Bone mineral density as a marker of hip implant longevity: a prospective assessment of a cementless stem with dual-energy X-ray absorptiometry at twenty years.

PURPOSE: Bone remodeling around the femoral component after total hip arthroplasty (THA) is considered to be an important factor in long-term stability and seems to be strictly related to the stem design, coating, and fixation. Stress shielding, micro-movement, and high intra-articular fluid pressure might activate macrophages and osteoclasts, causing progressive bone density decreases. Here we analyze the bone mineral density (BMD) around a cementless femoral stem during a 20-year period to better understand the adaptive bone changes around such implants during long-term follow-up. METHODS: In this retrospective study, 14 patients treated by THA were reviewed from a cohort of 84. Clinical evaluation with Harris Hip Score and radiographic assessment were performed throughout a 20-year follow-up. To evaluate the bone remodeling around the stem, we monitored the femoral BMD in four regions of interest with a dual-energy X-ray absorptiometry (DEXA) post-operatively and at one, two, three, five and 20 years of follow-up. RESULTS: The main BMD changes between the post-operative examination and the 20-year follow-up varied between + 11.19% and + 24.30%. Patients with signs of loosening, low Harris Hip Scores, and pain showed decreasing BMD values. CONCLUSIONS: The correlation between the clinical result and BMD values could suggest DEXA results as a predictor of implant loosening or longevity.

Negative prognostic factors in surgical treatment for trimalleolar fractures.

PURPOSE: Trimalleolar fractures are a common injury of the ankle that require surgical treatment to obtain an anatomic reduction of both malleoli and stabilization of the syndesmosis. This study aims to report the outcomes of surgical treatment for trimalleolar fractures, identifying the risk factors determining a worse result. MATERIALS AND METHODS: Between January 2013 and December 2016, 48 patients with trimalleolar fracture treated with open reduction and internal fixation were retrospectively analyzed. The mean age was 44.69 years, and average body mass index (BMI) was 29.04. According to the Danis-Weber classification, 30 (62.5%) fractures were type B and 18 (37.5%) were type C. Clinical and radiographic evaluations at 3, 6, and 12 months were assessed. The functional results of Visual Analogue Staircases and Olerud-Molander (O&M) ankle score were reported. RESULTS: No significant difference was found among the size of the PM in patients with and without ankle dislocation (p = 0.364). Therefore, there is no correlation between the size of the posterior fragment and the ankle dislocation and the size of the posterior malleolus and syndesmosis stability (p = 0.328). Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures. CONCLUSIONS: Surgical treatment for trimalleolar fractures needs accurate preoperative planning. Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures.

Potential presence of metals in patients treated with metal-metal coupling prostheses for hip arthroplasty at 7 and 10 years of follow-up.

BACKGROUND: Beginning in 2008, metal-on-metal prostheses have been in the spotlight owing to much higher revision rates than expected. Adverse local tissue reactions have been well described in the literature as potential complications. METHODS: Between 2012 and 2013, 13 patients with metal-on-metal total hip replacements were evaluated clinically and radiologically and with laboratory samples. The same tests were repeated between 2015 and 2016 on eight patients to assess any changes. In the laboratory assessment, we searched for chromium, cobalt, molybdenum, and nickel in blood and urine samples over 24 h. RESULTS: Clinical assessment has shown good score in all patients except one. On a second examination, between 2015 and 2016, all patients obtained results similar to those obtained in the first assessment, except a patient, who reported a recent fall. In the radiological assessment between 2012 and 2013, results were optimal, apart from a case of aseptic mobilization. The patients reassessed 3 years after the first examination showed radiological results similar to those previously obtained, apart from a patient, who showed signals of mobilization. Metal levels found in their blood decreased in most cases after 3 years. Urine levels of nickel increased in five subjects, and chromium levels increased in four, but levels of cobalt and molybdenum decreased in four patients. CONCLUSION: It could be hypothesized that the decreasing trend of metal ion levels is associated with a stable wear status. On the contrary, a progressive increase in metal ion levels must be considered as early proof of implant loosening.

