Chronic Diffuse Sclerosing Osteomyelitis of the Mandible: The Use of Bisphosphonates as a Treatment for a Rare and Challenging Condition.

Chronic diffuse sclerosing osteomyelitis is a very rare condition, described as a non-suppurative, inflammatory disease of the bone and characterized by a proliferative endosteal reaction, which clinically reveals itself with cyclic pain of the jaw and swelling. We reported two clinical cases, where patients suffered recurrent swelling and pain at the mandible irradiating to the preauricular area, denying any previous trauma or significant medical history. Odontogenic causes were excluded. An initial treatment with antibiotics and NSAIDs temporarily relieved the symptoms without complete resolution, prompting further investigations. After a comprehensive array of diagnostic tools (X-rays, CT scans, scintigraphy, bone biopsy, serum markers), both patients were diagnosed with chronic diffuse sclerosing osteomyelitis of the mandible. Bisphosphonates (clodronate and zolendronate) with different treatment schemes were used to treat the condition, until a full recovery from symptoms was reported. Bisphosphonates could therefore represent an effective option in managing this rare but impactful condition. Further research is warranted to better understand the underlying mechanisms of the disease and to optimize treatment strategies.

Multidimensional prognostic index predicts short- and long-term mortality and rehospitalizations in older patients with hip fracture.

BACKGROUND: Multidimensional Prognostic Index (MPI), calculated on cognitive, functional, nutritional, social, pharmacological and comorbidity domains, strongly correlates with mortality in older patients. Hip fractures are a major health problem and are associated with adverse outcomes in those affected by frailty. AIM: We aimed at evaluating whether MPI is a predictor of mortality and rehospitalization in hip fracture older patients. METHODS: We investigated the associations of MPI with all-cause 3- and 6-month mortality and rehospitalization in 1259 older patients admitted for hip fracture surgical treatment and managed by an orthogeriatric team [age 85 years (65-109); male gender: 22%]. RESULTS: Overall mortality was 11,4%, 17% and 23,5% at 3, 6 and 12 months from surgery (rehospitalizations: 15, 24,5 and 35,7%). MPI was associated (p < 0.001) with 3-, 6- and 12- month mortality and readmissions; Kaplan-Meier estimate for rehospitalization and survival according to MPI risk classes confirmed these results. In multiple regression analyses these associations were independent (p < 0.05) of mortality and rehospitalization-associated factors not included in the MPI, such as gender, age and post-surgical complications. Similar MPI predictive value was observed in patients undergoing endoprosthesis or other surgeries. ROC analysis confirmed that MPI was a predictor (p < 0.001) of both 3- and 6- month mortality and rehospitalization. CONCLUSIONS: In hip fracture older patients, MPI is a strong predictor of 3-, 6- and 12- months mortality and rehospitalization, independently of surgical treatment and post-surgical complications. Therefore, MPI should be considered a valid pre-surgical tool to identify patients with higher clinical risk of adverse outcomes.

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.

Intracellular osteopontin protects from autoimmunity-driven lymphoma development inhibiting TLR9-MYD88-STAT3 signaling.

