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).

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

INTRODUCTION: In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe. MATERIALS AND METHODS: A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty. RESULTS: The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was 4.9±1.38 months months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C. CONCLUSIONS: One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.

Forearm segmental bone defect: Successful management using the Masquelet Technique with the aid of 3D printing technology.

The management of forearm nonunion is challenging for orthopaedic surgeons because the forearm is a unique anatomical segment in which all the bones and structures involved embody a complex functional unit. Therefore, when treating such a complex condition, the surgeon must focus not only on bone healing but also on the restoration of the native anatomy in order to replicate the normal relationship between the bones and all the surrounding structures and thus the full function of the forearm, the elbow and the wrist. Here we report the case of a 53-year-old patient with a left forearm deformity due to an atrophic nonunion of the ulna and a malunion of the radius, which was successfully managed with the use of the Masquelet technique associated with a corrective osteotomy of the radius, performed with the aid of a 3D model.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures.

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Osteosarcopenia in Very Old Age Adults After Hip Fracture: A Real-World Therapeutic Standpoint.

Loss of bone and muscle mass and strength (i. e., osteosarcopenia) is a highly prevalent clinical condition in older adults, associated with an increased risk of fragility fractures and unfavorable clinical outcomes. Although sarcopenia is a potential risk factor for osteoporosis and subsequent fracture, and the management of this hazardous duet is the key to preventing osteoporotic fracture, evidence pertaining to the treatment of sarcopenia for the purpose of preventing fragile fractures remains insufficient. Given this scenario we aimed at prospectively compare the long-term effectiveness of bisphosphonates vs. denosumab, on bone and muscle, in a cohort of old age hip fractured patients by virtue of a timely osteo-metabolic and sarcopenic assessment. Ninety-eight patients consecutively enrolled at the IRCCS Hospital San martino, Genoa, Italy, received at baseline comprehensive geriatric assessment and Bone Densitometry (DXA) with the quantitative and quantitative bone analysis and evaluation of relative skeletal muscle index (RSMI) and longitudinally after 1 year form hip surgery. The results showed a slightly and non-significant osteo-metabolic improvement in the Alendronate group compared to the Denosumab group, and a positive trend of RSMI measurements in the Denosumab group. Although preliminary in nature, this is the first report to longitudinally analyze osteosarcopenia in a real-world cohort of very old age patients after hip fracture and moved a step forward in the understanding of the best osteo-metabolic therapy for long- term treatment, exploring as well the potential dual role of denousumab as antiresorptive and muscle strength specific drug for osteosarcopenia in this vulnerable population.

Frailty assessment, hip fracture and long-term clinical outcomes in older adults.

BACKGROUND: The primary aim of the study was determining the validation of the modified 19-item Frailty Index (mFI-19), based on the standard procedure for creating a frailty index scoring in the accumulation deficit theory of Rockwood and comparing it with the gold standard comprehensive geriatric assessment (CGA) in old age patients with hip fracture. As a secondary aim, we compared prognostic accuracies of mFI-19 and CGA in predicting long-term mortality after surgery. MATERIALS AND METHODS: A total of 364 older patients with hip fractures, each a candidate for surgery, were consecutively enrolled. All were subjected to CGA and mFI-19 at baseline and time to death (years from hip surgery) were collected prospectively. RESULTS: Mean patient age was 86.5 (SD: 5.65) years. The most common clinical phenotype (77%) was frail. Both CGA and mFI-19 performed similarly in predicting long-term mortality (Harrell's C-index: 0.66 and 0.68, respectively). CONCLUSIONS: The mFI-19 was validated, compared to the gold standard CGA, based on a systematic process for creating a frailty index in relation to the accumulation deficit. This is one of few prospective studies addressing long-term mortality in older adults with hip fractures, invoking a methodologically robust frailty screening assessment.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

BACKGROUND: Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs. METHODS: The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded. RESULTS AND CONCLUSION: Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Semiextended Tibial Nail Insertion Using an Extraarticular Lateral Parapatellar Approach: A 24-Month Follow-up Prospective Cohort Study.

OBJECTIVE: To analyze the outcomes of tibial shaft fractures treated with a lateral parapatellar approach in the semiextended position for intramedullary nail insertion. DESIGN: Prospective cohort study. SETTING: Level I trauma center. PATIENTS AND METHODS: Seventy patients treated from March 2012 to July 2015 with intramedullary nailing (IMN) using an extraarticular lateral parapatellar approach in the semiextended position were reviewed. Patients were clinically and radiographically checked at a minimum follow-up of 24 months, and the following data were recorded: fracture healing, any residual deformity, nail-apex distance, range of motion of the treated knee together with the contralateral side, knee functional outcome, and residual knee pain. RESULTS: Twenty-four months after surgery, all patients were clinically and radiographically healed, with 2 cases of malalignment (angular deformity <10 degrees). The average range of motion of the treated knee was 0-130.6 degrees (±8.6 degrees) compared with 0-131.1 degree (±7.9 degrees) of the contralateral. Lysholm knee score was excellent for 57 patients, good for 11, and fair for 2. The mean residual pain was 0.6 (±1.1) according to the visual analogue scale. CONCLUSIONS: The described technique represents an effective option for IMN of tibial fractures. It is suitable for all tibial fractures, including proximal and distal. The results of our series demonstrate the effectiveness of this technique with nearly complete recovery of knee function and negligible incidence of anterior knee pain at a minimum follow-up of 24 months. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review.

