Multiplex PCR in septic arthritis and periprosthetic joint infections microorganism identification: Results from the application of a new molecular testing diagnostic algorithm.

Purpose: Pathogen identification is key in the treatment of septic arthritis (SA) and periprosthetic joint infections (PJI). This study evaluates the outcome of the application of a new, score-based SA and PJI diagnostic algorithm, which includes the execution of molecular testing on synovial fluid. Methods: A score-based diagnostic algorithm, which includes serologic and synovial fluid markers determination using multiplex PCR (mPCR) and Next Generation Sequencing (NGS) molecular testing, has been applied to a consecutive series of patients with clinically suspected SA or PJI. Patients with a score ≥6 underwent synovial fluid molecular testing, together with traditional culture, to identify the pathogen and its genetically determined antibiotic resistance. Results: One hundred and seventeen joints in 117 patients (62.5% women; average age 73 years) met the criteria for possible SA/PJI. The affected joint was the knee in 87.5% (joint replacement 66.5%; native joint 21%) and the hip in 12.5% (all replaced joints). 43/117 patients (36.7%) were ultimately diagnosed with SA/PJI. Among the various testing technologies applied, mPCR was the main determinant for pathogen identification in 63%, standard culture in 26%, and mNGS in 11%. Staphylococcus aureus and Enterococcus faecalis were the top two microorganisms identified by mPCR, while Staphylococcus epidermidis was the prevalent organism identified by NGS. mPCR detected the presence/absence of the genetically determined antibiotic resistance of all identified microorganisms. The average timeframe for pathogen identification was 3.13 h for mPCR, 4.5 days for culture, and 3.2 days for NGS. Conclusions: Molecular diagnostic technologies represent an innovative screening for fast microorganism identification when a joint infection is clinically suspected. Level of Evidence: Level IV, case series.

Asymmetric gap balancing improves knee kinematic following primary total knee arthroplasty.

PURPOSE: The purpose of this study was to demonstrate closer-to-normal knee kinematics following primary total knee arthroplasty (TKA) performed establishing asymmetric gap balancing intraoperatively. MATERIAL AND METHOD: Two age-, sex-, BMI-matched groups of patients underwent medially stabilized TKA because of isolated knee disease. Group A (12 patients) underwent "unrestricted" kinematic alignment (uKA) according to Howell while group B (15 patients) received robot-assisted "simplified" KA (sKA) with an alignment goal (Hip-Knee-Ankle axis-HKA) ± 5° respect to the mechanical axis. Intraoperatively, in group B, the flexion gap at 90° was first set at an average of 1.5 mm (0-5 mm; SD 4.4 mm) tighter in the medial compartment with respect to the lateral; in the same way, the extension gap was then set at an average of 2.0 mm (0-4.5 mm; SD 3.1 mm) tighter in the medial compartment with respect to the lateral. All patients, including a non-arthritic cohort (group C: 5 controls) underwent gait analysis using an instrumented treadmill (WalkerView-WV) equipped with an instrumented belt armed with a 3D video camera. The WV software evaluated multiple spatiotemporal and kinematic parameters, including: (1) contact time (s); (2) knee ROM during gait cycle; (3) step length percentage with respect to total gait (%) and pure step length (cm). Statistical analyses included t-Test and ANOVA and were conducted by using SPSS. RESULTS: At the final FU, significant differences were noted during gait between the two TKA groups (uKA-sKA) and the controls. Both TKA groups showed superior mean contact time on the surgical knee (uKA 1 s; sKA 0.97 s) as compared to the controls (0.72 s) (P = 0.002) while no differences were found between them (P = 0.11). TKA groups showed a lower, maximum ROM in the surgical knee (mean uKA 36º; mean sKA 49º) relative to the controls (mean 57º) (P < 0.05) but a statistical difference was found between them (P = 0.003). Both TKA groups showed a higher step length percentage with respect to the total gait and a shorter step length on the surgical side (uKA: mean 8.28% and mean step length 35.5 cm; sKA: mean 8.38% and mean step length 34.6 cm) in comparison to the controls (mean 3.38%; mean step length 71.4 cm) (P < 0.05) while no statistical differences were found between them. CONCLUSION: To our knowledge, this was the first study to exhibit the kinematic advantages of a slightly asymmetric gap balancing during KA TKA. Combining a medially-stabilized implant design and a surgical technique aiming to obtain a tighter medial compartment represents a promising approach to improve outcomes after TKA.

Do working length and proximal screw density influence the velocity of callus formation in distal tibia fractures treated with a medial bridge plate?

