Stem revision vs. internal fixation in Vancouver B2/B3 periprosthetic hip fractures: systematic review and metanalysis.

INTRODUCTION: Vancouver B2 and B3 periprosthetic fractures (PFF) are associated with stem instability and often require a demanding stem implant revision (SR) or internal fixation (ORIF). This latter surgery is increasingly performed in the last few years instead of SR, but it is unclear which is the best treatment to manage PFF patients. The aim of this study is the compare the outcomes of B2/B3 PFF managed by either ORIF or SR, by performing a systematic review and meta-analysis of current literature. MATERIALS AND METHODS: Cochrane Database, PubMed, Google Scholar and MEDLINE were examined to find out relevant publications dealing with the different outcomes of SR vs. ORIF in B2/B3 PFF of the hip. The effect model (EM) was calculated using Cohen´s d index. RESULTS: Fifteen studies were included, reporting on a total of 1629 patients (564 ORIF and 1065 SR). The pooled random EM estimates for reoperation was 0.87 (95% CI, 0.39-1.96; I2 = 78%) in favor of ORIF surgery; EM for complications was 1.01 (95% CI, 0.45-2.27; I2 = 85%) without difference among procedures. The EM for transfusion was 0.72 (95% CI, 0.46-1.12; I2 = 62%) in favor of fixation. CONCLUSION: ORIF and SR were both suitable and effective options in PFF patients, being associated to similar complications rates. Our results show that ORIF performance in PFF patients is associated to significantly less in blood loss, surgical time and in-hospital stay. These advantages are particularly appealing in patients with multiple comorbidities.

Periprosthetic Hip Fractures around the Stem: Can the Stem Design Affect Fracture Features?

Background: Total hip arthroplasty is one of the most successful orthopedic surgeries; nevertheless, many of these surgeries are the causes of failure, and among them, periprosthetic fractures are one of the major causes of revision. Our study focuses on periprosthetic hip fractures with two different stem designs. The aim of the study was to analyze the obtained results, focusing on the features of periprosthetic stem fractures observed. Methods: We retrospectively reviewed periprosthetic fractures occurring between 2010 and 2023, involving Alloclassic® or CLS® uncemented femoral stems. We analyzed demographic data, proximal femur morphology, and the fracture type. Results: We identified 97 patients. Considering the proximal femur morphology, we found that there was statistically significant prevalence of Dorr A proximal femur morphology in the CLS® group and of Dorr C in the Alloclassic® group. Considering the distribution of the fracture pattern, we reported a non-statistically significant prevalence of the fracture pattern with stable stems in the CLS® group. Conclusions: The choice of the prosthetic design of the femoral stem is a crucial element when planning total hip arthroplasty. However, we found a non-statistically significant difference between the two stems considered, raising questions about the real role of stem design as a primary determinant of periprosthetic hip fractures.

What to Know about Antimicrobial Coatings in Arthroplasty: A Narrative Review.

Periprosthetic joint infections (PJIs) are one of the most worrying complications orthopedic surgeons could face; thus, methods to prevent them are evolving. Apart from systemic antibiotics, targeted strategies such as local antimicrobial coatings applied to prosthetics have been introduced. This narrative review aims to provide an overview of the main antimicrobial coatings available in arthroplasty orthopedic surgery practice. The search was performed on the PubMed, Web of Science, SCOPUS, and EMBASE databases, focusing on antimicrobial-coated devices used in clinical practice in the arthroplasty world. While silver technology has been widely adopted in the prosthetic oncological field with favorable outcomes, recently, silver associated with hydroxyapatite for cementless fixation, antibiotic-loaded hydrogel coatings, and iodine coatings have all been employed with promising protective results against PJIs. However, challenges persist, with each material having strengths and weaknesses under investigation. Therefore, this narrative review emphasizes that further clinical studies are needed to understand whether antimicrobial coatings can truly revolutionize the field of PJIs.

