Teriparatide and clodronate combination as a potential treatment for complex regional pain syndrome type I in delayed consolidation after foot surgery: a case report and review of the literature.

BACKGROUND: Complex regional pain syndrome type I is a pathological condition characterized by an exaggerated response of tissues to low or moderate pain stimuli. The exact pathogenesis and optimal medical treatment for complex regional pain syndrome type I are still not fully understood, although bisphosphonates have shown positive effects in reducing pain. Foot surgery can be complicated by the development of complex regional pain syndrome type I, leading to functional decline and difficulties in weight-bearing. CASE PRESENTATION: The authors present a clinical case involving complex regional pain syndrome type I that developed after surgical foot arthrodesis. The patient, a 42-year-old Caucasian male, did not respond to clodronate treatment but experienced successful outcomes upon the addition of teriparatide, which effectively stimulated the healing of arthrodesis. CONCLUSION: Teriparatide cannot be considered the primary treatment for complex regional pain syndrome due to insufficient solid clinical data. However, when complex regional pain syndrome is associated with or caused by delayed union, teriparatide can be used to address the underlying cause of complex regional pain syndrome.

Single-use, patient-specific instrumentation technology in knee arthroplasty: a comparative study between standard instrumentation and PSI efficiency system.

Patient-specific instrumentation is a surgical technique that was created to improve the accuracy of implantation, surgical time and workflow in total knee arthroplasty. This study is a single-center, single-surgeon randomized clinical trial. The aim of this work was to evaluate clinical efficacy of PSI versus standard surgical instrumentation in malalignment risk and blood loss reduction. From April 2015 to September 2016, 40 patients for a total of 40 knees were included in the randomization process. Each patient underwent CT scan of the lower limb including hip, knee and ankle joint with the realization of the PSI system and the TKA with Medacta GMK Primary®. Patients were evaluated 1 month after surgery with X-ray and after 2 months with clinical examination and assessment by Knee Society Score (KSS). Blood loss was detected by adding the values calculated in the operative room and the blood loss in the vacuum systems. In the study group, mean value of KSS was 85.2 (IC 95% 81.2-88.5), mean blood loss was 657 ml (IC 95% 580.6-735.4), and mean value of femorotibial angle was 178.8° (IC 95% 178.5-179.3). In the control group, mean value of KSS was 87.2 (IC 95% 85.3-89.4), mean blood loss was 866.5 ml (IC 95% 763.3-972.5), and mean value of femorotibial angle was 178.9°(IC 95% 177.6-180.3). The Student t test detected a significant difference in blood loss between groups (p < 0.05), and no differences were found between KSS. The single-use instrumentation should improve precision, operative time, turnover time, sterilization and maintenance costs and could help to reduce infection risks. Our results confirm only the improvement on reducing blood loss. In our opinion, this technique should be used in selected patients when the surgeon could have some difficulties to perform femoral cuts on coronal plane or when patients need to have a very little blood loss due to other conditions.

LARS™ in ACL reconstruction: evaluation of 60 cases with 5-year minimum follow-up.

PURPOSE: The injury of anterior cruciate ligament (ACL) causes joint instability and, in the absence of adequate treatment, progressive joint deterioration, meniscal lesions and development of post-traumatic osteoarthritis. METHODS: The purpose of this study was to evaluate the clinical, functional and radiographic outcomes and complications in a consecutive case series of 60 patients with minimum follow-up of 5 years who underwent an arthroscopic surgery for ACL reconstruction using LARS™ ligament. Patients with concomitant meniscal or chondral lesions in the same knee were excluded. RESULTS: The subjective evaluation of the patients involved in the study (Lysholm score, IKDC score and Tegner activity level scale) shows good/excellent results. The range of movement is optimal in most patients, and pain symptoms are considered mild. A total of 31.25% of the patients did not change their lifestyle that they had before the injury. None of the patients underwent resurgery in the same knee. In 85.4% of cases, X-ray images showed no signs of osteoarthritis after ACL reconstruction. CONCLUSIONS: Comparable with other series showed in the literature, this study assesses that the use of LARS™ in reconstruction of ACL is an excellent option for treating >40-year-old patients requesting rapid return to daily activities/sports also at the first surgery. By restoring knee stability, articular degeneration at short and medium follow-up was avoided.

The biphasic bioresorbable scaffold (Trufit(®)) in the osteochondral knee lesions: long-term clinical and MRI assessment in 30 patients.

BACKGROUND: Chondral or osteochondral defects have been reported in 60-67 % of patients in studies reporting knee arthroscopies. The surgical management of chondral and osteochondral defects (OCD's) of the articular surface of the knee joint remains a controversial topic. Osteochondral injuries can be treated with transfer cartilage procedure and with implantation of biodegradable scaffolds. For patients over 50 years old with largest osteochondral lesions, we prefer to use the biodegradable scaffold, like Trufit(®) plug (Smith & Nephew, Andover, MA). The purpose of this study is to evaluate the outcome of this series of surgical procedure with Trufit. METHODS: In our institute, the Trufit was used for the treatment of one or more focal osteochondral lesions of the femoral condyles positive MRI with or without concomitant ligamentous or meniscal pathology. We reviewed 30 patients with mean age of 60.57 years (range 32-79 years) with a clinical and imaging control at 6, 12, 24 and 48 months of follow-up. RESULTS: The clinical evaluation has shown the good outcome. The MRI conducted has shown the progressive partial integration of the scaffolds. CONCLUSIONS: The results obtained indicate a clear improvement of the clinical symptoms and slowing joint degeneration. The clinical and imaging results confirm that the Trufit constitutes a valid surgical alternative in case of focal osteochondral.

