Floating hip in polytraumatized patients: complications, mechanism of injury, and surgical strategy.

PURPOSE: Floating hip fractures are severe and rare injuries with high complication rate and lack of standard management. The purpose of this retrospective study was to review the outcomes of a case series of polytraumatized patients with floating hip injuries, in order to describe the relationship between complication rate and floating hip injury type, the pathomechanism of injury, and the surgical treatment strategy. METHODS: Forty-five patients with floating hip injuries were analyzed. Complication rate, mechanism of injury, and surgical strategy (damage control orthopedics, stages of internal fixation) were recorded. Fractures were classified using the Mueller system for floating hips and AO/OTA system for the other fractures. RESULTS: Of the 45 patients with floating hip injuries, 23 (51.1%) developed complications. The results revealed that the complication rate was associated with the instability and type of the pelvic or acetabular fracture (61-C AO/OTA pelvic fracture [73.3%; p = 0.04], 62-B AO/OTA acetabular fracture [88.8%; p = 0.03]). Vertical shear (VS) pelvic fractures were related to middle-distal femoral fractures and lateral compression/anteroposterior compression (LC/APC) pelvic lesions were associated to proximal femoral fractures (p = 0.012). CONCLUSIONS: Complications were associated with the severity and instability of the pelvic and acetabular type of fractures. The pathomechanism causing Mueller type B and C floating hip injuries was illustrated. A two-stage "femur first" surgical approach was the preferred one for definite internal fixation of fractures.

Arthroscopic management of greater trochanter pain syndrome and abductor tears has demonstrated promising results in terms of improvement in pain scores and functional outcomes: a scoping review.

PURPOSE: Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of 'greater trochanteric bursitis'. GTPS is common, particularly in women 50-79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature. METHODS: A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS. RESULTS: Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3-6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies. CONCLUSION: Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future. LEVEL OF EVIDENCE: IV.

Surgical interventions for external snapping hip syndrome.

PURPOSE: Snapping hip is a common clinical condition, characterized by an audible or palpable snap of the hip joint. When the snap is perceived at the lateral side of the hip, this condition is known as external snapping hip or lateral coxa saltans, which is usually asymptomatic. Snapping hip syndrome (SHS) refers to a painful snap, which is more common in athletes who require increased hip range of motion. The aim of this article is to review the most common endoscopic techniques for the treatment of ESHS, as well as their results and limitations. METHODS: This is a review of the current literature of endoscopic surgical procedures and of the results of the treatment of external snapping hip syndrome. RESULTS: The pathogenesis of SHS is mechanical. The initial treatment attempt is conservative, and usually provides good results. Patients who do not respond to conservative management are candidate for surgery. The endoscopic release of the ilio-tibial band or the endoscopic release of the femoral insertion of the gluteus maximum tendon is the most popular technique. CONCLUSION: Endoscopic techniques provide fewer complications compared to open surgery, a lower recurrence rate and good clinical outcomes. More comparative studies with a longer follow-up are required to adequate evaluate the full role of endoscopic techniques in periarticular hip surgery. LEVEL OF EVIDENCE: Level V.

Endoscopic gluteus maximus tendon release for external snapping hip syndrome: a functional assessment.

PURPOSE: The aim of this retrospective study was to investigate the clinical follow-up of patients with external snapping hip syndrome (ESHS) treated with endoscopic gluteus maximus tendon release and to compare the residual muscular strength and thigh circumference as an indirect outcome measure. METHODS: Patients of all ages with external snapping hip syndrome were treated with endoscopic gluteus maximus tendon release. Outcome measures evaluated included: visual analog scale (VAS), modified Harris Hip Score (mHHS), and Non-Arthritic Hip Score (NAHS). The gluteus maximus strength and the circumference of the thigh were also evaluated. RESULTS: Among 25 patients, 23 fulfilled the inclusion criteria and one patient was lost to follow-up. The series included 22 patients, 6 males and 16 females with a mean age of 27.9 ± 13.4 years (range 16-76 years). All patients had resolution of the snapping symptoms after the procedure. The mean follow-up was 18 ± 9.3 months. All outcomes improved in a statistically significant manner: VAS value decreased from 6.8 (range 6-8) to 0.6 (range 0-4) (p < 0.001), mHHS increased from 48.6 (range 17.6-67) to 88.2 (range 67-94.6) (p < 0.001), NAHS increased from 49.0 (range 21.5-66) to 90.8 (range 66-98.75) (p < 0.001). A statistically significant reduction of operated limb thigh circumference compared to the contralateral side (3.7%) was also found, while there were no statistical differences regarding the strength of gluteus maximus muscles. CONCLUSIONS: Endoscopic gluteus maximus tendon release is an excellent surgical option to treat snapping hip syndrome. The evaluated muscle strength revealed no functional impairment. The significance of the limb circumference reduction has yet to be determined. LEVEL OF EVIDENCE: IV: retrospective comparative trial.

