Current concepts in hip-spine relationships: making them practical for total hip arthroplasty.

Hip, spine, and pelvis move in coordination with one another during activity, forming the lumbopelvic complex (LPC). These movements are characterized by the spinopelvic parameters sacral slope, pelvic tilt, and pelvic incidence, which define a patient's morphotype. LPC kinematics may be classified by various systems, the most comprehensive of which is the Bordeaux Classification. Hip-spine relationships in total hip arthroplasty (THA) may influence impingement, dislocation, and edge loading. Historical 'safe zones' may not apply to patients with impaired spinopelvic mobility; adjustment of cup inclination and version and stem version may be necessary to achieve functional orientation and avert complications. Stem design, bearing surface (including dual mobility), and head size are part of the armamentarium to treat abnormal hip-spine relationships. Special attention should be directed to patients with adult spine deformity or fused spine because they are at increased risk of complications after THA.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study.

BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.

Total hip arthroplasty planning.

Preoperative planning is mandatory to achieve the restoration of a correct and personalized biomechanics of the hip.The radiographic review is the first and fundamental step in the planning. Limb or pelvis malpositioning during the review results in mislead planning.Correct templating is possible using three different methods: acetate templating on digital X-ray, digital 2D templating on digital X-ray and 3D digital templating on CT scan.Time efficiency, costs, reproducibility and accuracy must be considered when comparing different templating methods. Based on these parameters, acetate templating should not be abandoned; digital templating allows a permanent record of planning and can be electronically viewed by different members of surgical team; 3D templating is intrinsically more accurate. There is no evidence in the few recently published studies that 3D templating impacts positively on clinical outcomes except in difficult cases.The transverse acetabular ligament (TAL) is a reliable intraoperative soft tissue reference to set cup position.Spine-hip relations in osteoarthritic patients undergoing hip joint replacement must be considered. Cite this article: EFORT Open Rev 2019;4:626-632. DOI: 10.1302/2058-5241.4.180075.

Metal ion trend in patients with metal-on-metal total hip arthroplasty: a 10-year prospective study.

INTRODUCTION:: There have been reported adverse reactions in patients with large head metal-on-metal hip arthroplasty, therefore metal particle debris are a cause for concern. The aim of this study was to evaluate the release trend of metal ions and the correlated variables. METHODS:: 54 patients were prospectively enrolled into the study from 2004 to 2006. All patients had 36-mm metal head, Pinnacle acetabular component, Summit stem and Ultamet CoCr alloy liner (Depuy Inc.), and underwent clinical and radiological management. The haematic concentration of Cr-Co at 0, 6, 12, 24, 60 and 120 months after the implantation was analysed in a sub-cohort of 34 patients. RESULTS:: 10-year revision rate for each case was 8.9%. The average concentration of Co at 120 months was 3.12 µg/L (median 2.20) with 53% values >2 µg/L and 1 >7 µg/L. After 6 months the median levels of Cr and Co were higher than time 0 ( p < 0.0001); no significant differences were found between 6 and 24 months; while Co had significant increase between 60 and 120 months ( p = 0.002). Overweight, University of California at Los Angeles (UCLA) >9 and <50 years old patients have significantly higher circulating metal ions. DISCUSSION:: This is 1 of the few prospective studies on the argument. The revision rate is conforming to records. Our data shows ionic concentration is not predictive of revision or adverse reaction to metals. We described a 3-phase trend for Co probably due to the loss of integrity of the surfaces.

Impact of ATLS guidelines, trauma team introduction, and 24-hour mortality due to severe trauma in a busy, metropolitan Italian hospital: A case control study.

BACKGROUND: Advanced Trauma Life Support (ATLS) guidelines are widely accepted for use in initial management of trauma patients. The application of ATLS guidelines and introduction of management by means of trauma team (TT) both took place in April 2011. The aim of the present study was to evaluate related effects on mortality in the shock room (SR) and at 24 hours after admission. METHODS: Data were retrieved by administrative software based on patient admission for trauma of at least 48 hours. Study period was from April 2011 to December 2012, and control period was from January 2007 to March 2011. All admitted patients were identified by first diagnosis (ICD 9-CM), excluding traumatic brain injuries, and only patients admitted to the general intensive care, general surgery, and orthopedics units were included. RESULTS: The control group (CG) included 198 patients; the study group (SG) included 141. Differences were determined in patient age, which was mean 45.2 years (SD: 19.2) in the CG and mean 49.3 years (SD±18.3) in the SG (p=0.03). Differences were not found regarding gender, length of hospital stay, or Injury Severity Score (ISS). Among the patients who died, no differences were found in terms of systolic blood pressure, metabolic acidosis, or packed red blood cell consumption. Mortality was significantly higher in the CG, compared to the SG (14.1% vs 7.1%, respectively; p=0.033; confidence interval [CI]: 0.21-0.95). Mortality in the shock room was significantly lower in the SG, compared to the CG (0.7% vs 7.1%, respectively; p=0.002; CI: 0.004-0.592). CONCLUSION: The introduction of ATLS guidelines and TT had a positive impact on mortality in the first 24 hours, both in the SR and after admission.

