Screw Stress Distribution in a Clavicle Fracture with Plate Fixation: A Finite Element Analysis.

Clavicle midshaft fractures are mostly treated surgically by open internal reduction with a superior or anteroinferior plate and screws or by intramedullary nailing. Screw positioning plays a critical role in determining the stress distribution. There is a lack of data on the screw position and the appropriate number of cortices required for plate fixation. The aim of this study is to evaluate the mechanical behavior of an anterior plate implanted in a fractured bone subjected to 120° of lateral elevation compared to a healthy clavicle using numerical simulations. Contact forces and moments used were obtained from literature data and applied to the healthy and fractured finite element models. Stresses of about 9 MPa were found on the healthy clavicle, while values of about 15 MPa were calculated on the plate of the fractured one; these stress peaks were reached at about 30° and 70° of elevation when the stress shielding on the clavicle sums all the three components of the solicitation: compression, flexion, and torsion. The stress distribution in a clavicle fracture stabilized with plates and screws is influenced by several factors, including the plate's position and design, the type of screw, and the biomechanical forces applied during movements.

Total Talar Prosthesis, Learning from Experience, Two Reports of Total Talar Prosthesis after Talar Extrusion and Literature Review.

Recently, total talar prosthesis has been proposed to substitute the talus during the management of complex talar lesions such as talar extrusion, comminuted talar fractures, or avascular necrosis. Herein, we report two cases of talar extrusion treated with total talar replacement after a high-intensity trauma. Both cases subsequently required revision surgery due to degenerative changes of the tibial plafond (arthrodesis in the first case, conversion to a total ankle prosthesis in the latter). We report and analyze the literature concerning total talar replacement to discuss strategies that could help improve prosthesis survival and reduce the incidence of osteoarthritis.

The dramatic increase in sudden cardiac deaths and the alarming low survival: A global call to action to improve outcome with the engagement of tertiary education system.

The number of out-of-hospital cardiac arrests, cause of disability and death, has dramatically increased worldwide, but despite the progress, the incidence of survival does not appear to have increased significantly. Bystander cardiopulmonary resuscitation (CPR) remains the principal factor in saving out-of-hospital cardiac arrest victims. Analyzing the immense efforts produced by states and professional organizations to train people in CPR skills for immediate intervention in the occurrence of a cardiac arrest, the primary global strategy is centered on CPR education and training for schoolchildren. But the rate of CPR training remains low, with wide differences among communities. The concept of CPR training for schoolchildren to increase bystander CPR rates needs to be implemented. We suggest a global call to action for the tertiary education system for CPR learning and training, including all undergraduate students regardless of the degree course, as a possible method to improve the traditional CPR training today centered on the secondary education system. Extending CPR training courses to the university educational system could significantly increase the number of people educated in life-saving maneuvers. The final objective is to improve the survival rate of patients with out-of-hospital primary cardiac arrest, which has dramatically increased worldwide.

Haemophilia and Fragility Fractures: From Pathogenesis to Multidisciplinary Approach.

Haemophilia A (HA) and haemophilia B (HB) are X-linked inherited bleeding disorders caused by the absence or deficiency of coagulation factors VIII (FVIII) and IX (FIX), respectively. Recent advances in the development of effective treatments for haemophilia have led to a significant increase in life expectancy. As a result, the incidence of some comorbidities, including fragility fractures, has increased in people with haemophilia (PWH). The aim of our research was to perform a review of the literature investigating the pathogenesis and multidisciplinary management of fractures in PWH. The PubMed, Scopus and Cochrane Library databases were searched to identify original research articles, meta-analyses, and scientific reviews on fragility fractures in PWH. The mechanism underlying bone loss in PWH is multifactorial and includes recurrent joint bleeding, reduced physical activity with consequent reduction in mechanical load, nutritional deficiencies (particularly vitamin D), and FVIII and FIX deficiency. Pharmacological treatment of fractures in PWH includes antiresorptive, anabolic and dual action drugs. When conservative management is not possible, surgery is the preferred option, particularly in severe arthropathy, and rehabilitation is a key component in restoring function and maintaining mobility. Appropriate multidisciplinary fracture management and an adapted and tailored rehabilitation pathway are essential to improve the quality of life of PWH and prevent long-term complications. Further clinical trials are needed to improve the management of fractures in PWH.