INTRODUCTION: Aim of our study was to evaluate the influence of working length and screw density on callus formation in distal tibial fractures fixed with a medial bridge plate. MATERIALS AND METHODS: 42 distal tibia fractures treated with a bridge plate were analyzed. Minimum follow-up was 12 months. mRUST score (modified Radiographic Union Scale for Tibial fractures) was used to assess callus formation. Working length and screw density were  measured from post-operative radiographs. RESULTS: 39 (92.9%) fractures healed uneventfully. 32 (76.19%) patients showed signs of early callus formation 3 months post-surgery. In these patients a lower screw density was used compared to patients who didn't show early callus (33.4 vs. 26.6; p = 0.04). No differences was noticed in working length. CONCLUSION: Bridge plate osteosynthesis is a good treatment option in distal tibia fractures. In our series increasing the working length was not associated with a faster callus formation in distal tibia fractures. Conversely, a lower screw density proximally to the fracture site was associated to a faster callus growth.

Biomechanical considerations for an easily-restricted robot-assisted kinematic alignment: a surgical technique note.

BACKGROUND: In total knee arthroplasty, the normal kinematics of the knee may not be restored solely based on preoperative gait, fluoroscopic-based, and dynamic radiostereometric analyses. SURGICAL TECHNIQUE CASE PRESENTATION: This note introduced a 69-year-old male patient who sustained post-traumatic osteoarthritis of his right knee. He underwent robot-assisted total knee arthroplasty based on anatomical reproduction of knee stability during the swing phase of gait. The kinematic alignment was simply achieved within an easy-to-identified range after preoperative radiographic assessment, intraoperative landmarking and pre-validated osteotomy, and intraoperative range of motion testing. CONCLUSIONS: This novel technique allows personalized and imageless total knee arthroplasty. It provides a preliminary path in reproducing the anatomy alignment, natural collateral ligament laxity, and accurate component placement within safe-to-identified alignment boundaries.

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Joint Infections: A Consecutive Series.

INTRODUCTION: Periprosthetic joint infections (PJI) represent a devastating consequence following total joint arthroplasty (TJA). In this study, the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure (DAIR) to improve the possibilities of retaining an acutely infected TJA. MATERIALS AND METHODS: This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads in a setting of acute (<4 weeks from symptoms onset) PJI with pathogen identification. The combination of three different surgical techniques (tumor-like synovectomy, argon beam/acetic acid application and chlorhexidine gluconate brushing) aims to remove the bacterial biofilm from the implant without explanting the original hardware. RESULTS: In total, 62 patients met the acute infection criteria (<4 weeks of symptoms); there were 57 males and five females. The patients' average age at the time of treatment was 71 years (62-77) and the average BMI was 37 kg/m2. The micro-organism, always identified through synovial fluid analysis (culture, multiplex PCR or Next Generation Sequencing), was an aerobic Gram + in 76% (S. Coag-Neg 41%; S. aureus 16%), Gram-in 10% (E. coli 4%) and anaerobic Gram + in 4%. The DAPRI treatment was performed at an average of 3 days from symptoms onset (1-7 days). All patients underwent a 12-week course of post-operative antibiotic therapy (6 weeks I.V. and 6 weeks oral). All patients were available at the 2-year minimum FU (24-84 months). A total of 48 (77.5%) patients were infection-free at the final FU, while 14 patients underwent 2-stage revision for PJI recurrence. In total, four patients (6.4%) had a prolonged drainage from the wound after placement of the calcium sulphate beads. CONCLUSIONS: This study suggests that the DAPRI technique could represent a valid alternative to the classic DAIR procedure. The current authors do not recommend this procedure outside of the main inclusive criteria (acute scenario micro-organism identification).

The risk of infection in open distal tibial fracture: the DANGER score.

