Assessing Muscle Mass in the Orthopedic Clinical Setting: Application of the Ultrasound Sarcopenia Index in Elderly Subjects with a Recent Femoral Fracture.

BACKGROUND: Sarcopenia poses a risk factor for falls, disability, mortality, and unfavorable postoperative outcomes. Recently, the Ultrasound Sarcopenia Index (USI) has been validated to assess muscle mass, and this study aimed to apply the USI in the clinical setting. METHODS: This prospective observational study included 108 patients aged >65 years, hospitalized for proximal femoral traumatic fracture. Patients were divided into two groups based on anamnestic data: patients with independent walking (IW) and patients requiring walking aid (WA) before admission. All the participants received an ultrasound examination. Other parameters evaluated were handgrip strength, limb circumferences, nutrition (MNA), and activity of daily living (ADL) scores. RESULTS: Fifty-six IW patients (83 ± 6 y; 38 females) and 52 WA patients (87 ± 7 y; 44 females) were recruited. The USI was significantly higher in the IW group compared to the WA group (p = 0.013, Cohen's d = 0.489). Significant correlations were found between the USI and other sarcopenia-associated parameters, such as handgrip strength, MNA, ADLs, other muscle ultrasound parameters, and limb circumferences. CONCLUSION: The application of the USI in the orthopedic surgery setting is feasible and might support the diagnosis of sarcopenia when combined with other measures of strength and function.

Should the early surgery threshold be moved to 72 h in over-85 patients with hip fracture? A single-center retrospective evaluation on 941 patients.

AIM: Aim of the study was to assess whether early surgery and other clinical and orthogeriatric parameters could affect mortality rate in hip fracture patients aged > 85. MATERIALS AND METHODS: Data regarding a 42-month period were retrospectively obtained from the institutional medical records and registry data. Gender, age, fracture pattern, surgical technique, type of anesthesia, timing of surgical intervention (within 24, 48 or 72 h from admission), days of hospitalization, mortality rate divided in intra-hospital, at 30 days and at 1 year were collected for the whole population. Some additional data were collected for an orthogeriatric subgroup. RESULTS: 941 patients were considered, with a mean age of 89 years. Surgery was performed within 24, 48 and 72 h in 24.4%, 54.5% and 66.1% of cases, respectively. Intra-hospital mortality rate resulted to be 3.4%, while mortality at 30 days and 1 year resulted to be 4.5% and 31%, respectively. Early surgery within 48 and 72 h were significantly associated with a lower intra-hospital and 30-day mortality rate. In the orthogeriatric subgroup (394 patients), a significant association with a higher mortality rate was found for general anesthesia, number of comorbidities, ADL (Activities of Daily Living) < 3, transfer to other departments. CONCLUSIONS: In over-85 hip fracture patients, the threshold for early surgery might be moved to 72 h to allow patients pre-operative stabilization and medical optimization as intra-hospital and 30-day mortality rates remain significantly lower. Advanced age, male sex, number of comorbidities, pre-operative dependency in ADL, general anesthesia, length of hospitalization and transfer to other departments were significantly related to mortality rate.

Use of bone marrow aspirate concentrate (BMAC) in the treatment of delayed unions and nonunions: a single-center case series.

BACKGROUND AND AIM: Surgical treatment of delayed unions and nonunions requires adherence to the principles of mechanical stability, as well as consideration of biological environment. Bone marrow aspirate concentrate (BMAC) provides cellular and growth factor supply acting as an osteoinductive and osteogenic stimulus in bone healing. The aim of the study is to analyze the outcome of delayed unions and nonunions treatment with autologous bone marrow concentrate supplementation at our institution. METHODS: Study included all patients treated at the Orthopedic and Traumatology Unit of Cattinara Hospital-ASUGI (Trieste, Italy) between September 2015 and January 2022 for delayed union or nonunion who received bone marrow aspirate concentrate (BMAC) supplementation. Initial treatment, definitive surgical treatment, radiographic healing and complications were retrospectively evaluated. Data collection was conducted by clinical database searching. RESULTS: The study population included 11 patients, F:M 7:4, mean age 61 years. Initial treatment was surgical in 82% of patients. Radiographic healing of the fracture occurred in 100% of cases. None of the patients presented complications. CONCLUSIONS: Bone marrow aspirate concentrate (BMAC) has shown encouraging results and a high safety profile. Thus, it could be an effective and safe method in the treatment of delayed unions and nonunion. However, further studies will be needed to clarify its role.

