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In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

Introduction Femoral neck fractures (FNF) are frequent injuries and not rarely complicated by non-union, implant failure, and avascular necrosis. Some of these fractures represent a dilemma for trauma surgeons. Which fracture should be fixed? Which replaced with a prosthesis? How? The aim of this narrative review is to investigate the literature in order to provide the most updated and evidence-based knowledge about FNF’ treatment. Materials and methods A literature research has been performed to find the essential key points to consider when dealing with FNF and their treatment. The most representative papers and the new meta-analysis were matched with authors’ experience to give a concise but comprehensive view of the problem. Timing, age, comorbidities, vascularization of the femoral head, displacement, instability, comminution of the fracture, bone quality, and surgeon experience seem to be the major topics to consider in the decision making. We then focus on the optimal fixation or replacement as suggested by the literature. Results Age is the main independent factor to consider. Timing seems essential in the elderly population to reduce mortality and important in the younger patients to reduce complications. Vascular supply should be always considered. Displacement, instability, and comminution of the fracture are negative prognostic factors for fixation as well as, theoretically, bone quality. In the elderly hip replacement is mostly indicated. A stable and solid fixation is mandatory to allow early mobilization. Sliding Hip Screws (SHS) seem preferable to cannulated screws for displaced/unstable (Pauwels II-III, posterior comminution) and basicervical fracture patterns or in smokers. There is a tendency toward Total Hip Arthroplasty (THA) also in the elderly if the patient is an indipendent ambulator without severe comorbidities. Dual mobility cups are gaining popularity in THA for FNF. Conclusions FNF are frequent injuries and represent, in some cases, a dilemma for the trauma surgeon. Age, timing, comorbidities, bone quality, femoral head vascularization, fracture displacement, intrinsic instability, and comminution as surgeon experience should be carefully evaluated before surgery. A case-to-case analysis of the patient-related factors helps the surgeon to make the right choice and reduce the well-known complications.

Rural tourism (RT) has grown in many rural regions worldwide and today it is a stable driver of rural social and economic development. In this paper we argue that RT growth should follow a divergent path from sea tourism development, because failing to do so would likely push RT toward mass tourism, resulting in a harmful twofold effect: (i) given that mass tourism requires built-up expansion to accommodate larger number of tourists, in rural areas this will certainly compromise the beauty of the landscape, which is a fundamental local resource for RT; (ii) built-up growth required to satisfy seaside mass tourism expectations is often characterized as holiday resorts, artificial villages, and residential high-density condos, with a consequent loss of cultural-traditional identity, which is also a key element for rural landscapes’ attractiveness. In order to monitor the impact of RT on built-up growth we propose to investigate land development and soil consumption over time in the countryside using a GIS (Geographical Information System) approach. The analytical model will be applied to the case study of Tuscany considering circa the past quarter of century. Furthermore, we also aim at discussing the role of available planning instruments in regulating settlements and infrastructures development.

An infected non-union is a major and potentially devastating complication following bone fractures. It is often debilitating for the patients, physically and psychologically, because of its long healing period and emotional toll on patient and caregivers. Different surgical procedures (in one or two stages) are described in literature for its treatment. These range from external fixation (axial or circular) to internal fixation (nails or plates) associated or not with different types of biological support/augmentation (iliac crest bone graft, platelet rich plasma, bone morphogenic protein, etc.). This case report is about a 19 y.o. man affected by an infected non-union of the femoral shaft, who had to undergo a revision surgery a year after his accident. The treatment chosen by the senior author was the following one stage procedure: external fixator removal, surgical debridement, reduction and fixation of the fracture with a locked plate (internal fixator), bone graft and antibiotic cement usage. The use of new iliac crest bone graft after three months was necessary to obtain radiographic and clinical healing with great patient's satisfaction. The autologous iliac bone graft was chosen because it was necessary to give the patient the highest chance of healing. Despite the great experimental and clinical efforts to stimulate the biological healing process through the use of growth factors, stem cells, tissue scaffolds and other methods, today the gold standard of bone graft is still the autologous cancellous bone from the iliac crest.