ATB-346, a novel hydrogen sulfide-releasing anti-inflammatory drug, induces apoptosis of human melanoma cells and inhibits melanoma development in vivo.

Inflammation plays a key role in tumor promotion and development. Indeed, cyclooxygenase-2 (COX-2) expression is strongly associated with different types of cancer. An emerging class of compounds with significant anti-inflammatory properties is the hydrogen sulfide-releasing non-steroidal anti-inflammatory drugs (H2S-NSAIDs). They consist of a traditional NSAID to which an H2S-releasing moiety is covalently attached. We have recently demonstrated that H2S donors inhibit melanoma cell proliferation. In the current study, we evaluated the potential beneficial effects of a new H2S-releasing derivative of naproxen, ATB-346 [2-(6-methoxynapthalen-2-yl)-propionic acid 4-thiocarbamoyl phenyl ester] which inhibits COX activity but also releases H2S. We used cell culture and a mouse melanoma model to evaluate the effect of ATB-346 on: i) in vitro growth of human melanoma cells; ii) in vivo melanoma development in mice. Cell culture studies demonstrated that ATB-346 reduced the in vitro proliferation of human melanoma cells and this effect was associated to induction of apoptosis and inhibition of NF-κB activation. Moreover, ATB-346 had novel Akt signaling inhibitory properties. Daily oral dosing of ATB-346 (43µmol/kg) significantly reduced melanoma development in vivo. This study shows that ATB-346, a novel H2S-NSAID, inhibits human melanoma cell proliferation by inhibiting pro-survival pathways associated with NF-κB and Akt activation. Furthermore, oral treatment with ATB-346 inhibits melanoma growth in mice. In conclusion, the combination of inhibition of cyclooxygenase and delivery of H2S by ATB-346 may offer a promising alternative to existing therapies for melanoma.

Midterm results of surgical treatment of displaced proximal humeral fractures in children.

PURPOSE: To analyse the clinical outcomes of 26 children treated surgically for displaced proximal humerus fracture. MATERIALS AND METHODS: From January 2008 to December 2012, 26 children/adolescents (14 boys, 12 girls) were treated surgically for displaced fractures at the proximal extremity of the humerus. Ten were grade III and 16 were grade IV according to the Neer-Horowitz classification with a mean age of 12.8 ± 4.2 years. Twenty young patients were surgically treated with a closed reduction and direct percutaneous pinning; six required an open approach. To obtain a proper analysis, we compared the Costant scores with the contralateral shoulder (Δ Costant). RESULTS: The mean follow-up period was 34 months (range 10-55). Two grade IV patients showed a loss in the reduction after percutaneous treatment. This required open surgery with a plate and screws. On average, the treated fractures healed at 40 days. The mean Δ Costant score was 8.43 (range 2-22). There was a statistically significant improvement in the mean Δ Costant score in grade III patients. In grade IV patients, there was a significant improvement in the mean Δ Costant score in those treated with open surgery versus mini-invasive surgery. CONCLUSIONS: Our study shows excellent results with percutaneous k-wires. This closed surgery had success in these patients, and the excellent outcomes noted here lead us to prefer the mini-invasive surgical approach in NH grade III fractures. In grade IV, the best results were noted in patients treated with open surgery. We suggest an open approach for these patients. LEVEL OF EVIDENCE: III.

Treatment of Developmental Dysplasia of Hip With Tubingen Hip Flexion Splint.

