration of iron homeostasis the final intent. (www.actabiomedica.it).

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.

Acetabular de-escalation in hip revision.

BACKGROUND: The idea of ''de-escalation'' (DE) indicates an arthroplasty revision performed by changing a revision component by a primary component. Aim of this study is to verify if this technique can represent an option in case of cage or ring failure. METHODS: We observed five cases of revision hip cage loosening with complete allograft consolidation. This group of patients were revised with use of a primary cup and were specifically followed in ours institutions offices. Patients were clinically and radiologically followed every 6 months for the next two years and then annually Results: At final follow-up (15-2 years, mean 6 years) four patients (80%) showed a good recovery of their levels of activity. The mean Harris hip score improved from 20 points (range,7-38 points) preoperatively to 48 points (range, 16-88 points). At final radiological follow-up acetabular components were radiographically stable at the last follow-up. One patient (20%) at two years follow-up, was unable to walk without crutchies due to hip pain. X-rays showed cup loosening in all three zones. Patient was dissatisfied. Primary cup was revised with a Burch Schneider cage. CONCLUSIONS: De-escalation technique is a surgical option to consider in case of young patients, limited number of previous revisions and more than three years survivorship of loosened acetabular cage.

A preliminary experience with a new intramedullary nail for trochanteric fractures.

BACKGROUND AND AIM OF THE WORK: The worldwide incidence of fractures of the proximal end of the femur is increasing as the average age of the population rises. The current surgical gold treatment standard is intramedullary nail fixation. The Authors present their experience with the D-Nail system for intertrochanteric femur fractures. METHODS: From January 1st to February 21st 2020 (breakout of COVID-19 pandemic) 34 patients were treated with the D-Nail system: 11 with basicervical fractures, 16 with intertrochanteric stable fractures and 7 with intertrochanteric unstable fractures. In 11 cases, a single cephalic screw was used; in 23 cases, two of them were used. Distal locking was executed in 7 patients. Follow-up time ranged from 2 to 3 months. RESULTS: None of the reported intra- or post-operative complication was linked to the fixation device or the surgical technique. Patients were monitored with clinical and radiological checkups using modified Harris Hip Score to accurately evaluate the fluctuations in the rehabilitation period. CONCLUSION: The main advantages of this synthesis device are the proximal hole's peculiar shape, which allows the possibility to position one or two cephalic screws on the same nail, and the silicon coating, which provides numerous biological advantages. Distal locking was executed in selected cases only, based on fracture type. Optimum treatment involves rapid execution of surgery, minimal trauma during surgery, maximum mechanical stability, and rapid weight-bearing. Although our case number is small and follow-up time brief, our results are encouraging.

Proximal femur fractures in COVID-19 emergency: the experience of two Orthopedics and Traumatology Departments in the first eight weeks of the Italian epidemic.

INTRODUCTION: CoVID-19 (Coronavirus disease) is a worldwide infection which is causing millions of deaths. A significant number of elderly patients require hospitalization and develop serious and sometimes life-threatening complications. The aim of this study is to evaluate the preliminary impact (8 weeks) of CoVID-19, focusing on proximal femur fractures, analyzing data and results compared to the same period of 2019. MATERIALS AND METHODS: From February 22nd to April 18th, 2020 we surgically treated 121 proximal femur fractures (61 in Piacenza; 60 in Parma, 16 male, 44 female, mean age 81.1). In the same period of 2019, we treated 169 proximal femur fractures (90 in Piacenza, 33 male, 57 female, mean age 81.9; 79 in Parma, 29 males, 50 female, mean age 80.2). We had 21/61 (34.4%) patients resulted positive for COVID-19 and 11/61 in Parma (18.3%), based on nasal-pharyngeal swab, chest CT scan and/or lung US findings. RESULTS: The incidence of proximal femur fractures had a significant reduction during CoVID-19 spread in Piacenza and Parma. Authors have noticed an elevated number of deaths within 21 days after surgery. Piacenza: 4 cases in 2019 (4.4%) and 11 in 2020 (18.0%), of which 9 cases CoVID positive. In Parma in 2019 two deaths were encountered; in 2020 6 patients died and 5 cases were CoVID positive. CONCLUSION: In the first two months of the Italian epidemic, in the cities of Piacenza and Parma over 80% of deaths have occurred in patients over 70 years old. Even if preliminary, our study shows a significant increase in death in elderly patients surgically treated for proximal femur fractures, particularly in the Piacenza Hospital.

