A different perspective on sofosbuvir-ledipasvir treatment of patients with HCV genotype 1b cirrhosis: The ital-c network study.

The effectiveness of a 12-week course of sofosbuvir-ledipasvir in treatment-experienced HCV genotype 1b-infected patients with cirrhosis is still under debate. Our primary endpoint was to compare the sustained virological response at post-treatment week 12 (SVR12) of sofosbuvir-ledipasvir in combination with ribavirin for 12 weeks, and sofosbuvir-ledipasvir alone for 24 weeks. This was a prospective observational study that enrolled 424 (195 naive, 229 experienced; 164 treated for 12 weeks with Ribavirin and 260 with sofosbuvir-ledipasvir alone for 24 weeks) consecutive HCV genotype 1b-infected patients with cirrhosis. The SVR12 rates were 93.9% and 99.2% in patients treated for 12 and 24 weeks, respectively (P = .002). The baseline characteristics of patients treated for 12 weeks were significantly different from those treated for 24 weeks as regards their younger age (P = .002), prevalence of Child-Pugh class A (P = .002), lower MELD scores (P = .001) and smaller number of nonresponders (P = .04). The shorter treatment was significantly associated with a lower SVR12 in univariate and multivariate analyses (P = .007 and P = .008, respectively). The SVR rate was unaffected by age, gender, BMI, Child-Pugh class, MELD score or previous antiviral treatment. Patients receiving ribavirin experienced more episodes of ascites and headache but less recurrence of hepatocellular carcinoma (HCC), and were prescribed more diuretics and cardiopulmonary drugs. No patient discontinued treatment. The therapeutic regimen of sofosbuvir-ledipasvir plus ribavirin administered for 12 weeks was less effective than sofosbuvir-ledipasvir alone given for 24 weeks. At odds with European guidelines, the recommended 12-week treatment with sofosbuvir-ledipasvir alone might be suboptimal for this setting of patients.

Severe osteolysis and soft tissue mass around total hip arthroplasty: description of four cases and review of the literature with respect to clinico-radiographic and pathologic differential diagnosis.

Periprosthetic osteolysis is a well known phenomenon caused by wear particle-induced bone resorption, particularly common and extensively reported in total hip arthroplasty. Its typical radiographic feature is a radiolucent area adjacent to an implant, sometimes associated with a soft tissue mass. Osteolytic changes may be caused by numerous other pathologic processes, including infection, metabolic disease, and neoplasia. Four cases of massive periprosthetic bone destruction associated with a large soft tissue mass around a failed total hip replacement are presented. In three cases, a diagnosis of periprosthetic osteolysis was correctly made and managed by revision surgery. However, in one case angiosarcoma of the ipsilateral hemipelvis went long unrecognized despite aggressive clinical course, requiring hind-quarter amputation and ultimately resulting in the patient's death. Periprosthetic malignancy in the form of either primary sarcoma or metastatic cancer is a very rare yet reported event in the setting of previous hip replacement, likely leading to catastrophic consequences when diagnosis is not established in a timely manner. The differential diagnosis of periprosthetic osteolysis should consider the entire spectrum of conditions that can present with radiolucent changes. Thorough review of patient's history and course of symptoms, along with careful evaluation of standard roentgenograms should be always performed and possibly integrated with imaging modalities such as CT, MRI, and bone scintigraphy in order to increase diagnostic accuracy. If uncertainty remains, biopsy should always be considered to rule out malignancy.

Evaluation of homoplastic bone graft in hip replacement revision surgery.

A total of 17 patients submitted to hip replacement revision surgery in our clinic between 1986 and 1994 were evaluated in order to analyze the effectiveness of homoplastic support grafting. Loss of substance involved the acetabulum and the femur. Four parameters were evaluated radiographically: fusion time, restructuring time, flattening or collapse of grafts, and, finally, graft resorption. The results showed that the homoplastic graft is characterized by excellent biological behavior, and that the success of the new implant depends mostly on surgical method used as the graft was always integrated quickly and completely. In cases with considerable loss of substance it is important to use means of support that allow for partial unloading of the forces between prosthesis and host bone, thus avoiding excessive loading in the grafts.