BACKGROUND: Developmental dysplasia of the hip is an anomaly of the hip joint. In patients with early diagnosis, within 3 to 6 months of life, the treatment is essentially conservative and involves the use of dynamic harness. The indication for the use of the Tubingen hip flexion splint is a dysplastic hip. The aim of this study is to report the experience of the Orthopaedic Clinic of the "University of Catania" regarding conservative treatment with the Tubingen harness of dysplastic hips diagnosed in children within 3 months of life. METHODS: From January 1997 to July 2012, 5137 infants (10,274 hips) aged within 3 months of life were submitted to ultrasonographic hip assessment. Start, duration of treatment, and outcome were investigated. RESULTS: A total of 351 (6.83%) patients affected by developmental dysplasia of the hip for a total of 544 dysplastic hips (5.3%) were treated with the Tubingen hip flexion splint. Treatment was started on average 39 days of life. Harness were dressed for 24 hours a day and applied for a mean of 3.8 months. Mean follow-up was 6.4 years (range, 2.2 to 14 y). We obtained the following results: 482 (90.44%) dysplastic, unstable, or dislocated hips were successfully converted into type I hips with an α-angle of >64 degrees in the splint. Complications were reported in 3 (0.55%) hips.No statistically significant relationship was found between the duration of therapy and the time when treatment was started, early or late within the first week of life (P=0.152). CONCLUSIONS: Dysplastic, unstable, and dislocated hips can be successfully treated with the Tubingen hip flexion splint, reporting good clinical and ultrasonographic outcomes.

Hypophosphatemic rickets: etiology, clinical features and treatment.

Hypophosphatemic rickets (HR) is a genetic disorder, which prevents sufficient reabsorption of phosphate in the proximal renal tubule, with increased phosphate excretion, resulting in rickets. The more common form of HR is an X-linked inherited trait, with a prevalence of 1/20,000. The defective gene is located on the X chromosome, but females may present with a wide variety of clinical manifestations. The less common form of HR is caused by autosomal-dominant transmission. Activating mutations of the fibroblast growth factor 23 (FGF-23) gene and inactivating mutations in the phosphate regulating gene (PHEX gene with homologies to endopeptidases on the X chromosome), involved in the regulation of FGF-23, have been identified and have been implicated in the pathogenesis of these disturbances. A review of etiopathogenesis and clinical, differential diagnostic and therapeutic aspects of HR, with a particular emphasis on bone impairment, is reported.

Calcaneo-stop procedure in the treatment of the juvenile symptomatic flatfoot.

Flexible flatfoot is the most prevalent condition seen in pediatric orthopedic clinics. It is characterized by an absence of the medial arch and a valgus position of the calcaneus. The purpose of the present study was to report on the results obtained in children treated using the calcaneo-stop procedure. A total of 410 flatfeet in 242 consecutive patients were treated using the calcaneo-stop procedure from January 1999 to March 2010 (10 years, 3 months) and were followed up to February 2012. The mean age at surgery was 11 (range 7 to 14) years, and the mean follow-up duration was 88 (range 14 to 157) months. A clinical evaluation, podoscopic examination, and radiologic assessment were performed in the participating patients preoperatively and at 6 months postoperatively. Of the 242 patients, 168 (69.42%) underwent bilateral foot surgery and 74 (30.58%) unilateral intervention, involving 33 right (44.6%) and 41 left (55.4%) feet. At follow-up, the outcome was satisfactory in 397 feet (96.83%); heel valgus was observed in only 12 feet (2.92%), and the footprint was normalized in 328 feet (80%). The calcaneo-stop procedure is a simple, reliable, and minimally invasive procedure for the treatment of pediatric flexible flatfoot. It allows alignment of the talus and calcaneus, restoring a proper foot arch.

Does age affect outcome in children with clavicle fracture treated conservatively? QuickDash and MRC evaluation of 131 consecutive cases.