INTRODUCTION: Open fractures of the distal tibia can be functionally devastating, and they remain one of the most challenging injuries treated by trauma surgeons usually burdened with a high rate of complications, including surgical site infections (SSI). Our aim is to analyze the most significant risk factors of SSI and propose a new scoring system-called the DANGER scale-potentially able to predict reliably and quantify the infection risk in distal tibia open fractures. METHODS: We identified six variables summarized in the acronym DANGER where D stands for Diabetes, A for Antibiotic, N for Nature of trauma (high- or low-energy trauma), G represents Grade of fracture following the AO/OTA classification, E indicates Exposure of the fracture according to the Gustilo-Anderson classification, and R represents Relative risk of patient, including use of tobacco, alcoholism, and psychiatric disorders. Therefore, total score ranged from 1 to 14, with a lower score indicating less risk to develop SSI. RESULTS: A total of 103 patients with open distal tibial fractures were enrolled, 12 patients (11.6%) developed SSI. Regarding DANGER score, a rating of 8.2 was calculated in SSI group and 4.8 in non-SSI group. Based on Fisher's test, diabetes (odds = 31.8 p < 0.05), grade of articular involvement (p < 0.05), severity of open fracture (p < 0.05), and dangerous behavior such as use of tobacco, alcoholism, and psychiatric disorders (p < 0.05) were significantly correlated with infection. Significant difference between total DANGER scores in SSI and non-SSI groups was found (p < 0.001). ROC curve was calculated founding a potential threshold of 7.5 (p < 0.001). CONCLUSION: Based on the above well-accepted risk factors, DANGER scale represents an advantageous and practical tool in order to readily estimate the risk of surgical site infection of open distal tibial fractures.

Native knee kinematics is not reproduced after sensor guided cruciates substituting total knee arthroplasty.

PURPOSE: Gait analysis was used to evaluate knee kinematics in patients who underwent successful primary total knee arthroplasty (TKA) using two modern bi-cruciate substituting designs. The knee joint was balanced intraoperatively using real-time sensor technology, developed to provide dynamic feedback regarding stability and tibiofemoral load. The authors hypothesized that major differences exist in gait parameters between healthy controls and post-TKA patients. METHODS: Ten patients who underwent successful TKA using bi-cruciate substituting designs were evaluated at a minimum of 9 months postoperatively using three-dimensional knee kinematic analysis; a multi-camera optoelectronic system and a force platform were used. Sensor-extracted kinematic data included knee flexion angle at heel-strike (KFH), peak midstance knee flexion angle (MSKFA), maximum and minimum knee adduction angle (KAA) and knee rotational angle at heel-strike. Multiple gait analysis data from the study group were compared to a group of ten healthy controls who were matched by age, sex and BMI. Clinical outcome in the TKA group was also measured using the Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Clinically, at final follow-up, a statistically significant difference in pain, general symptoms, and activities of daily living was seen between the groups. From a gait analysis standpoint, TKA patients had significantly less rotation at heel strike (p = 0.04), lower late stance peak extension moments (p = 0.02), and less Knee Adduction Angle excursion during swing phase (p = 0.04) compared to the control group. No statistically significant difference was observed for knee flexion angle at heel strike, knee adduction moment, or peak knee flexion moment between the groups. CONCLUSIONS: Modern bi-cruciate substituting TKA designs failed to reproduce normal knee kinematics. The lack of full knee extension during the stance phase, absence of the "screw-home mechanism" typical of an ACL functioning knee, and the reduced fluctuation in knee adduction angle during the swing phase still represent major proprioceptive and muscular recruitment differences between normal and replaced knees.

A modified anterolateral swashbuckler approach for distal femoral fractures: description and outcomes.

BACKGROUND: The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures. METHODS: The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with an AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system. RESULTS: Twelve patients (2 males and 10 females) with a mean age of 67,8 years were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded. CONCLUSIONS: The modified swashbuckler approach allows anatomical reduction and appropriate fixation without sacrificing the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.

Nanotechnology as an Anti-Infection Strategy in Periprosthetic Joint Infections (PJI).

BACKGROUND: Periprosthetic joint infection (PJI) represents a devastating consequence of total joint arthroplasty (TJA) because of its high morbidity and its high impact on patient quality of life. The lack of standardized preventive and treatment strategies is a major challenge for arthroplasty surgeons. The purpose of this article was to explore the potential and future uses of nanotechnology as a tool for the prevention and treatment of PJI. METHODS: Multiple review articles from the PubMed, Scopus and Google Scholar databases were reviewed in order to establish the current efficacy of nanotechnology in PJI preventive or therapeutic scenarios. RESULTS: As a prevention tool, anti-biofilm implants equipped with nanoparticles (silver, silk fibroin, poly nanofibers, nanophase selenium) have shown promising antibacterial functionality. As a therapeutic tool, drug-loaded nanomolecules have been created and a wide variety of carrier materials (chitosan, titanium, calcium phosphate) have shown precise drug targeting and efficient control of drug release. Other nanotechnology-based antibiotic carriers (lipid nanoparticles, silica, clay nanotubes), when added to common bone cements, enhanced prolonged drug delivery, making this technology promising for the creation of antibiotic-added cement joint spacers. CONCLUSION: Although still in its infancy, nanotechnology has the potential to revolutionize prevention and treatment protocols of PJI. Nevertheless, extensive basic science and clinical research will be needed to investigate the potential toxicities of nanoparticles.

