Efficacy of a dual task protocol on neurophysiological and clinical outcomes in migraine: a randomized control trial.

The main aim of this study was to investigate the efficacy of a dual task protocol in people with episodic migraine with respect to both active exercises only and cognitive task only treatments, concerning some neurophysiological and clinical outcomes. A randomized control trial was adopted in people with episodic migraine without aura. Some neurophysiological and clinical outcomes were collected (t0): resting motor threshold (rMT), short intracortical inhibition (SICI) and facilitation (ICF), pressure pain threshold (PPT), trail making test (TMT), frontal assessment battery (FAB), headache-related disability (MIDAS) and headache parameters. Then, participants were randomized into three groups: active exercise only (n = 10), cognitive task only (n = 10) and dual task protocol (n = 10). After 3 months of each treatment and after 1-month follow-up the same neurophysiological and clinical outcomes were revaluated. A significant time x group effect was only found for the trapezius muscle (p = 0.012, pη2 = 0.210), suggesting that PPT increased significantly only in active exercise and dual task protocol groups. A significant time effect was found for rMT (p < 0.001, pη2 = 0.473), MIDAS (p < 0.001, pη2 = 0.426), TMT (p < 0.001, pη2 = 0.338) and FAB (p < 0.001, pη2 = 0.462). A repeated measures ANOVA for SICI at 3 ms highlighted a statistically significant time effect for the dual task group (p < 0.001, pη2 = 0.629), but not for the active exercises group (p = 0.565, pη2 = 0.061), and for the cognitive training (p = 0.357, pη2 = 0.108). The dual task protocol seems to have a more evident effect on both habituation and sensitization outcomes than the two monotherapies taken alone in people with migraine.

Chronic Diffuse Sclerosing Osteomyelitis of the Mandible: The Use of Bisphosphonates as a Treatment for a Rare and Challenging Condition.

Chronic diffuse sclerosing osteomyelitis is a very rare condition, described as a non-suppurative, inflammatory disease of the bone and characterized by a proliferative endosteal reaction, which clinically reveals itself with cyclic pain of the jaw and swelling. We reported two clinical cases, where patients suffered recurrent swelling and pain at the mandible irradiating to the preauricular area, denying any previous trauma or significant medical history. Odontogenic causes were excluded. An initial treatment with antibiotics and NSAIDs temporarily relieved the symptoms without complete resolution, prompting further investigations. After a comprehensive array of diagnostic tools (X-rays, CT scans, scintigraphy, bone biopsy, serum markers), both patients were diagnosed with chronic diffuse sclerosing osteomyelitis of the mandible. Bisphosphonates (clodronate and zolendronate) with different treatment schemes were used to treat the condition, until a full recovery from symptoms was reported. Bisphosphonates could therefore represent an effective option in managing this rare but impactful condition. Further research is warranted to better understand the underlying mechanisms of the disease and to optimize treatment strategies.

Multidimensional prognostic index predicts short- and long-term mortality and rehospitalizations in older patients with hip fracture.

BACKGROUND: Multidimensional Prognostic Index (MPI), calculated on cognitive, functional, nutritional, social, pharmacological and comorbidity domains, strongly correlates with mortality in older patients. Hip fractures are a major health problem and are associated with adverse outcomes in those affected by frailty. AIM: We aimed at evaluating whether MPI is a predictor of mortality and rehospitalization in hip fracture older patients. METHODS: We investigated the associations of MPI with all-cause 3- and 6-month mortality and rehospitalization in 1259 older patients admitted for hip fracture surgical treatment and managed by an orthogeriatric team [age 85 years (65-109); male gender: 22%]. RESULTS: Overall mortality was 11,4%, 17% and 23,5% at 3, 6 and 12 months from surgery (rehospitalizations: 15, 24,5 and 35,7%). MPI was associated (p < 0.001) with 3-, 6- and 12- month mortality and readmissions; Kaplan-Meier estimate for rehospitalization and survival according to MPI risk classes confirmed these results. In multiple regression analyses these associations were independent (p < 0.05) of mortality and rehospitalization-associated factors not included in the MPI, such as gender, age and post-surgical complications. Similar MPI predictive value was observed in patients undergoing endoprosthesis or other surgeries. ROC analysis confirmed that MPI was a predictor (p < 0.001) of both 3- and 6- month mortality and rehospitalization. CONCLUSIONS: In hip fracture older patients, MPI is a strong predictor of 3-, 6- and 12- months mortality and rehospitalization, independently of surgical treatment and post-surgical complications. Therefore, MPI should be considered a valid pre-surgical tool to identify patients with higher clinical risk of adverse outcomes.

