Ballistic femoral neck fractures are complex, high-energy injuries that require a management approach distinct from conventional blunt trauma. These current concepts review examines the evolving landscape of evaluation and treatment for these rare injuries based on contemporary literature. Initial management emphasizes the Advanced Trauma Life Support (ATLS) protocol, with a critical focus on identifying associated neurovascular and skeletal injuries, which are present in approximately one-third of cases. Diagnostic evaluation relies on plain radiography and thin-slice CT to delineate fracture morphology and bullet trajectory, with CT angiography recommended if vascular compromise is suspected. Surgical decision-making balances the goals of head preservation through open reduction and internal fixation (ORIF) against the definitive stability provided by total hip arthroplasty (THA). While ORIF remains the standard for young, active patients, clinicians must account for the historically high incidence of nonunion and infection associated with ballistic mechanisms. In cases of failed osteosynthesis or catastrophic articular comminution, conversion to THA offers a reliable salvage option with favorable functional outcomes. This review highlights the need for individualized treatment plans and meticulous clinical follow-up to manage the inherent risks of this challenging injury pattern.
Introduction: Staphylococcus aureus is the most frequently implicated pathogen in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with nasal colonization being a well-established risk factor for their onset. Despite this association, the role of routine preoperative screening and decolonization in reducing postoperative infection rates remains debated. Methods: This retrospective study analyzed 2,507 elective joint arthroplasty procedures performed between January 2022 and December 2024 at a single center in Italy. Starting in 2024, patients underwent nasal swab screening for methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA). Positive carriers received a decolonization protocol consisting of mupirocin nasal ointment and chlorhexidine showers in the days preceding surgery. The incidence of PJIs in this group was compared to that observed in a control cohort from 2022–2023, during which no screening or decolonization was implemented. Results: Among the 988 patients screened in 2024, 231 (25.2%) tested positive for MSSA and 18 (1.8%) for MRSA. Notably, no PJIs caused by MSSA or MRSA were reported that year, compared to three such cases recorded in the preceding 2 years. Overall, 11 PJIs (0.44%) were documented across the study period. All infections in 2024 occurred in patients who had tested negative for S. aureus colonization. However, the reduction in infection rates did not reach statistical significance (p = 1.00). Conclusions: Although the observed decrease in S. aureus-related periprosthetic joint infections was not statistically significant, the trend suggests that preoperative screening and targeted decolonization may contribute to a lower incidence of these infections. These findings support further investigation into standardized preventive strategies to enhance outcomes in joint replacement surgery.
Introduction : The increasing volume of total hip replacement (THR), coupled with longer life expectancy and greater patient demands, is expected to result in a corresponding increase in revision THR. The surgical approach used for revision THR may influence postoperative outcomes, particularly the risk of dislocation. This study aimed to compare clinical outcomes following revision THR performed through the lateral and posterior approaches, with particular emphasis on postoperative dislocation rates. Methods : We retrospectively reviewed prospectively collected registry data from 137 patients who underwent revision THR. Of these, 81 underwent revision THR through a lateral approach and 56 through a posterior approach. Propensity scores were generated using logistic regression to adjust for potential confounders, including age, sex, body mass index, and preoperative patient-reported outcome measures (Oxford Hip Score, WOMAC Pain, Stiffness and Physical Function scores, and SF-36 Physical and Mental Component Scores). Postoperative outcomes, including dislocation, blood loss, patient-reported outcome measures, and satisfaction, were compared between groups. Results : After propensity score matching, the incidence of dislocation was significantly higher in the posterior approach group than in the lateral approach group (16.1% vs. 1.8%, p = 0.02). The lateral approach was also associated with significantly lower postoperative blood loss compared with the posterior approach (change in haemoglobin: 1.5 vs. 2.5 g/dL, p < 0.001). No significant differences were observed between groups in SF-36, WOMAC, or Oxford Hip Scores at 6 months or 2 years postoperatively. However, patient satisfaction was significantly higher following the lateral approach at both 6 months (87.5% vs. 73.2% satisfied or very satisfied, p = 0.02) and 2 years (87.5% vs. 67.9%, p = 0.019). Discussion : In this cohort, revision THR performed through a lateral approach was associated with a significantly lower dislocation rate, lower blood loss, and higher patient satisfaction compared with the posterior approach, without significant differences in functional or health-related quality-of-life outcomes. The lateral approach appears to be a viable option for revision THR, particularly when minimising postoperative instability is a priority. Further comparative studies are warranted to validate these findings and determine the influence of surgical approach on outcomes following revision THR.
Introduction : The clinical value of three-dimensional (3D)–assisted planning in arthroscopic acromioplasty remains unclear, particularly regarding its ability to optimize subacromial decompression and improve clinically meaningful outcomes. Purpose : To evaluate whether 3D-assisted preoperative planning can improve radiologic parameters and functional outcomes in patients undergoing arthroscopic treatment for subacromial impingement syndrome. Study design : Descriptive observational study (combined retrospective and prospective). Methods : Fifty patients with subacromial impingement syndrome underwent arthroscopic acromioplasty with 3D-assisted preoperative planning. Clinical outcomes were assessed using the UCLA score. Radiologic parameters, including acromial index (AI), critical shoulder angle (CSA), lateral acromial angle (LAA), and acromiohumeral distance (AHD), were evaluated using static and dynamic 3D computed tomography preoperatively and postoperatively. Results : Postoperatively, AI and CSA significantly decreased toward normal ranges, while LAA improved. Both static and dynamic AHD increased significantly, indicating enhanced subacromial space. The mean UCLA score improved from 21.54 ± 2.66 to 33.22 ± 1.75 ( p < 0.01). Conclusion : 3D-assisted arthroscopic acromioplasty was associated with significant improvements in both radiologic parameters and functional outcomes. The ability to evaluate subacromial space dynamically and localize impingement sites may facilitate more precise and individualized decompression, potentially enhancing surgical effectiveness.
Introduction : Ipsilateral proximal and shaft femoral fractures are rare, high-energy injuries associated with substantial morbidity. Evidence on predictors of adverse outcomes after surgical treatment remains limited. Methods : We conducted a retrospective cohort study at a tertiary trauma center including all skeletally mature patients who underwent surgical treatment for ipsilateral proximal femoral fractures (femoral neck or trochanteric region) associated with femoral shaft fractures between January 2019 and December 2024. The primary outcome was a composite of major complications, including deep surgical site infection, delayed union, nonunion, symptomatic pulmonary embolism, or all-cause mortality. Bivariable analyses were performed to compare patients with and without major complications, followed by multivariable logistic regression to identify independent predictors. Results : Fifty-two patients were included, with a mean age of 41.8 years and a mean Injury Severity Score (ISS) of 23.1. Major complications occurred in 17 patients (32.7%). The most frequent major complications were all-cause mortality (13.5%) and deep surgical site infection (11.5%). In bivariable analysis, smoking, longer time to definitive treatment, and higher ISS were associated with major complications. In the multivariable model, smoking (adjusted odds ratio [OR] 19.24, 95% confidence interval [CI] 2.78–133.04; p = 0.003) and higher ISS (adjusted OR per point 1.10, 95% CI 1.01–1.19; p = 0.027) remained independently associated with the primary outcome, whereas time to definitive treatment and age did not. Conclusion : Major complications were frequent after surgical treatment of ipsilateral proximal and shaft femoral fractures, affecting nearly one-third of patients. Smoking and greater trauma severity, as measured by ISS, were the main independent predictors of adverse outcomes. These findings highlight the importance of perioperative risk stratification and support smoking as a relevant modifiable risk factor in this setting.
