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Background and Objectives: To assess the effect of continuous cold flow (CCF) therapy on pain reduction, opioid consumption, fast recovery, less perioperative bleeding and patient satisfaction in patients undergoing a total knee arthroplasty. Materials and Methods: Patients affected by knee osteoarthritis between September 2020 and February 2022 were enrolled in this case-control study. Patients were randomly divided into two groups (n = 50, each): the study group received postoperative CCF therapy while the control group was treated by cold pack (gel ice). The CCF device is a computer-assisted therapy with continuous cold fluid, allowing a selective distribution, constant and uniform, of cold or hot on the areas to be treated. In both groups, pre- and postoperative evaluations at 6, 24, 72 h and at the fifth day were conducted using Visual Analogic Scale (VAS), opioid consumption, passive range of motion, preoperative hematocrit, total blood loss by Gross formula, transfusion requirement and patient satisfaction questionnaire. Results: One hundred patients, 52 women (52%), were included in the study. Reduction of pain, opioid consumption and increase in passive range of movement were statistically significantly demonstrated in the study group on the first and third days. Patients were satisfied with adequate postoperative pain management due to CCF therapy (p = 0.01) and they would recommend this treatment to others (p = 0.01). Conclusions: A continuous cold flow device in the acute postoperative setting after total knee arthroplasty is associated with pain reduction and improving early movement. Patients were almost satisfied with the procedure. The management of perioperative pain control could improve participation in the early rehabilitation program as demonstrated by the increase in ROM, psychological satisfaction and reduction in opioid use.

Impaired autophagy, responsible for increased inflammation, constitutes a risk factor for the more severe COVID-19 outcomes. Spermidine (SPD) is a known autophagy modulator and supplementation for COVID-19 risk groups (including the elderly) is recommended. However, information on the modulatory effects of eugenol (EUG) is scarce. Therefore, the effects of SPD and EUG, both singularly and in combination, on autophagy were investigated using different cell lines (HBEpiC, SHSY5Y, HUVEC, Caco-2, L929 and U937). SPD (0.3 mM), EUG (0.2 mM) and 0.3 mM SPD + 0.2 mM EUG, significantly increased autophagy using the hallmark measure of LC3-II protein accumulation in the cell lines without cytotoxic effects. Using Caco-2 cells as a model, several crucial autophagy proteins were upregulated at all stages of autophagic flux in response to the treatments. This effect was verified by the activation/differentiation and migration of U937 monocytes in a three-dimensional reconstituted intestinal model (Caco-2, L929 and U937 cells). Comparable benefits of SPD, EUG and SPD + EUG in inducing autophagy were shown by the protection of Caco-2 and L929 cells against lipopolysaccharide-induced inflammation. SPD + EUG is an innovative dual therapy capable of stimulating autophagy and reducing inflammation in vitro and could show promise for COVID-19 risk groups.

Aim To investigate the role of cordonal blood platelet-rich plasma (PRP) intra-articular injections for treating the patients with knee osteoarthritis in terms of procedure safety and clinical outcomes. Methods Twenty-five patients affected by knee osteoarthritis were enrolled and received one single intra-articular knee injection of umbilical cord PRP in a volume of 10 mL. A follow-up was investigated at time 0, 4, 8, 12 weeks and 6 months, evaluating clinical parameters and functional performances. Results No serious adverse events were identified. The paired ttest analysis showed a significant difference between baseline and each follow-up times for all clinical scales (p0.05), with a significant improvement of clinical outcomes. Conclusion Allogeneic PRP can generate reliable therapeutic effect. The high content of tissue regenerative factors in cord blood platelets makes cordonal blood one of the ideal sources of PRP.

Nonunion of the humeral shaft occurs in 2%–10% of nonsurgically treated fractures and in up to 15% of fractures treated by primary open reduction and internal fixation. Gunshot humerus shaft fractures are a frequent type of injury; the degree of comminution and bone loss, as well as soft tissue disruption may influence the healing process, causing major sequelae with loss of function. Here we describe a 30 years old midshaft nonunion of the humerus, that occurred in a young woman after a gunshot. She was initially treated with hanging cast with definitive nonunion and secondary loss of limb function. After 30 years, careful management of the non union fracture ends, locked intramedullary nailing and bone grafting harvested from the femoral canal using the Reamer Irrigator Aspirator (RIA) system led to union with recovery of limb function.