Introduction Periprosthetic fractures are increasing. The treatment is mostly surgical, but it has a high complication rate. Re-fracture and non-union with implant failure are the more frequent complications. Those complications are difficult to treat and can lead to severe disability. The purpose of this study is to determine the clinical results of periprosthetic femoral re-fracture treatment. Materials and methods Twenty patients were treated for femoral re-fractures (17 women, 3 men). The mean age and follow-up are 75.7 years (46–95) and 6.15 years (0.4–15) respectively. The diagnosis of new periprosthetic fracture according to Vancouver classification were: 3 type A, 5 type B1, 1 type B2, 2 B3, 8 type C; 1 Lewis-Rorabeck type II. Patients were followed-up clinically, with a Harris Hip Score, and radiologically at 2, 4, 6, 12 months, and then annually. Results All patients healed except for two cases in which an infection occurred. Two cases, treated with plate osteosynthesis, had a malunion in varus. Six patients died for unrelated reasons after fracture healing. One patient was excluded because of a follow-up shorter than 12 months. In 16 cases (84%) a Trendelenburg gait or the use of aids for walking has been necessary. At final follow-up the mean HHS was 65 (range 45–82). Fractures treatment differed depending on the type of the fracture, prosthesis stability and bone loss. Tension band wiring, long plate fixation, revision with a long stem with cables or a sandwich technique (two plates or one plate plus one strut graft) have been performed according to fracture type. Conclusions Re-fractures and non-union with implant failure are common after periprosthetic fracture treatment. Infection and malunion are the main complications of their treatment. Residual limping with the necessity of aids even after fracture healing is often present. The choice of a correct surgical strategy is essential to minimize the risk of new complications and ensure the highest possibility to heal. The most important factor is to achieve a good stability, a reasonable vital environment and don’t leave new areas of lower resistance uncovered. Poor functional outcome has to be expected especially in refracture after a revision surgery.

In recent years, an increasing number of studies have stressed the relevance of the consumer experience in the research about new trajectories towards sustainability. These studies suggest that consumers should not be viewed solely as passive agents who select between different commercial options. This paper argues for a broader application of Technological Innovation System (TIS) conceptual framework and proposes an analytical approach that explicitly considers consumers and producers as interacting and then co-evolving actors. We apply the TIS framework to the food industry, a low-medium technology sector where several “alternative” food networks (AFN) are emerging and acting as innovative systems in the transition towards sustainability. The analysis allows us to better understand the common structure and the functional patterns shared by the various models of AFNs. The paper points out how the interactive relation between consumers and producers may foster the transition into a more sustainable socio-technical regime.

Rural tourism (RT) has moved into a more complex phase and today it is possible to point out different stages of development within European regions. In order to encompass the evolutionary processes of tourism development within rural areas, an evolutionary approach is proposed. If the attention moves from a static analysis of RT within a region, to the transition from a basic rural economy to a new economic specialisation, then the evolutionary economic geography (EEG) may be a useful framework. The EEG explains economical transitions as a shift from a historically predominant configuration to a new one, by the interplay of processes at three different levels: micro (local), meso (regional) and macro (European). The aim of this paper is to adapt the EEG approach to the study of RT. In this paper, the framework is applied to the case study of RT in Tuscany. We argue that in Tuscany the rural transition towards a tourism development was fostered by the weakness of the established rural configuration and its heritage of a large availability of empty buildings, which has been a primary input for tourism development. New trends at the macro-level fostered the transition towards RT, in particular the European funding for multifunctionality within agriculture and urban people seeking for natural life-style.

We present the case report of a 40-year-old woman who was HIV-positive in Highly Active Anti-Retroviral Therapy (HAART) and affected by femural pertrochanteric fracture, which was treated by endomedullary nailing. Two years after the surgical operation, the woman developed an aseptic symptomatic osteolysis around the implant. Hardware removal was resolutive. Aseptic and septic hardware mobilization, hardware removal, and implant decision in HIV patients with pertrochanteric fractures is discussed. The authors suggest close follow-up and prompt hardware removal, as soon as X-rays demonstrate healing signs, in HIV patients with fracture fixation, if general condition allows.

Patients with ASR implants (resurfacing and large-diameter (XL) metal-on-metal (MoM) total hip arthroplasty), even if asymptomatic and with a stable prosthesis, may present extremely high blood metal ion levels. We report on a consecutive series of fourteen ASR revisions, focusing on osteolysis and their radiographic correspondence and their correlation with blood metal ion levels. At revision, seven hips revealed severe periacetabular osteolysis which was radiographically undetectable in six and asymptomatic in five. Seven hips with no acetabular osteolysis had significantly lower serum Cr and Co ion concentrations (respectively 25.2, 41.1 μg/l) compared to the seven hips with severe acetabular bone loss (respectively 70.1, 147.0 μg/l). Elevated blood metal ion levels should be considered as a warning of undetectable and ongoing periprosthetic osteolysis in asymptomatic patients with ASR prosthesis.

Purpose The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature. Methods The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. Results Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives. Conclusions The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation. Level of Evidence Level IV, systematic review of Level II through IV studies.