Preliminary experience in the treatment of hip necrosis with BIOS screws associated with growth factors.

ntroduction: In this paper we present the preliminary results obtained in our clinic with the use of BIOS screws associated with injection of growth factors in the treatment of cephalic necrosis of the femoral head. MATERIALS AND METHODS: In the division of Orthopedics and Traumatology at Guglielmo da Saliceto" hospital in Piacenza were treated between 2012 and 2016 with the proposed technique 8 case of necrosis of the femoral head in 6 patients with a mean age of 41.8 years (between 31 and 60 years). All patients before surgery were affected by debilitating pain with VAS greater than 7 and functional limitation of the range of motion of the hip. In all patients was performed a decompression of the femoral head using cannulated screws BIOS and injection through the implants of growth factors. RESULTS: Our results have been extremely positive. All patients treated at two months have reported the resolution of the pain that affected them before surgery and the recovery of the function of the hip. At the last clinical control carried out no patient experienced recurrence of any symptoms related to necrosis. DISCUSSION: Cephalic necrosis due to various possible etiologies is a not so rare condition, often affecting young patients with high functional demands. Only few years ago the gold standard treatment for this kind of pathological condition was hip prosthesis and this fact was associated with long term complications related with the young age of patients. The treatment presented is simple, fast and very effective in allowing the penetration of growth factors through bony trabeculae of the femoral head, due to the fenestratures inside the screws. The results obtained in our experience are certainly promising, though longer follow-up is needed to evaluate the functional outcome long and to evaluate the possible re-emergence of pain. CONCLUSION: Conservative treatment using BIOS screws associated with growth factors in femoral head necrosis in our experience combine a low invasiveness to excellent functional results and should therefore be considered a valid option in treating this pathology in young patients.

The Italian Covid-19 Phase 2 in Piacenza: results of the first semester of 2020 and future prospective of new orthopedics surgical procedures.

INTRODUCTION: During the pandemic, Piacenza's Orthopedic and Traumatology Dep. firstly dealt with the emergency with the complete closure of all the elective surgical and outpatient activities.As general population, also healthcare workers were affected by Coronavirus, increasing difficulties of epidemic management.The aim of our study is to evaluate the activity trend of the first 6months of 2020 in our hospital.Data will be compared to the two semesters of 2019, in order to have two objective samples. MATERIALS AND METHODS: We retrospectively analyzed all the orthopedics surgical procedures performed at Guglielmo da Saliceto Hospital (Piacenza, Emilia Romagna, Northern Italy)between 1/1/20 and 30/06/20. 2019 semesters (1/01/20-30/6/20 and 1/07/20-31/12/20) have been used as control group to evaluate the activity trend of the first six months of 2020, compared to the two semesters of 2019. RESULTS: We noticed a significant increase of domestic and retirement houses accidents, a consistent increase in one-month mortality rate of 2020 first semester and a decrease of mean hospitalization time.About surgical procedures, we detect a drop in the total number: in the first semester of 2020 we performed 499 (-39.9%) surgeries less than the first semester of 2019 and 337 (-30.9%) then the second one. Traumatology recorded a decrease of 27.6% than the first semester of 2019 (-204 surgeries) and of 26.3% than the second one (-191 surgeries).Concerning orthopedic procedures, in comparison to the first semester of 2019 we registered a reduction of 57.6% (-295 surgeries) and of 40.2% to the second semester (-146 surgeries). DISCUSSION AND CONCLUSION: Covid-19 forced a reorganization of the Italian Health System that led to a clear reduction of surgical procedures performed in the orthopedic and traumatology department.The "Phase 2" can't be consider the last step of the emergency.We surely will have to get used to live with this enemy, at least until we will find an effective cure or a vaccine.