Direct anterior approach hip arthroplasty: How to reduce complications - A 10-years single center experience and literature review.

BACKGROUND: The direct anterior approach for total hip arthroplasty (DAA-THA) is increasing in popularity due to some advantages such as less surgical trauma, minimal dissection of soft tissues, shorter rehabilitation times, faster return to daily activities, lower incidence of dislocation. On the other hand, the literature reports a high rate of intraoperative complications, with many different rates and complication types in the published papers. AIM: To analyze our complications comparing results with the literature; to report measures that we have taken to reduce complications rate. METHODS: All DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre, between January 2010 and December 2019 were included in this retrospective study. All surgeries were performed using cementless short anatomical or straight stems and press fit cups. Patients' follow-up was performed, at 6 wk, 3 mo, then annually post-surgery with clinical and radiological evaluation. Primary outcomes were stem revision for aseptic loosening and all-cause stem revision. Second outcome was intra-operative and post-operative complications identification. RESULTS: A total of 394 patients underwent DDA-THA from January 2010 and December 2019, for a total of 412 hips; twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study. The average age at the time of surgery was 61 years (range from 28 to 78 years). Mean follow-up time was 64.8 mo (range 12-120 mo). Seven stems were revised. One cortical perforation, one trochanteric and lateral cortical wall intraoperative fracture, one diaphyseal fracture, three clinically symptomatic early subsidence and one late aseptic loosening. We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification. Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage, one early infection, one case of late posterior dislocation, 18 case of asymptomatic stem subsidence, 6 cases of lateral cutaneous femoral nerve dysesthesia. CONCLUSION: DAA is associated to good outcomes and lower incidence of dislocation. Complication rate can be reduced by mindful patient selection, thorough preoperative planning, sufficient learning curve and use of intraoperative imaging.

DIPHOS® nail for proximal humeral fractures: our experience with more than 190 procedures and surgical tips.

AIM: evaluate the outcome of proximal  humeral nailing over 5 years follow-up, focusing  on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure. MATERIALS AND METHODS: the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject. RESULTS: mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded "very good" / "good" results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails).  Second surgery was performed in 8.2% (16/194) of cases. CONCLUSION: intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support.

Retrospective analysis of outcomes and complications after Korus hemiarthroplasty in elderly patients with neck femur fractures.

BACKGROUND: Femoral neck fractures (FNF) is one of the most common traumatic events in elderly patients: the choice of an appropriate treatment is necessary to decrease the related mortality and to achieve the best possible outcomes. Nowadays, it is still debated whether or not to cement the stem in hemiarthroplasty and above all, which stem to use to best respect the integrity of the elderly bone. METHODS: From January 2017 to December 2019, a bi-centric study utilizing prospectively collected databases of elderly patients with FNF treated with uncemented Korus stem hemiarthroplasty was performed. Patients were preoperatively classified according to ASA score. Patients' clinical and X-ray follow-up was at 1, 3, 6, 12 months. Harris Hip Score (HHS) was used for analysed clinical improvement. On the X-rays, we analysed iatrogenic fractures, osteolysis area and radiolucent lines in the stem region during follow up. RESULTS: 233 patients were identified. Median follow-up was 12 months. Over time, 51 patients died (21.88%). Mean age was 89,56 ± 6,25. 75 patients had ASA score of 2 (32.3%), 102 patients a score of 3 (43.7%), 56 an ASA score of 4 (24,0%). The main Harris hip score was 68,66 ± 8.53 at 1 month of follow-up, 71,74 ± 9.65 after 3 months, 72,50 ± 10.66 at 6 months and 75,61 ± 9.63 at 12 months control. CONCLUSIONS: Hydroxyapatite coated stem with an accurate design guarantee early fixation, good clinical and radiographic results, low rate of re-intervention and mortality rate and a satisfying return to pre-injury activities.

Kinematics and kinetics comparison of ultra-congruent versus medial-pivot designs for total knee arthroplasty by multibody analysis.