Should the early surgery threshold be moved to 72 h in over-85 patients with hip fracture? A single-center retrospective evaluation on 941 patients.

AIM: Aim of the study was to assess whether early surgery and other clinical and orthogeriatric parameters could affect mortality rate in hip fracture patients aged > 85. MATERIALS AND METHODS: Data regarding a 42-month period were retrospectively obtained from the institutional medical records and registry data. Gender, age, fracture pattern, surgical technique, type of anesthesia, timing of surgical intervention (within 24, 48 or 72 h from admission), days of hospitalization, mortality rate divided in intra-hospital, at 30 days and at 1 year were collected for the whole population. Some additional data were collected for an orthogeriatric subgroup. RESULTS: 941 patients were considered, with a mean age of 89 years. Surgery was performed within 24, 48 and 72 h in 24.4%, 54.5% and 66.1% of cases, respectively. Intra-hospital mortality rate resulted to be 3.4%, while mortality at 30 days and 1 year resulted to be 4.5% and 31%, respectively. Early surgery within 48 and 72 h were significantly associated with a lower intra-hospital and 30-day mortality rate. In the orthogeriatric subgroup (394 patients), a significant association with a higher mortality rate was found for general anesthesia, number of comorbidities, ADL (Activities of Daily Living) < 3, transfer to other departments. CONCLUSIONS: In over-85 hip fracture patients, the threshold for early surgery might be moved to 72 h to allow patients pre-operative stabilization and medical optimization as intra-hospital and 30-day mortality rates remain significantly lower. Advanced age, male sex, number of comorbidities, pre-operative dependency in ADL, general anesthesia, length of hospitalization and transfer to other departments were significantly related to mortality rate.

Is intraoperative neuromonitoring effective in hip and pelvis orthopedic and trauma surgery? A systematic review.

INTRODUCTION: Sciatic nerve injury is an uncommon but potentially devastating complication in hip and pelvis surgery. Intraoperative nerve monitoring (IONM) was applied since the seventies in neurosurgery and spine surgery. Nowadays, IONM has gained popularity in other surgical specialities including orthopaedic and trauma surgery. Aim of this systematic review is to resume the literature evidences about the effectiveness of intraoperative monitoring of sciatic nerve during pelvic and hip surgery. METHODS: Two reviewers (GC and MD) independently identified studies by a systematic search of PubMed and Google Scholar from inception of database to 10 January 2021. Inclusion criteria were: (a) English written papers, (b) use of any type of intraoperative nerve monitoring during traumatic or elective pelvic and hip surgery, (c) comparison of the outcomes between patients who underwent nerve monitoring and patient who underwent standard procedures, (d) all study types including case reports. The present review was conducted in accordance with the 2009 PRISMA statement. RESULTS: The literature search produced 224 papers from PubMed and 594 from Google Scholar, with a total amount of 818 papers. The two reviewer excluded 683 papers by title or duplicates. Of the 135 remaining, 72 were excluded after reading the abstract, and 31 by reading the full text. Thus, 32 papers were finally included in the review. CONCLUSIONS: The use of IONM during hip and pelvis surgery is debated. The review results are insufficient to support the routine use of IONM in hip and pelvis surgery. The different IONM techniques have peculiar advantages and disadvantages and differences in sensitivity and specificity without clear evidence of superiority for any. Results from different studies and different interventions are often in contrast. However, there is general agreement in recognizing a role for IONM to define the critical maneuvers, positions or pathologies that could lead to sciatic nerve intraoperative damage. LEVEL OF EVIDENCE: Level 2.

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.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

BACKGROUND: Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs. METHODS: The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded. RESULTS AND CONCLUSION: Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients.

