Direct Anterior versus Lateral Approach for Femoral Neck Fracture: Role in COVID-19 Disease.

Background: During the COVID-19 emergency, the incidence of fragility fractures in elderly patients remained unchanged. The management of these patients requires a multidisciplinary approach. The study aimed to assess the best surgical approach to treat COVID-19 patients with femoral neck fracture undergoing hemiarthroplasty (HA), comparing direct lateral (DL) versus direct anterior approach (DAA). Methods: A single-center, observational retrospective study including 50 patients affected by COVID-19 infection (30 males, 20 females) who underwent HA between April 2020 to April 2021 was performed. The patients were allocated into two groups according to the surgical approach used: lateral approach and anterior approach. For each patient, the data were recorded: age, sex, BMI, comorbidity, oxygen saturation (SpO2), fraction of the inspired oxygen (FiO2), type of ventilation invasive or non-invasive, HHb, P/F ratio (PaO2/FiO2), hemoglobin level the day of surgery and 1 day post operative, surgical time, Nottingham Hip Fractures Score (NHFS) and American Society of Anesthesiologists Score (ASA). The patients were observed from one hour before surgery until 48 h post-surgery of follow-up. The patients were stratified into five groups according to Alhazzani scores. A non-COVID-19 group of patients, as the control, was finally introduced. Results: A lateral position led to a better level of oxygenation (p < 0.01), compared to the supine anterior approach. We observed a better post-operative P/F ratio and a reduced need for invasive ventilation in patients lying in the lateral position. A statistically significant reduction in the surgical time emerged in patients treated with DAA (p < 0.01). Patients within the DAA group had a significantly lower blood loss compared to direct lateral approach. Conclusions: DL approach with lateral decubitus seems to preserved respiratory function in HA surgery. Thus, the lateral position may be associated with beneficial effects on gas exchange.

CT-guided radiofrequency ablation of osteoid osteoma using a multi-tined expandable electrode system.

BACKGROUND AND AIM OF THE WORK: Radiofrequency ablation (RFA) is the gold standard for the treatment of symptomatic osteoid osteoma (OO) as RFA yields both a high success and low complication rate. It has been widely utilized over the years, but recurrences of OO after this treatment have been documented. These recurrences may be the result of various factors, including incomplete tumor ablation, and are significantly higher in lesions greater than 10 mm. Thus, the need to induce thermal ablation in a wider area led us to use a Multi-Tined Expandable Electrode System (MTEES). In this study we examined the efficacy and safety of RFA using a MTEES in symptomatic OO. METHODS: Between January 2005 and June 2007, 16 patients with symptomatic OO were treated by CT-guided percutaneous RFA using a MTEES. The diameter of OO ranged from 6 to 15 mm (mean 10±2.6 mm). Patients were evaluated for clinical outcomes, complications and recurrence. Pain evaluation was assessed preoperatively, 2 weeks postoperatively and at last follow-up. RESULTS: Clinical follow-up was available for all patients at a mean of 84.3 months (range 73-96 months). Mean preoperative VAS score was 7.4 (range 5-9), two weeks after the procedure mean VAS score was 0.3 (range 0-1) with a mean change of -7.06 points (p<0.0001). At the last follow-up a complete relief from pain has been observed in all patients. No major and minor complications were observed nor recurrences. CONCLUSIONS: RFA using a MTEES has been effective, safe and reliable for the treatment of OOs. This system, by increasing the size of the necrosis, could be a viable alternative to the single needle electrode in lesions larger than 10 mm, reducing the risk of recurrence.

A pseudotumoral lesion diagnosed for a hypertrofic fibrosis at the proximal stump in anterior tibialis tendon missed rupture: a case report.

The Anterior Tibialis is the most important muscle in ankle dorsiflexion. The anterior tibialis tendon (ATT)'s rupture is an infrequent condition which can be both traumatic and spontaneous. Clinic is poor and it is necessary to confirm the suspect by US or MRI. The reported case refers to a 40 years old man who had a direct trauma at ankle and midfoot which was originally conservatively treated for an ankle sprain. Three months later he returned with pain, swelling and paresthesia. MRI was performed showing a neoformation in the contest of ATT's rupture. The patient underwent open excisional biopsy which was diagnostic for hypertrofic fibrosis. After two weeks, the symptoms were completely decreased and patient didn't want to undergo surgery for tendon reconstruction because he had no limitation in daily activity life.

Hip arthroscopy in osteoarthritis consequent to FAI.

BACKGROUND: Femoral Acetabular Impingement (FAI) means a set of alterations involving the acetabulum, proximal femur, or both of these components that can results in osteoarthritis. Arthroscopy is a choice for the treatment of initial stages of osteoarthritis (OA) in order to reduce evolution of the degenerative processes; advanced degrees of osteoarthritis are absolute contraindications. MATERIALS AND METHODS: 40 patients affected by osteoarthritis in FAI  underwent hip arthroscopy between May 2010 and March 2015. In all 40 cases OA secondary to FAI was diagnosed. All patients were clinically and instrumentally analyzed pre-operatively and then post-operatively after 3, 6, and 12 months. We evaluated the degree of OA using the Tonnis classification; our study included only patients affected by Tonnis grade 0-2 osteoarthritis. RESULTS: The mean modified Harris Hip Score showed an evolution from 54.7 points to an average value of 89,1 points after 12 months. The Lower Extremities Functional Scale evolved by 43 points to an average value of 65,28 points. CONCLUSIONS: Based on the data of this study, supported by the concordance with recent literature reviews, in degrees Tonnis 0 and 1 an arthroscopic treatment is recommended. Instead the therapeutic algorithm in Tonnis grade 2 is still being discussed. We detect a significant response to arthroscopic intervention which leads us to suggest that validation of this method needs further confirmatory studies.

Ceramic liner fatigue fracture: 3-D CT findings in a late recurrent THA dislocation.

Dislocation is one of the most common complications of total hip arthroplasty (THA). To the authors' knowledge, late recurrent dislocation of a THA with a ceramic-on-ceramic coupling secondary to fatigue fracture of the ceramic liner has never been described. A 76-year-old woman with right hip osteoarthritis underwent cementless modular THA with a ceramic-on-ceramic coupling. Approximately 10 years postoperatively, she experienced right hip pain with no trauma, which resolved in 14 days. Family members reported that the patient had shown a progressive cognitive and muscular decline in the previous months. Six months later, the patient was admitted for THA dislocation, which was immediately reduced. Computed tomography revealed that the right acetabular component had a retroversion of 4° and an inclination angle of 45°. An orthopedic brace was applied, but dislocation recurred 2 days after discharge. A 3-dimensional CT reconstruction showed a fracture of the ceramic liner in the posterolateral region. The patient underwent revision surgery, and the ceramic liner breakage was confirmed. After removal of the acetabular components, a cemented polyethylene cup was implanted. The stability of the stem was verified. The existing modular neck was replaced with a chromium-cobalt neck, and a new ceramic head was applied. At 7-month follow-up, the patient had good functional recovery with no hip instability. Fatigue failure of a ceramic liner should be considered as responsible for late dislocation after ceramic-on-ceramic THA. As part of the diagnostic strategy, 3-dimensional CT reconstruction should be used to evaluate ceramic liner breakage.