A novel biplanar medial opening-wedge high tibial osteotomy: the Z-shaped technique. A case series at 7.2 years follow-up.

BACKGROUND: High tibial osteotomy (HTO) provides reliable and good long-term results, if performed with correct indications, but different techniques and types of fixation have been described. The purpose of this study is to present a novel modified biplanar medial opening-wedge (MOW) HTO technique where the osteotomies are performed in a Z-shaped fashion, and to present the medium-term clinical and radiographic results. MATERIALS AND METHODS: We present a case series of 75 patients (80 knees) with mean age of 45.8 years, affected by isolated medial knee osteoarthritis and symptomatic varus knee malalignment, who underwent novel biplanar Z-shaped MOWHTO. Clinical and radiological outcomes were collected, retrospectively before surgery and at median follow-up of 7.2 years (95% CI 5.6-9.2 months) after surgery. Clinical results and satisfaction were assessed by visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Likert scale. Radiological assessment involved the evaluation of the medial proximal tibial angle (MPTA), tibial slope (TS), Caton-Deschamps index, and knee osteoarthritis grade according to Ahlbäck classification. Pre- and postoperative results were compared using the two-tailed t-test or Wilcoxon's test of independent samples for paired data or nonparametric analog. P < 0.05 was considered significant. RESULTS: At medium-term follow-up, Z-shaped MOWHTO showed a survival rate of 95 ± 1.7% with failure occurring in four knees due to symptom recurrence and osteoarthritis progression. No perioperative complications were observed (intraarticular fracture, delayed union or nonunion, and neurological injury). Mean bone healing time was 12 weeks. Clinical scores showed significant improvement at last follow-up and a good grade of satisfaction. MPTA increased significantly, while Caton-Deschamps index decreased significantly. No significant TS increase was found. CONCLUSIONS: Modified biplanar Z-shaped MOWHTO is a safe and reliable technique that offers satisfactory clinical and radiological medium-term outcomes with low knee arthroplasty conversion rate. The unique three-dimensional geometrical conformation potentially provides a favorable environment for bone healing, increased anteroposterior and rotational stability, and safer opening-wedge loading force application with low lateral hinge fracture risk. LEVEL OF EVIDENCE: Level IV, retrospective observational case series study. Trial registration The study protocol was approved by the Internal Review Board of our Institution (authorization number 54/2019, 20 November 2019).

Image quality of hip MR arthrography with intra-articular injection of hyaluronic acid versus gadolinium-based contrast agent in patients with femoroacetabular impingement.

OBJECTIVE: To compare image quality of magnetic resonance arthrography (MRA) of the hip with intra-articular injection of high-viscosity hyaluronic acid (HA-MRA) versus Gd-based contrast agent (Gd-MRA) in patients with femoroacetabular impingement (FAI). MATERIALS AND METHODS: Design: single-centre, observational, retrospective, inter-individual, and cross-sectional. FAI patients who underwent HA-MRA (3 mL of high-viscosity HA plus 17 mL of saline) were compared with 37 age- and sex-matched FAI patients who underwent Gd-MRA (20 mL of 2 mmol/L solution of gadopentetate dimeglumine). Two independent blinded radiologists assessed image quality for all sequences (two-dimensional proton density, non-fat-sat axial, fat-sat coronal and sagittal; three-dimensional dual-echo steady state), using a 5-point Likert scale considering separately labrum, cartilage, round ligament, transverse ligament, and capsule. Pearson χ2 and Cohen κ were used. RESULTS: The HA-MRA group was composed of 37 patients (23 males, 14 females; median age 38 years), the Gd-MRA group of 37 patients (21 males, 16 females; median age 38 years), without significant difference for age (p = 0.937) and sex (p = 0.636). Image quality did not differ between the two readers for any structure: labrum (p ≥ 0.340), cartilage (p ≥ 0.198), round ligament (p ≥ 0.255), transverse ligament (p ≥ 0.806), and capsule (p ≥ 0.314). Inter-reader agreement (κ) ranged from 0.785 to 1.000. CONCLUSIONS: HA-MRA provided an image quality not significantly different from that of Gd-MRA. This may open the possibility of combining MRA and viscosupplementation in one single procedure.