BACKGROUND: Autoimmune disorders, including Systemic Lupus Erythematosus (SLE), are associated with increased incidence of hematological malignancies. The matricellular protein osteopontin (OPN) has been linked to SLE pathogenesis, as SLE patients show increased serum levels of OPN and often polymorphisms in its gene. Although widely studied for its pro-tumorigenic role in different solid tumours, the role of OPN in autoimmunity-driven lymphomagenesis has not been investigated yet. METHODS: To test the role of OPN in the SLE-associated lymphomagenesis, the SLE-like prone Faslpr/lpr mutation was transferred onto an OPN-deficient background. Spleen from Faslpr/lpr and OPN-/-Faslpr/lpr mice, as well as purified B cells, were analysed by histopathology, flow cytometry, Western Blot, immunohistochemistry, immunofluorescence and gene expression profile to define lymphoma characteristics and investigate the molecular mechanisms behind the observed phenotype. OPN cellular localization in primary splenic B cells and mouse and human DLBCL cell lines was assessed by confocal microscopy. Finally, gain of function experiments, by stable over-expression of the secreted (sOPN) and intracellular OPN (iOPN) in OPN-/-Faslpr/lpr -derived DLBCL cell lines, were performed for further validation experiments. RESULTS: Despite reduced autoimmunity signs, OPN-/-Faslpr/lpr mice developed splenic lymphomas with higher incidence than Faslpr/lpr counterparts. In situ and ex vivo analysis featured such tumours as activated type of diffuse large B cell lymphoma (ABC-DLBCL), expressing BCL2 and c-MYC, but not BCL6, with activated STAT3 signaling. OPN-/-Faslpr/lpr B lymphocytes showed an enhanced TLR9-MYD88 signaling pathway, either at baseline or after stimulation with CpG oligonucleotides, which mimic dsDNA circulating in autoimmune conditions. B cells from Faslpr/lpr mice were found to express the intracellular form of OPN. Accordingly, gene transfer-mediated re-expression of iOPN, but not of its secreted isoform, into ABC-DLBCL cell lines established from OPN-/-Faslpr/lpr mice, prevented CpG-mediated activation of STAT3, suggesting that the intracellular form of OPN may represent a brake to TLR9 signaling pathway activation. CONCLUSION: These data indicate that, in the setting of SLE-like syndrome in which double strand-DNA chronically circulates and activates TLRs, B cell intracellular OPN exerts a protective role in autoimmunity-driven DLBCL development, mainly acting as a brake in the TLR9-MYD88-STAT3 signaling pathway.

Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients.

BACKGROUND: Cut-out is the most common mechanical complication of the osteosynthesis of pertrochanteric fractures. This complication determines a significant increase in morbidity in elderly patient. Cut-out is defined as the varus collapse of the femoral head-neck fragment with the extrusion of the cephalic screw. Surgical treatment of cut-out might lead to further complications, longer rehabilitation, increased social burden and healthcare system costs. The aim of the study is to identify the predictors of cut-out to prevent its occurrence. MATERIALS AND METHODS: Study population included all patients affected by extracapsular fracture of the proximal femur who were admitted and treated with short cephalomedullary nailing at the Cattinara Hospital-ASUITS of Trieste between 2009 and 2014. A retrospective analysis of clinical and radiographic data was carried out and cut-out cases recorded. The data collected on the study population were analyzed to find an eventual correlation with the occurrence of cut-out. The independent variables were age, gender, side of the fracture, ASA class, Evans classification, nailing system, quality of reduction, TAD, CalTAD, and Parker ratio. RESULTS: The study population counted 813 cases, with an F:M ratio of 4:1 and a mean age of 84.7 years. The cut-out was recorded in 18 cases (2.2%). There was no statistically significant association between cut-out and age, sex, side of fracture, ASA class, and nailing system. The Evans classification, the quality of reduction, the TAD, the CalTAD, and the Parker's ratio demonstrated a significant correlation at univariate analysis with cut-out. The results of multivariate analysis confirmed that TAD, Parker AP, and quality of reduction were independently significantly correlated to cut-out. CONCLUSION: The results of the present study demonstrate that good quality of reduction and correct position of the lag screw are likely to decrease the risk of cut-out complication. A nomogram for cut-out prediction is proposed for clinical validation.

Post-traumatic complex regional pain syndrome: clinical features and epidemiology.

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that occurs after a tissue injury (fractures, sprain, surgery) of the upper or lower extremities. A clear pathophysiological mechanism has not been established yet and different patterns are considered to play a role in the genesis of the disease. The diagnosis is made by different diagnosis criteria and a gold standard has not been established yet. Incidence of CRPS is unclear and large prospective studies on the incidence and prevalence of CRPS are scarce. The aim of this review is to give an overview on the prevalent data regarding this chronic syndrome.

Treatment of complex regional pain syndrome.

