Lo Scalpello - Journal

Intra-articular fractures of the distal radius in high demand elderly patients: techniques and timing of treatment

Giancarlo Caruso — 2024-09-27

Fractures of the distal radius are frequent in the people older than 65 years, especially in women. Contrary to past assumptions of low activity levels among the elderly, there is a growing segment of this population that demand higher functional capabilities. This shift in demographics has led to a re-evaluation and evolution of treatment strategies. The aim of our study is to perform a review of the literature to better identify and define the optimal treatment for intra-articular distal radius fracture in active people 65 years old or more. The selection of papers included in the review was conducted on PubMed and Google Scholar databases: 10 studies were included. Current evidence demonstrates that surgical treatment provides measurable benefits in quicker return to daily activities and fewer complications for high demand patients older than 65 years than conservative treatment. However, this does not always correspond to clinical results and satisfaction of the patient. According to the literature, the treatment plan should be personalized for every patient taking into account the features of the fracture, functional requests, daily activities and possible comorbidities.

Morbidity and mortality following surgical treatment in periprosthetic femoral fractures. Is time to surgery the key?

Raffaella Alonzo — 2024-09-27

Objective. Total hip replacement is one of the most successful surgeries in recent years. The increase in total hip replacement procedures for the extension of indications, from primary/ secondary arthrosis to medial femoral neck fractures, is associated with an increase in the average age of the population leading to an inevitable increase in complications, such as periprosthetic proximal femoral fractures (PPFF), even if rare. However, the importance of this complication lies in the high mortality, poor outcomes, and often incomplete recovery. The objective of our study is to investigate whether time to surgery was a prognostic element in the treatment of these fractures, considering that these patients are often fragile and will require timely treatment like patients who fall within the native hip fracture protocol.
Methods. 112 patients suffering from PPFF, classified with x ray according to Vancouver Classification were selected from 2007 to 2022 in two different hospitals in Rome. The minimum follow-up was 1 year and mortality, post-operative complications, and outcome were assessed in relation to time to surgery.
Results. There was a significant correlation between mortality and time to surgery and each hour of delay to surgery the risk of mortality increased by 2%. Moreover, a statistical significance was found between the inability to restore walking ability in the early postoperative period and one year mortality.
Conclusions. Patients with PPFF should be surgically treated with the same timing of patients with femoral neck fracture, in order to improve clinical outcomes, reduce post operative complications, restore walking ability, and reduce mortality.

Simultaneous bilateral vision loss after total hip arthroplasty: what an orthopedic surgeon has to worry about

Marco Focaccia — 2024-09-27

Introduction. Perioperative visual loss (POVL) is a rare and unpredictable complication of non-ocular surgical procedures.
Case report. Here we report a case of visual loss after a routine orthopedic procedure. After a surgical procedure of total hip arthroplasty, sudden visual loss was referred by the patient and anterior ischemic neuropathy was diagnosed. Despite treatment, the patient has not regained his sight after more than a year.
Discussion. Multiple studies have tried to identify pre-existing conditions or intra-operative factors that may contribute to ischemic optic neuropathy. Age, sex, intraoperative anemia, and acute blood loss seems to predispose patients to POVL, even if no cut-off values have been defined. Preoperative anemia and peripheral vascular disease may be risk factors for this condition. Prone position and prolonged operative time are intraoperative risk factors. However, the development of POVL remains unpredictable and a multi-factorial etiology seems to be the most plausible explanation.
Conclusions. POVL is a rare and unpredictable complication that can occur in patients of all ages, even in routine uncomplicated orthopedic procedures. Pathogenesis and etiology are still to be defined and no preventive or treatment guidelines had been established.

CHEF-K, a hybrid technique for early recovery in complex tibial plateau fractures: a case report

Alessandro Isola — 2024-09-27

The treatment of complex tibial plateau fractures is a challenge for even experienced orthopedic surgeons. While it is established that type and timing of surgical treatment depends on the involvement of soft tissues, there is no agreement in the literature about post-surgical weight-bearing on the operated limb: it ranges from a total ban to a partial concession of 6 to 12 weeks. Weight-bearing modulation can be difficult in physically challenged or frail patients such as the elderly, with a real risk of hypokinesis, bedridden and related complications. To allow the early treatment of these fractures and immediate weight-bearing, we connected a circular external fixator (CEF) to a hinged knee external fixator (HEF) with specific axial load resistance characteristics. This hybrid technique, which we have called CHEF-K (Circular and Hinged External Knee Fixation), maintains and combines the mechanical characteristics of both devices. In selected cases we early stabilized the fracture in a minimally-invasive way associated with CEF, then protecting the osteosynthesis with HEF which bypassed the fracture during loading while also allowing movement of the knee. In the first case described herein, a 78-year-old woman showed rapid functional recovery, being able to walk without aids after 4 weeks.