We investigated functional and radiological outcome in 57 cases of midshaft clavicle nonunion treated with open reduction and internal fixation with plate and screws over a 13 year-period. Intercalary bone graft was used in 42 patients; opposite autologous strut graft was used in 31 cases to provide mechanical support to the host bone. Patients were analysed using chart and radiological review and assessed with DASH questionnaire obtained at the latest follow-up. 37 patients were male while 20 were females, with a mean age of 35 years (63–17). All cases were of nonunion, 35 atrophic and 22 hypertrophic. The dominant side was injured in 32 cases and the non dominant in 25 cases. Primarily, 43 cases were treated conservatively with a figure of eight bandage. Time between fracture and our operative treatment was on average 44 months (13–72 months). Only those patients who were symptomatic were included in this study. We used straight reconstruction LCP and low profile precontoured plates. By reviewing patients charts all the cases but one of nonunion progressed to osseous healing at a mean time of 14 weeks (range 12–16). The patient with non-union refused further surgery. 49 patients were available for a final follow up. DASH score was 16.7 at an average of 42 months. Open surgery and internal fixation, using plate and screws in a compression construct is the treatment of choice for symptomatic clavicular non-unions. Intercalary autologous or allograft bone graft should be used especially in patient with significant bone loss; autologous cortical strut graft provides optimum mechanical stability, thus assuring optimal screw purchase and allowing immediate limb movement.

Objectives To determine the efficacy of hybrid external fixation in the treatment of tibial pilon fractures. Design Retrospective, multicentre study. Patients/Participants Adult patients with tibial pilon fractures treated with hybrid external fixation. Intervention Fracture reduction with ligamentotaxis and fixation with XCaliber hybrid external fixator. Main outcome measurements Fracture union, complications, functional outcome (Mazur Ankle Score). Results Union was obtained in 159 fractures at an average of 125 days; there were three delayed unions and three non-unions. The most frequent complication was superficial pin‐track infections (48), all of which responded to local wound care and antibiotics. There were no deep infections and no DVT. Only one fracture had loss of reduction that required frame revision. The overall functional scores were 91 (excellent) for AO/OTA type A fractures, 89 (good) for type B fractures, and 75 (satisfactory) for type C fractures. Conclusions Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution. The minimally‐invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications. Level of evidence Level IV Case series.

We investigated whether a proximal femoral nail can be implanted without a distal locking screw in AO/OTA 31-A1 and 31-A2 pertrochanteric stable femur fractures. A multicentre, randomised study was conducted in six level-two trauma centres in our area (Puglia, Italy). A total of 333 patients received their allocated intervention (162 in the locking group [LG] and 171 in the unlocking group [UG]) and 266 patients were included in the final analysis at 1year. Our data showed no statistically significant difference between the two groups at 1-year follow-up for ability to walk, SF-36 questionnaire results, residual pain (visual analogue scale [VAS] score) and level of overall satisfaction. There were also no statistically significant differences between groups for mortality and length of hospital stay. Conversely, the UG was associated with shorter operation and fluoroscopy times, shorter surgical incision length, and less blood loss and residual thigh pain. Pertrochanteric stable fractures (31-A1, 31-A2) can be treated successfully with intramedullary nails without distal locking, reducing patient and clinical personnel radiation exposure and sanitary costs (surgery time and screws costs).

Femoral shaft fractures with third fragments have a high non-union rate, which may reach 14%. This study aims to assess the impact of the radiological features of the third fragment, evaluated on post-operative X-rays, on the outcome of femoral shaft fractures type 32-B managed with intramedullary nailing, in order to obtain an algorithm which could predict the fracture healing time. We have retrospectively evaluated a series of 52 patients. On post-operative X-rays, four radiological parameters were evaluated: the third fragment angle, the fracture gap, the third fragment size, and the mean third fragment displacement. All the patients underwent a radiologic follow-up at one, two, three, six, nine and 12 months post-operatively, to assess the bone healing. The patients were then divided into three groups, according to the fracture healing time: within six months (group A), between six and 12 months (group B), or fracture non-union after 12 months (group C). In 28 patients, out of 52 (53.85%), the fracture healing was observed at 6-month follow-up; in 18 patients, out of 52 (34.62%), the fracture healed within 12 months after trauma; and in six patients, out of 52 (11.54%), no fracture healing was observed at 12-month follow-up. The mean third fragment size was significantly different in each group (p