BACKGROUND: Acute compartment syndrome (ACS) is characterised by abnormal pressure inside a compartment, resulting in ischemia of muscles and nerves. Most orthopaedic surgeons, especially those who work in major trauma centres, have been or will be facing a case of ACS in their clinical activity. Fortunately, complications related to untreated compartment syndrome have become less frequent thanks to a better understanding of pathogenesis and to early recognition and prompt surgical treatment. The aim of this study is to identify the existing evidence regarding aetiology of trauma-related ACS of the leg. METHODS: A systematic review of the literature was undertaken using PubMed Medline, Ovid Medline and the Cochrane library, extended by a manual search of bibliographies. Retrieved articles were eligible for inclusion if they reported data about aetiology of trauma-related compartment syndrome of the tibia. RESULTS: Ninety-five studies that fulfilled the inclusion criteria were identified. By dividing the studies into three groups according to the traumatic aetiology, we were able to classify traumatic ACS as fracture related, soft tissue injury related and vascular injury related. Fracture related was the most represented group, comprising 58 papers, followed by the soft tissue injury related group which includes 44 articles and vascular injury related group with 24 papers. CONCLUSIONS: Although traditionally ACS has been associated mainly with fractures of tibial diaphysis, literature demonstrates that other localisations, in particular in the proximal tibia, are associated with an increased incidence of this serious condition. The forms of ACS secondary to soft tissues injuries represent an extremely variable spectrum of lesions with an insidious tendency for late diagnosis and consequently negative outcomes. In the case of vascular injury, ACS should always be carefully considered as a priority, given the high incidence reported in the literature, as a result of primitive vascular damage or as a result of revascularisation of the limb. Knowledge of aetiology of this serious condition allows us to stratify the risk by identifying a population of patients most at risk, together with the most frequently associated traumatic injuries.

Masquelet technique to treat a septic nonunion after nailing of a femoral open fracture.

Septic nonunion is one of the most serious complications after an open fracture because both the infection and the bone defect need to be dealt with. Treatment is always protracted and expensive, and the result is uncertain. In the 1980s, Masquelet first described the technique of the induced membrane and autologous bone grafting to manage critical size bone defects. In septic nonunions, the described approach, characterised by two different surgical steps, allows a radical approach to manage the infection, and gives a significant biological stimulus to bone healing. In this case, we present a 35-year-old male patient with an open grade II femoral shaft fracture (AO / OTA 32C3). The patient was initially treated with an intramedullary nail and the resulting septic nonunion was subsequently managed with the induced membrane technique and a double-plate osteosynthesis to protect the biological chamber.

Treatment of distal clavicle nonunion with and without bone grafting.

The management of distal clavicle nonunion represents a challenging task for orthopaedic trauma surgeon. Both the choice of the implant and whether a bone graft is needed are controversial points which must be addressed. Particularly, in the case of a hypertrophic nonunion, grafting may not necessarily be needed, but given a poor underlying biological environment, a bone graft becomes necessary in order to enhance fracture healing. We report the case of a 62-year-old patient who came to us with a hypertrophic nonunion of the left distal clavicle. She was initially treated with a hook plate without bone grafting. After an early peri-implant fracture she was treated again with anatomical S-shaped locking plate associated with autologous cancellous bone graft.

The In-Hospital Length of Stay after Hip Fracture in Octogenarians: Do Delirium and Dementia Shape a New Care Process?

BACKGROUND: Hip fracture is a major health problem and a patient's biological age, comorbidity, and cognitive vulnerability have an impact on its related outcomes. Length of stay (LOS) for these highly vulnerable patients is rather long and the possible causes have not been clearly identified yet. OBJECTIVE: We aimed to assess the main clinical factors associated with protracted LOS, focusing on delirium with or without dementia in older age hip fractured patients. METHODS: 218 subjects (mean age 86.70±6.18 years), admitted to the Orthogeriatric Unit of the Ospedale Policlinico San Martino (Italy), were recruited. All patients received physical and comprehensive geriatric assessment. Days to surgery, days from surgery to rehabilitation, and LOS were recorded. In-hospital and three months' mortality were reported. RESULTS: Prevalent delirium at hospital admission was of 3.1%. 35% of patients developed incident delirium. 56.4% were affected by dementia of Alzheimer-type. In addition, 52% of patients developed delirium superimposed to dementia. Mean LOS was 13.5±4.99 days. Namely, delirium, time to surgery, and complication rate disproportionally affected LOS. The analysis with 3 months mortality, based on cognitive vulnerability profiles, showed how delirium mainly affect short-term mortality in patients with dementia. CONCLUSION: Our exploratory study originally pointed out the high incidence of delirium superimposed to dementia in orthogeriatric wards and how delirium turns to be a moderator of LOS. The results meet the need for additional research by virtue of a deeper understanding of the impact of delirium and dementia on orthogeriatric clinical management and outcomes.

