Atypical Vancouver B1 Periprosthetic Fractures: The Unsolved Problem.

Atypical femoral fractures (AFF) are stress or insufficiency fractures induced by low energy trauma or no trauma, frequently correlated with prolonged bisphosphonate therapy. The diagnosis follows major and minor criteria, originally described by the Task Force of the American Society for Bone and Mineral Research in 2010 and updated in 2014. However, the definition of AFFs in the report excluded periprosthetic fractures. When atypical fractures occur close to a prosthetic implant the situation become critical, the surgical treatment is often demolitive and supported by medical treatment. Moreover, acute ORIF as a first line treatment is frequently burdened by a high failure rate , and often a stem revision is required as second line treatment. The healing process is long and difficult with poor functional results and impairing outcomes. We present a case treated at our institution of a 78 year old woman with a history of a femoral atypical periprosthetic fracture, complicated by multiple surgical revisions. Its arduous management reflects all the difficulties that these type of fractures could present to the surgeon, while its good final result may teach us how to approach them in a correct way.

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications.

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Assessment of fracture healing in orthopaedic trauma.

Fracture healing is a complex physiologic process, relying on the crucial interplay between biological and mechanical factors. It is generally assessed using imaging modalities, including conventional radiology, CT, MRI and ultrasound (US), based on the fracture and patient features. Although these techniques are routinely used in orthopaedic clinical practice, unfortunately, they do not provide any information about the biomechanical status of the fracture site. Therefore, in recent years, several non-invasive techniques have been proposed to assess bone healing using ultrasonic wave propagation, changes in electrical properties of bones and callus stiffness measurement. Moreover, different research groups are currently developing smart orthopaedic implants (plates, intramedullary nails and external fixators), able to provide information about the fracture healing process. These devices could significantly improve orthopaedic and trauma clinical practice in the future and, at the same time, reduce patients' exposure to X-rays. This study aims to define the role of traditional imaging techniques and emerging technologies in the assessment of the fracture healing process.

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.

Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members.

INTRODUCTION: Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy. MATERIALS AND METHODS: A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs. RESULTS: 114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%). CONCLUSION: An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.

A Newly Identified Complication of Patellofemoral Arthroplasty: Case Report and Literature Review.

Background: Patellofemoral arthroplasty (PFA) is a surgical option for patients older than 40 years old who are affected by patellofemoral osteoarthritis. Regarding the complications of PFAs, few studies have investigated periprosthetic fractures. The purpose of this literature review was to highlight a previously overlooked complication of primary prosthetic surgery of the patellofemoral joint. Methods: Three literature databases were searched for studies published between 2000 to 2020 using relevant keywords. A total of 4,942 articles were originally identified. After excluding duplicates and analysing the titles and abstracts, 20 studies were considered. From these, data regarding the number of cases, clinical outcomes and complications were extracted. Results: Among the 20 selected articles, only one described periprosthetic fractures as a complication of PFAs. Herein, we also report an illustrative case of an unknown fracture complication. No cases in the literature were found that described the type of complications experienced by our patient during the postoperative period. Conclusions: This review confirms the lack of data about clinical outcomes and fracture complications of PFAs. In primary prosthetic surgery of the patellofemoral joint, patient selection and close consideration of demographic factors (such as BMI and age) and intraoperative factors (such as patellar thickness and size of the trochlear component) play a key role in optimising pre-operative planning to avoid intraoperative periprosthetic fractures.

Is the Posterior Approach With Posterior locking compression plate and Anterior Allograft Useful and Safe in the Treatment of Periprosthetic Humeral Fractures Following Reverse Total Shoulder Arthroplasty?

