Autologous chondrocyte implantation provides good long-term clinical results in the treatment of knee osteoarthritis: a systematic review.

PURPOSE: To evaluate the mid- and long-term efficacy of autologous chondrocyte implantation (ACI) and matrix-assisted chondrocyte implantation (MACI) to treat patients with knee cartilage defects in the presence of osteoarthritis (OA). METHODS: PubMed and Cochrane databases were systematically searched for studies describing the treatment of knee OA with ACI or MACI (Kellgren-Lawrence (KL) ≥ 1, minimum follow-up 36 months). Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and included Lysholm, Western Ontario McMaster University and International Knee Documentation Committee scores. RESULTS: Of the 127 full-text articles assessed for eligibility, only five studies were selected based on inclusion/exclusion criteria (2 on ACI and 3 on MACI). In both groups, the defects were mainly located at femoral level, size 2.2-15.1 cm2 in the ACI and 2.0-7.6 cm2 in the MACI group. ACI was mostly used for patients affected by KL I, whereas MACI for patients with KL II-IV. The data obtained from 235 patients (161 ACI, 74 MACI) showed that ACI and MACI sustained stable clinical improvements up to 11 and 15 years, respectively, with a failure rate of about 10% up to 11 years. Scarce biological details regarding chondrocyte implantation were reported. CONCLUSIONS: ACI and MACI procedures for the treatment of knee cartilage lesions associated to OA showed long-term success and allowed delaying arthroplasty. Additional trials reporting homogenous data and precise patient characterization are needed to conduct an effective literature meta-analysis and identify the clinical relevance of these procedures. LEVEL OF EVIDENCE: IV.

Management of gunshot wound to the lumbosacral spine in a 17-year-old girl without neurological impairment.

We report the case of a young girl (17-year-old) wounded by an accidental gunshot. The bullet entered through the skin midline over the navel area, passed through the stomach perforating the vena cava and, by breaking the right pedicle of L4, moved inside the vertebral canal (bridging the cauda equina) stopping just in front of the body of S2. Because of the sudden onset of acute abdomen due to a massive retroperitoneal hematoma, the patient underwent emergency explorative laparotomy with the evacuation of the hematoma and the suture of the perforated cava vein, the peritoneum, and the stomach. No neurological deficits were observed after the gunshot. Two weeks later, the patient underwent spinal surgery to remove the bullet from the spinal canal, which was performed successfully without any instrumentation and with no onset of new neurological signs and symptoms or surgery-related complications. Patient was discharged on day 9 after surgery in good general conditions.

Modifications of spinopelvic parameters and acetabular orientation after spinal surgery for adult deformity in patient who underwent bilateral total hip arthroplasty.

The spine and the hip are two anatomical districts that have close biomechanical relationship. The management of their degenerative disorders involves an in-depth biomechanical analysis of the patient, in order to define the proper hip-spine relation, using different biomechanical classifications that have been proposed in recent years. The changes in the spino-pelvic and acetabular parameters induced by prosthetic hip surgery and spinal surgery must be carefully evaluated, calculated and foreseen in the pre-operative phase, as they play a crucial role in defining the clinical success or failure of the operations. In this paper we present a case of a patient who underwent spinal surgery after a bilateral THA analyzing both spino-pelvic parameters and acetabular orientation and highlighting the strict relations between spine and hip.

Posterior dynamic neutralization and hybrid stabilization in degenerative spine diseases: long-term clinical and radiological outcomes.