Closed Medial Malleolar Multifragment Fracture With a Posterior Tibialis Tendon Rupture: A Case Report and Review of the Literature.

Ankle fractures represent an exciting field of traumatology because of the wide variety of clinical presentations, injury mechanisms, and treatment options. Rupture of the posterior tibialis tendon (PTT) with ankle fracture can occur during trauma that involves pronation and external rotation of the foot or, less commonly, secondary to direct trauma to the ankle. This tendon injury is uncommon and probably misdiagnosed in many cases, because of the difficult clinical examination secondary to the pain and swelling. The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure. In the present report, we provide a review of the published data regarding ankle fractures associated with PTT rupture and describe our experience with a case of a multifragment medial malleolus fracture and complete rupture of the PTT diagnosed intraoperatively and surgically treated in a 34-year-old male, with 2.5 years of follow-up.

Late recurrent peripheral upper limb ischemia after non-union of a clavicle fracture.

A 74-year-old woman was referred to our hospital due to recurrent episodes of upper limb ischemia. Her past medical history included a clavicle non-union developed after a clavicle midshaft fracture that had occurred 30 years previously. After a long asymptomatic period, she started showing symptoms of chronic ischemia to the left arm that were misdiagnosed. Thoracic outlet syndrome (TOS) is a rare but possible complication of mal-union and non-union of clavicle fractures; symptoms related to arterial involvement (ATOS) amount to less than 1% of all existing forms of thoracic outlet syndrome. In case of clavicle non-union, local instability plays a key role in determining the initial injury to the vessels and the recurrence of symptoms. Restoration of local bone stability and anatomy, obtained by compression plating and autologous bone grafting, combined with an appropriate vascular surgery, is essential to achieve a clinical resolution of symptoms and to avoid the recurrence of symptomatology as seen in the herein case.

A modified rabbit ulna defect model for evaluating periosteal substitutes in bone engineering: a pilot study.

The present work defines a modified critical size rabbit ulna defect model for bone regeneration in which a non-resorbable barrier membrane was used to separate the radius from the ulna to create a valid model for evaluation of tissue-engineered periosteal substitutes. Eight rabbits divided into two groups were used. Critical defects (15 mm) were made in the ulna completely eliminating periosteum. For group I, defects were filled with a nanohydroxyapatite poly(ester urethane) scaffold soaked in PBS and left as such (group Ia) or wrapped with a tissue-engineered periosteal substitute (group Ib). For group II, an expanded-polytetrafluoroethylene (e-PTFE) (GORE-TEX(®)) membrane was inserted around the radius then the defects received either scaffold alone (group IIa) or scaffold wrapped with periosteal substitute (group IIb). Animals were euthanized after 12-16 weeks, and bone regeneration was evaluated by radiography, computed microtomography (µCT), and histology. In the first group, we observed formation of radio-ulnar synostosis irrespective of the treatment. This was completely eliminated upon placement of the e-PTFE (GORE-TEX(®)) membrane in the second group of animals. In conclusion, modification of the model using a non-resorbable e-PTFE membrane to isolate the ulna from the radius was a valuable addition allowing for objective evaluation of the tissue-engineered periosteal substitute.

A platelet-rich plasma-based membrane as a periosteal substitute with enhanced osteogenic and angiogenic properties: a new concept for bone repair.

The periosteum plays a pivotal role during bone development and repair contributing to bone vascularization and osteoprogenitor cells source. We propose a periosteal substitute engineered using a platelet-rich plasma (PRP) membrane incorporating autologous bone marrow-derived mesenchymal stem cells (PRP/BMSC gel membrane) to be wrapped around an osteoconductive scaffold for regeneration of compromised bone defects. The PRP/BMSC gel membrane was optimized using different compositions for optimal release of vascular endothelial growth factor (VEGF) and platelet derived growth factor-BB (PDGF-BB). Survival and proliferation of cells in the PRP gel membrane with time were confirmed in addition to their osteogenic capacity. Furthermore, to evaluate the possible effects of the PRP/BMSC gel membrane on surrounding progenitor cells in the injury area, we found that the PRP gel membrane products could significantly induce the migration of human endothelial cells in vitro, and increased the expression of bone morphogenetic protein 2 in cultured BMSC. These cells also secreted significant amounts of soluble proangiogenic factors, such as PDGF-BB, VEGF, and interleukin-8 (IL-8). Finally, the functionality of the PRP/BMSC gel membrane periosteal substitute for bone regeneration was tested in vivo both in an ectopic mouse model as well as in a rabbit segmental bone defect model providing evidence of its capacity to biomimic a periosteal response enhancing bone regeneration.