Rehabilitation of Gait and Balance in Cerebral Palsy: A Scoping Review on the Use of Robotics with Biomechanical Implications.

Cerebral palsy (CP) is a congenital and permanent neurological disorder due to non-progressive brain damage that affects gross motor functions, such as balance, trunk control and gait. CP gross motor impairments yield more challenging right foot placement during gait phases, as well as the correct direction of the whole-body center of mass with a stability reduction and an increase in falling and tripping. For these reasons, robotic devices, thanks to their biomechanical features, can adapt easily to CP children, allowing better motor recovery and enjoyment. In fact, physiotherapists should consider each pathological gait feature to provide the patient with the best possible rehabilitation strategy and reduce extra energy efforts and the risk of falling in children affected by CP.

Bone Health Status in Individuals with Amyotrophic Lateral Sclerosis: A Cross-Sectional Study on the Role of the Trabecular Bone Score and Its Implications in Neurorehabilitation.

Background and Objectives: Osteoporosis is a metabolic skeletal disease resulting in low bone mass with increased bone fragility and susceptibility to fractures. May lead to rapid loss of bone mineral density (BMD) due to physical inactivity and reduced muscle contractions. Generally, the diagnosis of osteoporosis is made using dual X-ray absorptiometry (DXA), by measuring BMD and the trabecular bone score (TBS), which can be useful for detecting bone fragility and susceptibility to fractures. Therefore, the aim of this study was to investigate, using BMD and TBS, the bone health status in a sample of amyotrophic lateral sclerosis (ALS) inpatients attending neurorehabilitation. Materials and Methods: Thirty-nine patients were included in the study and underwent electrocardiogram and blood tests, including calcium and parathyroid hormone, as well as vitamin D dosage, and DXA. Results: We found that the TBS of patients with osteoporosis was lower than that of those ALS patients with osteopenia or normal bone status, both in the lumbar spine and femoral neck, although no statistical significance was reached. In addition, Spearman's correlation coefficient indicated a moderate correlation between TBS and lumbar spine BMD (r = -0.34) and a mild correlation between TBS and femoral neck BMD (r = -0.28). Conclusions: This study confirmed the hypothesis that ALS patients may exhibit deteriorated bone health with lower bone density and focused on the possible role of the TBS in the multidisciplinary approach to ALS.

Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study.

INTRODUCTION: Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy.

Surgical approach to correction of severe knee malalignment in a pediatric population in Tanzania.

AIM: Severe knee malalignment in children usually needs surgery with different options available in surgical approaches. The aim of this study was to report the results of the surgical correction of severe knee malalignment in children treated with femoral and tibial osteotomy, temporarily fixed with percutaneous Kirschner wires, in a low- and middle-income country (LMIC), with limited medical resources.

Congenital and Bilateral Dislocation of the Knee: Case Report and Review of Literature.

Background: Congenital and bilateral dislocation of the knee is an uncommon disorder; it may be isolated or combined with other congenital muscoloskeletal disorders, associated with neurologic disorders or occur in syndromic conditions. The knee presents a typical pathologic hyperextension, with or without joint dislocation. If untreated, the knee may develop stiffness or instability. Case Summary: We report about a new-born baby girl presented at birth with an unusual position of both lower limbs with obvious hyperextended knees. Starting from the first hours of life, this baby was treated conservatively with reduction and serial cast immobilizations of the limbs. At the end of the treatment (21 days of life), the knees appeared completely corrected with physiologic active and passive range of motion and joint stability, and they were left free. Conclusion: A correct evaluation at birth, both of the newborn and the deformity, is mandatory in order to decide the proper treatment, that could be conservative or surgical. A prompt treatment can be very effective to completely resolve the problem.

Short- and Midterm Comparison of Platelet-Rich Plasma with Hyaluronic Acid versus Leucocyte and Platelet-Rich Plasma on Pain and Function to Treat Hip Osteoarthritis. A Retrospective Study.

