An inter- and intra-rater agreement assessment of a novel classification of pyogenic spinal infections.

PURPOSE: Pola et al. described a clinical-radiological classification of pyogenic spinal infections (PSI) based on magnetic resonance imaging (MRI) features including vertebral destruction, soft tissue involvement, and epidural abscess, along with the neurological status. We performed an inter- and intra-observer agreement evaluation of this classification. METHODS: Complete MRI studies of 80 patients with PSI were selected and classified using the scheme described by Pola et al. by seven evaluators. After a four-week interval, all cases were presented to the same assessors in a random sequence for repeat assessment. We used the weighted kappa statistics (wκ) to establish the inter- and intra-observer agreement. RESULTS: The inter-observer agreement was substantial considering the main categories (wκ = 0.77; 0.71-0.82), but moderate considering the subtypes (wκ = 0.51; 0.45-0.58). The intra-observer agreement was substantial considering the main types (wκ = 0.65; 0.59-0.71), and moderate considering the subtypes (wκ = 0.58; 0.54-0.63). CONCLUSION: The agreement at the main type level indicates that this classification allows adequate communication and may be used in clinical practice; at the subtypes level, the agreement is only moderate.

Revision of total knee arthroplasty with press-fit condylar SIGMA TC3-mobile bearing system and porous metaphyseal sleeves in type AORI type II and III bone defects. A long-term follow-up study.

BACKGROUND AND AIM: Revision total knee arthroplasty(rTKA) is a challenging and expensive treatment for orthopedic surgeons who have to deal with poor bone quality and bone loss. This study aims to retrospectively evaluate the clinical and radiological results of patients undergoing rTKA and porous metaphyseal sleeves in AORI type II and III bone defects. METHODS: We conducted a retrospective series of continuous patients treated for mechanical failure of TKA. All patients with aseptic loosening of TKR underwent revision arthroplasty. We included only patients with AORI type IIa/b and III bone defects. The Septic revision or other grades of bone defect or patients lost at follow-up or with less than 2 years follow-up were excluded. We evaluated knee function with Oxford Knee Score (OKS) pain with Visual Analogue Scale (VAS) and range of motion (flex-ext), while radiological evaluation was performed to evaluate any sign of loosening. RESULTS: The mean preoperative OKS was 13.85 +/- 5.39 (range 5 -22), and it improved to 33.89 +/- 3.98 (range 20 - 40) (p<0.00001). The mean preoperative VAS was 7.77 +/- 1.33 (range 5 - 9), and it improved to 1.89 +/- 0.92 (range 0 - 4) (p<0.00001). ROM improved from 62.23° +/- 13.71° (range 40° - 90°) to 100.53° +/- 6.93° (range 90° - 120°) (p<0.00001). No signs of loosening or implant migration were reported. CONCLUSIONS: Metaphyseal sleeves made knee revision in large bone defects reliable and effective with good results. Good implant stability was reached in all the cases treated with metaphyseal sleeves.

The major proximal femoral defects: megaprosthesis in non oncological patients - A case series.

We identified 39 patients (23 female and 16 male) underwent hip revisions through mega-prosthesis. The most common causes were periprosthetic fractures, periprosthetic osteolysis and consequences of infected arthroplasty. The average follow-up was 5 years (2.1 to 6.5), and average age was 69 years (47 to 78). At the final follow-up all the implants resulted functional and osteointegrated. The Merle D'Aubignè and Postel hip rating scale was used for the evaluation, better results were observed in periprosthetic fractures. Postoperative complications occurred in eight patients. Thus, megaprosthesis were a reasonable surgical option in the management of major femoral defects.

Revision arthroplasty with megaprosthesis after Girdlestone procedure for periprosthetic joint infection as an option in massive acetabular and femoral bone defects.

BACKGROUND AND AIM: To evaluate the clinical outcomes of patients treated with Girdlestone procedure (GP) or excision arthroplasty (EA) for periprosthetic infection with massive bone defects and undergoing revision arthroplasty. METHODS: All patients treated with EA or GP for hip periprosthetic infection between 2014 and 2017 and sustaining revision arthroplasty (RA) were included in the study. Patients with less than 24 months of follow-up or less than 12 months between GP or EA and RA were excluded. Any sign of implant mobilization or periprosthetic fracture was assessed through X-ray. Patients were evaluated with D'aubignè-Postel hip score before RA and at the last follow-up. Mann-Whitney U test was used to assess differences between pre-RA surgery and last follow-up. P value was set as <0.05. RESULTS: Twelve patients meet the inclusion criteria (mean follow-up 58+/-9.72 months). No radiographic sign of implant mobilization or periprosthetic fracture was reported. A significant difference was found for each parameter of the D'Aubigne-Postel score (p < 0.0001); none of the patients reached more than fair results in the absolute hip score. The difference between pre and post-operative global status showed a fair improvement. A significant difference was found for leg length discrepancy between pre and post RA (p<0.0001). CONCLUSIONS: Conversion from EA or GP to RA in patients suffering from massive acetabular and femur defects is challenging; conversion procedure is able to reduce patients' disability and to improve walking ability. (www.actabiomedica.it).