BACKGROUND: Non-operative treatment with immobilization is the gold-standard for paediatric clavicular fractures. Purpose of this study is to evaluate functional outcomes and efficacy of non-operative treatment of clavicular fractures in a succession of 131 children. METHODS: Between 2006 and 2012, we treated non-surgically 131 children for a clavicular fracture. All fractures have been classified according to Robinson classification. Clavicle shortening, range of movements and muscular strength through the Medical Research Council (MRC) Scale were evaluated. To assess the outcomes, QuickDASH questionnaire, dividing the sample in 3 age-related group, was administered. RESULTS: The average follow-up was 26 months (8-84 months). Clavicle shortening at the time of injury occurred in 18 cases. All fractures reached union. Average time to union was 34 days. Mean time return to activity was 12.6 weeks. No cases of nonunion or delayed union were reported. Complications occurred in 21 cases. A shortening persisted in 2 cases. Only one patient had a slight functional restriction. Average QuickDASH Score was 6.2±1.1 (range 4.3-9.4). All patients recovered to an MRC Score of 5, except for one patient with a score of 4. Best QuickDASH Scores were observed in the group aged under 8 years and in non-comminuted and lateral third fractures of the clavicle. CONCLUSIONS: Observing results, clavicle fractures have a satisfactory clinical healing as shown by the good scores at QuickDASH and MRC Scale. Younger children under 8 years can achieve the best results with a conservative treatment in terms of bone healing and activity level.

Congenital talipes equinovarus: an epidemiological study in Sicily.

BACKGROUND AND PURPOSE: Congenital talipes equinovarus (clubfoot) can present in 2 forms: "syndromic", in which other malformations exist, and the more common "idiopathic" form, where there are no other associated malformations. We analyzed the epidemiology of congenital talipes equinovarus in the Sicilian population, looking for potential etiological factors. PATIENTS AND METHODS: Among the 801,324 live births recorded between January 1991 and December 2004, 827 cases were registered (560 males; M/F sex ratio: 2.1). Control infants were randomly selected from a historical cohort of live births without any major congenital malformations. RESULTS: A positive family history of clubfoot, gender, and maternal smoking were found to be risk factors for clubfoot. Patients with clubfoot were born most frequently during the period January-March. No association was found between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity. INTERPRETATION: Our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors.

Hip Fractures and Visual Impairment: Is There a Cause-Consequence Mechanism?

BACKGROUND: Numerous studies have pointed out how visual impairment relates to falls in the elderly, causing dangerous consequences, such as fractures. The proximal femur fracture is one of the most frequent fracture types related to poor vision. This study investigates the link between fall-related hip fractures and visual impairment. METHODS: The present is an observational monocentric case-control study. We collected the ophthalmologic anamnesis and measured the visual acuity of 88 subjects with femur neck fracture (case group), comparing it with 101 adults without fractures and a recent fall history. RESULTS: The results showed no statistical difference between the two groups regarding visual acuity, with a p-value of 0.08 for the right eye and 0.13 for the left one. One of the major ophthalmologic morbidities found was cataracts, present in 48% of the control group and 30% of the case group. CONCLUSIONS: The data obtained suggest that visual impairment might not be crucial in determining falls in the elderly.

Use of 3D printing and pre-contouring plate in the surgical planning of acetabular fractures: A systematic review.

BACKGROUND: Acetabular fractures are caused by high energy injuries. The treatment aims to reconstruct the articular surface, restoring the anatomical structure. The surgical management of these fractures is difficult because it requires familiarity with the 3D anatomy of the pelvis. With the use of 3D printing technique for planning surgery, this limitation could be overcome. HYPOTHESIS: Studies examining the use of 3D printing in pre-operative planning of acetabular fractures tend to agree on its usefulness. METHODS: A systematic review of two electronic medical databases was performed by three independent authors, using the following inclusion criteria: any type of acetabular fracture and pre-operative use of 3D printing to plan the surgery. RESULTS: Among 93 screened articles, following selection criteria, six randomised controlled human trials (hRCT) were eligible for the study; articles compare a group in which a pre-contouring plate was performed through 3D printing with a control group in which the plate was intraoperatively modelled. CONCLUSION: This review demonstrates the advantage of 3D printing in terms of surgical time, reduction of blood losses, quality of fracture reduction, and fixation, and reporting best clinical outcomes. LEVEL OF EVIDENCE: II.

Bone Marrow Edema: Overview of Etiology and Treatment Strategies.