Optimization of Cellular analysis of Synovial Fluids by optical microscopy and automated count using the Sysmex XN Body Fluid Mode.

BACKGROUND: This study was planned to assess the impact of pre-treating synovial fluid (SF) samples with hyaluronidase (HY), defining the best procedure for optical microscopy (OM) analysis and evaluating the performance of Sysmex XN-9000 Body Fluid module (XN-BF). METHODS: The cell count by OM was carried out both with and without HY pre-treatment, and using 3 different types of staining reagents. The evaluation of XN-BF included data comparison with OM (100 SFs), carryover, Limit of Blank (LoB), Limit of Detection (LoD), Limit of Quantitation (LoQ) and linearity. RESULTS: Unlike cell count in Burker's chamber and staining with Stromatol, pre-treatment with HY and staining with Methylene Blue and Turk's promoted cell clustering. The SF samples pre-treated with HY displayed excellent morphological quality, contrary to samples without HY pre-treatment. Excellent correlation was found between total cells counting with both OM and XN-BF. Satisfactory agreement was also observed between polymorphonuclear neutrophils compared to XN-BF parameter, whereas mononuclear cell count on XN-BF had suboptimal agreement with OM. The carryover was negligible. The LoB, LoD, LoQ and linearity were excellent. CONCLUSION: XN-BF displays excellent performance, which makes it a reliable and practical alternative to OM for SF samples analysis in clinical laboratories.

Rotational alignment of the femoral component in total knee arthroplasty.

We describe here various surgical options to obtain a correct rotational alignment of femoral component in total knee arthroplasty (TKA). The correct rotational alignment is the key point to obtain a rectangular balanced flexion gap as well to have a good patellar tracking. For that reason, rotation alignment largely affects postoperative kinematic results particularly during flexion.

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery).

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Two-stage treatment of infected total knee arthroplasty: two to thirteen year experience using an articulating preformed spacer.

PURPOSE: Infection following knee replacement is an important cause of failure despite rigorous prophylaxis antibiotic protocols. The two-stage reimplantation procedure is considered the gold standard for treatment of subacute and chronic deep periprosthetic infections. The purpose of this study was to determine whether or not a preformed articulated spacer would allow comparable eradication of infection equal to rates reported in published studies and to see whether there is a resulting improvement in postoperative function with an acceptable quality of life, reducing postoperative pain and limiting surgical complications, thus simplifying the second stage of the procedure. METHODS: We retrospectively reviewed 50 patients with infected TKA who underwent a two-stage exchange arthroplasty using an articulating preformed spacer. The device, designed like an ultracongruent condylar knee prosthesis, is composed of acrylic cement impregnated with antibiotic, with tested and standardised mechanical properties and antibiotic content and release mechanism. RESULTS: The median follow-up period was seven (two to 13) years. Two-stage exchange arthroplasty was successful in controlling the infection in 92% of patients; 64% of patients where women, and median patient age was 68 (54-80) years. Median implantation time of the preformed spacer was 16 (four to 60) weeks; 4% of infections were delayed, and 96% were late. Forty-six percent were caused by coagulase-negative Staphylococcus (CoNS). Mean Knee Society Score (KSS) was 35.38 (clinical) and 37.96 (function) on presentation; it improved to a mean of 72.92 (clinical) and 76.04 (function) after the first stage and to a mean of 75.38 (clinical) and 80.58 (function) at the final review. Bone loss was unchanged between stages, and range of motion remained unchanged or improved after definitive reimplantation. CONCLUSION: The use of preformed articulated knee spacer during a two stage technique for infected TKA improves patient QOL between stages and increases patient compliance and cooperation, reducing social costs.

Return to Competition in a Chronic Low Back Pain Runner: Beyond a Therapeutic Exercise Approach, a Case Report.

Chronic low back pain (CLBP) is a disabling condition affecting both quality of life and performance in athletes. Several approaches have been proposed in the field of physiotherapy, manual therapy, physical exercise and counseling. None apparently is outdoing the other with the exception of trunk stability exercises in specific conditions. The present paper describes a clinical success in managing a CLBP runner affected by MRI documented disk herniation via dietary change. Dietary changes allowed our patient that had failed with previous standard therapeutic approaches, to regain an optimal pain-free condition. We advance the hypothesis that a visceral-autonomic concomitant or primary disturbance possibly generating mild gastrointestinal discomfort in CLBP patients should be ruled out as a possible cause of pain and disability at the somato-motor level.