Outcome of surgically treated acetabular fractures: risk factors for postoperative complications and for early conversion to total hip arthroplasty.

INTRODUCTION: The gold standard of Acetabular fractures treatment is open reduction and internal fixation (ORIF). Our purpose is to assess the short- to medium-term outcomes and complications of surgically treated acetabular fractures. We analysed factors influencing clinical outcomes, incidence of complications and predictors of conversion in total hip arthroplasty (THA). MATERIALS AND METHODS: We retrospectively analysed 102 patients with acetabular fracture surgically treated between December 2017 and September 2020. We evaluated the quality of reduction with x-ray measuring residual displacement, classified into 3 groups (Matta Radiological Score). At the final follow-up, radiographs were graded according to Matta's Radiological Outcome Grading, and the clinical outcomes were graded using Oxford Hip Score (OHS). RESULTS: 62 patients were enrolled. OHS was influenced by quality of reduction (p = 0.031), injury severity score (ISS) (p = 0.003) and BMI > 30 (p < 0.0001). The late sequelae were heterotopic ossification (HO) in 13 patients, osteoarthritis (OA) in 22 and avascular necrosis (AVN) in 4. HO was significantly affected by posterior approach and ISS > 15. The analysis showed a correlation between AVN and posterior hip dislocation. OA had a correlation with postoperative quality of reduction (p = 0.014). Eight patients required THA with a significant correlation between THA and posterior dislocation, isolated posterior wall fracture and ISS > 15. CONCLUSION: A high rate of patients with acetabular fractures still develop complications and require THA. Identification of predictors for poor outcome may help to inform surgical decision-making regarding options of plate osteosynthesis or 'Fix and Replace', to avoid poor outcomes and early revision surgery.

Periprosthetic femoral fractures in Total Hip Arthroplasty (THA): a comparison between osteosynthesis and revision in a retrospective cohort study.

BACKGROUND: Periprosthetic femoral fractures are challenging complications of hip arthroplasty. They are supposed to be a rare complication, but their incidence is rapidly increasing. Surgical treatment aims to achieve early mobilization and avoid the complications of prolonged bed rest. Aim of this study is to evaluate the clinical outcomes of surgical treatment comparing two surgical approaches: revision arthroplasty (RA) versus open reduction and internal fixation (ORIF). METHODS: Authors retrospectively reviewed a series of 117 patients with total hip arthroplasty treated for periprosthetic femur fractures in the period between January 2013 and March 2018 at a single tertiary referral center. Of these, 70 patients satisfied strict inclusion criteria. Patients were classified according to the Unified Classification System (UCS) and distributed in two groups according to surgical treatment. Clinical outcomes were assessed using the Oxford Hip recorded preoperatively and post operatively, Barthel Score, CIRS score (Cumulative illness rating scale), type of fracture and post-operative complications with a minimum follow up of 1 year. RESULTS: Nominal univariate statistical analysis revealed significant differences between the post and pre-operative Oxford Hip Score (Δ Oxford) and the surgical treatment (p = 0.008) and CIRS score (p = 0.048). Moreover, we observed a significant relationship between type of treatment and type of fracture (p = 0.0001). Multivariate analyses revealed that CIRS score was independently associated with Oxford Score improvement after surgery (p = 0.024). CONCLUSIONS: Data from this case series confirmed that surgical treatment was correlated to type of fracture, according to UCS classification. Patients treated by RA had a better functional outcome than patients treated with ORIF, but these results are strongly influenced from the patients' age, Barthel index and CIRS score. Also, authors found a correlation between functional outcome and comorbidities evaluated by CIRS score. Based on these data we suggest a multimodal approach to these patients, like those used for proximal femoral fractures.

The use of an injectable calcium sulphate/calcium phosphate bioceramic in the treatment of osteonecrosis of the femoral head.