➤: Bone marrow edema (BME) is a nonspecific but relevant finding, usually indicating the presence of an underlying pathology. ➤: The gold standard technique for detecting BME is magnetic resonance imaging (MRI), as it allows for a correct diagnosis to be made, which is extremely important given the heterogeneity of BME-related diseases. ➤: Depending on the severity of painful symptomatology and the MRI evidence, different treatment strategies can be followed: physical modalities, pharmacological options, and surgical therapy.

Growing pains: a study of 30 cases and a review of the literature.

BACKGROUND: Data from the literature regarding the clinical profile of growing pains are limited. The purpose of this study was to define the clinical features, familial history, laboratory findings, and therapeutic outcome of growing pains in children. METHODS: Thirty children (18 male and 12 female; 3 to 14 y of age) who presented with growing pains between January 2006 and December 2007 were enrolled and prospectively followed up for 1 year. The inclusion criterion was lower extremity pain, which was recurrent and lasted for >3 months. The exclusion criteria were any abnormal systemic or local symptoms and signs, joint involvement, and limp or limitation of activity. Laboratory tests, including complete blood count, erythrocyte sedimentation rate, and serum calcium and phosphorus levels, were performed in all children. RESULTS: The study group had pain during the night and afternoon in 43.3% and 56.7% of cases, respectively. Both lower limbs were involved in 80% of cases, causing awakening and crying episodes in 40% and 37% of cases, respectively. The frequency of pain was as follows: daily, 5%; weekly, 45%; monthly, 35%; and every 3 months, 15%. The pains were relieved by massaging the affected site in 95% of cases and by analgesics in 5% of children. A family history of growing pains was positive in 20% of patients. All patients had laboratory tests within normal values. CONCLUSION: Growing pain is a frequent noninflammatory syndrome consisting of intermittent, often annoying, pains that affect the lower extremities of children. Clinical diagnosis is easy if precise inclusion and exclusion criteria in the history and physical examinations are strictly followed. Patients and family reassurance is mandatory. LEVEL OF EVIDENCE: This is a Level I prospective study.

Use of different devices for surgical treatment of proximal humerus fractures in adults: a systematic review.

BACKGROUND AND AIM: Proximal humeral fracture is one of the most common osteoporotic fractures in elderly people. The proper treatment choice is controversial. Open reduction and internal fixation (ORIF) with plate and screws is currently the most common treatment for the majority of displaced proximal humeral fractures. The aim of this systematic review is to investigate the surgical treatment outcomes of PHFs, focusing on main used devices and surgical approaches. METHODS: From the earliest record up to 21 July 2020, two independent authors conducted a systematic review of two medical electronic database (PubMed and Science Direct). To achieve the maximum sensitivity of the search strategy, the following terms were combined: "(proximal NOT shaft NOT distal) AND humeral AND fracture AND (plate OR locking plate OR osteosynthesis NOT nail NOT arthroplasty)" as either key words or MeSH terms. The risk of bias of the included studies was assessed, agreeing to the Cochrane Handbook guidelines. RESULTS: Thirty-four articles were initially noticed after the term string research in the two electronic databases. Finally, after full-text reading and analyzing the reference list, 8 studies were selected. The mean age recorded was 69.5 years (Range 67-72). All the studies included two-, three-, four-fragments fracture. Seven studies investigated PHILOS (Synthes, Bettlach, Switzerland) implants results, while one investigated CFR-PEEK plate (PEEK Power Humeral Fracture Plate; Arthrex, Naples, Florida, USA) outcomes or other plates. Deltopectoral and Transdeltoid approaches were the more common used. CONCLUSIONS: Both deltopectoral and transdeltoid approaches are valid approach in plating after proximal humerus fractures, for these reasons, the surgeon experience is crucial in the choice. The more valid implant is still unclear. The develop of prospective randomized comparative studies is strongly encourages.

Dynamic and Static Splinting for Treatment of Developmental Dysplasia of the Hip: A Systematic Review.