Introduction: As the reverse total shoulder arthroplasty (RTSA) surgery has dramatically increased in the last few decades, many complications have followed through. The periprosthetic fracture, at the moment, is still a subject of debate in the orthopedic world. In this monocentric study, along with a literature review of periprosthetic humeral fractures, we would present our institutional experience with the treatment of periprosthetic humeral fractures with a posterior humeral approach, posterior cortex plate fixation, anterior strut allograft, screws, and cerclage wires. Materials and Methods: Our study consisted in a prospective monocentric study based on 18 patients, with a mean age of 75.3 years (range 64-88), all following a reverse shoulder total arthroplasty (RTSA). Postoperative follow-ups were taken at 1, 6, and 12 months with objective measurement of shoulder motion and strength, while clinical outcome measures were assessed using the American Shoulder and Elbow Surgeons (ASES score) and visual analog scale (VAS) for pain. Together with that, we performed a literature review focused on the management of periprosthetic humeral fractures after shoulder arthroplasty. Results: All fractures consolidated without complication at a mean 4.2 months (range 3-6). At final follow-up, the average active shoulder flexion was 88° (range 62-129°), active abduction 73° (range 52-91°) and active external rotation 22° (range 3-56°). The average ASES score was 73 (range 59-97), while average VAS score was 1.1 (range 0-3). Discussion: Surgical treatment of periprosthetic humeral fractures following a shoulder arthroplasty remains a hard challenge for every surgeon, and their treatment must consider fracture's location, displacement, and local bone quality. Conclusions: The posterior approach with a posterior plate placement and anterior strut allograft, which is appliable only in case of a B or C type fracture according to Worland classification, could be a good treatment option for periprosthetic humeral fractures.

The Free Tissue Transfer-Masquelet-Reamer-Irrigator-Aspirator Bone Graft Orthoplastic Approach for Lower Extremity Reconstruction.

SUMMARY: The management of critical-sized bone and soft-tissue defects of the lower extremity poses unique challenge to reconstructive surgeons. The aim of this article is to present the authors' current orthoplastic approach for the management of extended (more than 6 cm) osteocutaneous defects of the lower extremity, based on a sequential combination of two stages: free flap for soft-tissue coverage and the Masquelet technique (first step) followed by reamer-irrigator-aspirator cancellous bone graft and definitive osteosynthesis (second step). This study was a single-center observational retrospective review of prospectively collected data. Adult patients (>18 years of age) with segmental bone loss of the lower extremity caused by acute trauma (Gustilo type IIIB fracture) or nonunion (septic/aseptic) who were treated with the free flap for soft-tissue coverage-Masquelet technique-reamer-irrigator-aspirator approach between January of 2017 and December of 2020 were included. Time of consolidation and early and late complications were recorded. A total of 11 patients (nine male patients and two female patients) with a mean age of 45.8 years were identified. The average bone gap length (standard deviation) was 87.3 (24.9) mm. An anterolateral thigh flap was harvested in all cases. The average duration of the first stage (i.e., time from antibiotic cement spacer placement and free flap to time of bone grafting) was 50.4 days (range, 40 to 62 days). Bone consolidation was achieved in all cases after an average period (standard deviation) of 20.4 (3.3) weeks, with acceptable functional outcomes. The free flap for soft-tissue coverage-Masquelet technique-reamer-irrigator-aspirator approach could be considered a viable option in patients with segmental critical-sized bone defects associated with a large soft-tissue deficit of the lower extremity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series.

BACKGROUND: Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions. METHODS: Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire. RESULTS: From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery. CONCLUSIONS: This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review.

BACKGROUND: Elbow chronic instability is a disable complication, presenting as recurrent joint subluxations or dislocations. This systematic review aims to assess (1) the clinical outcome and (2) the complication rates of the surgical techniques currently used in the management of posterolateral rotatory elbow instability. METHODS: OVID-MEDLINE®, SCOPUS, and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The search terms used were "LUCL", "Posterolateral dislocation", "Elbow Docking technique", "Elbow Jobe technique" and "Elbow single strand technique". The methodological qualities of the studies were evaluated, relevant data were extracted. RESULTS: Three studies, published between 2012 and 2015, were included in this review. No studies concerning the single strand technique met the inclusion criteria. The included studies had a level of evidence IV and recruited 33 patients undergoing a Jobe technique reconstruction and 8 patients undergoing a Docking technique. Jobe procedure registered better clinical and functional outcome, assessed using the Mayo Clinic Elbow Performance Scale (MEPS), compared with patients managed with Docking technique. Nonetheless, this difference is not significant. There was not a significantly different complication rate (p = 0.57) between patients treated with these two different techniques. CONCLUSION: This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. However, future studies with larger sample size and a longer follow-up interval are needed to draw stronger conclusions on the efficacy of the different LUCL surgical reconstruction techniques.