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.

Preliminary experience in the arthroscopically assisted treatment of tibial plateau fractures.

BACKGROUND AND AIM OF THE STUDY: Fractures involving the tibial plateau make up 1% of all fractures. Treatment can take advantage of various techniques, including arthroscopically assisted surgical reduction. This procedure is certainly viable for Schatzker III fractures and, in some cases, for Schatzker II. The use of the arthroscope makes possible a smooth reduction of the fractured bone, decreasing the risk of post-traumatic osteoarthritis, and also allows to diagnose and, if necessary, also treat the associated intra-articular lesions, which often are not highlighted during the classical preoperative investigations. METHODS: In the last year we have operated with this technique 8 of the 22 cases of fracture of the tibial plate that have come to our emergency Department. Using the Schaztker classification, we performed an arthroscopically assisted reduction to treat type II and III fractures. The surgical operations involved a first arthroscopic phase, to assess intrarticular damage (bone, cartilage, ACL, PCL, menisci), a second phase for possible treatment of intrarticular lesions and reduction of fractures under arthroscope or open osteosinthesis. Finally, a last arthroscopic check was performed. RESULTS: We obtained excellent results, as we were able to always have a fracture reduction of less than 1 mm, while clinically all the patients could have an early and almost complete functional recovery after only 2 months. CONCLUSION: The arthroscopically assisted technique could be an effective way to adress the anatomical reduction of tibial plate fractures, but must only be used in the indicated cases.

Carbon-fiber reinforced intramedullary nailing in musculoskeletal tumor surgery: a national multicentric experience of the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group.

INTRODUCTION: Carbon fiber reinforced (CFR) implants have been proposed for the treatment of fractures or impending fractures of the long bones in the oncology patient. Aim of this study is to present the largest cohort of oncology patients operated by CFR nailing by the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group. METHODS: 53 adult oncology patients were operated on with a CFR-PEEK nail. All the data from adjuvants therapies were collected. Bone callus formation, response to radiotherapy, relapse or progression of the osteolysis were recorded. Hardware survival and failure, breakage and need for implant revision were also analysed. RESULTS: Anatomical implantation of nails include humerus (n = 35), femur (n =11) and tibia (n = 7). The most frequent tumors affecting the bone were myeloma (n = 13), breast (n = 11), lung (n = 8), and renal cell cancer (n = 7). Acrylic cement reinforcement was used in 2 patients. One patient was subjected to electrochemotherapy after nail insertion. Intraoperative and early postoperative complications occurred in 13.2% and 7.54% of patients respectively. Eight patients had local progression and one developed a stress fracture proximally to the distal static screw. Radiographic union occurred in 14 patients; one screw loosening was recorded. DISCUSSION: There is currently a lack of solid evidence on the clinical use of CFR nails in oncologic patients. This is the first and largest study of CFR nailing, with the longest available follow up. CONCLUSIONS: Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.

The importance of early rehabilitation in proximal humeral fracture: A clinical trial of efficacy and safety of a new endomedullary nail.