Os acetabuli and femoro-acetabular impingement: aetiology, incidence, treatment, and results.

PURPOSE: The purpose of this study was to investigate the pathogenesis, the incidence, and the results of arthroscopic treatment of os acetabuli (OSA) in a group of patients with diagnosis of femoro-acetabular impingement (FAI). METHODS: We retrospectively analyzed the full documentation of 294 hips in 273 patients (21 bilateral) operated for FAI through hip arthroscopy. We reviewed all radiographs and arthro-MRI in order to identify the incidence of OSA. All patients with OSA were then assessed with a modified Harris hip score (MHHS) pre-operatively and at the final follow-up. RESULTS: Twenty-one patients (7.7%), 20 (95%) of them were male, were diagnosed with concomitant FAI and os acetabuli. In 21 cases, OSA was excised and FAI was treated with rim trimming, femoral osteoplasty, or both. In one case, a large OSA fragment was fixed with a 4 mm screw avoiding an acetabular uncoverage if excised. The average follow-up was 31 months (range from 6 to 69 months). The MHHS showed an improvement from a pre-operative MHHS of 57.5 (range from 39 to 82) to 95 (range from 73 to 100). CONCLUSIONS: Os acetabuli is not uncommon and certainly associated with FAI and male gender. The etiology is probably microtraumatic. The arthroscopic OSA removal or fixation and concomitant FAI treatment showed very good results. Interestingly, these outcomes seem better than FAI treatment alone. Further studies with a wider number of patients and a longer follow-up are needed to confirm these results and understand the real role of OSA in this setting.

Total ankle replacement: is pre-operative varus deformity a predictor of poor survival rate and clinical and radiological outcomes?

PURPOSE: The objective of this study was to compare survival rate and clinical and radiological outcomes of a cementless mobile-bearing total ankle replacement (TAR) between two groups of patients, affected by end-stage ankle arthritis, with or without a pre-operative varus deformity. METHODS: A total of 81 patients (81 ankles) were included in the study and divided in two groups. Group A, "varus" group, includes 11 patients with pre-operative varus deformity of more than 10 ° and group B, "neutral" group, includes 70 patients, with a varus/valgus deformity of less than 10 °. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and Short Form (SF)-12 score were used to compare clinical outcomes. Radiological parameters, complications, and survival rate at last follow-up were also recorded. RESULTS: In both groups, all clinical and radiological parameters improved after surgery (p < 0.05) without statistically significant difference. Complications were similar between two groups. Overall in three cases, an implant revision was necessary: 1 in group A (9%) at 3.1 years follow-up and 2 (3%) in group B at 3.8 years, without statistically significant difference (p > 0.001). CONCLUSIONS: Severe varus malalignment should not be considered a contraindication for a mobile-bearing TAR. Nevertheless, TAR in severe deformity should be performed only by experienced surgeons.

The Extension-Thickness-Damage (ETD) score: a pre-operative hip MR arthrography-based classification to predict type of labrum surgery.

INTRODUCTION: Hip magnetic resonance arthrography (MRA) is the pre-operative imaging modality of choice in patients with labral damage, with several classifications of labral tears having been reported based on MRA findings. Nevertheless, none of the available classification systems allows the surgeon to predict before surgery how a labral tear could be treated. Our purpose was to develop a new MRA-based scoring system of labral tears to predict before surgery the treatment option more suitable for labral tears. MATERIALS AND METHODS: Forty-seven patients (29 males and 18 females; mean age: 35.9 ± 12.4) performed hip MRA for suspicious of femoroacetabular impingement and were afterwards subjected to arthroscopic treatment. Two musculoskeletal radiologists reviewed all pre-operative examinations and provided the Extension-Thickness-Damage score for each patient, based on Extension of tear, Thickness of labrum, and type of Damage. Chondral lesions grading was based on the arthroscopic findings according to Konan classification. For statistical purposes, patients were divided into two groups, depending on the type of treatment: labral repair or debridement. Mann-Whitney U, Chi-square, receiver operator curves, and Cohen kappa statistics were used. RESULTS: 35/47 underwent repair, while 12/47 were debrided. In both groups, the median chondral damage was grade III, with no significant differences (p = 0.439). The median Extension-Thickness-Damage score in the repair group (6) was significantly lower (p < 0.001) than that in the debridement group (8). The highest diagnostic performance (area under the curve) of Extension-Thickness-Damage was 0.819. The inter-observer agreement was substantial in the evaluation of Extension (k = 0.626) and Thickness (k = 0.771), and almost perfect for Damage (k = 0.827). Higher scores of Extension and Thickness were more frequently associated with debridement (p < 0.001; p = 0.0016, respectively), with no significant differences on the basis of Damage parameter (p = 0.284). CONCLUSIONS: The MRA-based Extension-Thickness-Damage score could represent a helpful pre-operative tool, expressing the extent of the damage and its reparability before arthroscopy.

Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review.

PURPOSE: The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature. METHODS: The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. RESULTS: Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives. CONCLUSIONS: The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Fluoroscopy- vs ultrasound-guided aspiration techniques in the management of periprosthetic joint infection: which is the best?

BACKGROUND: Fluid samples obtained from an affected joint still play a central role in the diagnosis of periprosthetic joint infection (PJI). It is the only preoperative test able to discover the causative microbiological agent. In the hip, fluid aspiration can be performed through fluoroscopy, ultrasound, or, less commonly, computed tomography. However, there is still a lack of consensus on which method is preferable in terms of efficacy and costbenefit. PURPOSES: We, therefore, asked whether (1) the benefits in terms of sensitivity and specificity and (2) the costs were comparable between fluoroscopy- and ultrasound-guided joint aspirations in a suspicious of hip PJI. METHODS: Between 2013 and 2016, 52 hip aspirations were performed on 49 patients with clinical, radiological, or serological suspicion of PJI, waiting for a revision surgery. The patients were divided in two groups: fluoroscopy- (n = 26) vs ultrasound-guided hip aspiration group (n = 26). These groups were also divided in control and infected patients. The criteria of MusculoSkeletal Infection Society (MSIS) were used, as gold standard, to define PJI. RESULTS: (1) Ultrasound-guided aspiration revealed valid sensitivity (89% vs 60%) and specificity (94% vs 81%) in comparison with fluoroscopic-guided aspiration. (2) The cost analysis was also in favor of ultrasound-guided aspiration (125.30€) than fluoroscopic-guided aspiration (343.58€). CONCLUSIONS: We concluded that ultrasound-guided hip aspiration could represent a valid, safe, and less expensive diagnostic alternative to fluoroscopic-guided aspiration in hip PJI.

Is the newest fibrin sealant an effective strategy to reduce blood loss after total knee arthroplasty? A randomized controlled study.

An RCT was conducted to ascertain whether, compared to control management, topical application of a novel fibrin sealant (Evicel, J&J) in patients undergoing primary TKA reduces peri-operative blood loss. Sixty-two patients were randomized to receive topical application of Evicel (N = 31) or not (N = 31). The mean total blood loss was 1.9L(± 0.7) in the control group and 1.8L(± 0.5) in the treatment group (P = 0.4). The transfusion rate was 32.3% in the control group and 25.8% in the treatment group (P = 0.5). The transfusion rate decreased linearly with increasing preoperative Hb levels in the treatment group (P = 0.005). The results of this study suggest that topical application of this novel fibrin sealant doesn't reduce perioperative blood loss and the need for allogeneic blood transfusion.

Kuntscher nail removal: Revision of a failed hip resurfacing above an incarcerated Kuntscher nail. A case report of a smart nail extraction technique through a custom-made instrumentation.

Removal of a retained and osseointegrated intramedullary femoral nail can represent a considerable problem, especially in the case of contemporary total hip arthroplasty or, even worse, in the case of revision hip arthroplasty. Usually, complex and invasive surgical techniques are required to remove incarcerated Kuntscher nails. We described a case of an incarcerated Kuntscher nail, inserted 39 years before, in a 75-year-old woman waiting for a revision total hip arthroplasty of a failed metal-on-metal hip resurfacing. A CT-based custom-made extra-long trephine reamer was designed and successfully used to easily extract the nail, leaving the proximal femur before a revision hip arthroplasty.

Last generation fluted modular titanium stem in revision hip arthroplasty: a narrative review of mid- and long-term outcomes.