BACKGROUND: Cut-out is the most common mechanical complication of the osteosynthesis of pertrochanteric fractures. This complication determines a significant increase in morbidity in elderly patient. Cut-out is defined as the varus collapse of the femoral head-neck fragment with the extrusion of the cephalic screw. Surgical treatment of cut-out might lead to further complications, longer rehabilitation, increased social burden and healthcare system costs. The aim of the study is to identify the predictors of cut-out to prevent its occurrence. MATERIALS AND METHODS: Study population included all patients affected by extracapsular fracture of the proximal femur who were admitted and treated with short cephalomedullary nailing at the Cattinara Hospital-ASUITS of Trieste between 2009 and 2014. A retrospective analysis of clinical and radiographic data was carried out and cut-out cases recorded. The data collected on the study population were analyzed to find an eventual correlation with the occurrence of cut-out. The independent variables were age, gender, side of the fracture, ASA class, Evans classification, nailing system, quality of reduction, TAD, CalTAD, and Parker ratio. RESULTS: The study population counted 813 cases, with an F:M ratio of 4:1 and a mean age of 84.7 years. The cut-out was recorded in 18 cases (2.2%). There was no statistically significant association between cut-out and age, sex, side of fracture, ASA class, and nailing system. The Evans classification, the quality of reduction, the TAD, the CalTAD, and the Parker's ratio demonstrated a significant correlation at univariate analysis with cut-out. The results of multivariate analysis confirmed that TAD, Parker AP, and quality of reduction were independently significantly correlated to cut-out. CONCLUSION: The results of the present study demonstrate that good quality of reduction and correct position of the lag screw are likely to decrease the risk of cut-out complication. A nomogram for cut-out prediction is proposed for clinical validation.

Post-traumatic complex regional pain syndrome: clinical features and epidemiology.

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that occurs after a tissue injury (fractures, sprain, surgery) of the upper or lower extremities. A clear pathophysiological mechanism has not been established yet and different patterns are considered to play a role in the genesis of the disease. The diagnosis is made by different diagnosis criteria and a gold standard has not been established yet. Incidence of CRPS is unclear and large prospective studies on the incidence and prevalence of CRPS are scarce. The aim of this review is to give an overview on the prevalent data regarding this chronic syndrome.

Treatment of complex regional pain syndrome.

Complex Regional Pain Syndrome (CRPS) is a multifactorial and disabling disorder with complex etiology and pathogenesis. Goals of therapy in CRPS should be pain relief, functional restoration, and psychological stabilization, but early interventions are needed in order to achieve these objectives. Several drugs have been used to reduce pain and to improve functional status in CRPS, despite the lack of scientific evidence supporting their use in this scenario. They include anti-inflammatory drugs, analgesics, anesthetics, anticonvulsants, antidepressants, oral muscle relaxants, corticosteroids, calcitonin, bisphosphonates, calcium channel blockers and topical agents. NSAIDs showed no value in treating CRPS. Glucocorticoids are the only anti-inflammatory drugs for which there is direct clinical trial evidence in early stage of CRPS. Opioids are a reasonable second or third-line treatment option, but tolerance and long term toxicity are unresolved issues. The use of anticonvulsants and tricyclic antidepressants has not been well investigated for pain management in CRPS. During the last years, bisphosphonates have been the mostly studied pharmacologic agents in CRPS treatment and there are good evidence to support their use in this condition. Recently, the efficacy of intravenous (IV) administration of neridronate has been reported in a randomized controlled trial. Significant improvements in VAS score and other indices of pain and quality of life in patients who received four 100 mg IV doses of neridronate versus placebo were reported. These findings were confirmed in the open-extension phase of the study, when patients formerly enrolled in the placebo group received neridronate at the same dosage, and these results were maintained at 1 year follow-up. The current literature concerning sympathetic blocks and sympathectomy techniques lacks evidence of efficacy. Low evidence was recorded for a free radical scavenger, dimethylsulphoxide (DMSO) cream (50%). The same level of efficacy was noted for vitamin C (500 mg per day for 50 days) in prevention of CRPS in patients affected by wrist fracture. In conclusion, the best available therapeutic approach to CRPS is multimodal and is based on the use of several classes of drugs, associated to early physiotherapy. Neridronate at appropriate doses is associated with clinically relevant and persistent benefits in CRPS patients.

Neurophysiological and Clinical Outcomes in Episodic Migraine Without Aura: A Cross-Sectional Study.