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.

Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk.

BACKGROUND AND AIM: Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF). There are many factors related to the risk of developing AVN, with fracture complexity being one of the most relevant. Aim of the present study is to evaluate the correlation between different classification systems and the risk of post-operative AVN in patients treated with locking plate fixation for Neer 3 and 4-part PHFs. METHODS: The study population included 44 patients (F:M 2:1, mean age 62) treated between December 2014 and April 2019. Fractures were classified according to Neer, Russo and Lego classifications and Hertel's criteria. AVN was established on postoperative radiographs after a minimum follow-up of 6 months. The odds ratio (OR) for AVN for each classification subtype was calculated. RESULTS: The incidence of necrosis was 11%. Significant association with AVN was found for Neer 4 part (OR=8), Russo IVB (OR=4), Lego pattern 12 (OR=8) and in presence of 3 mayor Hertel's criteria (OR=15,5). CONCLUSIONS: There is a significant association between AVN and Neer 4 part, Russo type IVB and Lego pattern 12 fractures. AVN risk is also significantly higher in presence of 3 major Hertel's criteria.

Can the medullary diameter/cortical thickness ratio be a predictor of diaphyseal fracture in elderly patients treated with cephalo-medullary nail for proximal femur fractures? A retrospective cohort study on 488 patients.

BACKGROUND AND AIM OF THE WORK: Diaphyseal femoral fracture occurring distal to the CM nail tip is an infrequent complication that presents some similarities with periprosthetic hip fractures. The purpose of this study is to evaluate the correlation between medullary diameter (MD) and cortical width (CW) ratio, a known risk factor for periprosthetic fracture, with the occurrence of diaphyseal fracture distal to the nail tip. RESEARCH DESIGN AND METHODS: Study population included patients > 65 years old treated with short CM nail for proximal femur fractures (PFF) at the Cattinara Hospital-ASUGI of Trieste (Italy) Orthopedics and Traumatology Unit between July 2014 and May 2018. Latest follow-up X-rays were evaluated to identify diaphyseal fracture occurrence. We recorded type of trauma, time lapse between CM nailing and diaphyseal fracture and calculate the MD/CW ratio on intra-operative X-rays. Data were analyzed to find out a correlation with the occurrence of diaphyseal fractures. RESULTS: The study population counted 488 patients. Diaphyseal fracture occurred in 14 cases (2.9%, F:M ratio 6:1, mean age 87 years), at mean 26.07 months after CM nailing. The MD/CW ratio identified a trend of increased risk of diaphyseal fractures as the ratio increases (OR 4.51; CI 0.826-24.642) although the correlation does not reach statistical significance (p 0.082). CONCLUSIONS: The results of the present study demonstrate a trend towards a higher risk of diaphyseal fracture as the MD/CW ratio increases, although the association did not reach statistical significance due to the small number of events.

"Shoulder pain and limitation of motion in a young girl: think different".

BACKGROUND: Primary Synovial Chondromatosis (PSC) is a rare benign tumor of the synovial membrane in which cartilage metaplasia produces calcific loose bodies within the articular space. Only a few cases are reported in the pediatric population and its etiology remains unknown. This condition typically affects large weight-bearing joints with pain, swelling and decrease range of motion. Due to its slow progressions, delayed diagnosis is frequent and differential diagnosis should consider other chronic arthritis and malignancies. While arthroscopic removal of loose bodies is the current treatment up to now, the association of partial or complete synovectomy is debated. CASE PRESENTATION: We report about a 14-year-old girl with a long-lasting right shoulder pain, especially during movements or exercise, localized tenderness and hypotonia of the glenohumeral joint. No previous trauma was mentioned. Blood exams, Mantoux test and plain radiography of the right shoulder were unremarkable. Ultrasound imaging revealed echogenic and calcified bodies stretching the glenohumeral joint and dislocating the long head of biceps tendon. Magnetic resonance showed a "rice-grain" pattern of the right shoulder. From an arthroscopic surgery, multiple loose white bodies were removed within the synovial membrane, and synovial chondromatosis was confirmed by histological analysis. At one month follow up visit, the patient completely recovered without pain. CONCLUSION: Synovial chondromatosis is a very uncommon cause of mono articular pain in children, especially when it affects shoulder. Pediatricians should keep in mind this condition to avoid delayed diagnosis and treatment, even in consideration of the low risk of malignant transformation. Through this case, we would highlight common diagnostic pitfalls and treatment of synovial chondromatosis.