Is vertebral stenting kyphoplasty a good choice in the treatment of osteoporotic vertebral fracture? A series of 47 patients (v2).

Background: The incidence of vertebral fragility fracture is increasing over last three decades with an essential impact on quality of life. Some devices were proposed to improve conventional kyphoplasty in the last five years, known as vertebral stenting kyphoplasty (VSK). Materials and Methods: All osteoporotic vertebral fractures (OVF) treated with VSK, single-level fracture without neurological impairment, and with more than 24 months of follow-up were included in the study. We recorded fracture types according to DGOU classification, fracture level, regional kyphosis angle (RKA), Oswestry disability index (ODI), and complications. Results: Forty-seven consecutive patients were included. RKA significantly improved from pre to postoperative values (p<0.000001) and to follow-up values (p<0.00001). A significant difference was found between preoperative RKA of (OF2+OF3) and OF4 (p<0.00001), confirmed immediately after surgery (p= 0.005425) and at last follow up (p= 0.000947). A significant difference was found in correction of RKA between (OF2+OF3) and OF4 at injury time and after treatment (p<0.00001), and it was confirmed at the last follow-up (p=0.000026). ODI showed a significant difference between (OF2+OF3) and OF4 type of fractures (p=0.038216). We recorded five complications: 2 cases of leakage without neurological impairment, two progressions of kyphosis, and one implant migration. Conclusions: VSK is an excellent and reliable option in the treatment of OVF, with good clinical results and preservation of obtained RKA at the time of treatment. However, in case of vertebral collapse with the involvement of both vertebral plates, surgeons must be aware of possible implant failure or migration. Level of Evidence: 4.

ACUTE DESTRUCTIVE HIP SEPTIC ARTHRITIS IN A YOUNG ADULT PATIENT: CASE REPORT (v2).

The Authors describe a case of rapid right hip destructive septic arthritis in a 50-year-old male patient with no previous noteworthy medical history. Patient arrived to our attention following a one week history of right hip pain. Laboratory markers and imaging at presentation were negative. However, on a follow-up examination significant joint effusion was noted and joint tap was performed. Despite wide spectrum antibiotic therapy institution, significant joint damage was observed. This required surgical femoral head excision with antibiotic loaded spacer, followed by hip arthroplasty surgery 12 weeks afterwards. Complete healing of the infection and recovery of pain-free joint motion was noted at 1 year follow-up.

Revision Surgery Using Retrograde Nail versus Replating in Nonunion Distal Femur Fracture Treated with Plate.

Articular distal femur fractures represent 4% to 6% of femur fractures. Locking compression plates (LCPs) are the main treatment option. Nevertheless, a reoperation rate of 12.9% has been reported; nonunion is reported at 4.8%, delayed union at 1.6%, and malunion at 0.6%. Treatment of nonunions can be challenging as no unanimous consensus regarding the best surgical technique has been reached. The aim of this study was to evaluate and compare two types of revision surgery as treatment of LCP-treated articular distal femoral fracture nonunion: retrograde nail or replating. A retrospective cohort study of patients admitted from January 2015 to February 2017 for nonunion of AO/OTA 33C2 fractures previously treated with a lateral LCP was conducted. Patients were treated either with intramedullary nailing (Group A) or with replating (Group B). One independent observer performed clinically and radiographically followed up at 1, 3, 6, 9, 12, 24, and 36 months after surgery. The nonunion scoring system (NUSS) was used. Nine patients were included in our study. The mean follow-up was 2 years. Five patients were treated with intramedullary nailing and four with replating. The NUSS score was 24.2 ± 6.8 in the nailing group and 37.3 ± 3 in the replating group (P=0.03). In the nailing group, radiographic consolidation was obtained in all cases. In the replating group, nonunion was found in 3 patients and failure of osteosynthesis in one patient. Therefore, four patients (Group B) underwent implant removal and retrograde femoral nailing, obtaining radiological healing. The union time was 7.6 months in the nailing group. Retrograde intramedullary nailing can be used as an effective treatment of aseptic AO-33C distal femoral nonunion following primary locking plating.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients.

BACKGROUND: Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures. AIM: To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85. METHODS: Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected. RESULTS: At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded. CONCLUSION: In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

Three generations of treatments for osteoporotic vertebral fractures: what is the evidence?