Few clinical studies have analyzed the utility of distal interlocking screws in stable and unstable intertrochanteric fractures treated with intramedullary devices. We performed a prospective analysis comparing short unlocked versus short dynamic and short static distal locked intramedullary nails.Nine level-II trauma centres were involved in the study. 240 patients over the age of 65 with a stable (AO/OTA 31-A1) or unstable intertrochanteric fracture (AO/OTA 31-A2) were prospectively investigated. The same type of nail was used in every patient. Patients were randomly divided into 3 groups according to the type of distal locking used. Intra-operative variables were examined and patients were followed clinically and radiographically at 1, 3, 6, 12 months postoperatively. All complications were recorded.A total of 212 patients completed 1 year of follow-up visits. In the Unlocking Group (UG) the operation time, blood loss, fluoroscopy time, total length of incision were significantly decreased compared to both the Dynamic Group (DG) and the Static Group (SG) (p 0.05). Conversely, no reliable differences in intraoperative variables were noted between the Dynamic Group and the Static Group (p 0.05). In terms of time of fracture union we found no differences among the three Groups (p 0.05). Moreover, no cases of limb shortening1 cm or varus collapse were detected in any group. The 3 Groups were similar in terms of HHS, SF-12 and Barthel index results at 1-year follow-up (p 0.05). Finally, no significant differences were demonstrated across the three Groups in terms of major complications.This clinical study further confirms the hypothesis that short intramedullary nails do not need to be locked for stable and unstable intertrochanteric fractures.

A 25-year-old man was admitted to our Department with an open humeral shaft fracture (Gustilo III C); two large wounds were noticed with ulnar artery and median nerve completely dissected. Initial primary treatment included irrigation, debridement and fracture stabilization with a monolateral external fixator followed by vascular and nerve repair and wound closure. At 6 months follow up the patient was able to use his arm without any painful stimuli and a CT scan showed the presence of postero-medial callus formation. Consequently, the external fixator was removed and the patient was discharged to physiotherapy. After 7 months, the patient presented with severe pain and functional impairment with no history of trauma. X rays showed recent re-fracture on a background of oligotrophic nonunion. Revision surgery included debridement of the non-union bone edges, reaming of the medullary canal and insertion of a humeral nail. Six months later osseous healing was noted with complete restoration of shoulder and elbow movement and partial recovery of the median nerve.

To evaluate the clinical outcomes of radial head excision for multifragmentary radial head fracture in patients over 65 years old. We retrospectively examined 30 patients over 65 years of age treated with radial head excision for comminuted radial head fractures. Patients were evaluated through clinical examinations, administrative questionnaires (DASH—Disabilities of the Arm, Shoulder and Hand; MEPS—Mayo Elbow Performance Score, VAS—Visual Analog Scale) and plain films. The mean follow-up was 40 months (range 24–72 months); 27 out of 30 patients claimed to be satisfied. The mean DASH score was 13 (range 3–45.8) and mean MEPS was 79 (range 65–97). The radiographic evaluation showed 21 cases of elbow arthritis; only two of them complained about pain. Heterotopic ossification was evident in six cases with functional impairment in only one patient. Six patients with increased ulnar variance had clinical distal radio-ulnar joint instability. Radial head excision has been considered a safe surgical procedure with satisfactory clinical outcomes. Development in biomechanical studies and prosthetic replacement of the radial head question the validity of radial head excision. In current literature, there are neither long-term follow-up studies on radial head prosthesis outcomes nor studies which consider elderly patient samples. Radial head resection remains a good option when a radial head fracture occurs in elderly patients, taking into account the influence of poor bone quality and comorbidities on the outcome. Radial head excision is not indicated in the presence of associated lesions, because of the risk of residual elbow instability; complications associated with advanced age must be considered and a strict follow-up granted.