Next generation sequencing for pathogen detection in periprosthetic joint infections.

Periprosthetic joint infections (PJI) represent one of the most catastrophic complications following total joint arthroplasty (TJA). The lack of standardized diagnostic tests and protocols for PJI is a challenge for arthroplasty surgeons.Next generation sequencing (NGS) is an innovative diagnostic tool that can sequence microbial deoxyribonucleic acids (DNA) from a synovial fluid sample: all DNA present in a specimen is sequenced in parallel, generating millions of reads. It has been shown to be extremely useful in a culture-negative PJI setting.Metagenomic NGS (mNGS) allows for universal pathogen detection, regardless of microbe type, in a 24-48-hour timeframe: in its nanopore-base variation, mNGS also allows for antimicrobial resistance characterization.Cell-free DNA (cfDNA) NGS, characterized by lack of the cell lysis step, has a fast run-time (hours) and, together with a high sensitivity and specificity in microorganism isolation, may provide information on the presence of antimicrobial resistance genes.Metagenomics and cfDNA testing have reduced the time needed to detect infecting bacteria and represent very promising technologies for fast PJI diagnosis.NGS technologies are revolutionary methods that could disrupt the diagnostic paradigm of PJI, but a comprehensive collection of clinical evidence is still needed before they become widely used diagnostic tools. Cite this article: EFORT Open Rev 2021;6:236-244. DOI: 10.1302/2058-5241.6.200099.

Kinematic Comparison between Medially Congruent and Posterior-Stabilized Third-Generation TKA Designs.

Background: This study compares knee kinematics in two groups of patients who have undergone primary total knee arthroplasty (TKA) using two different modern designs: medially congruent (MC) and posterior-stabilized (PS). The aim of the study is to demonstrate only minimal differences between the groups. Methods: Ten TKA patients (4 PS, 6 MC) with successful clinical outcomes were evaluated through 3D knee kinematics analysis performed using a multicamera optoelectronic system and a force platform. Extracted kinematic data included knee flexion angle at heel-strike (KFH), peak midstance knee flexion angle (MSKFA), maximum and minimum knee adduction angle (KAA), and knee rotational angle at heel-strike. Data were compared with a group of healthy controls. Results: There were no differences in preferred walking speed between MC and PS groups, but we found consistent differences in knee function. At heel-strike, the knee tended to be more flexed in the PS group compared to the MC group; the MSKFA tended to be higher in the PS group compared to the MC group. There was a significant fluctuation in KAA during the swing phase in the PS group compared to the MC group, PS patients showed a higher peak knee flexion moment compared to MC patients, and the PS group had significantly less peak internal rotation moments than the MC group. Conclusions: Modern, third-generation TKA designs failed to reproduce normal knee kinematics. MC knees tended to reproduce a more natural kinematic pattern at heel-strike and during axial rotation, while PS knees showed better kinematics during mid-flexion.

First metatarsal extracapsular osteotomy to treat moderate hallux valgus deformity: the modified Wilson-SERI techinique.

From February 2017 to December 2018, 20 patients had undergone the proposed modified Wilson-SERI osteotomy technique, for moderate hallux valgus. The mean age of patients was 58,25 years (range 19 to 78). The hallux valgus angle (HVA), the intermetatarsal angle between first and second metatarsal bone (IMA) and the distal metatarsal articular angle (D.M.A.A) were measured. The feet were assessed based on the scoring system used by Broughton and Winson and by the American Orthopedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. All twenty one patients were followed up postoperatively for a minimum of 12 months. The mean HVA angle decreased significantly from 31,1° before surgery (range 22.9°-40°SD 5.0) at 11,2° (range 2.5° to 22.0°SD 5.3) at twelve months follow up. The mean IMA angle decreased significantly from 12,5° (range 8.0°-18.6°SD 3.8) before surgery at 7,4° (range 3.4°-14.0°SD 2.5) at twelve months follow up. The mean DMMA angle decreased significantly from 15.1° (range 5.3° to 20.0°SD 4.4) before surgery at 7,4 °(1.5°- 10.7°SD 2.5) at twelve months follow up. The mean score according to the AOFAS forefoot was increased from 22,1 (range 13-30 SD 5.0) to 88,2 (Range 77-96 SD 5.2) (p<0.0001). No complications, like dislocations, avascular necrosis of the first metatarsal and deep venous thrombosis, were observed in the post-operative period. Short term results at twelve months after surgery are quite satisfactory but further studies are necessary, to better comprehend an overall outcome of such approach in the long run.

