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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.

Dagli anni '60, i litorali sardi hanno ospitato sempre più turisti, che hanno cau- sato la perdita di habitat costieri. Grazie all'uso del GIS e di database statistici regionali e nazionali, questo lavoro mostra i risultati dell'analisi sulle strutture ricettive a fini turistici lungo la fascia costiera sarda. La polarizzazione nord-sud dei flussi turistici e dell'attività edilizia intensiva sottolineano l'importanza di con- siderare il costruito nel processo di valutazione ambientale.

This work investigates how to prevent sustainable tourism from turning into over-tourism dynamics. As a matter of fact, the former has shown to be capable of bringing profit to traditional rural activities (i.e. agriculture), the tourism sector, the environment and the cultural heritage of a region; whereas the latter, more often than not, harms and brings detriment to the natural landscape. Hereof, landscape heritage is a fundamental resource at the base of both rural tourism (RT) and traditional rural activities, and it is reasonable that to adequately support RT a certain degree of built-up growth (i.e. new accommodation facilities and cognate areas) is somewhat needed. However, we want to problematize that these dynamics shall be carefully calibrated and appropriately regulated in a non-conflictual way. We modeled that: (i) land can be either devoted to RT-hosting facilities or agriculture; (ii) RT impacts landscape resources more harmfully, thus diminishing profitability of both sectors. We also posit a policy instrument to preserve landscape resources, financed through RT revenues. The analysis shows that if no policy is applied, over-RT is ineluctable. Conversely, with such a policy instrument it is possible to determine an economic space where all rural economic activities peacefully coexist, and landscape impacts are minimized.

Purpose The aim of this retrospective study was to investigate the clinical follow-up of patients with external snapping hip syndrome (ESHS) treated with endoscopic gluteus maximus tendon release and to compare the residual muscular strength and thigh circumference as an indirect outcome measure. Methods Patients of all ages with external snapping hip syndrome were treated with endoscopic gluteus maximus tendon release. Outcome measures evaluated included: visual analog scale (VAS), modified Harris Hip Score (mHHS), and Non-Arthritic Hip Score (NAHS). The gluteus maximus strength and the circumference of the thigh were also evaluated. Results Among 25 patients, 23 fulfilled the inclusion criteria and one patient was lost to follow-up. The series included 22 patients, 6 males and 16 females with a mean age of 27.9 ± 13.4 years (range 16–76 years). All patients had resolution of the snapping symptoms after the procedure. The mean follow-up was 18 ± 9.3 months. All outcomes improved in a statistically significant manner: VAS value decreased from 6.8 (range 6–8) to 0.6 (range 0–4) (p < 0.001), mHHS increased from 48.6 (range 17.6–67) to 88.2 (range 67–94.6) (p < 0.001), NAHS increased from 49.0 (range 21.5–66) to 90.8 (range 66–98.75) (p Conclusions Endoscopic gluteus maximus tendon release is an excellent surgical option to treat snapping hip syndrome. The evaluated muscle strength revealed no functional impairment. The significance of the limb circumference reduction has yet to be determined. Level of evidence IV: retrospective comparative trial.

Direct anterior approach total hip arthroplasty (DAA THA) has gained significant popularity in the last decade as it is a muscle-sparing procedure. Modern techniques for DAA THA utilize both a standard operating table and an orthopedic traction table. As the use of an orthopedic traction table shows technical ease and predictability, this article will focus on the use of the orthopedic table or table extension to facilitate DAA THA. Primary or secondary arthritis requiring THA; revision surgery—both acetabular and femoral. Posterior wall hardware requiring removal; posterior mass (tumor) to be removed at surgery: large, overhanging pannus; need for gluteal tendon reconstruction; anterior skin envelope not conducive to DAA. The incision is made over the tensor fascia latae. Capsulotomy is performed exposing the hip joint. After osteotomy of the femoral neck, traction is placed on the leg utilizing the orthopedic table and the head is removed. The acetabular cup is inserted. Traction, flexion, and internal reduction are used simultaneously while directing the femoral head into the acetabulum. In a meta-analysis, operative time (100 vs. 71 min), blood loss (531 vs. 382 ml), and intraoperative fracture rate (1.7 vs. 1.3%) were increased in the traction table cohort. All other complications and outcome measurements were the same. Traction-table related complications such as pudendal nerve palsy and ankle fractures were not found. An assessment of the senior author’s initial 855 DAA THAs (2008–2014) showed a mean operative time of 65 min with a mean blood loss of 238 ml. Operative times decreased to average 56 min. Intraoperative fracture rate was 0.8%. Infection rate was 2.1%. Finally, 1.5% femoral implants did not osseointegrate and required revision after an average of 3.0 years.