Angular stable plates in proximal meta-epiphyseal tibial fractures: study of joint restoration and clinical and functional evaluation.

BACKGROUND: The tibial plateau fractures involve one of the main weight bearing joints of the human body. The goals of surgical treatment are anatomical reduction, articular surface reconstruction and high primary stability. The aim of this study was to evaluate the clinical and functional outcomes after internal plate fixation of this kind of fractures. MATERIALS AND METHODS: From January 2009 to December 2012, we treated 75 cases of tibial plateau fracture with angular stable plates. We used Rasmussen Score and the Knee Society Score for the clinical and functional evaluation. Twenty-five cases that underwent hardware removal had arthroscopic and CT evaluation of the joint. RESULTS: No complications occurred. The clinical and functional evaluation, performed by the KSS and Rasmussen Score, highlighted the high percentage of good-to-excellent results (over 90 %). In every case, the range of motion was good with flexion >90°. Arthroscopy showed the presence of chondral damage in 100 % of patients. In all the cases, we found that X-ray images seem better than the CT images. CONCLUSIONS: Angular stable plates allow to obtain a good primary stability, permitting an early joint recovery with an excellent range of motion. Avoiding to perform a knee arthrotomy at the time of fracture reduction could prove to be an advantage in terms of functional recovery. The meniscus on the injured bone should be preserved in order to maintain good function of the joint. X-ray images remain the gold standard in checking the progression of post-traumatic osteoarthritis.

Atypical femoral fractures: retrospective radiological study of 319 femoral fractures and presentation of clinical cases.

SUMMARY: There is still no clarity on the etiology and epidemiology of atypical femoral fractures. The purpose is to show, after a radiological review, that the incidence of atypical fractures is higher than that reported in the literature when compared to "typical" fractures that occurred in the same anatomical site. INTRODUCTION: At present, it is difficult to define the true incidence of atypical fractures associated with bisphosphonate. Our purpose is to show that the incidence of atypical fractures is higher than that reported in the literature when compared to "typical" fractures that occurred in the same anatomical site. METHODS: The authors analyzed 319 femoral fracture Rxs of patients over 60 who have had access to the PS of Clinical Orthopaedics and Traumatology II of the University of Pisa from January 2011 to February 2013. The atypical fractures have been investigated from clinical point of view, biohumoral exams, densitometry and contralateral femur X-rays, and in one case using SPECT-Tc. RESULTS: The total number of femoral fractures was 319. The medial femur fractures were 60 (46 females and 14 males), and the lateral ones were 316 (237 females and 79 males). Subtrochanteric and diaphyseal fractures were 40 (29 females and 11 males). Among these cases, two atypical fracture cases were related to female patients, one was 79 years old and the other was 77. CONCLUSIONS: The most recent literature reports that the incidence of atypical fractures is 0.6 %. However, taking into consideration only the fracture locations suitable for the identification of atypical fractures, the percentage rises to 5 %. To date, there is still no clarity on the exact etiology of fractures even if it seems to be related to a bone mineral component alteration.

Pseudoarthrosis in atypical femoral fracture: case report.

Atypical femoral fractures can be subsequent to a long-term biphosphonates treatment; they have a high frequency of delayed healing. The authors describe a femoral pseudoarthrosis of an atypical fracture treated with intramedullary nailing in a female after prolonged alendronate therapy. Atypical femoral fractures can be subsequent to a long-term biphosphonates treatment even if, in the literature, there is no clarity on the exact pathogenetic mechanism. The Task Force of the American Society for Bone and Mineral Research described the major and minor features to define atypical fractures and recommends that all the five major features must be present while minor features are not necessary. Another controversial aspect regarding the atypical femoral fractures is the higher frequency of the delayed healing that can be probably related to a suppressed bone turnover caused by a prolonged period of bisphosphonates treatment. This concept could be corroborated by the Spet Tc exam. In the case of a pseudoarthrosis, there is not a standardization of the treatment. In this report, the authors describe a femoral pseudoarthrosis of an atypical fracture treated with intramedullary nailing in a female after prolonged alendronate therapy; the patient was studied with clinical, bioumoral end SPECT-Tc exam of both femurs. Many studies show the relationship between bisphosphonates and the presence of atypical fractures. These fractures should be monitored more closely due to the risk of nonunion and they require considering an initial treatment with pharmacological augmentation to reduce the complications for the patient and the health care costs.

Treatment of pseudoarthrosis of the upper limb using expanded mesenchymal stem cells: a pilot study.