Nowadays, several configurations of total knee arthroplasty (TKA) implants are commercially available whose designs resulted from clinical and biomechanical considerations. Previous research activities led to the development of the so-called medial-pivot (MP) design. However, the actual benefits of the MP, with respect to other prosthesis designs, are still not well understood. The present work compares the impact of two insert geometries, namely the ultra-congruent (UC) and medial-pivot (MP), on the biomechanical behaviour of a bicondylar total knee endoprosthesis. For this purpose, a multibody model of a lower limb was created alternatively integrating the two implants having the insert geometry discretized. Joint dynamics and contact pressure distributions were evaluated by simulating a squat motion. Results showed a similar tibial internal rotation range of about 3.5°, but an early rotation occurs for the MP design. Furthermore, the discretization of the insert geometry allowed to efficiently derive the contact pressure distributions, directly within the multibody simulation framework, reporting peak pressure values of 33 MPa and 20 MPa for the UC and MP, respectively. Clinically, the presented findings confirm the possibility, through a MP design, to achieve a more natural joint kinematics, consequently improving the post-operative patient satisfaction and potentially reducing the occurrence of phenomena leading to the insert loosening.

Tronco-conical locking plate in distal radius fractures.

INTRODUCTION: Volar locked plates represent the most popular fixation technique for distal radius fracture (DRF). However, threaded screw-hole angular stability mechanism has some issues. The purpose of our study is to evaluate clinical and radiological outcome of a tronco-conical locking mechanism for volar plating of DRF. MATERIALS AND METHODS: Eighty patients with DRF treated with tronco-conical locking volar plates between May 2013 to December 2017 in two institutions were collected. We analysed clinical and radiological outcomes and peri-operative complications, like loss of reduction, fragment displacement, deformation or implant-related problems and surgical and other general complications. RESULTS: 78 patients were available for at final follow-up. The average follow-up period was 11.4 months (range, 6-18 months). All fractures healed within three months. Five cases of final reductions were defined unsatisfying. According to Gartland and Werley's scoring system at final follow up, 36 patients had excellent results, 40 patients had good results, one patient had fair and one patient had poor results. Five complications were observed. No complications were observed during surgical plate removal. CONCLUSION: Complications found in our study are not related to tronco-conical locking mechanism and are like those found in the literature. Further studies are needed to evaluate functional results or radiographic parameters of this new type of angular stability mechanism. Tronco-conical locking plate is an attractive alternative threaded screw-hole angular stability mechanism.

Clinical Activities, Contaminations of Surgeons and Cooperation with Health Authorities in 14 Orthopedic Departments in North Italy during the Most Acute Phase of Covid-19 Pandemic.

Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors' viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study.

BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.

Promising medium-term results of anterior approach with an anatomical short stem in primary hip arthroplasty.