Early weight bearing in tibial plateau fractures treated with ORIF: a systematic review of literature.

BACKGROUND: To review the current clinical evidence on advantages and risks of early weight bearing (EWB) after internal fixation for tibial plateau fracture. METHODS: Data source: PubMed and Google Scholar from inception of database to 20 August 2021, using PRISMA guidelines. The included studies were randomized controlled trials, prospective and retrospective observational studies, case reports. Data extraction was performed independently by 2 reviewers. Collected data were compared to verify agreement. Statistical analysis was not performed in this study. RESULTS: The literature search produced 174 papers from PubMed and 186 from Google Scholar, with a total amount of 360 papers. The two reviewers excluded 301 papers by title or duplicates. Of the 59 remaining, 33 were excluded after reading the abstract, and 17 by reading the full text. Thus, 9 papers were finally included in the review. CONCLUSIONS: EWB can be considered safe and effective in selected cases after internal fixation for tibial plateau fractures. Level of evidence Therapeutic Level III.

Flexor hallucis longus transfer and composite anterolateral thigh fascio-cutaneous flap for reconstruction of massive chronic and infected Achilles tendon lesion. A case report and review of the literature.

Achilles tendon reconstruction with substance loss and infection in the overlying soft tissues is a challenge. There is no standardized treatment in literature for these cases. We describe a one-stage tendon reconstruction, using flexor hallucis longus (FHL) tendon transfer and an anterolateral thigh flap with vascularized fascia lata in a patient with re-rupture of the Achilles tendon, soft tissue infection and a tendon defect of 10 cm in length. The surgical procedure has had a successful outcome; patient has recovered normal gait, has recovered complete ankle range of motion with only a partial loss in plantar flexion of the big toe, without any loss in strength. No complications have emerged at follow-up. This technique is promising in treating large Achilles tendon defects with overlying soft tissue infection in a one-stage procedure.

Mechanobiology of indirect bone fracture healing under conditions of relative stability: a narrative review for the practicing clinician.

BACKGROUND AND AIM: Mechanical influence on secondary fracture healing remains an incompletely understood phenomenon. This is of special importance in biological osteosynthesis, where stability is sacrificed for the sake of an optimal biological fracture environment. Under condition of relative stability, a wide range of biomechanical conditions can be achieved. Mechanobiology, which studies mechanical influences on biological systems has become a large, interdisciplinary field. The aim of this article is to present a comprehensive synthesis of the literature for the practicing clinician, with insights relevant to their practice of fracture care. METHODS: The MEDLINE online database (Pubmed) was searched in September 2021 for relevant articles Results: The search provided 816 results, which were scanned by the first author by the title and abstract. With relevance to the research topic, 59 articles were chosen and read in detail. Another 70 articles were added by screening the references of relevant articles. A total of 129 articles were read and analysed Conclusions: Mechanical environment plays a crucial role in the fracture healing process. The definition of an optimal mechanical environment still evades us, due to the complexity of the problem. Computational models could replicate the complex mechanical environment of bone healing in humans but require detailed knowledge of mechano-transduction and material properties of healing tissues. The literature reminds us of the importance of adequate stiffness of constructs used under conditions of relative stability. Hopefully, further research in this field will result in not only empirical but more accurate and evidence-based assessments of osteosynthesis fixations.

Should age be a factor in treatment choice of periprosthetic Vancouver B2-B3 proximal femur fractures? A retrospective analysis of mortality and functional outcomes in elderly patients.

Background and aim of the work Revision Arthroplasty (RA) is considered the treatment of choice for periprosthetic femur fractures (PFF) presenting with a loose stem. In the elderly RA may be associated with high post-operative mortality and complications. The aim of this study is to compare mortality and functional outcomes of open reduction internal fixation (ORIF) and RA for B2-B3 PFF in the elderly. Methods The study population included 29 patients (>65 years) surgically treated for B2-B3 PFF at the Orthopedic and Traumatology Unit of Cattinara University Hospital in Trieste (Italy) between January 2015 and December 2019. 16 patients were treated with ORIF and 13 with RA. Mortality and functional outcomes were analyzed. Results In-hospital (6,25% vs 7,69%) and 3 months (6,25 vs 15,38%) mortality was higher in the RA group. Mortality rates were particularly high in the > 85-year-old patients within four months from RA treatment. One year (38,46% and 16,67%) and overall mortality (69,22% and 25%) was higher after ORIF. Average time to weight-bearing and ambulation was 2.6 and 5.25 months for ORIF patients and 1.3 and 2.4 months for RA. A correlation was found between delayed weight-bearing and overall mortality. Conclusions Age is a risk factor for short term mortality following RA. Patients >85 years of age could benefit from a less invasive procedure such as ORIF. Long term outcomes are generally better for patients who undergo RA but further studies are necessary to evaluate the risk-benefit ratio of RA treatment compared to ORIF in elderly patients.