The Legg–Calve–Perthes disease (LCPD) is a rare pathology with an incidence of 4–32 cases per 100 000 but represents one of the most common causes of permanent femoral head deformity in childhood [1]. Almost 30–50% of the affected patients will develop progressive osteoarthritis (OA) in adulthood [2]. Early conservative surgery aims to minimize the femoral head deformity and, in case, the acetabular orientation, to try to reduce the risk of secondary OA [1]. The indications for an effective containment surgery are still being debated, with uncertain predicting factors for the outcomes. In recent times, the ability to safely perform a surgical dislocation of the hip (SHD) has revolutionized the potential of the treatment of LCPD sequelae [2]. Different algorithms to approach the functional analysis of the hip deformities and eventually select the appropriate surgical treatment, especially for young patients, have been described [2, 3]. The intracapital osteotomy is the ultimate limit of conservative hip surgery and consists of an intracapsular osteotomy of the femoral head intending to restore its spherical shape [4, 5]. The most significant expected risk of such surgery is certainly avascular necrosis (AVN). Few cases have been described in literature [5–9]. A case of a young lady treated with an intracapital osteotomy and concomitant periacetabular osteotomy (PAO) for severe and incapacitating sequelae of Perthes Disease and tensor fasciae latae aplasia is presented. Unfortunately, this case ended in progressive hip OA requiring a total hip replacement.

Greater trochanteric pain syndrome (GTPS) refers to the constellation of signs and symptoms related to pain in the trochanteric region and has recently replaced the previously ubiquitous term of ‘greater trochanteric bursitis’. GTPS is common, particularly in women 50–79 years of age, and the understanding and management of GTPS have expanded considerably in recent years to include management with arthroscopic and endoscopic techniques in recalcitrant cases. The purpose of this scoping literature review was to summarize the current evidence on arthroscopic management of GTPS including sources of evidence, key concepts, and gaps in the literature. A thorough electronic database search included studies published from 2009 to June 14, 2020. A total of 52 peer-reviewed articles were identified within the literature on arthroscopic or endoscopic management of GTPS. Of the 52 identified papers, 12 were technique descriptions, 10 papers were review articles, and 30 papers were original clinical papers. Of the 30 clinical papers, 24 (80%) were of level IV evidence, 5 (17%) were of level III evidence, and 1 (3%) was level II evidence. Among the 30 clinical studies, 988 patients were included with 761 (77%) female. Indications for surgical management included a failed trial of conservative management in all 30 studies, typically after a period of 3–6 months. Surgical management consisted of arthroscopic/endoscopic abductor tendon repair in 16 (53%) studies, arthroscopic/endoscopic bursectomy and iliotibial band release in 12 (40%) studies, and arthroscopic/endoscopic gluteal tendon contracture release in 2 (7%) studies. Overall, results following arthroscopic management of GTPS and abductor tears have been promising, including significantly improved pain scores and functional outcomes at final post-operative assessment. These studies support continued use and investigation of arthroscopic management strategies of GTPS and pave the way to conduct larger prospective studies to confirm these results in the future. IV.

Purpose Snapping hip is a common clinical condition, characterized by an audible or palpable snap of the hip joint. When the snap is perceived at the lateral side of the hip, this condition is known as external snapping hip or lateral coxa saltans, which is usually asymptomatic. Snapping hip syndrome (SHS) refers to a painful snap, which is more common in athletes who require increased hip range of motion. The aim of this article is to review the most common endoscopic techniques for the treatment of ESHS, as well as their results and limitations. Methods This is a review of the current literature of endoscopic surgical procedures and of the results of the treatment of external snapping hip syndrome. Results The pathogenesis of SHS is mechanical. The initial treatment attempt is conservative, and usually provides good results. Patients who do not respond to conservative management are candidate for surgery. The endoscopic release of the ilio-tibial band or the endoscopic release of the femoral insertion of the gluteus maximum tendon is the most popular technique. Conclusion Endoscopic techniques provide fewer complications compared to open surgery, a lower recurrence rate and good clinical outcomes. More comparative studies with a longer follow-up are required to adequate evaluate the full role of endoscopic techniques in periarticular hip surgery. Level of evidence Level V.