Dynamic spinal stabilization aims to reduce some of the problems inherent with traditional fusion. The aim of our study is to analyse clinical and radiological outcomes and to identify the causes of clinical failure in patients who underwent posterior dynamic neutralization or posterior hybrid stabilization because of degenerative lumbar spine diseases. We retrospectively analysed 80 patients at 7.1 years mean follow-up (Range: 5.1 - 8.3 years): 50 were treated with Dynamic Stabilization System (Dynesys) (mean age 47 years old) and 30 with Dynamic Transition Option (mean age 48 years old). We performed clinical pre-and post-operative evaluation using Visual Analogue Scale (VAS), Oswestry Low Back Pain Scale (ODI) and X-rays study. Results: we reported an important reduction of VAS from 7 to 2 (p<.001) and minimal disability in 65% of the patients, moderate disability in 18.2%, severe disability in 12.5% and crippling back pain in 4.3%. X-ray analysis showed a significative decrease of 3.5° with respect to the preoperative values, exactly 2° in neutral position postop, 1.2° in flexion postop and 2.5° in extension postop. Data showed greater reduction of extension than flexion in postoperative period. Dynamic neutralization limits more the extension than flexion. The correct preoperative planning, the careful selection of patients and the meticulous surgical technique are mandatory to avoid clinical failures. It is very important to identify the correct screw positioning and to avoid excessive pre-tensioning of the implant. Posterior dynamic neutralization and hybrid stabilization are valid alternative to spinal fusion in degenerative spine disease.

Two-stage total hip arthroplasty for septic arthritis through the minimally invasive direct anterior approach.

The use of minimally invasive direct anterior approach to perform total hip arthroplasty is gaining increasing popularity for its short-term advantages, compared to other approaches. Nevertheless, its use in hip revision surgery has been criticized. We report here the first case of hip septic arthritis treated with two-stage THA through this tissue-sparing approach, with good implant positioning and functional results.

Sport injuries in professional volleyball players.

Recently there has been a considerable surge in interest in volleyball by both physiotherapists and orthopaedic surgeons. Only few previous studies specified the nature, frequency, and demographics of volleyball injuries. The study was conducted during two league seasons. After the approvals of local bioethics committee and clubs` authorities, contact with the club's doctors was established. A special survey was designed to standardize the process of acquiring data on a weekly basis. One-hundred-and-ninety-eight women and 301 men were under supervision of the research group. On average, 45% of all players (56% males and 26% females) suffered from injuries and musculoskeletal disorders over two seasons. Relatively high incidence of injuries during matches was between 17.3 and 33.8 injuries per each 1000 hours of playing. Almost 50% of musculoskeletal problems occurred in the first phase of the season. Over 50% of musculoskeletal problems were reported during trainings. The blockers are the most affected players in both sex groups. Acute injuries mainly involved knee and ankle joints, while chronic problems affected knee, shoulder, spine and abdominal muscles. Professional volleyball is not a safe sport, especially during a league season. Attention should be especially paid to ankle, shoulder and knee joints, which are the most commonly injured structures. The study revealed that blockers were the most susceptible to injuries and should be protected by special training regime. These findings can help to prepare sports medicine personnel and to guide further related research to prevent injuries among volleyball professionals.

Bilateral osteochondritis dissecans of the patella in an adolescent skier with patellofemoral maltracking treated with pulsed electromagnetic field therapy.

Juvenile osteochondritis dissecans of the knee typically occurs in young athletes, and usually localizes on the medial femoral condyle. Bilateral localization is uncommon. Patellofemoral involvement is rare, mainly found in basketball and soccer players, and never related to patellofemoral congenital problems such as trochlear dysplasia. We report here the first case, to our knowledge, of bilateral juvenile osteochondritis dissecans with patellar localization in a young skier with patellofemoral maltracking and trochlear dysplasia.

Combined circular external fixation and flexible intramedullary nailing for pediatric bilateral open tibia fractures in blast injury.