OBJECTIVE: The aim of this study was to assess differences between people with episodic migraine and healthy controls in some neurophysiological and clinical outcomes, which, in turn, may highlight the differences in sensory processing, especially in cortical excitability, pain processing, and executive function. METHODS: A cross-sectional study was performed, including the following outcomes: pressure pain thresholds with algometry; resting motor threshold, short-interval intracortical inhibition, and intracortical facilitation with transcranial magnetic stimulation; and executive functions with the trail making test and the frontal assessment battery. RESULTS: Thirty adults with migraine (36 ± 10 years) and 30 healthy controls (29 ± 14 years) were included in this study. Compared with the healthy controls, participants with migraine presented lower pressure pain thresholds values in all the assessed muscles ( P < 0.001), lower resting motor threshold (-10.5% of the stimulator output, 95% CI: -16.8 to -4.2, P = 0.001, Cohen d = 0.869) and higher short-interval intracortical inhibition motor-evoked potential's amplitude at 3 ms (0.25, 95% CI: 0.05 to 0.46, P = 0.015, Cohen d = 0.662), and worse performances both in trail making test (7.1, 95% CI: 0.9 to 13.4, P = 0.027, Cohen d = 0.594) and frontal assessment battery (-1.1, 95% CI: -1.7 to -0.5, P = 0.001, Cohen d = 0.915). CONCLUSIONS: Participants with migraine presented significant differences in cortical excitability, executive functions, and pressure pain thresholds, compared with healthy controls.

The Acute Effects of Cold Water Immersion and Percussive Massage Therapy on Neuromuscular Properties and Muscle Soreness after Exercise in Young Male Soccer Players.

Cold water immersion (CWI) and percussive massage therapy (PMT) are commonly used recovery techniques in team sports. In particular, despite its wide use, PMT has been scarcely investigated in the literature, especially regarding neuromuscular measures and in comparison with other techniques. This study aimed to evaluate and compare the acute and short-term effects (24 h) of CWI and PMT on muscle strength, contractile properties, and soreness after exercise. A randomized crossover study was performed on sixteen male soccer players (22 years, 20-27) who participated in three experimental sessions involving a fatiguing protocol consisting of a Yo-Yo Intermittent Endurance Test followed by 3 × 10 squat jumps and a wall sit for 30 s, and 12 min of recovery including CWI (10 °C water), bilateral PMT on the anterior and posterior thigh, or passive resting. Outcomes were assessed immediately after the exercise protocol, after the recovery intervention, and at 24 h. Isometric knee extension (IKE) and flexion (IKF) and tensiomyography (TMG) were assessed. Muscle soreness and fatigue were scored from 0 to 10. PMT increased strength after the treatment (p = 0.004) and at 24 h (p = 0.007), whereas no significant differences were found for the other two recovery modalities. At post-recovery, compared to CON, CWI resulted in a longer TMG contraction time (p = 0.027). No significant differences were found at 24 h. Finally, PMT and CWI enhanced muscle soreness recovery compared to passive rest (F4,60 = 3.095, p = 0.022, pη2 = 0.171). Preliminary results from this study suggest that PMT might improve isometric strength after strenuous exercise, and both PMT and CWI reduce muscle soreness perception, while the effects on TMG parameters remain controversial.

Assessing Muscle Mass in the Orthopedic Clinical Setting: Application of the Ultrasound Sarcopenia Index in Elderly Subjects with a Recent Femoral Fracture.

BACKGROUND: Sarcopenia poses a risk factor for falls, disability, mortality, and unfavorable postoperative outcomes. Recently, the Ultrasound Sarcopenia Index (USI) has been validated to assess muscle mass, and this study aimed to apply the USI in the clinical setting. METHODS: This prospective observational study included 108 patients aged >65 years, hospitalized for proximal femoral traumatic fracture. Patients were divided into two groups based on anamnestic data: patients with independent walking (IW) and patients requiring walking aid (WA) before admission. All the participants received an ultrasound examination. Other parameters evaluated were handgrip strength, limb circumferences, nutrition (MNA), and activity of daily living (ADL) scores. RESULTS: Fifty-six IW patients (83 ± 6 y; 38 females) and 52 WA patients (87 ± 7 y; 44 females) were recruited. The USI was significantly higher in the IW group compared to the WA group (p = 0.013, Cohen's d = 0.489). Significant correlations were found between the USI and other sarcopenia-associated parameters, such as handgrip strength, MNA, ADLs, other muscle ultrasound parameters, and limb circumferences. CONCLUSION: The application of the USI in the orthopedic surgery setting is feasible and might support the diagnosis of sarcopenia when combined with other measures of strength and function.