A rare case of subcutaneous traumatic index finger both extensor tendons rupture. Results of WALANT extensor digiti minimi transfer and literature review.

Traumatic subcutaneous index finger both extensor tendons ruptures are rare injuries. Aim of the present paper is to review the literature about this uncommon lesion and to describe the case of 56 years old woman injured when her hand became stuck under a weight during a wrist hyperflexion movement. Surgical treatment was undertaken after 7 days. An extensor digiti minimi (EDM) tendon transfer and a Pulvertaft tenodesis on the index EDC to middle EDC using wide awake local anesthesia no tourniquet (WALANT) technique was performed. The advantage is to allow immediate visualization of active motion and confirmation of appropriate soft tissue tensioning. In our patient no complications were observed and an early rehabilitation program was started. The patient recovered full function at 2 months and resumed hear heavy labour working activity at 4 months.

Trabecular bone porosity and pore size distribution in osteoporotic patients - A low field nuclear magnetic resonance and microcomputed tomography investigation.

The study of bone morphology is of great importance as bone morphology is influenced by factors such as age and underlying comorbidities and is associated with bone mechanical properties and fracture risk. Standard diagnostic techniques used in bone disease, such as Dual-Energy X-ray absorptiometry and ultrasonography do not provide qualitative and quantitative morphological information. In recent years, techniques such as High Resolution Computed Tomography (HR-CT), micro- CT, Magnetic Resonance Imaging (MRI), and Low Field Nuclear Magnetic Resonance (LF-NMR) have been developed for the study of bone structure and porosity. Data obtained from these techniques have been used to construct models to predict bone mechanical properties thanks to finite element analysis. Cortical porosity has been extensively studied and successfully correlated with disease progression and mechanical properties. Trabecular porosity and pore size distribution, however, have increasingly been taken into consideration to obtain a comprehensive analysis of bone pathology and mechanic. Therefore, we have decided to evaluate the ability of micro- CT (chosen for its high spatial resolving power) and LF-NMR (chosen to analyze the behavior of water molecules within trabecular bone pores) to characterize the morphology of trabecular bone in osteoporosis. Trabecular bone samples from human femoral heads collected during hip replacement surgery were from osteoporosis (test group) and osteoarthritis (control group) patients. Our data show that both micro- CT and LF-NMR can detect qualitative changes in trabecular bone (i.e., transition from plate-like to rod-like morphology). Micro- CT failed to detect significant differences in trabecular bone morphology parameters between osteoporotic and osteoarthritic specimens, with the exception of Trabecular Number and Connectivity Density, which are markers of osteoporosis progression. In contrast, LF-NMR was able to detect significant differences in porosity and pore size of trabecular bone from osteoporotic versus osteoarthritic (control) samples. However, only the combination of these two techniques allowed the detection of structural morphometric changes (increase in the larger pore fraction and enlargement of the larger pores) in the trabecular bone of osteoporotic specimens compared to osteoarthritic ones. In conclusion, the combined use of LF-NMR and micro- CT provides a valuable tool for characterizing the morphology of trabecular bone and may offer the possibility for a new approach to the study and modeling of bone mechanics in the context of aging and disease.

Is intraoperative neuromonitoring effective in hip and pelvis orthopedic and trauma surgery? A systematic review.