In order to study complex transformation of rural areas in the long term, our paper aims to integrate the concepts of rural restructuring and evolutionary economic geography. We argue that these approaches can complement each other to understand the mechanisms shaping rural evolutionary paths. We apply our theoretical framework to the case of rural areas evolving under the influence of large-scale farms in Hungary, namely the so-called manorial settlements. Tracing the processes on three different scales (global, national and local) we claim that during the last one hundred years the rural configuration in these areas shows a number of continuities despite the significant political-economic transitions throughout this period. The global dependency and semi-peripheral position of Hungary is apparent, and also the role of global agri-food regimes can be observed. Political transitions on the national scale appear primarily as ‘external shocks’. Despite the strong path dependency in terms of powerlessness and passivity of local societies at manorial settlements, the role of certain local actors in path creation should not be ignored.

Introduction Periprosthetic femoral fracture around hip arthroplasty are growing in the world, nevertheless management and treatment options for fractures “around the stem” are still debated due to lack of high-level studies. Materials and method A 85-item survey were fill out by 40 Italian Orthopedic Surgeon member of SIOT (Società Italiana di Ortopedia e Traumatologia) and AIR (Associazione Italiana Riprotesizzazione) to assess their current opinion in the management of type B periprosthetic femoral fractures. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training. Results Vancouver/UCS fracture classification showed a good interobserver agreement (k value = .76). ORIF were the treatment of choice for UCS type B1 fractures (100%), revision stem for B2 (85%) and B3 (100%). Locked plates were preferred to cable plate and cerclage without a plate for B1 fractures (50% vs 40% vs 10%); revision with modular stem was preferred to monoblock stem for B2 fractures (50% vs 35%) and B3 (75% vs 15%). Responders tended to postpone at 1-month weight-bearing in patients with B1 fractures. Regarding postoperative pharmacological treatment there was absolute lack of consensus. Discussion The primary finding of our survey confirmed the preference of ORIF for B1 fractures and stem revision for B2 and B3 fractures. However, there is no definitive operative technique for all UCS B fractures. Surgeons tended to favor locked plating over cable plating, although only slightly. This general lack of consensus coincides with the inconclusive evidence that currently exists in the literature, which demonstrates both favorable and unfavorable outcomes for both techniques Conclusions The absence of complete homogeneity among participants showed the need for prospective randomized studies to set up stronger guidelines for classification, management, surgical treatment, rehabilitation, and pharmacological support of periprosthetic femoral fractures.