Management of blast injuries with open fractures and extensive soft tissue damage in pediatric patients is a challenging task even in experienced hands. This article reports the case of an 8-year-old boy with bilateral open tibia fractures and soft tissue loss due to the accidental explosion of a skyrocket. After the emergency procedures with lavage, debridement and temporary bone stabilization, we performed the definitive reconstruction surgery using a combined circular external fixation and flexible intramedullary nailing technique on both legs. This technique allowed easy access to the wounds for plastic surgery procedures and early bilateral weight bearing. All implants were removed within 6 months, the fractures healed with good axial alignment and the patient returned to his preinjury activities one year after the trauma. In this case, the combined use of circular external fixation and flexible intramedullary nailing ensured optimal fractures stabilization, minimizing the damage to the soft tissues and the obstruction for plastic surgeons. We believe that this technique should be considered in pediatric patients with open fractures of the lower limbs and extensive soft tissue injuries.

Bilateral total hip arthroplasty through minimally invasive direct anterior approach after Legg-Calvé-Perthes disease.

Bilateral secondary osteoarthritis of the hip may affect also young patients following bilateral hip diseases such as slipped capital femoral epiphysis and developmental hip dysplasia. We report the case of an 18- year old male with a previous diagnosis of Legg-Calvé-Perthes disease who underwent a bilateral total hip arthroplasty through minimally invasive direct anterior approach, with optimal results at 1-year follow up.

Use of lordotic cages in L5-S1 Anterior Lumbar Interbody Fusion (ALIF) procedures

Anterior Lumbar Interbody Fusion (ALIF) has gained popularity in the last few years, thanks to its numerous advantages. Recently the use of lordotic cages has been described, allowing theoretically a better lordosis restoration of the lumbar disc space. We described the results obtained with the use of lordotic cages in 27 patients who underwent ALIF procedure for L5-S1 disc degenerative disease, in terms of segmental lordosis and global lumbar lordosis changes.

Inter-rater reliability of classification systems of scapular dyskinesis.

Prevalence of scapular dyskinesis varies across records, with overhead athletes being more frequently affected than non-overhead athletes A number of methods have been described to evaluate scapular kinematics and scapular dyskinesis. The "yes/no" and the "4-type" classification systems are widely accepted and diffusely used among orthopaedics and physical therapists. The inter-rater reliability for both the "yes/no" and the "4-type" classification systems may be different. Moreover, differences between physical therapists and orthopaedic surgeons may exist. Seven examiners (2 orthopaedic surgeons and 5 physical therapists) were asked to evaluate a mixed sequence of video recordings of healthy subjects and patients affected by shoulder, scapular or clavicular disorders and to assess scapular dyskinesis using the "yes/no" and the "4-type" classification systems. Cohen's kappa coefficient (κ) and weighted kappa were used to measure inter-rater reliability. Twenty-four subjects were enrolled. In general, the "4- type" system has higher κ values than ''yes/no'' classification system and orthopaedic surgeons achieve higher reliability than physical therapists for both systems. The clinical evaluation of active shoulder movements permits reproducible assessment and classification of scapular dyskinesis, in particular for the "4-type" classification system. The "4-type" classification system can be used to assess and classify scapular dyskinesis, especially among orthopaedic surgeons.

Kinematic versus mechanical alignment in total knee arthroplasty: a preliminary study.

Despite the great advances of the technology in the joint prosthesis and the high execution rate of total knee arthroplasty (TKA), there are still about 15% of clinical unsatisfactory rate in this surgery. TKAs are currently performed using a mechanical alignment of the knee, correcting varus/valgus deformities with the purpose to achieve a longer implant survivorship, but this surgical technique results in an alteration of the normal knee kinematics. Nowadays, the idea to restore the pre-arthritic alignment of the knee with the goal to obtain a normal kinematics and better functional results becomes more and more consistent and the kinematic alignment (KA) was developed as alternative to the mechanical one. The aim of this preliminary study is to analyse the functional outcomes in patients who underwent KA-TKA in the short-term follow-up and to compare them with those obtained in patients treated by the mechanical alignment (MA) TKA. Therefore, skeletally mature patients, with no history of previous knee surgical procedures, who underwent isolated TKA for knee osteoarthritis, were included in this study. The patients were prospectively divided into two homogeneous groups according to the different surgical techniques performed (KA-TKA and MA-TKA groups). Clinical and functional scores (VAS, KOOS-PS, MCS-12, Final KSS, and Functional KSS) were collected pre- and postoperatively at a mean follow-up of 3 three months. As a result, 26 patients were included in the study, with a mean age of 69.3±7.61 years old (range: 55 - 84 years old). There were 38.5% male and 61.5% female. There were 13 patients in KA-TKA and 13 patients in MA-TKA. Three months after surgery each of the scores tested demonstrated statistically significant better outcomes in KA-TKA, compared to the MA-TKA group. MCS-12 resulted comparable in the two study groups. This preliminary study compares the short-term clinical and functional outcomes between KA and MA in total knee replacement. Further studies are required to confirm these results and to extend the sample size to obtain reliable clinical evidences.