INTRODUCTION: Sciatic nerve injury is an uncommon but potentially devastating complication in hip and pelvis surgery. Intraoperative nerve monitoring (IONM) was applied since the seventies in neurosurgery and spine surgery. Nowadays, IONM has gained popularity in other surgical specialities including orthopaedic and trauma surgery. Aim of this systematic review is to resume the literature evidences about the effectiveness of intraoperative monitoring of sciatic nerve during pelvic and hip surgery. METHODS: Two reviewers (GC and MD) independently identified studies by a systematic search of PubMed and Google Scholar from inception of database to 10 January 2021. Inclusion criteria were: (a) English written papers, (b) use of any type of intraoperative nerve monitoring during traumatic or elective pelvic and hip surgery, (c) comparison of the outcomes between patients who underwent nerve monitoring and patient who underwent standard procedures, (d) all study types including case reports. The present review was conducted in accordance with the 2009 PRISMA statement. RESULTS: The literature search produced 224 papers from PubMed and 594 from Google Scholar, with a total amount of 818 papers. The two reviewer excluded 683 papers by title or duplicates. Of the 135 remaining, 72 were excluded after reading the abstract, and 31 by reading the full text. Thus, 32 papers were finally included in the review. CONCLUSIONS: The use of IONM during hip and pelvis surgery is debated. The review results are insufficient to support the routine use of IONM in hip and pelvis surgery. The different IONM techniques have peculiar advantages and disadvantages and differences in sensitivity and specificity without clear evidence of superiority for any. Results from different studies and different interventions are often in contrast. However, there is general agreement in recognizing a role for IONM to define the critical maneuvers, positions or pathologies that could lead to sciatic nerve intraoperative damage. LEVEL OF EVIDENCE: Level 2.

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.

Distal femur periprosthetic knee fractures in elderly patients: clinical and radiographic outcome after internal fixation.

BACKGROUND AND AIM OF THE WORK: The incidence of periprosthetic knee fractures is steadily increasing, especially in the geriatric population. Surgical treatment in these patients must consider the poor bone quality and the risks of general complications related to age and comorbidities. The aim of the present study is to analyze the clinical and radiographic outcome of internal fixation for periprosthetic knee fractures of the distal femur in elderly patients (>75aa). METHODS: All patients treated at the Orthopedic and Traumatology Unit of Cattinara Hospital-ASUGI (Trieste, Italy) between September 2014 and September 2019 for distal femur periprosthetic fracture after total knee replacement were included in the study. Mortality, complications, radiographic healing and functional outcomes were retrospectively evaluated. Data collection was conducted by clinical database searching and telephone interview. Results were compared with the literature. RESULTS: The study population included 19 patients, F:M 16:3, mean age 84 years. Plate fixation was used in the majority of cases (90%). One-year mortality was 21.05%. Radiographic healing of the fracture occurred in 92% of cases. Nonetheless, 61% of patients saw a worsening in their functional outcome. CONCLUSION: Internal fixation is a valuable and safe option for distal femur periprosthetic fracture treatment in the elderly. The significant impact of periprosthetic knee fractures on the medium- to long-term survival and quality of life of the elderly patient is confirmed.

Simultaneous bilateral olecranon fracture: a case report and review of the literature.

BACKGROUND AND AIM OF THE WORK: A bilateral fracture of the olecranon is a rare injury, with only few cases reported in the literature. METHODS: A single case of bilateral Mayo type II A olecranon fracture in a 88 years old woman is described. A research of all articles regarding simultaneous bilateral olecranon fracture was performed in the PubMed database. RESULT: The reported case demonstrated good clinical and radiographic results at 5 months follow-up with surgical treatment. The literature search produced other 6 cases in 5 case reports. Except for one case of fatigue fracture that had been treated conservatively, the others received surgical treatment with satisfactory results. CONCLUSION: Simultaneous bilateral olecranon fracture is very uncommon. Bilateral internal fixation yields good clinical and radiographic results in most cases.

Bucket-handle meniscal tears in children under the age of 10: a literature review.

BACKGROUND AND AIM OF THE WORK: Traumatic meniscal tears are raising in skeletally immature patients due to increasing participation in sport activities. Nonetheless, meniscal tears remain a rare injury in children, with a lack of evidence regarding treatment and outcome. The aim of the study is to review the literature on BHMT in children aged under 10 years. METHODS: Two independent reviewers conducted a systematic search of Embase, Medline and Pubmed databases to report a summary of literature evidence about epidemiology, clinical presentation, diagnosis, treatment and outcome of BHMTs in children under the age of 10. RESULT: Eight articles have been considered, including seven case reports and one case series. We found 21 cases of BHMTs in children under 10 years. The injury occurred in the medial meniscus in 8 cases (66,7%), while in 4 cases (33,3%) on a lateral discoid meniscus. The mean reported age is 4,6 years (range 2 years - 9 years), with prevalence of the female sex (62,5%). CONCLUSION: BHMT is an uncommon lesion in children under 10 years old. It can be suspected after a history of knee trauma in patients with knee pain, effusion and locking. MRI is the best technique for the diagnosis. Current strategy of treatment is to preserve the meniscus through different arthroscopic suture techniques.

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.

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.