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).

Clinical and radiological outcomes of autologous humeral bone grafting for radial head reconstruction: a minimum 2-year follow-up.

PURPOSE: The aim of this prospective study was to assess the clinical and functional results of radial head reconstruction with an autologous bone graft from distal humerus in 12 patients, with a follow-up for a period of 24 months. METHODS: From March 2017 to June 2018, we surgically treated 12 patients using an autologous bone graft from the lateral distal metaphysis of the homolateral humerus. Patients were divided into two groups: -Group A consisted of patients with previous failed ORIF for radial head fracture. Patients underwent revision surgery at an average time of 7 months (between 6 to 8 months) from the first surgery. All the patients reported pain during the elbow range of motion with no gross clinical signs or instability of the joint. They all presented standard X-ray and CT-scan of the elbow suggestive of non-union fracture. None of them presented osteoarthritic modification at the time of surgery. -Group B consisted of patients reporting acute irreparable radial head fractures. Patients were evaluated clinically at 6-, 12-, and 24-months duration according to Disabilities of the Arm. Shoulder and Hand (DASH), Mayo Elbow Performance Score (MEPS), and Visual analogue score for pain (VAS);, range of motion (ROM) was evaluated at 6 and 24 months after surgery. Plain radiographs on anteroposterior and lateral views of the elbow were evaluated at final follow-up. RESULTS: In both, groups (A and B) patients showed a significant improvement with regards to VAS, MEPS, and DASH at each follow-up (p < 0.05). X-rays showed complete bone healing in all patients with no sign of mobilisation or loosening of the screws. One case in group A presented asymptomatic partial ossification of LUCL. No cases of fracture or residual pain at the donor site. Furthermore, no other complications such as infection, wound issues, elbow instability, elbow stiffness, ulnar neuritis, graft non-union were reported. CONCLUSIONS: Distal humerus bone graft should be considered a reliable option for the treatment of acute fractures that are unrepairable fractures or revision surgery for failed ORIF of the radial head, especially among young patients where prosthesis may be reserved as a salvage procedure, and radial head resection is a damaging and is not considered desirable. LEVEL OF EVIDENCE: Level IV - Prospective Case Series.

Stress fractures in the elderly: different pathogenetic features compared with young patients.

Stress fractures mainly occur in the lower limb as a result of cyclic submaximal stresses. Most commonly affected by this specific type of fractures are young athletes, military or elderly subjects with metabolic bone diseases like osteoporosis. In consideration of the heterogeneity of affected patients is presumable that there are different pathogenic mechanisms. In young person bone tissue, although metabolically intact, is not able to withstand the stresses to which it is chronically subjected, also because of muscle fatigue. This leads to a macrostructural failure and to the development of "fatigue" fractures. Instead, in elderly patients, there are numerous physiological conditions that determine a bone metabolism alteration. This is the main reason for the structural changes in trabecular and cortical bone, which is reflected in reduced biomechanical strength. In addition, muscular situation, such as muscle fiber atrophy, is unable to correctly support bone tissue, leading to the development of insufficiency fractures.

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.