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.

Early weight bearing in acetabular and pelvic fractures.

BACKGROUND AND AIM OF THE WORK: The incidence of pelvic and acetabular fractures is increasing during the years, counting 37 pelvic fractures per 100000 people annually. No weight bearing or toe touch weight bearing are usually chosen in the initial management to allow fracture and ligamentous healing and avoid fracture displacement and fixation failure. On the other hand, early weight bearing may stimulate fracture healing and allow prompt functional recovery, faster return to work and recreational activities and reduce complications linked to late rehabilitation.  Aim of the study is to review the literature about weight bearing indications for pelvic and acetabular fractures to highlight clinical and biomechanical evidence supporting early weight bearing. METHODS: Two independent reviewers independently extracted studies on early weight bearing of pelvic and acetabular fractures. All selected studies were screened independently based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. RESULTS: 44 studies including reviews, meta-analysis, clinical and biomechanical studies were selected. CONCLUSIONS: Despite biomechanical data, few clinical evidences can be found to support early weight bearing in pelvic and especially acetabular fractures treatment. The promising results of some clinical experiences, however, should direct further studies to clearly define the indications and limits of early weight bearing in these injuries. Recognizing intrinsic lesion stability and bone and fixation technique quality, together with patient age and compliance, should be the mainstay for post-operative management choice.

Role of the transverse ligament of the ulnar collateral ligament of the elbow: a biomechanical study.

BACKGROUND: The ulnar collateral ligament (UCL) complex of the elbow plays a primary role in valgus and posteromedial stability of the elbow. The anterior oblique ligament (AOL) of the UCL is believed to provide the majority of resistance to external forces on the medial elbow. The transverse ligament (TL) of the UCL is generally thought to have minimal contribution to the elbow's overall stability. However, recent studies have suggested a more significant role for the TL. The primary aim of this study was to identify the TL's contribution to the stability of the elbow joint in determining the joint stiffness and neutral zone variation in internal rotation. METHODS: Twelve cadaveric elbows, set at a 90° flexion angle, were tested by applying an internal rotational force on the humerus to generate a medial opening torque at the level of the elbow. The specimens were preconditioned with 10 cycles of humeral internal rotation with sinusoidal torque ranging from 0 to 5 Nm. Elbow stiffness measures and joint neutral zone were first evaluated in its integrity during a final ramp loading. The test was subsequently repeated after cutting the TL at 33%, 66%, and 100% followed by the AOL in the same fashion. RESULTS: The native UCL complex joint stiffness to internal rotation measured 1.52 ± 0.51 Nm/°. The first observable change occurred with 33% sectioning of the AOL, with further sectioning of the AOL minimizing the joint stiffness to 1.26 ± 0.32 Nm/° (P = .004). A 33% resection of the TL found an initial neutral zone variation of 0.376 ± 0.23° that increased to 0.771 ± 0.41° (P < .01) at full resection. These values were marginal when compared with the full resection of the AOL for which we have found 3.69 ± 1.65° (P < .01). CONCLUSION: The TL had no contribution to internal rotation elbow joint stiffness at a flexion angle of 90°. However, sequential sectioning of the TL was found to significantly increase the joint neutral zone when compared with the native cadaveric elbow at a flexion angle of 90°. This provides evidence toward the TL having some form of contribution to the elbow's overall stability.

Fibula fractures management.

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy.

BACKGROUND AND AIM OF THE WORK: complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures. METHODS: The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications. RESULTS: 65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device. CONCLUSIONS: INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature.

BACKGROUND AND AIM OF THE WORK: Post-operative periprosthetic shoulder fractures incidence is gradually raising due to aging of population and increasing of reverse total shoulder arthroplasty (RTSA). Management of this complication represents a challenge for the orthopedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of post-operative periprosthetic humeral  fractures occurring on RTSA. METHODS: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. RESULTS: 31 studies including reviews, meta-analysis, case reports, clinical and biomechanical studies were selected. CONCLUSIONS: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation and revision arthroplasty are both valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Bent femoral intramedullary nail: a case report and review of the literature.

Intramedullary nailing is considered the gold standard technique for the treatment of femoral shaft fractures. A rare complication of this technique is nail bending after a new trauma. In these cases nail removal might be really challenging. The present paper provides a brief review of surgical techniques purposed in the literature for bent nail removal and describes a clinical case.

Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome.

BACKGROUND AND AIM OF THE WORK: Periprosthetic knee fractures incidence is gradually raising due to aging of population and increasing of total knee arthroplasties. Management of this complication represents a challenge for the orthopaedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of periprosthetic knee fractures. METHODS: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. RESULTS: 52 studies including reviews, meta-analysis, clinical and biomechanical studies were selected. CONCLUSIONS: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation, intramedullary nailing and revision arthroplasty are all valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Treatment of intracapsular fractures of the proximal femur with bipolar hemiarthroplasty in patients under the age of 70: clinical and radiographic results at mean 20 years follow-up.

BACKGROUND AND AIM OF THE WORK: Hemiarthroplasty (HA) for femoral neck fractures in relatively young patients has been reported to have poor results. Moreover, cotyloiditis has been described for HA as a possible cause of revision. Nontheless, in the literature there is lack of studies specifically evaluating this topic, particularly in relatively young patients. Aim of the study was to evaluate bipolar HA clinical and radiographic results at long term follow up in patients treated under the age of 70. METHODS: Study population counted 137 patients treated between 1990 and 2000. In 2015 alive patients who did not undergo implant revision were clinically evaluated. Harris Hip Score and EQ-5D questionnaire were administrated. Acetabular erosion was identified and classified on follow-up radiographs. RESULTS: At follow-up there were 39 living patients, mean age 64, 80.5% women. 3 patients were not traceable. Revision rate was 32% (12/37), because of cotyloiditis in 2 cases. In the 22 non-revised patients at mean 20 years follow up 3 cases presented moderate to severe acetabular erosion. Mean HHS and EQ values were 73.23 and 0.527 respectively. CONCLUSIONS: Bipolar HA provided satisfying results in relatively young patients at long term follow-up. In the present study age turned out to be the most relevant variable to influence results. Data suggest that acetabular erosion might have a secondary role in determining both the implant's survival and the long term clinical results.