Modular neck stems in total hip arthroplasty: current concepts.

Modular neck (MN) implants can restore the anatomy, especially in deformed hips such as sequelae of development dysplasia.Early designs for MN implants had problems with neck fractures and adverse local tissue, so their use was restricted to limited indications.Results of the latest generation of MN prostheses seem to demonstrate that these problems have been at least mitigated.Given the results of the studies presented in this review, surgeons might consider MN total hip arthroplasty (THA) for a narrower patient selection when a complex reconstruction is required.Long MN THA should be avoided in case of body mass index > 30, and should be used with extreme caution in association with high offset femoral necks with long or extra-long heads. Cr-Co necks should be abandoned, in favour of a titanium alloy connection.Restoring the correct anatomic femoral offset remains a challenge in THA surgeries.MN implants have been introduced to try to solve this problem. The MN design allows surgeons to choose the appropriate degree and length of the neck for desired stability and range of motion. Cite this article: EFORT Open Rev 2021;6:751-758. DOI: 10.1302/2058-5241.6.200064.

The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: A randomized clinical trial.

BACKGROUND: In recent years, Minimally Invasive Plate Osteosynthesis (MIPO) has been gaining popularity in the treatment of distal tibia fractures, because it is a minimally invasive surgical procedure, thus it limits the soft-tissues damage. This prospective randomized study aims to assess the impact of lag screw in the healing time of distal tibia fractures treated with MIPO technique, in a six-month follow-up. METHODS: Patients between 20 and 70 years of age with distal tibial fracture, type 43-A according to AO/OTA classification system were included. All the patients were randomized into two groups, to receive MIPO without lag screw (Group-A) or MIPO with percutaneous lag screw (Group-B). Patients were followed clinically and radiographically at 3, 6, 12 and 24 weeks postoperatively. The main outcome measure was the time needed to achieve the painless full weight-bearing (FWB) after surgery. Unpaired t-test after ANOVA (analysis of variance) was performed to assess AOFAS score differences between the 2 groups at each follow-up. Pearson correlation test also was performed. The tests were two-tailed with a confidence level of 5%. RESULTS: 42 patients (24 male and 18 female, mean age 49.54 years old, range 25-80) were recruited. A significant shorter mean time until painless FWB (p = 0.016) was observed in Group-B (11.22 ± 3.06 weeks) compared with Group-A (13.48 ± 2.42 weeks) (Table 2). The mean AOFAS score was comparable in patients treated with (Group-B) and without lag screw (Group-A) at all follow-ups. CONCLUSIONS: This prospective randomized clinical study has shown that the use of lag screw in distal tibia fractures treated with MIPO technique speeds the fracture healing, thus shortening the time needed to achieve FWB.

Minimally invasive osteosynthesis technique in the treatment of transverse patellar fractures in the elderly.