Factors affecting bone strength other than osteoporosis.

Osteoporosis is the most common cause of bone fragility, especially in post-menopausal women. Bone strength may be compromised by several other medical conditions and medications, which must be ruled out in the clinical management of patients affected by fragility fractures. Indeed, 20-30% of women and up to 50% of men affected by bone fragility are diagnosed with other conditions affecting bone strength other than osteoporosis. These conditions include disorders of bone homeostasis, impaired bone remodeling, collagen disorders, and medications qualitatively and quantitatively affecting bone strength. Proper diagnosis allows correct treatment to prevent the occurrence of fragility fractures.

The incidence of fragility fractures in Italy.

Osteoporosis can significantly impact on the risk of developing a fracture. Thus, fragility fractures represent a challenge for health professionals and decision makers of the twenty-first century. The aim of this work is to review the literature concerning osteoporotic fractures in Italy in terms of incidence, rate of hospitalization, relative risk of a new fragility fracture, and costs for the national health system. It was estimated that the costs of treating proximal femur fragility fractures in 2002 summed up to 1 billion Euros. The number of fragility fractures in Italy was calculated as follows: 91.494 hip fractures, 61.009 clinical vertebral fractures, 57.401 humeral fragility fractures, and 94.045 forearm/wrist fragility fractures. The incidence of fragility fractures in Italy is very high, and osteoporosis is the leading cause of morbidity in the Italian population.

Scapular dyskinesis and SICK scapula syndrome following surgical treatment of type III acute acromioclavicular dislocations.

PURPOSE: To evaluate the incidence of scapular dyskinesis and SICK scapula syndrome (defined as scapular malposition, infero-medial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) in patients treated surgically for acute type III AC dislocation. METHODS: Development of scapular dyskinesis and SICK scapula syndrome following conservative treatment has been described in the literature. In the present study, we evaluated 34 patients treated with different surgical techniques for acute type III AC dislocations. Functional outcome, radiographic evaluation of clavicular reduction and scapular kinematics were all evaluated. RESULTS: Scapular dyskinesis was observed in only 4 (11.7%) patients, of which only 1 (2.9% of the sample) was affected by SICK scapula syndrome. Scapular dyskinesis was classified as type I in 3 cases (75%) and type III in 1 case (25%). Constant shoulder scores (mean 95.7 points, SD ± 5.3) and Simple Shoulder Test results (mean 11.2 points, SD ± 0.8) were excellent. Recurrence of separation was observed in 4 patients. CONCLUSIONS: Surgical treatment of type III acute AC joint dislocations is associated with a lower incidence of scapular dyskinesis and SICK scapula syndrome, if compared to data reported in the literature on conservative treatment. LEVEL OF EVIDENCE: Retrospective study, Level IV.

Perception of biological motion. No sensitivity differences between patients with Parkinson's disease and healthy observers.

The use of biological motion (BM) stimuli (point-light walkers PLW) may be a novel alternative to improve the clinical impact of Action Observation treatments in Parkinson's Disease, by directing the patient's attentional focus on gait kinematics. However, the recognition of biological motion in Parkinson's patients has thus far been controversial. To evaluate the clinical feasibility of using BM stimuli in Action Observation treatments, we aimed at investigating whether Parkinson's patients in the ON-state condition can identify and use gender-specific cues conveyed by the body structure and by the kinematics of gait of a PLW. 30 Parkinson's patients and 30 healthy elderly observers were tested in a gender identification task with PLW. Parkinson's patients were able to correctly identify the gender of PLW; no differences were found between the two groups of observers. While for both groups, the gender identification task was easier when it required a judgment on a healthy PLW. Lastly, we found that females were more sensitive than males in our identification task. Our study shows that Parkinson's patients in the ON-state condition are able to extract subtle structural and kinematic characteristics from biological motion stimuli, which is favorable to the use of BM in Action Observation treatments.