BACKGROUND: In the last decade, the increase in the use of the direct anterior approach to the hip has contributed to the diffusion of the use of short stems in orthopedic surgery. The aim of the study is to verify the medium-term clinical and radiographic results of a cementless anatomic short stem in the anterior approach to the hip. We also want to verify whether the use of the standard operating room table or the leg positioner can affect the incidence of pre- and postoperative complications. MATERIALS AND METHODS: All total hip arthroplasty patients with a 1-year minimum follow-up who were operated using the MiniMAX stem between January 2010 and December 2019 were included in this study. Clinical evaluation included the Harris Hip Score (HHS), Western Ontario and McMaster Universities Hip Outcome Assessment (WOMAC) Score, and Short Form-36 (SF-36) questionnaires. Bone resorption and remodeling, radiolucency, osteolysis, and cortical hypertrophy were analyzed in the postoperative radiograph and were related to the final follow-up radiographic results. Complications due to the use of the standard operating room table or the leg positioner were evaluated. RESULTS: A total of 227 patients (238 hips) were included in the study. Average age at time of surgery was 62 years (range 38-77 years). Mean follow-up time was 67.7 months (range 12-120 months). Kaplan-Meier survivorship analysis after 10 years revealed 98.2% survival rate with revision for loosening as endpoint. The mean preoperative and postoperative HHS were 38.35 and 94.2, respectively. The mean preoperative and postoperative WOMAC Scores were 82.4 and 16.8, respectively. SF-36 physical and mental scores averaged 36.8 and 42.4, respectively, before surgery and 72.4 and 76.2, respectively, at final follow-up. The radiographic change around the stem showed bone hypertrophy in 55 cases (23%) at zone 3. In total, 183 surgeries were performed via the direct anterior approach (DAA) on a standard operating room table, and 44 surgeries were performed on the AMIS mobile leg positioner. Comparison between the two patient groups did not reveal significant differences. CONCLUSION: In conclusion, a short, anatomic, cementless femoral stem provided stable metaphyseal fixation in younger patients. Our clinical and radiographic results support the use of this short stem in the direct anterior approach. LEVEL OF EVIDENCE: IV.

Proximal humerus fractures in COVID-19 lockdown: the experience of three orthopedics and traumatology departments in the first ten weeks of the Italian epidemic.

INTRODUCTION: Coronavirus disease (CoVID-19) is causing millions of deaths worldwide and the crisis of the global healthcare system.  Aim Of The Study: evaluate the preliminary impact of CoVID-19 in three Italian Orthopedics and Traumatology Departments in the first 10 weeks of the national lockdown. We focused on proximal humerus fractures, analyzing data and results in comparison with the same period of 2019. MATERIALS AND METHODS: From February 22nd to May 3rd 2020, 55 patients were admitted to our departments for promixal humerus fractures. Our cohort of patients is composed by 13 males (23.6%) and 42 females (76.4%), with an average age of 73.8 ± 11.7 years (range 44 - 94). Trauma occurred at home in 43 cases (78.2%), by the roadside in 10 cases (18.2%), in a retirement home in 1 case (1.8%), and at work in 1 case (1.8%). We proposed surgical treatment in 15/55 cases, but 4 patients refused hospitalization, mainly because of the risk of contracting n-CoV19 infection. RESULTS: We noticed a decrease in proximal humerus fractures compared to 2019 (-37.5%). Particularly, we observed a significant drop in traumas occurred on the road and at work respectively 23.9% and 3.4%% in 2019, and 18.2% and 1.8% in 2020, probably due to the consequences of the national lockdown. Sports traumas had a reset during the pandemic (6 cases in 2019, 0 in 2020). As consequence, surgical treatment had a decrease due to the reduction in number of fractures, indications and patient's consent. CONCLUSION: The incidence of proximal humerus fractures had a significant reduction during CoVID-19 spread. We assume that the reasons of this reduction are to be found in the national lockdown (since March 10th, 2020) and Ministerial Decrees that limited the access to the E.R. only in case of severe traumas in order to avoid CoVID-19 spread.

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.

Acetabular de-escalation in hip revision.

BACKGROUND: The idea of ''de-escalation'' (DE) indicates an arthroplasty revision performed by changing a revision component by a primary component. Aim of this study is to verify if this technique can represent an option in case of cage or ring failure. METHODS: We observed five cases of revision hip cage loosening with complete allograft consolidation. This group of patients were revised with use of a primary cup and were specifically followed in ours institutions offices. Patients were clinically and radiologically followed every 6 months for the next two years and then annually Results: At final follow-up (15-2 years, mean 6 years) four patients (80%) showed a good recovery of their levels of activity. The mean Harris hip score improved from 20 points (range,7-38 points) preoperatively to 48 points (range, 16-88 points). At final radiological follow-up acetabular components were radiographically stable at the last follow-up. One patient (20%) at two years follow-up, was unable to walk without crutchies due to hip pain. X-rays showed cup loosening in all three zones. Patient was dissatisfied. Primary cup was revised with a Burch Schneider cage. CONCLUSIONS: De-escalation technique is a surgical option to consider in case of young patients, limited number of previous revisions and more than three years survivorship of loosened acetabular cage.