Background and Objective: Tapered fluted titanium stems (TFTS), were introduced to overcome proximal femur bone defects. They obtain stable fixation even in catastrophic proximal bone loss. Modular ones have the advantage to adjust length, rotation, off-set independently from the distal module. Short-term publications have been showing favorable outcomes burdened by an unacceptably high rate of stem failure. Still, there is a paucity of mid- and long-term reports. This narrative review aims at analyzing recent literature on modular TFTS with at least 5 years of minimum follow-up to gain a better understanding of implant survival, performance, and complications. Methods: A search of the PubMed database was performed with selected key terms. Results were screened after the application of strict inclusion and exclusion criteria. Extracted data were subsequently evaluated to obtain an up-to-date overview of the results and complications of TFTS. Key Content and Findings: Modular TFTS showed a consistent increase in patient reported outcomes that persists at 10 years and above. Femoral fractures were the most common intraoperative complication. Despite modularity, dislocation still occurs at a variable rate (1.2-12%). With revision for any cause as an endpoint, overall survival approaches 83% after 10 years of follow-up. If femoral revision only is evaluated, excellent survival rates (>95%) have been published. Stem subsidence over 5 mm was reported in less than 5% of patients, only 1 requiring femoral revision. The mean incidence of stem mechanical failure was 3.39%, although most breakages occurred in stems eventually retired from the market. Conclusions: Satisfactory survival rates were observed, with an acceptable rate of complications. Stem mechanical failure, excluding those stems eventually retired from the market, remains a marginal event. Therefore, the use of modular TFTS in revision surgery is safe and effective even in the long term.

Groin Pain Syndrome Italian Consensus Conference update 2023.

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Radiographically undetectable periprosthetic osteolysis with ASR implants: the implication of blood metal ions.

Patients with ASR implants (resurfacing and large-diameter (XL) metal-on-metal (MoM) total hip arthroplasty), even if asymptomatic and with a stable prosthesis, may present extremely high blood metal ion levels. We report on a consecutive series of fourteen ASR revisions, focusing on osteolysis and their radiographic correspondence and their correlation with blood metal ion levels. At revision, seven hips revealed severe periacetabular osteolysis which was radiographically undetectable in six and asymptomatic in five. Seven hips with no acetabular osteolysis had significantly lower serum Cr and Co ion concentrations (respectively 25.2, 41.1 µg/l) compared to the seven hips with severe acetabular bone loss (respectively 70.1, 147.0 µg/l). Elevated blood metal ion levels should be considered as a warning of undetectable and ongoing periprosthetic osteolysis in asymptomatic patients with ASR prosthesis.

Femoral neck fractures: Key points to consider for fixation or replacement a narrative review of recent literature.

INTRODUCTION: Femoral neck fractures (FNF) are frequent injuries and not rarely complicated by non-union, implant failure, and avascular necrosis. Some of these fractures represent a dilemma for trauma surgeons. Which fracture should be fixed? Which replaced with a prosthesis? How? The aim of this narrative review is to investigate the literature in order to provide the most updated and evidence-based knowledge about FNF' treatment. MATERIALS AND METHODS: A literature research has been performed to find the essential key points to consider when dealing with FNF and their treatment. The most representative papers and the new meta-analysis were matched with authors' experience to give a concise but comprehensive view of the problem. Timing, age, comorbidities, vascularization of the femoral head, displacement, instability, comminution of the fracture, bone quality, and surgeon experience seem to be the major topics to consider in the decision making. We then focus on the optimal fixation or replacement as suggested by the literature. RESULTS: Age is the main independent factor to consider. Timing seems essential in the elderly population to reduce mortality and important in the younger patients to reduce complications. Vascular supply should be always considered. Displacement, instability, and comminution of the fracture are negative prognostic factors for fixation as well as, theoretically, bone quality. In the elderly hip replacement is mostly indicated. A stable and solid fixation is mandatory to allow early mobilization. Sliding Hip Screws (SHS) seem preferable to cannulated screws for displaced/unstable (Pauwels II-III, posterior comminution) and basicervical fracture patterns or in smokers. There is a tendency toward Total Hip Arthroplasty (THA) also in the elderly if the patient is an indipendent ambulator without severe comorbidities. Dual mobility cups are gaining popularity in THA for FNF. CONCLUSIONS: FNF are frequent injuries and represent, in some cases, a dilemma for the trauma surgeon. Age, timing, comorbidities, bone quality, femoral head vascularization, fracture displacement, intrinsic instability, and comminution as surgeon experience should be carefully evaluated before surgery. A case-to-case analysis of the patient-related factors helps the surgeon to make the right choice and reduce the well-known complications.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety.

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.