Sensor-guided technology helps to reproduce medial pivot kinematics in total knee arthroplasty.

METHODS: Two cohorts of 50 patients each were preoperatively matched to receive the same TKA, having a J-curve femoral design with an adapted "medially congruent" polyethylene insert; the second cohort (group B) underwent the intraoperative sensor-check. Intraoperative sensor data were recorded as tibiofemoral load at 10°, 45°, and 90°. We considered stable knees those with a pressure <50 lbs on the medial compartment, <35 lbs on the lateral, and a mediolateral inter-compartmental difference <15 lbs. Clinical outcomes were evaluated according to the Oxford Knee Score (OKS) and Knee Society Score (KSS). RESULTS: All patients (group A: no sensor; group B: sensor) were available at 2-year minimum follow-up (FU; min. 24 months, max. 34 months); no preoperative statistical differences existed between groups in the average range of motion (ROM), OKS, KSS, and body mass index. There were no statistical differences at final FU between groups in the average OKS (group A: 41.1; group B: 41.5), in the average KSS (group A: 165.7; group B: 166.3), or in final ROM (group A: 123°; group B: 124°). One patient in each group required a manipulation under anesthesia. In the sensor group, an accessory soft tissue release/bone recut was necessary after sensor testing with trial components in 24% to obtain the desired loads; in the same group, the level of constraint in the final components was increased to posterior-stabilized in 12% because of an inter-compartmental difference >40 lbs. Surgical time was 8 min longer in the sensor group. CONCLUSION: The use of this sensing technology did not improve the clinical outcome but supported multiple intraoperative decisions aimed to better reproduce the medial pivot kinematic of the normal knee.

Debridement, antibiotic pearls, and retention of the implant in the treatment of infected total hip arthroplasty.

In this article the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining a total hip arthroplasty (THA) undergoing acute periprosthetic joint infection (PJI). This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads. The combination of 3 different surgical techniques (tumour-like synovectomy, Argon Beam application and chlorhexidine gluconate brushing) might enhance the disruption and removal of the bacterial biofilm which is the main responsible of antibiotics and antibodies resistance. The timing of the diagnosis (6 weeks from the original surgery or 1 week from clinical symptoms appearance in the case of an hematogenous infection) and the preoperative isolation of the germ are fundamental in order to obtain a satisfactory outcome. A 12-week course of postoperative antibiotic therapy (6 weeks I.V. and 6 weeks oral) complete the postoperative protocol used by the authors.The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous PJI.

No clinical differences at the 2-year follow-up between single radius and J-curve medial pivot total knee arthroplasty in the treatment of neutral or varus knees.

PURPOSE: Modern total knee arthroplasty (TKA) systems are designed to reproduce the normal knee kinematics and improve patient outcome. The authors compared two different third-generation medial pivot TKA implants, having a single-radius or a J-curve design in their sagittal plane, hypothesizing no clinical differences. METHODS: Two cohorts of 50 patients who underwent primary TKA were first preoperatively matched by sex, deformity, body mass index (BMI), Oxford Knee Score (OKS), Knee society score (KSS) and range of motion (ROM) and then statistically analyzed at a minimum follow-up (FU) of 2 years. An identical surgical technique, which aimed to reproduce a slightly tighter medial than lateral compartment, was used in all knees. RESULTS: At a minimum follow-up of 2 years (range 24-34 months) there were no statistically significant differences in OKS and KSS between the two implant groups. The final ROM differed statistically between the two groups: the average maximum active flexion was 123° in the J-curve femoral design group with an adapted "medially-congruent" polyethylene insert, and 116° in the single radius femoral design with a medial "ball-in-socket" articulation. CONCLUSION: No clinical and radiological differences were found when the two cohorts of patients were compared. This study showed that the implant design played a minor role in the final outcome as opposed to a precise surgical technique. LEVEL OF EVIDENCE: Retrospective case-control study, Level III.

Sensor guided unicompartmental to total knee arthroplasty revision: Surgical technique.