Hip osteoarthritis (HOA) leads to pain and reduced function. The use of intra-articular injections based on corticosteroids, platelet-rich plasma (PRP), or hyaluronic acid (HA) is becoming a common symptomatic therapy for HOA. For the first time, we compare the effectiveness of plasma with a high concentration of platelets and leukocytes (L-PRP) with PRP+HA in patients with mild to moderate HOA. A total of 26 patients in each group were administered with either L-PRP or PRP+HA. Outcomes were evaluated at baseline, 3 months, and 1 year after the injection. The mean visual analog scale (VAS) and Harris hip score (HHS) within and between groups among different time points were compared using repeated measures ANCOVA (age set as a covariate). Both treatments were effective in reducing VAS, but not in significantly increasing HHS. In the group treated with L-PRP, VAS showed interaction between time and treatment (in favor of L-PRP). Pairwise comparison for treatment and time point evidenced a significant difference at 1-year follow-up between L-PRP and PRP-HA. Outcomes support the idea that both treatments may be effective in reducing pain, with maximal pain reduction achieved after 3 months. L-PRP showed better results in reducing VAS over time. Both treatments are effective at reducing pain in the short to medium term. L-PRP could be the treatment of choice due to a more marked effect over time. Nevertheless, further research is needed to better describe the clinical outcome of these formulations.

Platelet-Rich Plasma Combined with Hyaluronic Acid versus Leucocyte and Platelet-Rich Plasma in the Conservative Treatment of Knee Osteoarthritis. A Retrospective Study.

Background and objectives: Knee osteoarthritis (KO) is one of the most common joint diseases, determining knee pain and reduction of mobility, with a negative effect on quality of life. Intra-articular injections of different formulations of platelet-rich plasma (PRP) are an increasingly common non-surgical treatment for KO. Recently, in order to combine the anti-inflammatory effect of platelet rich plasma and the viscosupplementation effect of hyaluronic acid, a formulation of PRP combined with hyaluronic acid (PRP + HA) has been proposed. The purpose of this study is to retrospectively compare the effectiveness of plasma with high concentration of platelets and leukocytes (L-PRP) with PRP + HA in patients with mild to moderate (Kellgren-Lawrence scale II-III grade) KO. Materials and Methods: Among the 51 patients included, 28 have been treated with L-PRP, while 23 with PRP + HA. A retrospective evaluation at baseline (T0), after 3 months (T1) and 1 year (T2) has been performed. The outcome analyzed are the Knee Society Score (KSS), the Visuo Analogic Scale (VAS) (at T0, T1, and T2) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) (T0 and T2). We evaluated change in mean scores within and between groups among different time points using repeated measures ANCOVA. Results: Although the two treatments have been both effective in reducing VAS, the group treated with PRP + HA showed a significantly lower KSS. Conclusions: Our results show that the use of both treatments may help to reduce pain in patients with mild to moderate KO. PRP + HA showed better results in improving knee mobility and function. These results should be considered only preliminary: Further research is needed to completely describe the clinical effectiveness of these formulations.

Platet Rich Plasma or Hyperbaric Oxygen Therapy as callus accellerator in aseptic tibial non union. Evaluate of outcomes.