BACKGROUND: Developmental dysplasia of the hip (DDH) is one of the most common pediatric conditions. The current gold-standard treatment for children under six months of age with a reducible hip is bracing, but the orthopedic literature features several splint options, and each one has many advantages and disadvantages. The aim of this review is to analyze the available literature to document the up-to-date evidence on DDH conservative treatment. METHODS: A systematic review of PubMed and Science Direct databases was performed by two independent authors (C.d.C. and A.V.) using the keywords "developmental dysplasia hip", "brace", "harness", "splint", "abduction brace" to evaluate studies of any level of evidence that reported clinical or preclinical results and dealt with conservative DDH treatment. The result of every stage was reviewed and approved by the senior investigators (V.P. and G.T.). RESULTS: A total of 1411 articles were found. After the exclusion of duplicates, 367 articles were selected. At the end of the first screening, following the previously described selection criteria, we selected 29 articles eligible for full text reading. The included articles mainly focus on the Pavlik harness, Frejka, and Tubingen among the dynamic splint applications as well as the rhino-style brace, Ilfeld and generic abduction brace among the static splint applications. The main findings of the included articles were summarized. CONCLUSIONS: Dynamic splinting for DDH represents a valid therapeutic option in cases of instability and dislocation, especially if applied within 4-5 months of life. Dynamic splinting has a low contraindication. Static bracing is an effective option too, but only for stable hips or residual acetabular dysplasia.

Use of short stems in revision of standard femoral stem: A case report.

BACKGROUND: Short stems are usually uncemented prosthetics and are recommended in the treatment of traumatic or degenerative diseases of hip. In revision procedures for elderly patients with serious comorbidity, applying a short stem could reduce peri- and post-operative secondary surgical risks to femoral osteotomy, which are necessary for the removal of parts of the implant or acrylic cement from the medullary canal. There are no cases in the literature that apply a short stem for prosthetic revision by acrylic cement anchorage. CASE SUMMARY: A male patient had a left hip replacement in 1995 due to coxarthrosis. At the age of eighty the patient reported an accidental trauma and walked with pain in the left thigh. The X-ray highlighted the stem breakage in the distal section without fracturing the femoral cortex. The patient had various comorbidities (diabetes, anaemia, heart deficiency, and arrhythmia) presenting a high operation risk (ASA 4). During the revision procedure, the distal apex of the stem could not be removed from the femoral cortex. Because of the poor general health of the patient, the surgeon decided not to perform a Wagner femoral osteotomy to remove the distal section of the stem and decided to implant a short stem to avoid removing the stem section of the previous implant. The patient had his left femur X-rayed 15 d post-trauma. CONCLUSION: A field of application of short stem may be the development of a cemented short stem to reduce the complexity of the revision procedure.

Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review.

Background: Rotator cuff tendinopathy (RCT), subacromial impingement (SAIS), and medial (MEP) and lateral (LEP) epicondylitis are the most common causes of upper limb pain caused by microtrauma and degeneration. There are several therapeutic choices to manage these disorders: extracorporeal shockwave therapy (ESWT) has become a valuable option. METHODS: A systematic review of two electronic medical databases was performed by two independent authors, using the following inclusion criteria: RCT, SAIS, MEP, and LEP, ESWT therapy without surgical treatment, with symptoms duration more than 2 months, and at least 6 months of follow-up. Studies of any level of evidence, reporting clinical results, and dealing with ESWT therapy and RCT, SAIS, MEP, and LEP were included. RESULTS: A total of 822 articles were found. At the end of the first screening, following the previously described selection criteria, we selected 186 articles eligible for full-text reading. Ultimately, after full-text reading, and reference list check, we selected 26 articles following previously written criteria. CONCLUSIONS: ESWT is a safe and effective treatment of soft tissue diseases of the upper limbs. Even in the minority cases when unsatisfied results were recorded, high energy shockwaves were nevertheless suggested in prevision of surgical treatment.