Arthrodesis of the knee after tumor resection: a comparison between autografts and allografts.

Cases of arthrodesis of the knee performed after bone tumor resection using autografts (Group I) and allografts (Group II) were compared (follow-up was comparable). The two groups show differences in type of pathology, treatment and length of resection. Nonetheless, the percentage of complications and the final results were similar. Despite the fact that arthrodesis of the knee is used less and less for reconstruction, it is our belief that the use of autografts should be substituted by allografts whenever possible.

Effect of electromagnetic fields on patients undergoing massive bone graft following bone tumor resection. A double blind study.

Massive bone allograft after tumor resection has been used for over 20 years. Many factors negatively influence the healing of the junction between the allograft and the host bone, resulting in a low healing rate and lengthy time to union. This study evaluated whether pulsing electromagnetic field stimulation could be advantageously used in these patients. A double blind prospective randomized study was designed. Eighty three host graft junctions in 47 patients were considered. The overall host graft junction healing rate was the same (67%) in both control and active stimulated patients. Although not statistically significant, a positive effect of pulsing electromagnetic fields was observed for those host graft junctions with a cortico-cortical contact between allograft and host bone. When adjuvant postoperative chemotherapy was not employed, a definite effect of pulsing electromagnetic field stimulation was observed: the healing time decreased from 9.4 months in the control group to 6.7 months in the active stimulated group (p < 0.001). This effect would have been lost if chemotherapy was employed. There was also no advantage in supplement with iliac crest autografts at the host graft junction site if chemotherapy was used. Factors that significantly influenced the host graft junction healing rate were: chemotherapy; type of allograft host bone contact; quality of host graft junction; and, in intercalary allografts, use of the osteosynthesis device. No difference was observed between control and active groups for patient survival or number of local or distal tumor recurrences.

The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study.

A multicentric study was conducted by the European Musculoskeletal Oncology Society on 113 cases of resection for tumors of the major long bones and reconstruction with massive allografts, as intercalary diaphyseal or for arthrodesis. The follow-up was at least 12 months. There was a 14% incidence of infection, with a higher frequency (18.5%) in intercalary grafts as compared to arthrodeses (7%). Fracture of the graft occurred in 15.5% of the cases with a prevalence in the humerus (28.5%) as compared to the tibia (21.4%) and femur (14.7%). Fracture constantly occurred after osteosynthesis with screws, in 16% of the cases after osteosynthesis with a plate, and in 12.5% of the cases after osteosynthesis with an intramedullary nail. It was observed in 32% of the grafts preserved at -30 degrees, in 17% of those irradiated, and in 7% and 7.6% of those preserved at -180 degrees and -80 degrees, respectively. Delayed union and non-union was observed in 57% of the cases: 63% in intercalary grafts, 48% in arthrodeses. Final results after treatment of complications were excellent and good in 63% of the entire series. The results should, however, be evaluated after 3 years, as during this period of time important transformation phenomena of the graft occur. Complications are observed in 75% of the cases, but they may be reduced if planning is correct and surgery is accurate. Each complication may be dealt with and resolved without high risks for preservation of the limb.

Neurogenic arthropathy. Differential diagnosis.

Neurological affections responsible for secondary arthropathic pathology are: tabes, syringomyelia, diabetes mellitus, congenital insensitivity to pain syndrome, alcoholism, leprosy. Each of the affections shows predilection for specific joints: syringomyelia the shoulder, tabes the hip and knee, diabetes mellitus the foot, congenital insensitivity to pain the lower limb, alcoholism the shoulder and knee. The authors discuss two cases of hip arthropathy in previous dorsal myelic fractures.