BACKGROUND AND AIM OF THE WORK: The incidence of long bone non-unions has been estimated to range between 5-10%. Nonunion of fracture is a delayed complication of fracture. A large bone resection, associated with Ilizarov's osteo-distraction technique, is commonly used in these cases. The war experience was very important for dealing with these injuries. The purpose of this study is to report whether the use of Platelet Rich of Plasma(PRP) or Hyperbric Oxygen Therapy(HOT) as an adjuvant to the osteogenic distraction of Ilizarov with respect to the classical method has advantages. METHODS: From 183 tibial non union, we enrolled 50 patients suffering by Type B according ASAMI non union classification.  We divided the patients into two groups. The first group was a retrospective group of patient treated by Ilizarov Tecnique plus PRP. Instead the second group, patients were treated by Ilizarov Tecnique associated with  HOT. The chosen criteria to evaluate the two groups during the clinical and radiological follow-up were: the complication after the surgery in the two groups; the duration of surgery; the objective quality Bone results and functional results were evaluated according to ASAMI classification while the subjective quality of  life correlated with Ilizarov frame function by the Short Form 12 Health Survey (SF-12); The correlation between bone regenerate/bone healing and X-rays. The evaluation endpoint was set at 12 months from the remotion of Ilizarov's frame for both groups. RESULTS: In comparing the complications  of the two populations, there were a significant statistically difference(p<0.05) in the local skin inflammation and Dockin Point Skin retraction  for HOT group while  in refracture  p<0.05 was for group PRP. From the SF-12 we discovered not statistically differences p<0.05. The average correlation between Bone Regenerate-Bone Healing/ X-rays is absolutely in the PRP as in the HOT, p>0.05. The average Time for remove Ilizarov's Frame in months was 15.37(±7.34; range 9-32) in PRP while in HOT was15.22(± 7.83; range 9-31), p>0.05. CONCLUSIONS: From our study we can conclude that the association of HOT and PRP with the Ilizarov technique does not improve the functional outcomes but allows a more rapid healing of the regenerated bone and therefore an early removal of the device and a corresponding improvement in the quality of life.

Standard plating vs. cortical strut and plating for periprosthetic knee fractures: a multicentre experience.

Aim Periprosthetic fracture after knee arthroplasty occurs more frequently in the supracondylar area of femur, especially after low energy trauma associated with torsional or compressive forces. Several techniques have been described for the treatment of displaced fractures. The aim of this study is the evaluation of the outcomes and bone healing of periprosthetic femoral fractures managed by standard plate fixation compared to plating with bone grafting. Methods Thirty-six periprosthetic fractures around the knee were selected. Eighteen patients underwent standard plate and screws fixation while other eighteen were treated by plating associate with a cortical strut. Knee Society Score (KSS) and Short Form 12 (SF12) with the UNION SCORE (RUS) were used for the evaluation of results. Results After a minimum follow-up of 12 months, the results showed a statistically significant difference in SF-12, KSS, and RUS in favour of plating associated to bone graft with respect to the plating alone; four cases of non-union were recorded in the group of patients treated by standard plating. Conclusions Our experience once again demonstrated that plating and bone grafting may ensure a mechanical and biological support for the healing of periprosthetic fracture of the knee more than simple plating.

Conservative Treatment of Spondylodiscitis: Possible Therapeutic Solution in Case of Failure of Standard Therapy.

INTRODUCTION: Spondylodiscitis (SD) is an uncommon disease but not rare, because it represents around 3-5% of all cases of osteomyelitis. Late diagnosis and/or inadequate treatment often cause irreversible damage to cause neurological deficit. Most require only conservative treatment, sometimes a surgical approach is required. AIM: The purpose of this study is to propose a conservative protocol to treat spondylodiscitis when the standard conservative treatment has failed. This alternative treatment has been for a long time at the Codivilla-Putti Institute. METHODS: We performed a prospective cohort study of 192 consecutive patients who underwent paravertebral intramuscular injections of antibiotic associated with standard treatment at our Center from January 2010 to December 2015 with SD. Of this 192 patients we selected 98 who had already undergone standard antibiotic therapy at another hospital without resolution of the disease. All patients have performed our protocol that provides a total of 3 cycles, each of 3 weeks, repeated at approximately 5 weeks apart. For each patient we evaluated Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), White Blood Cells (WBC) indexes, SF36 and VAS Score at the beginning and at the end of the treatment. RESULTS: At a mean follow up of 22 months (range 60-12), clinical healing was achieved in 87 patients (88,9%) of cases with significant reduction in back pain and functional limitation. The VAS Score and the SF36 were better at the end of treatment compared to previous "GOLD STANDARD" treatments in the previous hospitalization in another hospital. In most cases there were slightly reduced in inflammatory indexes. CONCLUSION: There are no studies in the literature demonstrating the effective efficacy of local infiltrative treatment with antibiotics, associated with standard treatment protocol. We believe that our protocol in treating SD, favors an early functional recovery, and be able to offer more chance of success than the standard treatment.