Histological assessment of new bone formation with biomimetic scaffold in posterolateral lumbar spine fusion.

Spinal fusion procedures often require the use of bone grafts (autograft or allograft) to help bone healing and to increase stability. However, the application of autografts is frequently limited by donor site morbidity. In recent years, different synthetic bone substitutes have been introduced in the clinical practice to overcome these limitations. The purpose of this paper is to report a case where a biomimetic, synthetic and osteoconductive bone graft substitute was successfully implanted in a patient during lumbar spine arthrodesis. The case of a 58-year-old female subjected to lumbar spine arthrodesis with bone augmentation is described. The bone graft substitute RegenOss® (Finceramica, Faenza, Italy) was implanted during spinal arthrodesis. The successful bone integration was evaluated by X-rays. After 11 months, the patient underwent a second surgery due to spine imbalance; the debris of the bone graft was therefore collected and analyzed by macroscopic evaluation and by histology. The bone substitute was successfully implanted during a spinal arthrodesis procedure. Histologic evaluation of the removed bone graft debris showed the complete resorption of the implant and the formation of new bone, which was well integrated with the host bone. This bone substitute may represent a safe and effective alternative to autologous bone grafts, avoiding adverse events related to donor-site morbidity.

Correction of post traumatic tibial varus deviation with hexapodalic external fixator.

Physeal fractures are typical in childhood and for their involvement of the germinal layer of the physis they can be followed by growth complications. Axial deviation is one of these. Considering the young age of the patients it is critical to restore articular correct alignment with the least invasive surgery possible. We report here the first case of correction of post traumatic tibial varus deviation with exapodalic external fixator.

Reliability of S.A.R.A. (sterilization and reimplantation autograft) technique in long bone open fractures.

The reimplantation of small or large extruded bone segments is one of the most complex clinical management scenarios in the treatment of open fractures. No consensus exists regarding the efficiency of this technique. The aim of the study was to analyse the clinical and radiological outcomes of Sterilization and Reimplantation Autograft (S.A.R.A.) technique in open fractures. Therefore, fifteen skeletally mature patients with Gustilo-Anderson -IIIB type fractures treated with autograft reimplantation, were included in this study. The sample size was divided in two groups: patients with a loss of small segments (Group A - less than 5 cm) and those with large segments (Group B - greater than 5 cm). Eight patients belonged to Group A and seven to Group B. The treatment of contaminated bone may be performed by the following protocols: saline rinse, povidone-iodine scrub and saline rinse, retain periosteum, immersion in antibiotic solution (clindamycin and gentamicin and metronidazole), washing with physiological solution, acute reimplantation in Group A or reimplantation after 21 days in Group B after a bone freezing at -80°C. The Radiographic Union Score (RUS), pain visual analogic score (VAS), patient satisfaction and return to work were assessed at a mean follow-up of 24 months. No cases of superficial or deep infection were reported at 2-year follow-up. The fractures achieved a complete union in 14 patients; one patient belonging to Group A had a malabsorption of the replanted bone. Furthermore, povidone-iodine scrub, antibiotic solution immersion, and washing with physiological solution preserved the articular surface morphology. This study suggests that reimplantation of extruded short or long segments may represent a reliable alternative to amputation in open long bone fractures. Further studies are needed to define the most efficient technique for sterilizing the bone autograft to reduce the complication rate.