Two-thirds of hindfoot fractures involve the calcaneus. The best treatment for intraarticular fractures is still debated. The goal of treatment has been focussed for years on the anatomical reduction of the articular surface. Open reduction and internal fixation enables the surgeon to view the articular surface directly, but it is associated with a high rate of wound breakdown and infection. Therefore, length, width and angular replacement of the great tuberosity are actually the main parameters to consider when treating this type of fracture. This is a report of our experience of 20 patients treated with a minimally invasive technique of reduction using an inflatable bone tamp filled with tricalcium phosphate, with a mean follow-up of 12.25 months (range 7-26 months). Percutaneous K-wires were used to help reduction and to direct balloon inflation. Surgical goals were restoration of the mechanical stability for earlier full weight-bearing and patient mobilisation.

Introduction Treatment of displaced heel fractures is controversial; however, ORIF is widely described in the literature to be the gold-standard. Percutaneous reduction and monolateral external fixation is gaining increasing attention because it provides a good and stable reduction, and minimises soft tissue complications due to open surgery, such as deep infections and delays in wound healing. The aim of this study was to show that the new Orthofix Calcaneal Minifixator (six pins) provides a greater stability than the four-pin version to enable a better and more stable reduction, an earlier weight-bearing (30 days) and improved functional outcomes. Methods A series of 69 consecutive closed heel intraarticular displaced fractures treated with the new Orthofix Calcaneal Minifixator were evaluated. Patients were assessed clinically with the Maryland Foot Score and radiologically with standard radiographs. Results The clinical results at follow-up were excellent in 37 cases (53.6%), good in 27 (39.2%), fair in two (2.9%) and poor in three (4.3%). The mean preoperative Bohler's angle was 5.2˚ (range 0–18˚) and the mean postoperative value was 28.5˚ (range 16–38˚). Conclusion The excellent functional outcomes were despite some radiological images of imperfect posterior facet anatomical reduction and seemed to correlate with the use of a good and stable minimally-invasive surgical technique. This technique enabled early weight-bearing, minimised complications, respected the delicate biology of this anatomical site and restored the good heel volume and Bohler angle.

Patellar tendon rerupture is a relatively uncommon condition that severely compromises the function of the extensor mechanism of the knee. Few cases described in the literature does not show a unique mode of treatment for this type of lesion. We report the case of a young athlete with traumatic patellar tendon rerupture. The first rupture was treated with the use of Statak anchors. Following a second rerupture incident as a result of a sporting accodent, the tendon was reconstructed with the use of an autologous graft tendon of semitendinosus and biological augmentation with gracilis tendon. For both tendons the distal insertion part was preserved to facilitate the healing process. The treatment was completed with the application of a neutralization cerclage wire and with local injection of plateket reach plasma (PRP). At 12 months follow up, a full recovery of the structure and function of the extensor mechanism was observed and the patient was able to resume normal sports competitive activity.

Purpose To compare clinical outcomes of ORIF with volar locking plates and the Epibloc system (ES) in the treatment of distal radius fractures (DRFs) in patients aged over 65 years. Methods We retrospectively examined a consecutive series of 100 patients with intra-articular or extra-articular DRF who were admitted to our Department of Orthopaedics and Traumatology between January 2007 and January 2013. Fifty patients were treated using the Epibloc System; and the other 50 patients using ORIF with volar locking plates. In all patients, functional evaluation (wrist range of motion [ROM], grip strength and Disability of the Arm, Shoulder and Hand [DASH] Score) and radiographic assessment (radial inclination, volar tilt, ulnar variance and articular congruity) were performed at 2 and 6 weeks, and 3, 6 and 12 months postoperatively; then every 12 months thereafter. Results ORIF with volar locking plates was associated with better outcome than ES in the intra-articular and extra-articular DRF groups, generating higher average ROM, DASH and visual analogue scale (VAS) scores. Grip strength mean values, however, were quantified over the minimum level for a functional wrist (>60%) in both groups. There were no differences between the two techniques in X-ray parameters, and no further correlation was found with functional outcome and ROM. Conclusions In a low-functioning patient with multiple medical comorbidities, minimally-invasive surgery with the ES is a safe option, enables early mobilisation of the wrist and is likely to produce acceptable clinical outcomes.