InFix – a technique for anterior subcutaneous pelvic internal fixation in the management of pelvic ring injury

Rahul Vaidya — 2024-09-27

The anterior subcutaneous pelvic internal fixation or ASIPF tecnique, more commonly known as INFIX, has been described and utilized since 2008 as an innovation in the traditional management of pelvic injuries 1. The purpose of this article is to identify indications, describe the technique, equipment, review clinical and radiographic outcomes, complications and technical tips on the utilization of pelvic INFIX. The main indication is represented by anterior stabilization of unstable pelvic ring injuries, following the appropriate posterior fixation, particularly in large, obese patients. Pooled analysis showed overall good radiological (mean percentage of excellent to good reduction = 91.4%, 95% CI 0.860-0.969) and functional outcomes (mean Majeed score = 86.48, 95% CI 83.34-89.61) with InFix 2,3. The INFIX and the appropriate posterior fixation results in healing of pelvic ring injuries in 99.5% of cases 4. This technique can be considered as a viable alternative to anterior symphysis pubis plating or to applications of anterior pelvic external fixators. It has the advantage of less blood loss, better nursing for the patients, rapid recovery along with comparable functional outcomes, when compared to plating and an overall better tolerability by the patients when considering application of classic pelvic external fixators.The most common complications is lateral femoral cutaneous nerve (LFCN) injury (overall rate 28%, 95% CI 15.1-41% usually resolves at removal) and heterotopic ossification (HO) (overall rate 9.4%, 95% CI 5.5-13.3%), infection 1-3% 4,5.

Percutaneous screw insertion using a navigation system for acetabular fractures: case report

Antonella Benedetto — 2024-09-27

Percutaneous screw fixation is a surgical procedure that is increasingly used in pelvic and acetabular fractures which reduces the complications that often happen during open reduction and internal fixation. Despite this, it requires experience, surgical accuracy, a long operation time, and substantial radiation exposure to patient and doctors. The purpose of this case report is to analyze a new fluoroscopic computer-assisted navigation system applied to acetabular fractures that can significantly reduce radiation exposure and shorten the operative time.

Does the current Italian healthcare system deal with the perspective of young surgeons? An assessment of the quality of professional life among orthopedists within the first 10 years of their careers

Francesco Addevico — 2024-09-27

Objective. To assess the professional experiences and quality of life of young orthopedic surgeons within the Italian National Health Service (SSN) during their first 10 years of practice.
Methods. A survey was distributed to young orthopedic surgeons in Italy, collecting data on demographics, professional experience, working conditions, job satisfaction, and economic satisfaction. Responses were analyzed using basic statistical measures to identify key trends.
Results. The survey received 550 responses, with 76.9% males and a mean age of 36.8 years. Significant dissatisfaction was noted, with only 24% satisfied with compensation and 68.3% feeling it inadequate. Additionally, 44.7% reported a shortage of more than two units in their departments, and about 70% worked more than 36 hours per week. High levels of frustration (3.4/5) and fatigue (4.3/5) were reported. Only 27.3% positively rated professional development opportunities. To attain more favorable work conditions, 57.3% of respondents indicated they would prefer changing jobs within the next two years.
Conclusions. Young orthopedic surgeons in Italy face challenging working scenarios, inadequate staffing, and economic dissatisfaction, leading to significant attrition risk from the SSN. Systemic reforms are needed to improve retention and job satisfaction.

Homologous osteochondral graft transplantation for spontaneous bilateral osteonecrosis of the femoral condyle in a young patient: case report and narrative review

Leonardo Puddu — 2024-09-27

Spontaneous osteonecrosis of the knee (SONK) is a rare degenerative disease, the causes of which remain largely unknown. SONK develops gradually, leading to progressive pain with functional impairment, and is often misdiagnosed due to the complexity of the clinical examination, which is hampered by pain and swelling. Early diagnosis and treatment are essential to prevent joint damage and ensure good functional outcomes. We review the current literature on SONK and present a case of bilateral SONK in a 31-year-old woman who was treated with a homologous osteochondral implant. The patient of this case report had high functional demands and no comorbidities. A two-stage procedure was performed including diagnostic arthroscopy, removal of subchondral sclerosis, and allograft insertion using the compression-fit technique. At 36-month follow-up, the patient reported significant functional improvement and a reduction in pain, demonstrating the effectiveness of this therapeutic approach.