Minimally invasive approach in total hip arthroplasty for the treatment of femoral neck fractures with a hemiarthroplasty.Femoral neck fractures of patients without hip osteoarthritis where the acetabulum is still intact.Lesions and infections of the skin in the approach area; hip osteoarthritis; surgeon's lack of experience with the technique.The direct anterior approach (DAA) uses the Smith-Peterson interval between the tensor fasciae latae (TFL) and the rectus and sartorius muscle. After coagulation of the ascending branches of the femoral circumflex vessels, the capsule is opened. The remaining parts of the femoral neck are removed and osteotomized if necessary. The femoral head is removed with a cork screw. Then the shaft is supported by 2 sharp retractors at the greater trochanter from cranial, and the leg is externally rotated, hyperextended, and adducted. A TFL release can be performed which we also recommend. The femoral canal is opened step by step and extended with rasps which are introduced with the double curved broach handle. Cement and the final implant are introduced and after the trial reduction also the final head. The hip is reduced, the capsule adapted and the wound closed.For this approach, there are no approach specific recommendations. Postoperative treatment depends on whether the approach was extended with muscle releases and on the type of reconstruction performed. If the approach was limited to the minimally invasive direct anterior portal, quicker rehabilitation can be expected due to the reduced muscle damage. We prefer mobilization with full weight bearing as tolerated on the next day.OPERATIONSZIEL: Der minimalinvasive Zugang ist muskelschonend, erlaubt eine rasche Operation und frühe Mobilisation.Indikationen für eine Versorgung mit einer Hemiarthroplastik sind Schenkelhalsfrakturen in Fällen ohne Koxarthrose, in denen das Azetabulum noch intakt ist.Läsionen und Infektionen der Haut im Zugangsgebiet, Koxarthrose sowie die fehlende Erfahrung des Operateurs sind Kontraindikationen.Der direkte anteriore Zugang erfolgt über das Smith-Peterson-Intervall zwischen M. tensor fasciae latae (TFL) und M. rectus bzw. M. sartorius. Unter Koagulation der aufsteigenden Äste der Vasa circumflexa femoris wird die Kapsel dargestellt und eröffnet. Die freien Schenkelhalsreste werden entfernt, und eine glatte Osteotomie wird auf der gewünschten Höhe hergestellt. Der Hüftkopf wird mit einem Korkenzieher entfernt. Der Schaft wird mit einem 2‑spitzigen Heben am Trochanter major von kranial her unterstützt und das Bein in Außenrotation, Hyperextension und Adduktion gebracht. Zur Verbesserung der Exposition des Femureingangs kann ein TFL-Release erfolgen, was die Autoren empfehlen. Danach wird der Markkanal schrittweise eröffnet und mit Raspeln, die an einem doppelt kurvierten Handgriff befestigt sind, erweitert. Zement und das finale Implantat werden eingebracht und nach Probereposition auch der definitive Kopf. Danach wird die Hüfte reponiert, die Kapsel adaptiert und die Wunde verschlossen.Für diesen Zugang gibt es keine zugangsspezifischen Empfehlungen. Die postoperative Behandlung hängt von vorgenommenen Erweiterungen des Zugangs mit Muskelablösungen und der Art der erfolgten Rekonstruktion ab. Wenn der Zugang auf das minimalinvasive direkte anteriore Portal beschränkt war, ist durch den reduzierten Muskelschaden eine deutlich raschere Rehabilitation zu erwarten. Die Autoren empfehlen Mobilisation mit voller Belastung, falls erträglich, am nächsten Tag.

Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. Of 164 patients who underwent primary total hip arthroplasty (December 2016–May 2017) by a single surgeon, a double mobility cup through DAA and the “head-first” technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85–220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The “head-first” technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

One of the types of modern tourism is rural tourism that has proceeded into a more complicated stage and now it is possible to imply various stages of development in developing countries like Iran. In this case, an evolutionary approach is proposed to carry out multilevel analysis of RT within a region, to the transition from a basic rural economy to a new economic formation, and then the evolutionary economic geography may be a suitable framework. The EEG explains economical transitions as a change from a historically dominant configuration to a new one by the interplay of processes at three various levels, micro (local), meso (regional), and macro (ISDB). The paper is to adjust the EEG approach to the study of RT. We discuss that in Iran the rural transition towards a tourism development was brought up by the sluggishness of the established rural con?guration, less capability and subsequently misalignment of economically associated units, shortage of leadership in micro and meso levels are those important problems that have turned into factors disrupting RT development in Iran

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.

Floating hip fractures are severe and rare injuries with high complication rate and lack of standard management. The purpose of this retrospective study was to review the outcomes of a case series of polytraumatized patients with floating hip injuries, in order to describe the relationship between complication rate and floating hip injury type, the pathomechanism of injury, and the surgical treatment strategy. Forty-five patients with floating hip injuries were analyzed. Complication rate, mechanism of injury, and surgical strategy (damage control orthopedics, stages of internal fixation) were recorded. Fractures were classified using the Mueller system for floating hips and AO/OTA system for the other fractures. Of the 45 patients with floating hip injuries, 23 (51.1%) developed complications. The results revealed that the complication rate was associated with the instability and type of the pelvic or acetabular fracture (61-C AO/OTA pelvic fracture [73.3%; p = 0.04], 62-B AO/OTA acetabular fracture [88.8%; p = 0.03]). Vertical shear (VS) pelvic fractures were related to middle-distal femoral fractures and lateral compression/anteroposterior compression (LC/APC) pelvic lesions were associated to proximal femoral fractures (p = 0.012). Complications were associated with the severity and instability of the pelvic and acetabular type of fractures. The pathomechanism causing Mueller type B and C floating hip injuries was illustrated. A two-stage “femur first” surgical approach was the preferred one for definite internal fixation of fractures.