The treatment for humeral diaphyseal fractures is still controversial. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating humeral distal third diaphyseal fractures by using external fixation technique. We retrospectively review 65 cases of diaphyseal humeral fractures (31 type A, 23 type B and 11 type C of the AO/OTA classification) treated with external fixation (Orthofix FAD small) between 2008 and 2013. The mean follow-up was 48 months (24–72 months). There were 12 open fractures; however, no cases of concomitant vascular injury were described. The transolecranic traction was always applied to promote partial reduction through ligamentotaxis. In case of interposition of soft tissues impeding reduction, a small incision was performed allowing mobilization of bone ends. All fractures resulted healed at a mean of 11 weeks (range 9–13 weeks); the average time of removal of the external fixator was 88 days (range 65–95 days). At the last follow-up, the mean elbow flexion was 132.6° (Min 126°–Max 137°) and the mean elbow extension was 6.4° (Max 0°–Min 13°). The Cassebaum’s index rated as excellent in 47.8 % (31 patients), good in 37 % (24 patients), fair in 9.2 % (6 patients) and poor in 6 % (4 patients). The mean DASH score at the final follow-up was 14.7 (range 0–33); 15 patients had a range score between 10 and 20, 43 had less than 10, and seven had more than 20. We observed three cases of superficial infections and two cases of acute radial nerve palsy recovered within 3 months. According to the excellent clinical results and full rate of consolidation, we state external fixation as a valid option in the treatment of distal third humeral diaphyseal fractures.

The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus. Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p0.05. The mean healing time was 17.6 ± 2.8 weeks in the group treated with standard screws and 13.5 ± 1.8 weeks in the group treated with DLS (t=5.5, p0.0001). The DLS was associated with early healing and triplanar bone callus.

The success of prosthetic surgery has led to an increase in the percentage of the population having more than one prosthetic implant. This, combined with an increase in the average life expectancy and functional requirements for the elderly, has led to a higher incidence of periprosthetic and interprosthetic fractures. More precisely, the femoral shaft is compressed between two ipsilateral implants with most of these fractures being located on the supracondylar femoral shaft. Their treatment is not only technically demanding and challenging, but can also be associated with serious complications. Treatment must be determined and assessed according to the type of fracture, the stability of the prosthesis, the bone quality and the general condition of the patient. There is little information in the literature about this type of injury: there are several published case reports detailing unconventional solutions and the case studies presented are limited and not significant. This review aims to provide an updated and comprehensive list of diagnostic and therapeutic protocols accepted today, while recognising that these protocols are being continuously updated according to experience gained.

Heterotopic ossification is a condition characterized by the presence of mature lamellar bone and often bone marrow in soft tissues surrounding a major joint. It represents a common complication after total hip arthroplasty (THA). The etiology and predisposing factors are not completely known, but some authors reported that the implant of a non-cemented prosthesis seems to be associated with a greater incidence of HO. Two hundred and two non-cemented total hip arthroplasties were performed between October 1997 and February 2002. The mean age was 70.2 years. The average follow-up for 181 hips included in the study was 96 months (range, 72–120 months). A standard lateral approach (Hardinge) was performed for the implant of a non-cemented femoral component and a non-cemented acetabular component. Radiographs were done before and after surgery, at 1, 4 and 12 months postop, then every year. The incidence of HO was assessed in the antero-posterior view at each interval and graded according to Brooker classification. Out of 181 implants, HO was observed in 52 hips (28,7%). Heterotopic bone was graded as class I in 32 (17.7%) hips, class II in 14 (7.73%) hips, class III in 6 (3,3%) hips and class IV in none (0%). The mean preoperative Harris hip score was 48; at the last follow-up, the mean postoperative score was preoperatively to a mean of 89 points (range, 76–97 points) in HO Hip and of 91 points (range, 78–100 points) in the other Hip. In our experience, non-cemented THA led to a higher incidence of class I and II HO according to Brooker Classification, the incidence of HO is comparable to the rates reported in recent studies about the HO finding after a non-cemented THA, the importance of clinical symptoms in the presence of HO is very low.