Use of bone marrow aspirate concentrate (BMAC) in the treatment of delayed unions and nonunions: a single-center case series.

BACKGROUND AND AIM: Surgical treatment of delayed unions and nonunions requires adherence to the principles of mechanical stability, as well as consideration of biological environment. Bone marrow aspirate concentrate (BMAC) provides cellular and growth factor supply acting as an osteoinductive and osteogenic stimulus in bone healing. The aim of the study is to analyze the outcome of delayed unions and nonunions treatment with autologous bone marrow concentrate supplementation at our institution. METHODS: Study included all patients treated at the Orthopedic and Traumatology Unit of Cattinara Hospital-ASUGI (Trieste, Italy) between September 2015 and January 2022 for delayed union or nonunion who received bone marrow aspirate concentrate (BMAC) supplementation. Initial treatment, definitive surgical treatment, radiographic healing and complications were retrospectively evaluated. Data collection was conducted by clinical database searching. RESULTS: The study population included 11 patients, F:M 7:4, mean age 61 years. Initial treatment was surgical in 82% of patients. Radiographic healing of the fracture occurred in 100% of cases. None of the patients presented complications. CONCLUSIONS: Bone marrow aspirate concentrate (BMAC) has shown encouraging results and a high safety profile. Thus, it could be an effective and safe method in the treatment of delayed unions and nonunion. However, further studies will be needed to clarify its role.

Total hip arthroplasty monobloc stem neck rupture in patient with massive heterotopic ossifications: a case report and literature review.

BACKGROUND AND AIM OF THE WORK: Fractures of the femoral stem neck are a rare complication in hip prosthetic surgery, especially in non-modular components. The authors report a case associated with massive heterotopic ossifications, with the purpose to analyze risk factors and specific characteristics. METHODS: A case of femoral monobloc stem neck rupture is described. A non-systematic literature review regarding risk factors for femoral stem neck fracture was conducted in the PubMed database. RESULTS: We report the case of a 61-year-old male who underwent surgery to remove calcifications four years after THA. Four months later the patient reported acute pain in the left hip, arising after a combined movement of external rotation and axial load while standing on the left foot, in the absence of any prodromic symptom. On radiographs, a displaced fracture of the neck of the hip prosthesis was revealed, together with massive heterotopic ossifications. After THA revision the patient's symptoms were resolved. CONCLUSIONS: Prosthetic femoral neck fractures are a rare complication. We suggest that this case represents a unique type of fatigue rupture, where neck length and the presence of massive heterotopic calcifications contributed to flexion forces, resulting in failure in the midpoint of the neck.

Can the medullary diameter/cortical thickness ratio be a predictor of diaphyseal fracture in elderly patients treated with cephalo-medullary nail for proximal femur fractures? A retrospective cohort study on 488 patients.

BACKGROUND AND AIM OF THE WORK: Diaphyseal femoral fracture occurring distal to the CM nail tip is an infrequent complication that presents some similarities with periprosthetic hip fractures. The purpose of this study is to evaluate the correlation between medullary diameter (MD) and cortical width (CW) ratio, a known risk factor for periprosthetic fracture, with the occurrence of diaphyseal fracture distal to the nail tip. RESEARCH DESIGN AND METHODS: Study population included patients > 65 years old treated with short CM nail for proximal femur fractures (PFF) at the Cattinara Hospital-ASUGI of Trieste (Italy) Orthopedics and Traumatology Unit between July 2014 and May 2018. Latest follow-up X-rays were evaluated to identify diaphyseal fracture occurrence. We recorded type of trauma, time lapse between CM nailing and diaphyseal fracture and calculate the MD/CW ratio on intra-operative X-rays. Data were analyzed to find out a correlation with the occurrence of diaphyseal fractures. RESULTS: The study population counted 488 patients. Diaphyseal fracture occurred in 14 cases (2.9%, F:M ratio 6:1, mean age 87 years), at mean 26.07 months after CM nailing. The MD/CW ratio identified a trend of increased risk of diaphyseal fractures as the ratio increases (OR 4.51; CI 0.826-24.642) although the correlation does not reach statistical significance (p 0.082). CONCLUSIONS: The results of the present study demonstrate a trend towards a higher risk of diaphyseal fracture as the MD/CW ratio increases, although the association did not reach statistical significance due to the small number of events.