Unicompartmental Knee Arthroplasty (UKA) is an effective surgical option for managing unicompartmental knee osteoarthritis; it represents 10% of all knee arthroplasties worldwide, increasing 32.5% annually in the United States alone. Despite evolution in surgical technique and implant design, success rate and long-term survivorship of UKA have been historically lower than Total Knee Arthroplasty (TKA). The most common causes of UKA failure leading to revision are polyethylene wear, progression of arthritis, aseptic loosening and patella-femoral symptoms due to poor patient selection in many cases. Historically, UKA revisions have presented technical challenges mainly related to managing residual bone defects and ligament insufficiency ultimately leading to knee instability: the fear of instability has often pushed surgeons to lower the threshold for an increase of the intra-articular level of constraint. Unfortunately, the use of more constrained implants requires sacrificing bone stock and has been related to higher rates of re-revision secondary to recurrence of aseptic loosening. Because of these challenges, the authors developed a surgical technique that could combine balancing the knee during revision surgery with the use of the less constrained polyethylene option. To achieve this, we started evaluating a novel device (VERASENSE, Orthosensor, FL) designed to support soft tissue balancing during primary TKA. This intraoperative sensing technology dynamically quantifies intra-articular loads during TKA trial with the goal of correcting any residual imbalance in real time. Herein we propose a novel surgical technique, which might allow use of a primary TKA design characterized by a lower level of constraint, instead of a constrained or hinged revision knee system, during UKA revision. A key aspect of this technique is the use of sensing technology during intraoperative stability testing.

Detachment of Extensor Carpi Ulnaris and Anterior Branches of the Radial Collateral Ligament from the Epicondyle: A Modification of Kocher Lateral Approach for the Treatment of Radial Head Fractures.

Purpose The aim of this study is to present clinical results of a retrospective case series that includes patients treated with an extensive modification of the Kocher lateral approach to the elbow with surgical detachment of the anterior branches of the radial collateral ligament. Methods From January 2016 to January 2018, nine patients with closed isolated displaced or multifragmentary radial head fractures (Mason type II, III, or IV) who underwent osteosynthesis or arthroplasty through a modified Kocher lateral elbow approach were available for follow-up. Results There were six female and three male patients. The median age at the time of surgery was 52 years old (range: 26-70). The dominant upper limb was injured in 22.2% of patients. After a median follow-up of 8 (range: 6-27) months, all patients regained completely all their daily activities and no cases of infections were recorded. Conclusion We believe that the approach proposed can be a useful choice to deal with these challenging injuries. Our strategy may represent a valid alternative to more popular approaches as the use of anchors decreases the risk of instability that is the major danger considered in the past when soft tissues as tendons and ligaments are detached. Level of Evidence This is a level IV study (therapeutic case series).

A remarkable pattern of a tibial plateau fracture - use of a safe technique with practical advantages in the surgical field.

Bicondylar plateau fractures are complex injuries often requiring a challenging treatment. We report a case of a 68 year-old-male patient with a complicated tibial plateau bicondylar fracture. The fracture of the tibial plateau involved all columns (lateral, medial, posterior). The fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions. Posterior-medial and the medial plating result in increased stability. The posteromedial approach to the knee that we used in our case, offers various advantages. We recommend the option of the posteromedial access, as an approach that allows excellent control of the posterior involvement of this pattern of tibial plateau fracture.

Plate fixation in periprosthetic femur fractures Vancouver type B1: preliminary report of macroscopic evaluation of the cement mantle and short literature review.

he goal of our preliminary report is to investigate hip stem stability and intra-operative cement mantle integrity after screw insertion in plate fixation of periprosthetic Vancouver B1 femur fractures. From a cohort of 50 patients with a periprosthetic femur fracture treated in our department from February 2012 until February 2017, we included in our study patients with a periprostethic Vancouver B1 femoral fracture in cemented hip arthroplasty and hemiarthroplasty, operated with ORIF using a 4.5/5.0 LCP Proximal Femoral Hook Plate ® (Synthes, Switzerland) with at least one screw perforating the cement mantle. Anteroposterior and lateral femur views and pelvis X-rays were performed preoperatively. The stability of the hip implant and the cemented mantle integrity was evaluated intra-operatively in a macroscopic way and with a post-operative X-ray in anteroposterior and lateral views. Only 7 patients satisfied the inclusion criteria; no lesion/break of the cement mantle occurred intra-operatively at any step during drilling or screw insertion, also confirmed with C-arm assessment. No cases of stem mobilization were found and cement mantle integrity was maintained in every case. Insertion of screws around a cemented stem for plate fixation in periprosthetic femur fractures Vancouver type B1 could be considered a safe procedure. However, further and more extended studies are necessary for proving additional knowledge at the evaluation of the cement mantle in osteosynthesis procedures.