Pilon fractures: A new classification system based on CT-scan.

Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. These classifications are less reproducible and do not provide necessary information for proper surgical planning. Aim of the study is to (1) propose a new classification system based on CT scan; (2) to check the prognostic value of this classification and (3) to evaluate its reliability and (4) reproducibility. We retrospectively reviewed 71 cases of pilon fracture. All fractures were classified according to AO, Ruedi Allgower and new proposed classification system by 5 surgeons. Clinical and radiographic evaluation were performed at a mean follow-up of 36 months. Cohen's K value was calculated in order to evaluate the interobserver and intraobserver agreement. Sixty-four of 71 fractures healed. Average AOFAS score was 91,7±7,8 in the Type I of new classification proposed, 87,7±7,8 in the Type II, 82±18,6 in type III, and 67,2±20,9 in type IV. Using the AO classification system the average K weighted value among the five reviewers was 0,51; using Ruedi Allgower classification it was 0,50 and using the new classification system it was 0,88 (p<0.0005). This study demonstrated that the new classification system is prognostic, reliable and reproducible. Moreover it provides a new treatment-oriented classification for this challenging fracture which affect the quality of life of the patients more than chronic diseases like diabetes and coronaropathy or pelvic fractures.

An uncommon case of irreducible ankle fracture-dislocation: the "Bosworth-like" tibio-fibular fracture.

An irreducible ankle-fracture dislocation characterized by the dislocation of the proximal fragment of the fibula posteriorly to the tibial tubercle is defined as "Bosworth injury". In the present report it is described, for the first time in literature, a complex case where the Bosworth injury was associated to a tibial plafond fracture: the proximal fibular fragment was entrapped between the tibial pilon and the fractured posterior tibial tubercle, which acted as a clamp, thus avoiding ankle reduction. Due to the presence of the tibial fracture, it was not possible to observe the typical radiological signs of Bosworth injury and therefore two unsuccessful reductions were attempted before performing a CT scan that revealed the complexity of the case, that required an immediate ORIF procedure to prevent the onset of complications.

Early radial head excision for displaced and comminuted radial head fractures: considerations and concerns at long-term follow-up.

OBJECTIVES: The aim of this study is to retrospectively review the outcomes of patients with comminuted radial head fractures surgically treated with early radial head excision. DESIGN: Retrospective follow-up study. SETTING: University orthopaedic trauma center. PATIENTS: Forty-two patients with unilateral, isolated, closed, displaced, or comminuted radial head fracture (Mason type 2-10, Type 3-32). INTERVENTION: Early radial head excision. MAIN OUTCOME MEASUREMENTS: Patients were clinically and radiographically evaluated at an average follow-up of 18 years. The uninjured contralateral limb was used as a comparison. Clinical evaluation was rated using the Broberg and Morrey system, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and the visual analog scale (VAS) for pain. RESULTS: At last follow-up, 36 patients had no complaints, whereas six admitted to occasional pain. The mean Broberg and Morrey score was 91.2 ± 6.3, and the mean Disabilities of the Arm, Shoulder and Hand score was 10.1 ± 8.8. CONCLUSION: Early radial head excision represents a viable option in case of displaced and comminuted fractures. According to the results of this study, it demonstrated a high rate of good results and patient satisfaction, a quick recovery after surgery, and a low rate of complications with durable results at long-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total hip arthroplasty in developmental hip dysplasia using cementless tapered stem. Results after a minimum 10-year follow-up.

