Periprosthetic fractures are becoming increasingly frequent due to aging population and growing number of total joint replacements involving joints different from hip and knee, such as shoulder and elbow. The treatment of these fractures still represents one of the major challenges for the orthopedic surgeon. Despite all efforts to understand and treat these patients, high rate of failure and mortality are still reported. In this review, the epidemiology of periprosthetic fractures, risk factors and results of surgical treatment are disclosed. Moreover, we propose a treatment algorithm based on the findings of the New Unified Classification System.

Introduction: We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population. Methods: We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions. Results: We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year. Conclusions: The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies.

We performed a systematic review of the literature involving a number of databases to identify studies that included outcomes of surgical treatment of acetabular fractures in patients aged > 55 years. An initial search identified 1564 studies. After exclusion by two independent reviewers, 15 studies met the inclusion criteria. All studies were case series and the mean Coleman Methodology score for methodological quality assessment was 43.7 (standard deviation 12.3). There were 354 patients with acetabular fractures. Pooled analysis revealed a mean age of 71.6 years (55 to 96) and a mean follow-up of 43 months (20 to 188). Complex fractures were reported in 70.1% of patients. Seven studies presented the results of open reduction and internal fixation (ORIF); in eight other studies a total hip arthroplasty (THA), alone or combined with different internal fixation techniques, was the chosen treatment. In the ORIF sub-group, conversion to THA was performed at a mean of 25.5 months with anatomical reduction in 11.6% and imperfect and poor reduction in 22.3%. In the THA sub-group, an acetabular ring or cage with a cemented acetabular component was used in four studies (52 patients) and a cementless acetabular component was implanted in five studies (78 patients). Six patients (4.9%) underwent revision at a mean of 39 months after the index procedure. The analysis of intra-operative and post-operative parameters showed a statistical difference between the two sub-groups with regards to the mean operating time (236 mins ORIF vs 178 mins THA), the mean blood loss (707 mL ORIF vs 974 mL THA) and the mean mortality rate at one year (22.6% ORIF vs 8.8% THA). Based on the current data available, acute THA (alone or in combination with internal fixation) may have a role in the treatment of older patients with complex acetabular fractures. Despite the wide heterogenecity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures. Cite this article: EFORT Open Rev 2017;2:97-103. DOI: 10.1302/2058-5241.2.160036

In young patients with osteonecrosis of the femoral head (ONFH), short-stem total hip arthroplasty (THA) could allow a potential advantage in preserving metaphyseal bone-stock, when revision surgery might become necessary. However, only a few studies have evaluated the outcome of short-stem THAs in ONFH. We reviewed the prospectively collected data of a cementless partial neck-retaining short-stem with ceramic-on-ceramic bearings in ONFH patients. Thirty patients (37 hips) younger than 60 years (mean age at surgery, 51.5 years) underwent THA with the NANOS® stem (Smith and Nephew, Marl, Germany) from January 2006 to December 2012. All patients received a 32-mm or 36 mm ceramic femoral head. Harris hip score, WOMAC and UCLA activity score were recorded. Postoperative radiographs were evaluated for bone-implant fixation and osteolysis. Further analysis correlated clinical findings with implants characteristics and patient demographics at mean 5.6 years’ follow-up (range, 3–10 years). The clinical and functional results improved significantly (p < 0.001). At latest follow-up, mean HHS, WOMAC, and UCLA activity scores were 90 (range, 71–100), 94 (range, 76–100), and 6.3 (range, 4–10) points, respectively. The diameter of the femoral head did not influence the clinical outcome (p = 0.661). All hips showed bone ingrowth fixation of the acetabular and femoral components. No patients showed osteolysis. No revision for any reason was performed during the study period. The excellent clinical results and fixation pattern at mean 5.6 years’ follow-up reveal this implant as a reliable option in advanced stage of ONFH either. Further investigations are crucial to determine the long-term durability and to assess whether the association of ceramic-on-ceramic bearings, can be useful to achieve longer survivorship and lower complications rates. Registry number: ISRCTN 91336248 ; date of registration: 04/07/2017.

This study aims to explore if the arthroscopically assisted reduction and internal fixation (ARIF) technique is superior to the traditional open reduction and internal fixation (ORIF) technique in the treatment of tibial lateral plateau fractures. Forty patients with tibial plateau fractures (Schatzker type I–III) treated with ARIF or ORIF from 2012 to 2017 were included in this retrospective study. All patients received pre-operative radiographs and CT scans. The patients were divided into two groups (ARIF or ORIF). All patients had a minimum follow-up of 12 months and an average follow-up of 44.4 months. The clinical and radiographic outcomes were evaluated according to the Knee Society Score (KSS) and the modified Rasmussen radiological score. Satisfactory clinical and radiological results were found in 39 out of 40 (97.5%) patients. KSS and modified Rasmussen radiological score were significantly better in ARIF group. The mean KSS was 92.37 (± 6.3) for the ARIF group and 86.29 (± 11.54) for the ORIF group (p < 0.05). The mean modified Rasmussen radiographic score was 8.42 (± 2.24) for the ARIF group and 7.33 (± 1.83) for the ORIF group (p = 0.104). Worst clinical and radiological results were related to concomitant intra-articular lesions (p < 0.05). Meniscal tears were found and treated in 17 out of 40 (42.5%) patients. The overall complication rate was 10%. Both ARIF and ORIF provided a satisfactory outcome for the treatment of Schatzker I–III tibial plateau fractures. However, ARIF led to better clinical results than ORIF. No statistically significant differences were found in perioperative complications, radiological results, and post-traumatic knee osteoarthritis. Level III