A preliminary experience with a new intramedullary nail for trochanteric fractures.

BACKGROUND AND AIM OF THE WORK: The worldwide incidence of fractures of the proximal end of the femur is increasing as the average age of the population rises. The current surgical gold treatment standard is intramedullary nail fixation. The Authors present their experience with the D-Nail system for intertrochanteric femur fractures. METHODS: From January 1st to February 21st 2020 (breakout of COVID-19 pandemic) 34 patients were treated with the D-Nail system: 11 with basicervical fractures, 16 with intertrochanteric stable fractures and 7 with intertrochanteric unstable fractures. In 11 cases, a single cephalic screw was used; in 23 cases, two of them were used. Distal locking was executed in 7 patients. Follow-up time ranged from 2 to 3 months. RESULTS: None of the reported intra- or post-operative complication was linked to the fixation device or the surgical technique. Patients were monitored with clinical and radiological checkups using modified Harris Hip Score to accurately evaluate the fluctuations in the rehabilitation period. CONCLUSION: The main advantages of this synthesis device are the proximal hole's peculiar shape, which allows the possibility to position one or two cephalic screws on the same nail, and the silicon coating, which provides numerous biological advantages. Distal locking was executed in selected cases only, based on fracture type. Optimum treatment involves rapid execution of surgery, minimal trauma during surgery, maximum mechanical stability, and rapid weight-bearing. Although our case number is small and follow-up time brief, our results are encouraging.

Contraceptive subcutaneous device migration: what does an orthopaedic surgeon need to know? A case report and literature review.

Subdermal contraceptive implant is approved in more than 60 countries and used by millions of women around the world. Although relatively safe in nature, their implantation and removal may be associated with potential complications, some of which may require surgical intervention. Two types of peripheral neurological complications are reported: complications related to compressive neuropathy caused by device decubitus and complications related to device improper removal. An healthy 35-year-old woman come to our attention for paresthesia from medial side of right elbow to fourth and fifth fingers. Tinel sign was positive on medial side of distal third of right arm, above the elbow, as well. Clinical history of patients revealed a subcutaneous placement of a etonogestrel implant 3 years before. Patients reported disappearing of tactile feeling of subcutaneous contraceptive implant since two months. At clinical examination, implant was not felt in its original subcutaneous place. X-rays control revealed its proximal and deep migration. Surgical exploration for subcutaneous contraceptive implant removal revealed it lying on the ulnar nerve. Patient referred immediate paresthesia disappearing after surgery. At 1 month follow up no motor or sensory alteration were evident. Removal of implants inserted too deeply must be carefully performed to prevent damages to nervous and vascular structures and it should be performed by operators who are very familiar with the anatomy of the arm. In case of chronic neuropathy caused by implant nerve compression only an appropriate patients information about rare but possible neuropathic symptoms related to device migration and a careful medical history collecting can avoid a mistaken diagnosis of canalicular syndrome.

Conical coupling angular stable plate fixation: a retrospective study.

BACKGROUNDS: Conical coupling represents an alternative to screw coupling on angular stable plate fixation. Aims of the present study was to evaluate clinical effectiveness  and ease of plate removal of conical coupling locking plates into different scenario regarding quality of bone, type of fracture and operative technique. METHODS: From May 2013 to December 2017, 198 patients with 206 fractures underwent open reduction and internal fixation with conical locking plate. In most cases fixation involved wrist (38%) and clavicle (24%) fractures but a varied type of fractures and bone were included in the study. RESULTS: Ten complications related to plate fixation were observed (5,1%). Two case of intra-articular positioning of screws of wrist plate. One case of loss of reduction and breakage of wrist plate due to an inappropriate proximal fracture fixation.  Five cases of complications involved clavicle fixation: three cases of non-union, one case of peri-implant fracture, one screw loosening. One non-union of distal tibial fracture, one non-union in olecranon fracture were finally observed. Thirty-four patients that have symptoms that could be traceable to the implants in-situ underwent plate removal. No complications were observed during surgical plates removal. Conical coupling angular stability plate represents an actractive alternative to threaded angular stability plate.  Bush titanium insert, eliminating the problems of cold welding and cross-threading, simplifies surgical screws and plate removal.