BACKGROUND: In orthopedic field is growing interest in the use of stem cells: this mesenchymal multipotent line (MSCs) can lead to differentiation into osteocytes and thus the formation of bone tissue. In literature applications of this line are described in injuries of tendons and ligaments, small bony avulsions, nonunion fractures and cartilage defects. AIM: Utilize MSCs expanded in laboratory in case of atrophic pseudoarthrosis of the upper limb. MATERIALS AND METHODS: We obtain the amount of cell necessary for the implant by the collaboration with the UO Haematological Department. For the procedure we make a blood sample from the iliac crest bone marrow and a subsequent phase of selection and cultivation of mesenchymal line for 3 weeks, to get a sufficient amount of tissue to be used, which is presented at the time of surgery on a scaffold made by autologous plasma gel and CaCl(2). We reassessed our experience in 8 different types of upper limb fractures result in pseudarthrosis and delayed of consolidation: 4 women and 4 men, average 44 years old followed with a follow-up of 50.3 months. In all cases the site of non-union has been revitalized (by microfractures and drilling) and a synthesis was performed with a rigid plate. So we fill the bone gap with autologous bone and mesenchymal stem cells expanded in the laboratory. RESULTS: We have a radiographic healing in 8 cases and no adverse events were highlighted. CONCLUSIONS: Using this cells line we obtained encouraging but certainly not conclusive impressions, according to the limited number of cases and lack of adequate comparative studies. In tissue engineering are also certainly needed further investigations and developments.

Elastofibroma dorsi: case series of a rare benign tumour of the back.

We analyse this rare pseudotumour with few case reports in the orthopaedic literature. Elastofibroma dorsi is an uncommon benign soft tissue pseudotumour usually located at the lower pole of the scapula. This study is a clinical assessment of 5 patients. All the patients had their diagnosis based on clinical and MRI findings and had excision biopsy. The patients were followed for a mean period of 24 months. No patient had residual symptoms. We have only one recurrence. Surgical excision is recommended when it causes functional disability, compression symptoms, an asymmetric outline of the chest wall, or when it is more than 5 cm in diameter. Pre-operative tissue diagnosis is not necessary in most cases. Despite its rarity, the elastofibroma dorsi should always be suspected with the emergence of a swelling in the subscapularis, especially in females and in old age.

Atrophic femoral nonunion successfully treated with teriparatide.

Teriparatide is a synthetic polypeptide hormone that contains the 1-34 aminoacid fragment of the recombinant human parathyroid hormone. It has been approved for the treatment of postmenopausal women with osteoporosis who are at high risk for sustaining a fragility fracture. It has been shown that teriparatide also accelerates fracture healing by improving the biomechanical properties of the fracture callus, increasing endochondral ossification and bone remodeling in animal models. This effect has been observed in several case reports. Fracture healing disorders negatively affect the patient's quality of life and result in high healthcare costs, as a second surgery is required to stabilize the fracture and stimulate bone biology. Future biotechnologies that accelerate fracture healing may be useful tools. We present a case report of delayed union of a femoral fracture treated with teriparatide. She was diagnosed with right distal metaphyseal femoral fracture on total knee arthroplasty. She underwent surgery at our center consisting of ORIF with lateral femoral locking plate in October 2011. Radiologic controls at 5 and 7 months did not show any signs of healing. After 2 months of treatment with teriparatide, the X-ray showed the presence of bone bridges and a decreased gap between fragments and a different aspect of neoformed bone. After 3 months of treatment, healing was complete. Our case report seems to confirm the possible effect of TPTD as bone induction through a more rapid healing of fractures. The TPTD could have a potentially important role in treating some forms of nonunion and delay in consolidation. Thus, one could hypothesize the possibility of a medical treatment with TPTD both as a preventive way and also as a support to the synthesis in high risk of nonunion fractures and complexed fractures in osteoporotic bone.

Shoulder resurfacing with Durom Cup: clinical and radiological re-assessment.

BACKGROUND: The purpose of this study was to analyze and report functional and radiological results obtained with the Durom™ Shoulder Cup. METHODS: From 2004 to 2009, 42 consecutive shoulder resurfacing prostheses were implanted in a cohort of forty patients with morphologically and functionally healthy rotator cuff. Those cases were evaluated preoperatively and postoperatively after an average of 33.5 months on the basis of Constant score, ASES score, and X-rays. RESULTS: The Constant score increased from 29.88 points preoperatively to 82.34 after a mean follow-up period of 33.5 months. The ASES score went from 30.55 points preoperatively to 76.61. Radiologically we noticed neither radiolucent lines nor any aseptic loosening of the prosthetic cup. In the post-operative X-rays evaluation we found no significant central migration of the humeral head from the first postoperative X-ray. CONCLUSIONS: The good functional results observed with a mean follow-up of approximately 3 years doubtless resulted from the reduction in implant-placement error, as a result of the resurfacing procedure, and from the normal rotator cuff function. This technique facilitates surgical reconstruction of the anatomical and biomechanical conditions required for physiological function of the shoulder.