PURPOSE: The purpose of our study is to describe the rationale, the surgical technique and the early clinical and radiographic results of the treatment of patients with early stage osteonecrosis of the femoral head (ONFH) by performing: core decompression, injection of autologous bone marrow concentrate and the use of a new composite injectable bone substitute (PRO-DENSE(®)), as a mechanical supplementation associated with decompression. METHODS: The study included 37 hips (31 patients, 14 females, 17 males; mean age 43.9 years, range 24-56 years) with stages IC-IIIA ONFH. The outcome was determined by the changes in the Harris hip score (HHS), by progression in radiographic stages and by the need for hip replacement. The mean follow-up was 20.6 months (range 12-32 months). RESULTS: At final follow-up the mean HHS increased from 68 points pre-operatively to 86 points post-operatively. The radiological results showed that 29 hips (78.4 %) improved or had no further collapse. The overall clinical success rate of the procedure was 86.5 %, with three conversions to THA, and a failure rate of only 3.3 % in the pre-collapse group. CONCLUSIONS: We are encouraged by these early results using core decompression, injection of the autologous bone marrow concentrate and backfilling the defect with an injectable bioceramic for the treatment of early stages of ONFH; as far as a conclusion can be drawn from the current data, this treatment seems to relieve hip pain and prevent the progression of ONFH in the majority of the cases.

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.

Surgical technique: extraarticular knee resection with prosthesis-proximal tibia-extensor apparatus allograft for tumors invading the knee.

BACKGROUND: Intraarticular extension of a tumor requires a conventional extraarticular resection with en bloc removal of the entire knee, including extensor apparatus. Knee arthrodesis usually has been performed as a reconstruction. To avoid the functional loss derived from the resection of the extensor apparatus, a modified technique, saving the continuity of the extensor apparatus, has been proposed, but at the expense of achieving wide margins. In tumors involving the joint cavity, the entire joint complex including the distal femur, proximal tibia, the full extensor apparatus, and the whole inviolated joint capsule must be excised. We propose a novel reconstructive technique to restore knee function after a true extrarticular resection. DESCRIPTION OF TECHNIQUE: The approach involves a true en bloc extraarticular resection of the whole knee, including the entire extensor apparatus. We performed the reconstruction with a femoral megaprosthesis combined with a tibial allograft-prosthetic composite with its whole extensor apparatus (quadriceps tendon, patella, patellar tendon, and proximal tibia below the anterior tuberosity). PATIENTS AND METHODS: We retrospectively reviewed 14 patients (seven with bone and seven with soft tissue tumors) who underwent this procedure from 1996 to 2009. Clinical and radiographic evaluations were performed using the MSTS-ISOLS functional evaluation system. The minimum followup was 1 year (average, 4.5 years; range, 1-12 years). RESULTS: We achieved wide margins in 13 patients (two contaminated), and marginal in one. There were three local recurrences, all in the patients with marginal or contaminated resections. Active knee extension was obtained in all patients, with an extensor lag of 0° to 15° in primary procedures. MSTS-ISOLS scores ranged from 67% to 90%. No patients had neurovascular complications; two patients had deep infections. CONCLUSIONS: Combining a true knee extraarticular resection with an allograft-prosthetic composite including the whole extensor apparatus generally allows wide resection margins while providing a mobile knee with good extension in patients traditionally needing a knee arthrodesis. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Obturator dislocation of the hip associated with ipsilateral quadrilateral plate fracture: A rare case report.

Traumatic hip dislocations typically result of high-energy trauma and frequently involve young patients. The obturator dislocation is not a common condition and rarely combined with acetabular fracture. We report a rare case of a 48-year-old male patient with a trauma of the left hip following a car-vs-car frontal accident. He presented with an obturator hip dislocation combined with ipsilateral quadrilateral plate fracture. The patient underwent a clinical and imaging evaluation to identify the acetabular fracture dislocation. The CT scan showed a severe dislocation of the acetabular medial wall. Closed reduction under conscious sedation was performed in Emergency Department. The patient underwent open reduction and internal fixation. During surgery, obturator nerve was entrapped inside the fracture rim and then it was released. No intra-operative complications were observed. The patient was followed, with accurate clinical and radiological follow up assessments for 24 months reporting excellent clinical outcomes according to Oxford Hip Score (47/48 points), a good hip range of motion and a complete recovery of basic activities of daily living. After two years of follow-up, no evidence of femoral head necrosis was reported and the patient returned to sport activity.

A rare case of avulsion fracture of the iliac crest apophysis in a young female athlete.

Avulsion fractures of the iliac crest in the adolescent are rare injuries poorly described in literature. The rarity of this injury along with the late ossification of the growth plate of the iliac crest can lead to misdiagnosis and improper treatment. In presence of high clinical suspicion and negative x-ray findings, second level imaging is advisable. Case reports and some case series report on successful outcome of both surgical and non-surgical treatment. We present the case of a fifteen year old female athlete who sustained an avulsion fracture of the iliac crest during a running race. The patient was treated conservatively and returned to previous sport activities after four months from injury. Mechanism of injury, diagnostic options and treatment opportunities are also described.