The management of vertebral compression fractures (VCFs) is based on conservative treatment and minimally invasive vertebral augmentation procedures. However, the role of vertebral augmentation is now being questioned by clinical trials and extensive studies. The aim of this review is to report the most relevant evidences on effectiveness, safety, and indications of the currently available vertebral augmentation techniques. Conservative treatment with bracing is effective in reducing acute but it has no effect on segmental kyphosis progression and pseudoarthrosis can occur. Percutaneous vertebroplasty (PV) was the first vertebral augmentation technique to be proposed for the treatment of VCFs. Two blinded and randomized clinical trials compared PV to a sham procedure and no significant differences in terms of efficacy were reported. More recent studies have suggested that PV can still benefit patients with acute VCFs and severe pain at onset. Balloon kyphoplasty (BK) was developed to improve the segmental alignment restoring the height of collapsed vertebrae. BK allows similar pain relief and disability improvement, as well as greater kyphosis correction compared to PV, moreover BKP seems to reduce cement leakage. Vertebral body stenting (VBS) and the KIVA system are third generation techniques of vertebral augmentation. VBS aims to increase the effectiveness in restoring the segmental alignment, while the KIVA system can prevent cement leakage. These techniques are effective and safe, even if their superiority to BK has yet to be proven by studies with a high level of evidence.

WHICH PROBLEMATICS IN THA AFTER ACETABULAR FRACTURES: EXPERIENCE OF 38 CASES.

Background: Within a timeframe of 8 years (2008-2016), 38 patients have undergone total hip replacement surgery for coxarthrosis or aseptic necrosis secondary to acetabulum fractures. Materials and Methods: The study included 27 males and 11 females between 42 and 70 years of age, all of whom came from other institutions. The follow-up period ranged between a minimum of 4.6 and a maximum of 9.7 years. Results: At the final follow-up, all patients were evaluated using the Merle D'Aubigne and Pastel model. Optimal results were found in all the cases. Three patients benefited from surgical revisitation with implant exchange following infection and one/two state reimplatation at seven, fourtheen et twenty-seven months respectively. Two patients benefited from cotyle revision due to chronic instability of the implant. Conclusions: The scope of the study was to present all the possible surgical difficulties that can come up with prosthetic implants. More particularly, hip implants after acetabulum fractures qualifies as a "difficult primary implant".

A Detailed Analysis of Clinical Features and Outcomes of Patients with Pyogenic Spondylodiscitis Presenting without Axial Back Pain.

STUDY DESIGN: Retrospective analysis of a single institution prospective, longitudinal database of spinal pyogenic infections. Diagnosis of pyogenic spondylodiscitis (PS) can be challenging. Although presenting symptoms are often non-specific, acute non-remitting axial back pain is the most striking feature. Nevertheless, several authors have reported on the uncommon occurrence of patients with PS without axial back pain. The aim of this study was to characterize presenting symptoms, causative agents, comorbidities, and treatment outcomes of patients presenting with painless pyogenic spondylodiscitis. A total of 214 patients diagnosed with PS were reviewed; patients were divided into two groups: patients presenting with no axial back pain (no pain group, n = 16), and patients presenting with axial back pain (control group, n = 198). Analyzed data comprised general demographics, presenting symptoms, comorbidities, spinal infection location, and amount of spinal involvement. While average age (62.4 vs. 65.0) and sex distribution was similar between the two groups, a significant diagnostic delay was noted in the control group (53 vs. 17 days, p < 0.001). Patients in the no pain group were more likely IV drug abusers or have had liver failure/cirrhosis. Anatomic distribution (i.e., cervical vs thoracolumbar) of the infection did not differ between the two groups, but a higher number of post-surgical infections was noted in the no pain group (37.5 vs. 15.6%, p = 0.026). E. coli and Pseudomonas spp. were more commonly seen in no pain group patients, and mortality was also higher in this group (12.5 vs. 6.0%, p = 0.004).

10-Year Clinical, Functional, and X-ray Follow-Up Evaluation of a Novel Posterior Percutaneous Screw-Rod Instrumentation Technique for Single-Level Pyogenic Spondylodiscitis.

Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.

Fresh autologous stromal tissue fraction for the treatment of knee osteoarthritis related pain and disability.

Knee osteoarthritis (KOA) is a very common condition with multifactorial etiology leading to severe pain and disability in the adult population. Although KOA is considered a non-inflammatory arthritis, upregulation of inflammatory and catabolic pathways with increased production of proinflammatory cytokines leading to cartilage degradation and extracellular matrix degeneration has been reported. Intra-articular injection of fresh fat derived stromal vascular fraction (SVF) fraction has been proposed as a valid and alternative treatment for symptomatic KOA that guarantees mechanical support through viscosupplementation, anti-inflammatory, and anabolic action. We retrospectively reviewed a case series of 84 consecutive adult patients with KOA who underwent intra-articular injection of fresh fat derived SVF. Significant improvement in pain levels (NRS score decrease 3.5±1.1, p<0.001), WOMAC pain (-7.02±3.45 score change, p<0.001), WOMAC stiffness (-1.97±1.02, p<0.001), and ROM improvement (+17.13±5.22°, p<0.001). The only complication noted was knee joint swelling lasting for less than 7 days after the injection in 7% of the patients.