BACKGROUND: The aim of the surgical treatment in proximal humeral fractures is to maintain bone alignment facilitating an early shoulder mobilization. This can be obtained with the use of an endomedullary nail with specific characteristics: a proximal angular multiplanar stability and the possibility to place proximal screws in the calcar region. The objective of this randomized controlled trial is to investigate the effects of an early rehabilitation program in 3-part proximal humeral fractures treated with endomedullary nailing. MATERIALS AND METHODS: 126 patients treated with the Diphos Proximal Humeral Nail (PHN), followed with an Intensive Rehabilitation Program (IRP) started in the second postoperative day, were compared to 62 patients with a Standard Rehabilitation Program (SRP) where shoulder mobilization started after 3 weeks. The age of patients was under 65 years. Main Outcome measures were improvement of shoulder function based on Constant Score and quality of life on DASH questionnaire at 1, 3, 6 and 12 months after surgery. Safety outcome was no loss of radiological reduction at any follow-up control. RESULTS: A difference considered statistically significant (95% confidence interval) was demonstrated by Constant scores at 3 and 6 months and by DASH questionnaire scores at 1 month after surgery between IRP and SRP groups, however without loss of radiological reduction and maintaining the full fracture healing at the same mean period of 1,8 ± 0,7 months. DISCUSSION: This experience allows to highlight essential features of this new kind of endomedullary humeral nail, by its mechanical properties, in proximal humeral fractures in order to permit an early rehabilitation without creating displaced or consolidation delay. LEVEL OF EVIDENCE: III, randomized clinical-case-control study.

Long endomedullary nail in proximal third humeral shaft fractures.

INTRODUCTION: Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking. MATERIALS AND METHODS: Forty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. RESULTS: Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. CONCLUSIONS: The results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. STUDY DESIGN: retrospective, cohort of cases. LEVEL OF EVIDENCE: IV.

Efficacy of Rivaroxaban for thromboprophylaxis after Knee Arthroscopy (ERIKA). A phase II, multicentre, double-blind, placebo-controlled randomised study.

Without thromboprophylaxis, knee arthroscopy (KA) carries a low to moderate risk of venous thromboembolism. Over 5 million arthroscopies are performed worldwide yearly. It was our study objective to assess the efficacy and safety of rivaroxaban for thromboprophylaxis after therapeutic KA. Patients undergoing KA in nine Italian teaching or community hospitals were allocated to once-daily rivaroxaban (10 mg) or placebo for seven days in a phase II, multicentre, double-blind, placebo-controlled randomised trial. The primary efficacy outcome was a composite of all-cause death, symptomatic thromboembolism and asymptomatic proximal DVT at three months; major bleeding represented the primary safety outcome. All patients underwent whole-leg ultrasonography at day 7(+1), or earlier if symptomatic. A total of 241 patients were randomised (122 rivaroxaban, 119 placebo), and 234 completed the study. The primary efficacy outcome occurred in 1/120 of the rivaroxaban group and in 7/114 of the placebo group (0.8 % vs 6.1 %, respectively, p=0.03; absolute risk difference, -5.3 %, 95 % CI, -11.4 to -0.8; crude relative risk 0.14, 95 % CI, 0.02 to 0.83; number-needed-to-treat=19). No major bleedings were observed. We found no association between different arthroscopic procedures and thrombotic events. Small sample size, high exclusion rate, and low number of anterior cruciate ligament reconstruction procedures are the main limitations of our study. In conclusion, a seven-day course of 10-mg rivaroxaban may be safely employed for thromboprophylaxis after KA. Whether prophylaxis after KA should be given to all patients, or to selected "high-risk" subjects, remains to be determined. A larger trial to verify our preliminary results is warranted.

Apixaban versus enoxaparin in elective major orthopedic surgery: a clinical review.

Despite current guidelines recommendations about anticoagulant prophylaxis, many studies have shown an high venous thromboembolism (VTE) incidence in patients undergoing total hip and knee arthroplasty. A number of anticoagulants are currently available, but they have some limitations that affect their applicability and consequently their effectiveness. Several new oral anticoagulants (NOACs) have been developed in an attempt to overcome these limitations. Apixaban is a NOAC that selectively inhibits the coagulation factor Xa; it is approved for the prevention of VTE after total hip replacement and total knee replacement surgery. This review examines the results of main trials designed to test efficacy and safety of apixaban in major elective orthopedic surgery.