Acetabular and femoral abnormalities make total hip arthroplasty in developmental hip dysplasia a challenging procedure. We present details of long-term follow-up of a series of patients affected by developmental hip dysplasia treated with total hip arthroplasty using a cementless tapered stem. Thirty-five hips in 20 patients (18 women and 2 men) aged between 44 and 60 years (mean 51 years) were observed. Clinical evaluation was conducted using the Harris Hip Score (HHS). Radiographic evaluation consisted in standard anteroposterior and axial view radiographs of the hip. According to Crowe's classification, 25 hips had grade 2 and 10 hips grade 3 dysplasia. All patients were treated with total hip arthroplasty using a cementless tapered stem (Wagner Cone Prosthesis™). After surgery the patients were clinically and radiographically evaluated at 1, 2, 3, 6 and 12 months and annually thereafter. The average follow-up was 12 years (range 10-14 years). The average HHS was 57±7 (range 45-66) preoperatively, 90±7 (range 81-100) 12 months after surgery and 90±6 (range 83-100) at last follow-up. Radiographic evaluation demonstrated excellent osseointegration of the implants in most cases. Signs of bone resorption were present in 5 hips, but no evidence of loosening was observed and none of the implants have been revised. The tapered stem achieved adequate stability and orientation, and may be a suitable option for total hip arthroplasty for arthritis following developmental hip dysplasia.

Sagittal segmental alignment as predictor of adjacent-level degeneration after a cloward procedure.

BACKGROUND: The Cloward anterior interbody fusion is commonly performed for cervical disc herniation or spondylosis. In followup studies, various authors have noted clinically relevant adjacent-level degeneration. However, factors associated with adjacent-level degeneration are not well known. QUESTIONS/PURPOSES: We asked whether the postoperative sagittal segmental alignment of the fused vertebrae could be used as a predictor of adjacent-level degeneration. METHODS: We retrospectively studied 107 patients, aged 35 to 55 years, with one-level cervical disc disease between C4 and C7 operated on from 1985 to 1995 by discectomy and one-level anterior cervical fusion according to the Cloward procedure. In standard radiographs of the cervical spine in lateral view, the alignment of the involved intervertebral space (sagittal segmental alignment) and the sagittal alignment of the cervical spine were measured and the adjacent-level degeneration was assessed using the Kellgren and Lawrence criteria. The minimum followup was 10 years (mean, 16 years; range, 10-23 years). RESULTS: Preoperatively, mean sagittal segmental alignment was 0.6°±2.0° and sagittal alignment of the cervical spine was 17.0°±4.9°. At last followup, the mean sagittal segmental alignment was 1.8°±4.1° and mean sagittal alignment of the cervical spine was 19.7°±6.6°. Adjacent-level degeneration was present in 60% of cases with postoperative sagittal segmental alignment of 0° or less and in 27% of cases with postoperative sagittal segmental alignment of more than 0°. CONCLUSIONS: To prevent adjacent-level degeneration, we recommend proper lordotic sagittal segmental alignment when anterior interbody fusion of the cervical spine is indicated. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical treatment of post-traumatic malalignment of the ankle.

Post-traumatic malalignment is evident in cases of malunion of ankle fractures. This condition predisposes to the development of chronic pain, functional impairment, and finally post-traumatic arthritis. The aim of this paper is to present a joint-saving surgical treatment of post-traumatic ankle malalignment. It is based on the review of a series of patients who developed fracture malunion and were treated with articular reconstruction. Twenty-two ankle fractures, which malunited and resulted into valgus deformity and fibular shortening are presented. Pre-reconstruction and mid-term follow-up evaluation included the AOFAS score and standard weight-bearing radiographs. Surgical treatment consisted in articular reconstruction with malleolar osteotomies. Post-operatively, the non-weight-bearing period extended to 6 weeks post-surgery, while full weight-bearing was allowed at 12 weeks on average. All osteotomies healed, while no intra-operative or early post-operative complications were reported. The average pre-operative AOFAS score was 45, while post-operatively climbed to 87. At the last follow-up, on average at 5-years post-surgery, 10 patients reported "excellent" function, 7 "good", 3 "fair" and 2 "poor" function. The correction of the malalignment was maintained in 20 cases. The two patients with poor function and loss of reduction underwent ankle fusion. Articular reconstruction with malleolar osteotomies is indicated for the treatment of ankle post-traumatic malalignment, offering reduction of pain, improvement of the ankle function, delaying the development of post-traumatic arthritis, and minimising the need of radical surgery such as ankle fusion or prosthetic replacement. Moreover, once a correct alignment of the joint is achieved, secondary surgery, if necessary, can be performed more easily, and with better results.