Subtrochanteric fractures: two case reports of non-union treatment.

Proximal femoral fractures are a very common disease which affect elderly patients after low energy trauma, but can also affect the young population as a consequence of high energy trauma. Classification of sub trochanteric fractures has not yet been clearly defined representing a major issue in comparing different treatment techniques among the scientific literature.These fractures are well known by orthopaedic surgeons for intraoperative difficulties in reduction and post-operative high rate of non-unions and malunions.We present two clinical cases, one treated with an intramedullary device and one with an extramedullary device, both failed and revised with open surgery using a condylar angled bladeplate, following AO principles of anatomical reduction and stable fixation.

Late treatment-related complications in 214 patients with extremity soft-tissue sarcoma treated by surgery and postoperative radiation therapy.

BACKGROUND: We assessed the occurrence of long-bone fracture and other side effects in a group of 214 consecutive patients who underwent radical excision for soft-tissue sarcoma of the limb followed by postoperative irradiation. METHODS: Two hundred fourteen patients underwent postoperative irradiation after radical excision of soft-tissue sarcoma of the limb; 156 (73%) received postoperative brachytherapy (BRT) plus external-beam radiation therapy (EBRT), and 58 (27%) underwent postoperative EBRT only. All patients were followed-up for a median time of 4.5 years (range 3 months to 10 years). RESULTS: Seven patients developed bone fracture, which is considered severe morbidity; time between surgery and occurrence of fracture ranged between 10 and 72 months (average 31). Severe sclerosis with impairment of limb function was diagnosed in 5 and peripheral nerve damage in 3 patients. Wound complications were detected in 8 patients. CONCLUSIONS: In our series, no statistically significant correlation between bone fracture and clinical features or "technical" parameters was found, but all of the patients who experienced bone fracture (7 of 7) were postmenopausal women >55 years old.

Well-differentiated chondrosarcoma of the humerus with prominent granular cell component: a hitherto unreported occurrence.

We report the case of a well-differentiated chondrosarcoma of the proximal humerus in a 60-year-old man that featured a prominent component of granular cells, the granules being shown by electron microscopy to be lysosomal. Although secondary granular cell changes have been described in a large variety of tumor types, this is, to the best of our knowledge, the first documentation of this phenomenon in a skeletal chondrosarcoma.

Modular Endoprostheses for Nonneoplastic Conditions: Midterm Complications and Survival.

The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1-167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (p = 0.921), nor to the reconstruction site (p = 0.402). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (p = 0.851). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease.

A new protocol of surgical treatment of long bone metastases.

Background. The choice of proper treatment way is one of the most important things in surgically treated long bones metastases.
The aim of this research was evaluation of the treatment way according to neoplasm's type and metastasis localisation and spreading.
Material and methods. The evaluation underwent 158 patients who were divided in 4 groups. The first one consists of 13 patients with single metastasis of cancer with good prognosis. In the second group were 69 patients with bone fracture. The third group included 36 patients with such bone destruction that fracture was expected. The last fourth one had 40 patients with osteoblastic metastases or osteolitic in unloaded bones.
Results and Discussion. In group I long lasting reconstructive implants are required and postoperative irradiation is recommended, in groups II and III the aggressiveness of treatment should be related to three parameters: survival expectancy, mechanical properties of the affected bone, predictive response to adjuvants. Based on the above parameters the quidelines of the protocol allow to identify the most appropriate reconstructive indication for every single case ranging from simple osteosynthesis (bad prognosis, low fracture risk, goodresponse to adjuvants) to prosthetic replacement (good prognosis, high fracture risk, bad response to adjuvants). Patients from group IV were admitted to oncology treatment ward after biopsy.

Cost effectiveness of tibial nonunion treatment: A comparison between rhBMP-7 and autologous bone graft in two Italian centres.