Complex Regional Pain Syndrome (CRPS) is a multifactorial and disabling disorder with complex etiology and pathogenesis. Goals of therapy in CRPS should be pain relief, functional restoration, and psychological stabilization, but early interventions are needed in order to achieve these objectives. Several drugs have been used to reduce pain and to improve functional status in CRPS, despite the lack of scientific evidence supporting their use in this scenario. They include anti-inflammatory drugs, analgesics, anesthetics, anticonvulsants, antidepressants, oral muscle relaxants, corticosteroids, calcitonin, bisphosphonates, calcium channel blockers and topical agents. NSAIDs showed no value in treating CRPS. Glucocorticoids are the only anti-inflammatory drugs for which there is direct clinical trial evidence in early stage of CRPS. Opioids are a reasonable second or third-line treatment option, but tolerance and long term toxicity are unresolved issues. The use of anticonvulsants and tricyclic antidepressants has not been well investigated for pain management in CRPS. During the last years, bisphosphonates have been the mostly studied pharmacologic agents in CRPS treatment and there are good evidence to support their use in this condition. Recently, the efficacy of intravenous (IV) administration of neridronate has been reported in a randomized controlled trial. Significant improvements in VAS score and other indices of pain and quality of life in patients who received four 100 mg IV doses of neridronate versus placebo were reported. These findings were confirmed in the open-extension phase of the study, when patients formerly enrolled in the placebo group received neridronate at the same dosage, and these results were maintained at 1 year follow-up. The current literature concerning sympathetic blocks and sympathectomy techniques lacks evidence of efficacy. Low evidence was recorded for a free radical scavenger, dimethylsulphoxide (DMSO) cream (50%). The same level of efficacy was noted for vitamin C (500 mg per day for 50 days) in prevention of CRPS in patients affected by wrist fracture. In conclusion, the best available therapeutic approach to CRPS is multimodal and is based on the use of several classes of drugs, associated to early physiotherapy. Neridronate at appropriate doses is associated with clinically relevant and persistent benefits in CRPS patients.

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.

Factors affecting bone strength other than osteoporosis.

Osteoporosis is the most common cause of bone fragility, especially in post-menopausal women. Bone strength may be compromised by several other medical conditions and medications, which must be ruled out in the clinical management of patients affected by fragility fractures. Indeed, 20-30% of women and up to 50% of men affected by bone fragility are diagnosed with other conditions affecting bone strength other than osteoporosis. These conditions include disorders of bone homeostasis, impaired bone remodeling, collagen disorders, and medications qualitatively and quantitatively affecting bone strength. Proper diagnosis allows correct treatment to prevent the occurrence of fragility fractures.

The incidence of fragility fractures in Italy.

Osteoporosis can significantly impact on the risk of developing a fracture. Thus, fragility fractures represent a challenge for health professionals and decision makers of the twenty-first century. The aim of this work is to review the literature concerning osteoporotic fractures in Italy in terms of incidence, rate of hospitalization, relative risk of a new fragility fracture, and costs for the national health system. It was estimated that the costs of treating proximal femur fragility fractures in 2002 summed up to 1 billion Euros. The number of fragility fractures in Italy was calculated as follows: 91.494 hip fractures, 61.009 clinical vertebral fractures, 57.401 humeral fragility fractures, and 94.045 forearm/wrist fragility fractures. The incidence of fragility fractures in Italy is very high, and osteoporosis is the leading cause of morbidity in the Italian population.

Prophylaxis protects infants with congenital heart disease from severe forms of RSV infection: an Italian observational retrospective study : Palivizumab prophylaxis in children with congenital heart disease.