BACKGROUND: This prospective study aims to describe our experience in the management of transverse patellar fractures in elderly patients with minimally invasive osteosynthesis technique (MIOT), at 12-months follow-up. METHODS: Patients older than 60, with transverse patellar fracture, type 34-C1 according to the AO/OTA classification system, referred to our trauma centre, between January 2014 and December 2017 were prospectively recruited. All the patients were managed using MIOT surgical procedure and underwent a clinical and radiological follow-up at 2 weeks, 6 weeks and at 3, 6, 12 and 15 months postoperatively. The clinical evaluation was performed using the Lysholm Knee Scoring System (LKSS) and the Visual Analogue Scale (VAS) for pain. The hardware removal was planned at 12-months follow-up. The paired t-test was performed. The test was two-tailed with a confidence level of 5%. RESULTS: 61 patients were recruited. The mean VAS was significantly lower in MIOT group until the 3-months follow-up (p = 0.001). ROM in flexion and LKSS score were significantly better in MIOT-group at all follow-ups, whereas ROM in extension showed no differences, between the two groups, starting from the 6-months follow-up. In the open surgery group, a significantly higher rate of delayed wound healing (p = 0.014), broken wires (p = 0.001) and non-cosmetic scar (p = 0.0221) was observed. CONCLUSIONS: This prospective study shows that MIOT is a safe option for treatment of patellar transverse fractures in elderly patients, since it reduces the intra-operative blood loss, shortens the operating time, and is endowed with lower rates of postoperative complications.

The use of a gentamicin-coated titanium nail, combined with RIA system, in the management of non-unions of open tibial fractures: A single centre prospective study.

BACKGROUND: Nonunion is a quite common complication of open tibial shaft fractures. This prospective case series investigates the use of the gentamicin-coated titanium intramedullary tibial nail, in association with the RIA system, in patients with tibial exposed nonunions. METHODS: Between January 2015 and January 2018, patients meeting the inclusion and exclusion criteria were recruited. INCLUSION CRITERIA: patients aged 18 or more; non-union after an open tibial shaft fracture; previous treatment with a circular external fixator. EXCLUSION CRITERIA: a known allergy to aminoglycosides; pin tract infections; persistent soft-tissues damage; patients pregnant, breastfeeding or planning to become pregnant during the study; history of malignant disease; a life expectancy of fewer than three months; medical illness or cognitive disorders precluding participation in the follow-up examination. All the patients underwent a clinical and radiological follow-up at one-, three-, six- and twelve-months post-operatively. Clinical evaluation was performed using the following validated scores: Euro-Quality 5 D (EQ-5D); American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the Visual Analogue Scale (VAS) for pain. RESULTS: Seventeen patients met the inclusion and exclusion criteria (male: 11; female: 6; mean age: 41.12 ± 11.4). Fracture healing was observed in all the patients; the mean time needed to obtain the fracture healing was 7.18 months. A significant improvement of the quality of life, evaluated with the EQ-5D, and of the mean VAS for pain was observed from the three-months follow-up. The mean AOFAS score showed a significant increase at six-months follow-up. CONCLUSIONS: The use of gentamicin-coated nails in association with the RIA system demonstrated a safe and effective treatment of tibial non-unions.

Comparison of plate, calcanealplasty and external fixation in the management of calcaneal fractures.

OBJECTIVE: Managing displaced intra-articular calcaneal fractures remains controversial. The purpose of this study is to compare and identify the surgical technique with the best outcomes for the treatment of intra-articular calcaneal fractures. MATERIALS AND METHODS: This is a retrospective multicentric study conducted between February 2000 and June 2014 in 206 patients with intra-articular calcaneal fractures presenting to the outpatient or emergency department of three different orthopaedic departments. The patients were treated with one of the following techniques: 1. Open reduction and internal fixation with screws and plate; 2. Percutaneous reduction and monolateral external fixation; and 3. Balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation. RESULTS: Patients treated with open reduction and internal fixation using an extensive lateral approach had a mean AOFAS score of 71 points; those treated through a minimal incision and reduction and fixation with an external fixator had a mean score of 83.1 points; and those treated with the balloon-assisted reduction, pin fixation and tricalcium phosphate augmentation had a mean score of 78.75 points. No statistically difference was found comparing the three types of treatment. CONCLUSION: Displaced intra-articular calcaneal fractures are still technically demanding injuries to manage. The results of this study suggest that in comparison to open reduction, a percutaneous reduction and fixation leads to higher but not statistical functional scores minimizing the wound-healing complications.