PEEK radiolucent plate for distal radius fractures: multicentre clinical results at 12 months follow up.

INTRODUCTION: Open reduction and internal fixation (ORIF) with plate and screws represents the recommended treatment for unstable intra-articular distal radius fractures. Although significant progresses in surgical technique have been made, anatomical reconstruction of radio-carpal articular surface still represent a difficult task, especially in multifragmentary fractures. Available PEEK reinforced-carbon fiber composite radiolucent devices allow both an easier and more careful assessment of intra-operative reduction of the articular surface of distal radius and prompt correction of any residual step deformity. MATERIALS AND METHODS: We retrospectively reviewed clinical and radiological multicentre results of 71 consecutive AO B and C fracture pattern of distal radius treated using the same PEEK reinforced-carbon fiber composite radiolucent plate. RESULTS: Three patients lost at final follow up and 4 cases with incomplete radiological documentations were excluded from the study. 64 patients (38 females, 26 males) were available and formed the basis of this report. Fracture types included 9 patients with 23-B, 13 patients 23-B2,15 patients with 23-B3,10 patients with 23-C1, 7 patients with 23-C2 and 10 patients with 23-C3. Mean Modified Mayo wrist Score was on average 38.11 (SD 10.1; range 24-75, 95%CI 34.7-41.4), 67.22 (SD 9.6, range 50-90, 95%CI 64-70.4), 90.54 (SD 6.3, range 75-100, 95%CI 88.4-92.6) at one, two and twelve months of follow-up, respectively. A statistically significant difference was found between mean scores at different follow-up periods (p = 0.001). We noted 1 case of distal screw fixation aseptic loosening at 5 months post surgical intervention. CONCLUSIONS: PEEK reinforced-carbon fiber composite radiolucent plate represents a useful device for treatment of complex distal radius fractures in the adult population. It possesses unique biomechanical properties and allows for an easier anatomical reduction during surgical intervention.

Risk of stem undersizing with direct anterior approach for total hip arthroplasty.

PURPOSE: The direct anterior approach (DAA) for total hip arthroplasty (THA) is claimed to be as effective but less invasive than the conventional posterior approach (PA). However, the higher risk of femoral fracture and soft tissue damage cannot be underestimated. The present authors believe that the difficult femoral exposure and the surgeon's knowledge of possible complications related to femoral preparation may result in a higher rate of undersized stems when compared to PA, even when a short femoral component is employed to minimise these risks. METHODS: A retrospective study was performed to compare the effective adherence of surgical sizing to preoperative planning in a series of 112 short stem THAs, of which 59 were implanted through PA and 53 through DAA without intraoperative imaging, by a single surgeon skilled in both techniques. RESULTS: the frequency of stems smaller than expected was 3-times higher with DAA than with PA (54.72% vs 16.95%, p<0.001), while the frequency of stems at least 2 sizes smaller than expected was more than 6-times higher with DAA than with PA (24.53% vs 3.39%, p = 0.001). Conversely, no differences of size discrepancy distribution were found for cups and prosthetic heads. Postoperative x-rays confirmed an inferior mean canal fill in the DAA group, but excluded a different incidence of frontal malalignment between the groups. CONCLUSIONS: The technical difficulty of femoral preparation and the surgeon's knowledge of possible related complications might lead to implant undersized stems more frequently through DAA than through PA, especially if intraoperative imaging controls are not used.