Limb lengthening with PRECICE magnetic nail in pediatric patients: A systematic review.

BACKGROUND: Limb lengthening techniques play an increasingly important role in the pediatric orthopedic field. The principles of the osteogenesis distraction bonded traditionally with external fixators; however, the recent deployment of fully implantable systems has been able to overcome severities related to external fixators. The PRECICE® is an implantable limb lengthening intramedullary nail system that is remotely controlled and magnetically driven. AIM: To review the current literature available on this matter in order to assess the PRECICE clinical and radiological outcomes and its possible complications in a population of pediatric patients undergoing limb lengthening. METHODS: Only five studies met the inclusion criteria and were consequently included in the review for a total of 131 patients and 135 femurs. The clinical and radiological outcomes of interest were: the main lengthening obtained, the distraction rate, the period of time to full weight bearing, the consolidation index, and the Association for the Study and Application of Methods of Ilizarov score. RESULTS: In conclusion, data collected from the articles under investigation were comparable with the exception of the consolidation index. Unfortunately, the study population was too small and the patients' follow-up was too short to make definitive conclusions. CONCLUSION: This review shows that the PRECICE Nail System is still a therapeutic challenge in limb lengthening for pediatric orthopedic surgeons; however, careful pre-operative planning and an accurate surgical technique could allow the correction of more complex deformities with a low rate of complications.

Hand's aneurysmal bone cyst: A rare localization. Case report and systematic literature review.

Aneurysmal bone cysts are benign, rare bony tumours frequently observed among children and young adults principally located in the long bones, pelvis, and spine and rarely in other anatomical district such as the hand. We report the case of a 12-year-old girl with an aneurysmal bone cyst, in active stage, involving the still-open epiphysis of the fourth metacarpal of the right hand, which was in a first time treated by curettage, and 3 months later, occurring a recurrence, by a radically excision of the bone and reconstruction with a graft from the iliac crest. At 10-year follow-up the patient had good cosmetic results and a functioning hand. We also performed a systematic Literature review in order to retrieve the key information regarding: the diagnosis, the clinical features and the treatment.

Uncorrect diagnosis of tubercolar spondylodiscitis in aggressive and bone destructive metastasis of melanoma: A case report and literature review.

Differential diagnosis of destructive osteolytic spinal lesions can be a diagnostic challenge. In this study, we described a rare case of spinal metastases from primary desmoplastic melanoma which had incorrectly been diagnosed and treated as tuberculous spondylodiscitis. An 82-year-old male patient with ongoing low back pain and a history of lumbar localized Pott's performed a lumbar spine MRI that showed osteolytic lesion with first hypothesis of spondylodiscitis L2-L3. The patient was hospitalized and cause of worsening of the lumbar pain underwent a following series of non-diagnostic CT-guided and open lumbar biopsy at L2-L3 with unsuccessful antibiotic-antitubercular therapy. A new MRI revealed a worsening of previous lesions, extension of the osteolytic lesion at the level of L1-L2 and L3-L4 with neurological impairment. The diagnosis of metastatic melanoma was obtained with surgical decompression and open posterior biopsy procedure. The case described is pathognomonic of the difficulty in detecting the correct diagnosis in front of similar clinical and radiological manifestations. The presence of a previous Pott's disease in the same involved vertebral site was of crucial importance in deflecting the correct diagnostic classification of the pathology, which was possible to ascertain only following an extensive biopsy sampling in the last surgery performed.

A rare case of tertiary syphilis spondylodiscitis of the upper cervical spine: Diagnostic and therapeutic complexity, review of literature.

Syphilis is a sexually transmitted disease caused by the spirochetes Treponema pallidum. Syphilitic spinal lesions present as erosive bone lesions often simulating spondylodiscitis or cancer. In this article we describe a rare case of cervical osteolytic lesion from tertiary syphilis. A 45-year-old male with axial neck pain, without fever presented with an isolated osteolytic lesion at C3. Tuberculous spondylitis was initially suspected. A new CT and contrast enhanced MRI of the cervical spine and of the neck showed an extention of the bone lesion at C3 with bilateral lymphadenomegaly. To confirm the diagnosis of tertiary syphilis, US-guided biopsy of the lymph nodes was performed. The patient was treated with i.m. benzylpenicillin 2.4 MIU and the follow-up showed clinical and radiological resolution of the condition. The aim of this case report is to raise awareness of tertiary syphilis in the differential diagnosis of lytic lesions of the spine among the spinal community.