Internal snapping hip is a common clinical condition and is usually asymptomatic, but in few cases, mostly in athletes and professionals who participate in activities requiring extreme ranges of hip motion, the snap may become painful (internal snapping hip syndrome—ISHS). Traditionally, the ISHS pathogenesis was described as a snapping of the tendon over the anterior femoral head or the iliopectineal ridge, but currently the pathological mechanism is considered multifactorial. Most patients respond well to conservative treatment, but in recalcitrant cases, surgery may be indicated. Arthroscopic iliopsoas fractional lengthening can be performed in the central compartment, peripheral compartment or at the tendon’s insertion on lesser trochanter. Better results have been reported with endoscopic iliopsoas tendon release compared with open techniques, which may be related to the treatment of concomitant intra-articular pathologies. Furthermore, endoscopic treatment showed fewer complications, decreased failure rate, and postoperative pain. Sub-spine impingement is an extra-capsular cause of femoroacetabular impingement (FAI) resulting in diminished hip range of motion and groin pain during hip flexion-based activities. Arthroscopic resection of the deformed AIIS, decompression of the sub-spine region, and treatment of concomitant FAI usually result in good clinical outcome. Calcific tendinitis of the rectus femoris (CTRF) is another underreported condition because it is usually self-limiting. Endoscopic treatment of CTRF is indicated for symptomatic cases recalcitrant to conservative treatment. Recently, arthroscopically assisted reduction of developmental dislocation of the hip (DDH) via medial approach has been developed with advantage of minimally invasive surgery. In this chapter, the endoscopic techniques are outlined.

Osteoid osteoma (OO) of the acetabulum is a quite rare pathology, with an overall incidence of 0,5%. Frequently the diagnosis of OO may not be simple to obtain, because the clinical presentation can mimic other common hip pathologies. We present a case report of OO of the anterior/superior edge of the acetabular fossa associated with a degenerative lesion of the acetabular labrum and with a concomitant femoral neck cam. The patient was refractory to prior pharmacological therapy with NSAIDs so arthroscopic treatment was performed. As a rational strategy, we trimmed the region of the tumor and we finally excised the nidus of the OO. Finally a femoroplasty and a partial labrectomy were performed. At the last follow-up the patient was symptom-free and able to walk with full weight bearing. The nocturnal pain was gone and his ROM improved fully without pain. The arthroscopic procedure, being less invasive, represents a valid option in the treatment of OO, allowing to treat radically the tumor and concurrently diagnose and repair any chondral or soft tissue injuries.

Mechanotransduction is the ability of cells to translate mechanical stimuli into biochemical signals that can ultimately influence gene expression, cell morphology and cell fate. Tenocytes are responsible for tendon mechanical adaptation converting mechanical stimuli imposed during mechanical loading, thus affecting extracellular matrix homeostasis. Since we previously demonstrated that MD-Tissue, an injectable collagen-based medical compound containing swine-derived collagen as the main component, is able to affect tenocyte properties, the aim of this study was to analyze whether the effects triggered by MD-Tissue were based on mechanotransduction-related mechanisms. For this purpose, MD-Tissue was used to coat Petri dishes and cytochalasin B was used to deprive tenocytes of mechanical stimulation mediated by the actin cytoskeleton. Cell morphology, migration, collagen turnover pathways and the expression of key mechanosensors were analyzed by morphological and molecular methods. Our findings confirm that MD-Tissue affects collagen turnover pathways and favors cell migration and show that the MD-Tissue-induced effect represents a mechanical input involving the mechanotransduction machinery. Overall, MD-Tissue, acting as a mechanical scaffold, could represent an effective medical device for a novel therapeutic, regenerative and rehabilitative approach to favor tendon healing in tendinopathies.