Current evidences show that recombinant human bone morphogenetic protein 7 (rhBMP-7, eptotermin alfa) can be considered an effective alternative to autologous bone graft (ABG) in the treatment of tibial nonunions. Few studies, so far, have analysed the costs of treating tibial nonunions with either rhBMP-7 or ABG and none of them has specifically considered the Italian situation. The aim of the present study was to capture, through observational retrospective methods, the direct medical costs associated with the treatment of tibial nonunions with rhBMP-7 or ABG in Italy and to compare the cost effectiveness of the two interventions. The secondary objective was to perform a cost-reimbursement analysis for hospitalisations associated with the two treatments. Data of 54 patients with indication for tibial nonunion were collected from existing data sources. Of these patients, 26 were treated with ABG and 28 with rhBMP-7. The study captured the direct medical costs for treating each tibial nonunion, considering both inpatient and outpatient care. The hospital reimbursement was calculated from discharge registries, based on diagnosis-related group (DRG) values. A subgroup of patients (n=30) was also interviewed to capture perceived health during the follow-up, and the quality-adjusted life years (QALYs) were subsequently computed. The two groups were similar for what concerns baseline characteristics. While the medical costs incurred during the hospitalisation associated with treatment were on average €3091.21 higher (P<0.001) in patients treated with rhBMP-7 (reflecting the product procurement costs), the costs incurred during the follow-up were on average €2344.45 higher (P=0.02) in patients treated with ABG. Considering all costs incurred from the treatment, there was a borderline statistical evidence (P=0.04) for a mean increase of €795.42, in the rhBMP-7 group. Furthermore, the study demonstrated that, without appropriate reimbursement, the hospital undergoes significant losses (P=0.003) when using rhBMP-7 instead of ABG. In contrast to these losses, in Italy, the average cost to achieve a successful outcome was €488.96 lower in patients treated with rhBMP-7 and, additionally, the cost per QALY gained was below the cost-utility threshold of $50,000.

Tissue engineering for bone defect healing: an update on a multi-component approach.

SUMMARY: The need for an interdisciplinary approach in order to establish new therapeutic strategies for the therapy of bone defects has been acknowledged by the scientific community for many years. This awareness makes itself felt when looking at the multitude of approaches--ranging from cell-based to scaffold-based strategies and also including the use of osteogenic growth factors and genetic engineering--that are currently being combined to assess their potential to develop effective concepts for the treatment of extensive loss of osseous tissue. With a strong focus on the preclinical research in this field, the goal of this review is to give an update on the multi-component approaches that are currently being investigated in tissue engineering of bone.

Application of BMP-7 to tibial non-unions: a 3-year multicenter experience.

SUMMARY: The effective treatment of the often debilitating, longlasting and large-asset-consuming complication of fracture non-unions has been in the centre of scientific interest the last decades. The use of alternative bone substitutes to the gold standard of autologous graft includes the osteoinductive molecules named bone morphogenetic proteins (BMPs). A multicenter registry and database (bmpusergroup.co.uk) focused on the application of BMP-7/OP-1 was created in December 2005. We present the preliminary results, using the prospective case-series of aseptic tibial non-unions as an example. Sixty-eight patients fulfilled the inclusion criteria for this observational study, with a minimum follow-up of 12 months. The median duration of tibial non-union prior to BMP-7 application was 23 months (range 9-317 mo). Patients had undergone a median of 2 (range 0-11) revision procedures prior to the administration of BMP-7. In 41% the application of BMP-7 was combined with revision of the fixation at the non-union site. Non-union healing was verified in 61 (89.7%) in a median period of 6.5 months (range 3-15 mo). No adverse events or complications were associated with BMP-7 application. The safety and efficacy of BMP-7 was verified in our case series, and was comparable to the existing evidence. The establishment of multicenter networks and the systematic and long-term follow- up of these patients are expected to provide further information and significantly improve our understanding of this promising osteoinductive bone substitute.

Clinical applications of BMPs.

Bone morphogenetic proteins (BMPs) are polypeptides discovered by Marshall Urist in 1965 and later defined by his co-workers as multifunctional cytokines involved in osteoinduction. They are members of the transforming growth factor-beta superfamily with the exception of the BMP-1. Till now at least 20 BMPs have been identified and studied, but only BMP 2, 4 and 7 have been able in vitro to stimulate the entire process of stem cell differentiation into osteoblastic mature cells. After in vitro studies BMPs have been tested in preclinical and clinical studies, showing their definite potential in osteoinduction and have been approved for clinical use in open fracture of long bones, non-unions and vertebral arthrodesis. But more clinical use of these molecules is under investigation and the possibility of using gene therapy in selected pathologies seems the most appealing.