Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures.

BACKGROUND: There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS: The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS: Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS: This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION: not applicable (consensus paper).

New Trends in Spinal Surgery: Less Invasive Anatomical Approach to the Spine. The Advantages of the Anterior Approach in Lumbar Spinal Fusion.

AIM: To describe the history of the anterior approach to the lumbar spine from the beginning to the minimal invasive techniques that the authors have developed, and to discuss its advantages and drawbacks. MATERIAL AND METHODS: The authors collected published data on the evolution of the anterior approach in the lumbar spine, and described its potential in different pathologies focusing on minimally invasive techniques. RESULTS: Several successful techniques of anterior lumbar approach have been developed over the years, leading to a progressive less invasive anatomical exposure of the spine. Anterior approaches of the lumbar spine gained popularity as an alternative to posterior routes in the management of tumors, infections, traumas, degenerative or deformity diseases and as a salvage procedure after posterior surgery. CONCLUSION: Advantages of the retroperitoneal anterior approach of the lumbar spine are well accepted: it preserves the anatomical structures of the abdomen and posterior tension band, avoiding muscle dissection. The implantation of lordotic cages with larger footprint improves local lordosis and fusion rate even in revision surgery. Drawbacks of traditional retroperitoneal approaches may be: vascular injury, deep venous thrombosis, risk of retrograde ejaculation in male in case of L5-S1 dissection. Therefore, several minimal invasive techniques have been developed to decrease the risks related to the traditional approaches. However, a long learning curve is required to achieve good skills and to manage possible technical concerns and complications.

Quality of Life in Young Adults after Flatfoot Surgery: A Case-Control Study.

The true impact of surgery for flatfoot deformities on patient's quality of life and health status remains poorly defined. The aim of this study is to evaluate the quality of life and the return to daily tasks and sports or physical activities in young adults after surgical correction of flatfoot deformity. Patients treated for bilateral symptomatic flat foot deformity were retrospectively studied. The healthy control group comprised a matched reference population with no history of foot surgery or trauma that was voluntary recruited from the hospital community. All subjects were asked to fill out questionnaires centered on the assessment of the health-related quality of life (Short-form 36; SF-36) and physical activity (International Physical Activity Questionnaire; IPAQ). Most study group SF-36 subscales were lower when compared to the control group. Among the study group, post-operatively, 36.6% of patients managed to resume low levels of sports activity, 40% were sufficiently active and were able to perform moderate sports activity (an activity that requires moderate physical effort and which forces the patient to breathe with a frequency only moderately higher than normal), while 23.3% of them were active or very active and were able to perform intense physical activity. Most IPAQ scores were statistically different from the control group. The present study suggests that patients treated with medializing calcaneal osteotomy and navicular-cuneiform arthrodesis for symptomatic flafoot had lower levels of quality of life and physical activity when compared to healthy subjects. After surgery, patients showed a significant improvement in the clinical scores.

Direct superior approach versus posterolateral approach in total hip arthroplasty: a randomized controlled trial on early outcomes on gait, risk of fall, clinical and self-reported measurements.

Background and purpose - Several surgical approaches are used in primary total hip arthroplasty (THA). In this randomized controlled trial we compared gait, risk of fall, self-reported and clinical measurements between subjects after direct superior approach (DSA) versus posterolateral approach (PL) for THA.Patients and methods - Participants with DSA (n = 22; age 74 [SD 8.9]) and PL (n = 23; age 72 [7.7]) underwent gait analysis, risk of fall assessment and Timed Up and Go Test (TUG) before (PRE), 1 month (T1) and 3 months after (T3) surgery. Data on bleeding and surgical time was collected.Results - DSA resulted in longer surgical times (90 [14] vs. 77 [20] min) but lower blood loss (149 [66] vs. 225 [125] mL) than PL. DSA had lower risk of fall at T3 compared with T1 and higher TUG scores at T3 compared with T1 and PRE. PL improved balance at T3 compared with T1 and PRE. Spatiotemporal gait parameters improved over time for both DSA and PL with no inter-group differences, whereas DSA, regarding hip rotation range of motion, showed lower values at T3 and T1 compared with PRE and, furthermore, this group had lower values at T1 and T3 compared with PL. All foregoing comparisons are statistically signficant (p < 0.05)Interpretation - DSA showed longer surgical time and lower blood loss compared with PL and early improvements in TUG, spatiotemporal, and kinematic gait parameters, highlighting rapid muscle strength recovery.

Opportunities to improve feasibility, effectiveness and costs associated with a total joint replacements high-volume hospital registry.

BACKGROUND: Clinical registries are powerful tools for collecting uniform data longitudinally, thus making it possible to evaluate the outcome of patients affected by a specific pathology. In the context of total joint arthroplasty, registries serve also as post-market surveillance. Adoption of registries is a heavy burden for clinical settings in terms of resources and infrastructures. Excessive workload leads to incomplete data collection which undermines the effectiveness of a registry and consequently the workload needs to be optimised. METHODS: Starting from the use case of the Istituto Ortopedico Galeazzi, the time and personnel dedicated to the registry was estimated. Analysis of the data collected in the first years enabled us to propose a methodology for workload reduction. Different Machine Learning models were leveraged to predict patients with excellent satisfaction to reduce the number of assessments in their clinical post-operative follow-up. Moreover, feature selection was used to identify any unnecessary clinical scale to collect. RESULTS: Given an acceptance rate of 3500 patients per year, 22 doctors and 6 non-medical employees were required to adopt a registry properly. Among the tested models, the Naïve Bayes gave the best performance (AUPRC = 0.81) in predicting patient satisfaction at six months. Moreover, we found that the 12-item Short Form was poorly informative in predicting satisfaction at six-months. CONCLUSIONS: In this study machine learning was leveraged to provide a methodology to reduce workload in the use of pathology registries. Such workload reduction can have a considerable impact at a larger scale, and improve registry feasibility in high-volume hospitals.