Direct anterior approach total hip arthroplasty (DAA THA) has gained significant popularity in the last decade as it is a muscle-sparing procedure. Modern techniques for DAA THA utilize both a standard operating table and an orthopedic traction table. As the use of an orthopedic traction table shows technical ease and predictability, this article will focus on the use of the orthopedic table or table extension to facilitate DAA THA.Primary or secondary arthritis requiring THA; revision surgery-both acetabular and femoral.Posterior wall hardware requiring removal; posterior mass (tumor) to be removed at surgery: large, overhanging pannus; need for gluteal tendon reconstruction; anterior skin envelope not conducive to DAA.The incision is made over the tensor fascia latae. Capsulotomy is performed exposing the hip joint. After osteotomy of the femoral neck, traction is placed on the leg utilizing the orthopedic table and the head is removed. The acetabular cup is inserted. Traction, flexion, and internal reduction are used simultaneously while directing the femoral head into the acetabulum.In a meta-analysis, operative time (100 vs. 71 min), blood loss (531 vs. 382 ml), and intraoperative fracture rate (1.7 vs. 1.3%) were increased in the traction table cohort. All other complications and outcome measurements were the same. Traction-table related complications such as pudendal nerve palsy and ankle fractures were not found. An assessment of the senior author's initial 855 DAA THAs (2008-2014) showed a mean operative time of 65 min with a mean blood loss of 238 ml. Operative times decreased to average 56 min. Intraoperative fracture rate was 0.8%. Infection rate was 2.1%. Finally, 1.5% femoral implants did not osseointegrate and required revision after an average of 3.0 years.ZIELSETZUNG: Die Hüfttotalendoprothese mit direktem anteriorem Zugang („direct anterior approach total hip arthroplasty“, DAA-THA) hat im letzten Jahrzehnt erheblich an Ansehen gewonnen, da es sich um ein muskelschonendes Verfahren handelt. Bei modernen Techniken für die DAA-THA werden sowohl ein Standardoperationstisch als auch ein orthopädischer Traktionstisch verwendet. Da sich der Einsatz eines orthopädischen Traktionstisches als anwenderfreundlich und gut planbar erwiesen hat, liegt der Schwerpunkt dieses Manuskripts auf der Verwendung des orthopädischen Tisches bzw. einer Tischverlängerung, um die DAA-THA zu unterstützen.Primäre oder sekundäre Arthritiden und Arthrosen, die mit einer Hüftgelenktotalendoprothese zu versorgen sind, sowohl azetabuläre als auch femorale Revisionsoperationen.Posterior gelegenes, zu entfernendes Material, posteriore Läsion (Tumor), die im Rahmen der Operation entfernt werden soll, großer, überhängender Pannus, Notwendigkeit für eine Glutealsehnenrekonstruktion, ungeeigneter Hautmantel im Zugangsgebiet.Die Inzision wird über den Tensor fascia latae gesetzt. Unter Freilegung des Hüftgelenks wird die Kapsulotomie durchgeführt. Nach Osteotomie des Femurhalses wird das Bein mithilfe des Traktionstisches angezogen, der Femurkopf wird entfernt, die Hüftpfanne eingesetzt. Unter gleichzeitiger Anwendung von Traktion, Flexion und interner Reposition wird der Hüftkopf in die Hüftpfanne eingebracht.Nach einer Metaanalyse waren in der Gruppe der am Traktionstisch operierten Patienten die Operationszeit (100 vs. 71 min), der Blutverlust (531 vs. 382 ml) und die intraoperative Frakturrate (1,7 vs. 1,3 %) erhöht. Alle anderen Komplikationen und Ergebnismessungen waren identisch. Traktionstischbedingte Komplikationen, z. B. Pudendusparese und Knöchelfrakturen, wurden nicht gefunden. Eine Auswertung der ersten 855 DAA-THAs des Erstautors (2008–2014) ergab eine mittlere Operationszeit von 65 min bei einem mittleren Blutverlust von 238 ml. Die Operationszeiten verringerten sich auf durchschnittlich 56 min. Die intraoperative Frakturrate betrug 0,8 %. Die Infektionsrate lag bei 2,1 %. Schließlich kam es bei 1,5 % der femoralen Implantate nicht zu einer ossären Integration, sodass nach durchschnittlich 3,0 Jahren eine Revision erforderlich war.

Aims The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work. Methods A cross-sectional descriptive survey was designed with ten open and closed questions and sent to a representative sample. The sample was selected on a convenience basis of 27 senior surgeons, members of an international surgical society, who were all frontline workers in the COVID-19 pandemic. This study was reported according to the Standards for Reporting Qualitative Research (SRQR) checklist. Results Responses were received by all 27 surgeons from 22 countries across six continents. A number of the study respondents reported COVID-19-related infection and mortality in HCWs in their countries. Differing areas of practice and policy were identified and organized into themes including the specification of units receiving COVID-19 patients, availability and usage of personal protective equipment (PPE), other measures to reduce staff exposure, and communicating with and supporting HCWs. Areas more specific to surgery also identified some variation in practice and policy in relation to visitors to the hospital, the outpatient department, and in the operating room for both non-urgent and emergency care. Conclusion COVID-19 presents a disproportionate risk to HCWs, potentially resulting in a diminished health system capacity, and consequently an impairment to population health. Implementation of these recommendations at an international level could provide a framework to reduce this burden.