A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years.

INTRODUCTION: Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture. MATERIAL AND METHODS: Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages. RESULTS: At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay. CONCLUSION: Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages.

Major concern in the multiligament-injured knee treatment: A systematic review.

PURPOSE: The purpose of this systematic review was to address the treatment of multiligament knee injuries in three major aspects, specifically (1) surgical versus nonoperative treatment, (2) repair versus reconstruction of injured ligamentous structures, and (3) early versus late surgery of damaged ligaments. METHODS: Two independent reviewers performed a search on PubMed from 1966 to March 2016 using Levy's review as a starting-point, and the same terms "knee dislocation," "multiple ligament-injured knee," and "multiligament knee reconstruction." Study inclusion criteria were (1) levels I to IV evidence, (2) "multiligament" defined as disruption of at least 2 of the 4 major knee ligaments, (3) measures of functional and clinical outcomes, and (4) minimum of 12 months' follow-up, with a mean of at least 24 months. RESULTS: Two high-level studies compared surgical treatment with nonoperative treatment. There was a higher Lyshom scores (85 v 67) in surgically treated patients, as well as higher excellent/good IKDC scores (69% v 64%) and return to sport (41% v 18%). There were four studies comparing repair with reconstruction of damaged structures, with similar mean Lysholm scores (84 v 84) and excellent/good IKDC scores (63% v 63%). Nevertheless, repair of the posterolateral corner had a higher failure rate (39% v 8%) and a lower return to sport activities (25% v 51%). Similarly, repair of the cruciates achieved decreased stability and range of motion. There were six studies comparing early surgery (within 3 weeks) with delayed surgery. Early treatment resulted in higher mean Lysholm scores (89 v 82) and a higher percentage of excellent/good IKDC scores (57% v 41%), as well as higher mean ROM (129° v 124°). CONCLUSIONS: Our review suggests that the best treatment does not exist, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. Surgery must be performed within the first three weeks. Delayed ACL reconstruction allows to reduce arthrofibrosis rate.

The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study.

INTRODUCTION: Femoral shaft fractures with third fragments have a high non-union rate, which may reach 14%. This study aims to assess the impact of the radiological features of the third fragment, evaluated on post-operative X-rays, on the outcome of femoral shaft fractures type 32-B managed with intramedullary nailing, in order to obtain an algorithm which could predict the fracture healing time. MATERIALS AND METHODS: We have retrospectively evaluated a series of 52 patients. On post-operative X-rays, four radiological parameters were evaluated: the third fragment angle, the fracture gap, the third fragment size, and the mean third fragment displacement. All the patients underwent a radiologic follow-up at one, two, three, six, nine and 12 months post-operatively, to assess the bone healing. The patients were then divided into three groups, according to the fracture healing time: within six months (group A), between six and 12 months (group B), or fracture non-union after 12 months (group C). RESULTS: In 28 patients, out of 52 (53.85%), the fracture healing was observed at 6-month follow-up; in 18 patients, out of 52 (34.62%), the fracture healed within 12 months after trauma; and in six patients, out of 52 (11.54%), no fracture healing was observed at 12-month follow-up. The mean third fragment size was significantly different in each group (p < 0.05), while the mean third fragment displacement was significantly higher in group C, compared with group A (p = 0.0006) and group B (p = 0.0027). In group B, a positive correlation was found between the fracture healing time and the mean third fragment size (R = 0.594, p = 0.036); in group C, the fracture union time was positively related to the third fragment size (R = 0.689, p = 0.013) and the mean third fragment displacement (R = 0.7107, p = 0.006). Regression analysis showed that the third fragment size and the mean third fragment displacement are the most important features which affect the fracture healing time. CONCLUSIONS: The third fragment size (cutoff 40 mm) is the leading parameter to influence the fracture healing within or in more than six months. The mean third fragment displacement (cutoff 12 mm); on the other hand, impacts on the fracture delayed rather than absent healing.