BACKGROUND: In children with congenital heart disease (CHD) respiratory syncytial virus (RSV) infection may have a severe course, with increased risk of morbidity and mortality, requiring hospital admission and intensive care. The aim of the present study was to evaluate the effect of prophylaxis with palivizumab in preventing RSV-associated hospitalization in infants with CHD. METHODS: We carried out an observational, retrospective study in a paediatric cardiology division at a secondary-care centre in Italy, extracting from the database children with CHD who, from November 2004 to March 2022, matched the criteria for palivizumab prophylaxis, to evaluate the hospitalization rate in CHD patients with and without palivizumab prophylaxis and their RSV-related hospitalization characteristics compared with a group of children without CHD and no other underlying clinical conditions (control group, CG), hospitalized for RSV infection. RESULTS: One hundred twenty-eight children with CHD were enrolled in the study, mainly (71.9%) with increased pulmonary flow, and received palivizumab prophylaxis. Twenty-seven received hospital care for bronchiolitis. Almost all CHD patients hospitalized for bronchiolitis (26 out of 27) received partial prophylaxis (≤ 3 doses). CHD patients with bronchiolitis stay longer in the hospital than control (14.4 ± 21.7 days vs 6.2 ± 2.3 days) some of which require intensive care (n = 4). CONCLUSIONS: Our study provides evidence of the efficacy of palivizumab in protecting patients with hemodynamically significant CHD under the age of 2 years from RSV disease and its life-threatening complications. Reducing hospitalisation rate, morbidity, and mortality in this category of patients, passive immune prophylaxis with palivizumab may impact healthcare resource availability and utilisation.

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.

Rewiring innate and adaptive immunity with TLR9 agonist to treat osteosarcoma.

BACKGROUND: Osteosarcoma (OS) is the most common primary bone tumor in children and adolescent. Surgery and multidrug chemotherapy are the standard of treatment achieving 60-70% of event-free survival for localized disease at diagnosis. However, for metastatic disease, the prognosis is dismal. Exploiting immune system activation in the setting of such unfavorable mesenchymal tumors represents a new therapeutic challenge. METHODS: In immune competent OS mouse models bearing two contralateral lesions, we tested the efficacy of intralesional administration of a TLR9 agonist against the treated and not treated contralateral lesion evaluating abscopal effect. Multiparametric flow cytometry was used to evaluate changes of the tumor immune microenviroment. Experiments in immune-deficient mice allowed the investigation of the role of adaptive T cells in TLR9 agonist effects, while T cell receptor sequencing was used to assess the expansion of specific T cell clones. RESULTS: TLR9 agonist strongly impaired the growth of locally-treated tumors and its therapeutic effect also extended to the contralateral, untreated lesion. Multiparametric flow cytometry showed conspicuous changes in the immune landscape of the OS immune microenvironment upon TLR9 engagement, involving a reduction in M2-like macrophages, paralleled by increased infiltration of dendritic cells and activated CD8 T cells in both lesions. Remarkably, CD8 T cells were needed for the induction of the abscopal effect, whereas they were not strictly necessary for halting the growth of the treated lesion. T cell receptor (TCR) sequencing of tumor infiltrating CD8 T cells showed the expansion of specific TCR clones in the treated tumors and, remarkably, their selected representation in the contralateral untreated lesions, providing the first evidence of the rewiring of tumor-associated T cell clonal architectures. CONCLUSIONS: Overall these data indicate that the TLR9 agonist acts as an in situ anti-tumor vaccine, activating an innate immune response sufficient to suppress local tumor growth while inducing a systemic adaptive immunity with selective expansion of CD8 T cell clones, which are needed for the abscopal effect.

Inertial sensors-based assessment to detect hallmarks of chronic ankle instability during single-leg standing: Is the healthy limb "healthy"?