Hip magnetic resonance arthrography (MRA) is the pre-operative imaging modality of choice in patients with labral damage, with several classifications of labral tears having been reported based on MRA findings. Nevertheless, none of the available classification systems allows the surgeon to predict before surgery how a labral tear could be treated. Our purpose was to develop a new MRA-based scoring system of labral tears to predict before surgery the treatment option more suitable for labral tears. Forty-seven patients (29 males and 18 females; mean age: 35.9 ± 12.4) performed hip MRA for suspicious of femoroacetabular impingement and were afterwards subjected to arthroscopic treatment. Two musculoskeletal radiologists reviewed all pre-operative examinations and provided the Extension–Thickness–Damage score for each patient, based on Extension of tear, Thickness of labrum, and type of Damage. Chondral lesions grading was based on the arthroscopic findings according to Konan classification. For statistical purposes, patients were divided into two groups, depending on the type of treatment: labral repair or debridement. Mann–Whitney U, Chi-square, receiver operator curves, and Cohen kappa statistics were used. 35/47 underwent repair, while 12/47 were debrided. In both groups, the median chondral damage was grade III, with no significant differences (p = 0.439). The median Extension–Thickness–Damage score in the repair group (6) was significantly lower (p

Osteitis pubis is a common cause of chronic groin pain, especially in athletes. Although a precise etiology is not defined, it seems to be related to muscular imbalance and pelvic instability. Diagnosis is based on detailed history, clinical evaluation, and imaging, which are crucial for a correct diagnosis and proper management. Many different therapeutic approaches have been proposed for osteitis pubis; conservative treatment represents the first-line approach and provides good results in most patients, especially if based on an individualized multimodal rehabilitative management. Different surgical options have been also described, but they should be reserved to recalcitrant cases. In this review, a critical analysis of the literature about athletic osteitis pubis is performed, especially focusing on its diagnostic and therapeutic management.

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.

The purpose of this study was to investigate the pathogenesis, the incidence, and the results of arthroscopic treatment of os acetabuli (OSA) in a group of patients with diagnosis of femoro-acetabular impingement (FAI). We retrospectively analyzed the full documentation of 294 hips in 273 patients (21 bilateral) operated for FAI through hip arthroscopy. We reviewed all radiographs and arthro-MRI in order to identify the incidence of OSA. All patients with OSA were then assessed with a modified Harris hip score (MHHS) pre-operatively and at the final follow-up. Twenty-one patients (7.7%), 20 (95%) of them were male, were diagnosed with concomitant FAI and os acetabuli. In 21 cases, OSA was excised and FAI was treated with rim trimming, femoral osteoplasty, or both. In one case, a large OSA fragment was fixed with a 4 mm screw avoiding an acetabular uncoverage if excised. The average follow-up was 31 months (range from 6 to 69 months). The MHHS showed an improvement from a pre-operative MHHS of 57.5 (range from 39 to 82) to 95 (range from 73 to 100). Os acetabuli is not uncommon and certainly associated with FAI and male gender. The etiology is probably microtraumatic. The arthroscopic OSA removal or fixation and concomitant FAI treatment showed very good results. Interestingly, these outcomes seem better than FAI treatment alone. Further studies with a wider number of patients and a longer follow-up are needed to confirm these results and understand the real role of OSA in this setting.

FAST-TRACK OF PROXIMAL FEMUR FRACTURES IN PATIENTS OVER 65 YEARS: ANALYSIS OF THE EPICRISIS AND DEVELOPMENT OF EFFECTIVE ORGANIZATIONAL MODELS During the Trauma Meeting 2017 in Riccione an important Round Table took place entitled “Analysis of the epicrisisand development of effective organizational models” within the session “Fast-track of proximal femur fractures inpatients over 65 years”. Given the great relevance of the topic and the precious contribution of the participants, it wasdecided to create the following scientific manuscript of Discussion and Consensus, which contains the answers to thefive questions that were the subject of the Round Table.

The most common conservative approaches to the hip joint are the anterior, the Ganz safe surgical dislocation and the medial approach. The anatomy of these approaches is described in detail in this review. Each approach is also evaluated considering the surgical conservative indications, technique, and complications.