BACKGROUND: Chronic ankle instability can be common in sportsmen and can increase the risk of damaging the articular surfaces and result in negative consequences to joint health. Balance assessment is often used to evaluate ankle instability characteristics and guide rehabilitation protocols. This study aims to investigate balance-related parameters in people with chronic ankle instability and healthy-matched controls, using inertial sensors. METHODS: Ten young adults with a history of multiple ankle sprains (30 y, 25-34, 5 females) and ten matched healthy controls (30 y, 23-39, 5 females) were invited to participate in the study. Inertial sensors were placed on the head of the astragalus and on the chest to collect kinematic parameters during a 20-s single-leg stance performed on the leg with ankle instability (and corresponding for the healthy controls) and on the contralateral leg, randomly. Outcomes were calculated with MATLAB and subsequently analyzed. FINDINGS: A significant group effect was found only for the inversion angle (F1,15 = 12.514, p = 0.003, pη2 = 0.455), consisting of individuals with ankle instability being characterized by higher inversion angles (4.999 degrees, 95% CI: 1.987-8.011, p = 0.003) without significant side differences. No significant side x group effects were found for the assessed parameters. INTERPRETATION: Results from this study suggest that young adults with chronic ankle instability might be characterized by worse single-stance control in terms of inversion angle, and such worse performance could also be found in the contralateral leg. As such, inertial sensors could be used to assess kinematic parameters during balance tasks in people with chronic ankle instability.

Triggering CD40 on endothelial cells contributes to tumor growth.

Inflammatory cells can either promote or inhibit tumor growth. Here we studied whether CD40, a key molecule for adaptive immune response, has any role in mammary carcinogenesis of BALB/NeuT transgenic tumor-prone mice. We transferred the HER2/neu oncogene into CD40-null background to obtain the CD40-KO/NeuT strain. CD40-KO/NeuT mice showed delayed tumor onset and reduced tumor multiplicity. BM (BM) transplantation experiments excluded a role of BM-derived cells in the reduced tumorigenicity associated with CD40 deficiency. Rather, CD40 expressed by endothelial cells (ECs) takes part to the angiogenic process. Accordingly, large vessels, well organized around the tumor lobular structures, characterize BALB/NeuT tumors, whereas tiny numerous vessels with scarce extracellular matrix are dispersed in the parenchyma of poorly organized CD40-KO/NeuT tumors. Activated platelets, which may interact with and activate ECs, are a possible source of CD40L. Their localization within tumor vessels prompted the idea of treating BALB/NeuT and CD40-KO/NeuT mice chronically with the anti-platelet drug clopidogrel, known to inhibit platelet CD40L expression. Treatment of BALB/NeuT mice reduced tumor growth to a level similar to CD40-deficient mice, whereas CD40-KO/NeuT mice treated or not showed the same attenuated tumor outgrowth, indicating that activated platelets are the likely source of CD40L in this model. Collectively, these data point to a participation of CD40/CD40L in the angiogenic processes associated with mammary carcinogenesis of BALB/NeuT mice.

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.

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.

Postoperative Dehydration Is Associated with Frailty and Decreased Survival in Older Patients with Hip Fracture.

BACKGROUND: Hyperosmolar dehydration (HD) is a risk factor for severe complications in hip fracture in older patients. However, evidence for recommending screening of dehydration is insufficient and its relation with frailty and mortality is unclear. We tested the hypothesis that postoperative HD is associated with frailty and increased mortality. METHODS: We recruited 625 older (>65 years) patients surgically treated for hip fracture and co-managed by an orthogeriatric team over one year in 2017. Pre- and postoperative HD (serum osmolarity > 300 mmol/L) was diagnosed. Frailty and associated mortality risk were assessed by the Multidimensional Prognostic Index (MPI). RESULTS: The prevalence of preoperative HD was 20.4%. Compared with no-HD, MPI was similar in HD patients despite higher (p < 0.05) prevalence of polypharmacy, arterial hypertension, diabetes, chronic kidney disease and heart failure. After surgery the incidence of HD decreased to 16.5%, but increased (p = 0.003) in the MPI high-risk subgroup. Postoperative HD was associated with more complications and was an independent determinant of adjusted hospital length of stay (LOS) and of 60- to 365-days mortality. CONCLUSIONS: Older frail patients with hip fracture are prone to developing postoperative HD, which independently predicts prolonged hospital LOS and mortality. Systematically screening older patients for frailty and dehydration is advisable to customize hydration management in high-risk individuals.

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.

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

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