When math meets surgery: how to improve femoral interference screw alignment in ACL reconstruction. A cadaveric study.

Transtibial femoral tunnel drilling is still an alternative technique in ACL reconstruction. Femoral interference screw divergence is a potential pitfall associated with transtibial tunnel technique, as angles greater than 15° jeopardize graft fixation. Our mathematical model theorizes the proper degrees of knee flexion during femoral screw insertion and the correct screwdriver position to obtain a minimal divergence of the screw in the femoral tunnel. The cadaveric study confirms our method. Mathematical model: using rototranslation matrices, a correlation is demonstrated between the ACLtibial- guide angle, the knee flexion, and the screwdriver position. A theoretical minimal divergence between femoral interference screw and the femoral tunnel is obtainable following these assumptions: 1) knee hyperflexion during femoral screw insertion is obtained adding a flexion corresponding to the ACL-tibial-guide angle to the flexion while drilling the femoral tunnel; 2) screwdriver position (through the AM portal) is kept parallel to tibial plateau at a rotation of 15° medial to tibial sagittal plane. Cadaveric study: 24 cadaver knees were used. The transtibial tunnel was drilled with an 8 mm drill bit with the help of an ACL tibial guide set at 55°. To simulate femoral tunnel direction, a 2.4 mm K. wire was drilled through the femur with a transtibial 7 mm offset femoral drill guide. To simulate the femoral screw direction, a second 2.4 mm K. wire was drilled from the femoral entry point of the first wire through the femur, with a cannulated screwdriver. Screwdriver direction and knee flexion during the simulation were obtained following two different methods: GROUP A (mathematical model group, 12 knees), screwdriver direction and knee flexion were calculated following the mathematical model; in GROUP B (control group, 12 knees), knee hyperflexion and screwdriver medialization were manually obtained by a senior surgeon. The divergence between the femoral interference screw and the femoral tunnel was identified as the angle formed by the two wires, measured on the plane formed by the direction of the wires. Mean divergence angles between the K. wires were significantly different (p< 0.05) between the groups: GROUP 1 (mathematical rule): 7.25° (SD 2.2); GROUP 2 (free-hand technique): 17.3° (SD 2.9). Our study shows that a minimal divergence between the femoral tunnel and the screwdriver can be achieved simply by following a mathematical rule for correct intraoperative knee flexion and screwdriver position without the need for any specialized instrumentation. Namely, during femoral interference screw insertion through the anteromedial portal: 1) the correct knee flexion is the sum between the knee flexion angle while drilling the transtibial femoral tunnel AND the ACL tibial guide angle used during tibial tunnel drilling; 2) Correct screwdriver position is parallel to the tibial plateau, engaging the femoral tunnel with a position of 15° medial to tibial sagittal plane. This simple concept has clinical relevance in helping the surgeons in obtaining an optimal alignment between the femoral tunnel and the femoral interference screw during transtibial ACL reconstruction. Furthermore, following the assumptions of this study, a starting knee flexion angle around 70° during femoral tunnel drilling seems preferable for ACL reconstruction when the transtibial tunnel technique is used. Indeed, because ACL-tibial-guide angles range commonly from 50° to 60° and in vivo, the maximal intraoperative knee flexion attainable is 130°, a starting knee flexion around 70° is optimal to allows for adding flexion angles up to 60° before reaching the physiological limit value of 130°.

Periprosthetic osteolysis: a narrative review.

Periprosthetic osteolysis is still one of the major limitations of prosthetic joints longevity. The process of this "silent" iatrogenic disease involves both mechanical and biological factors that initiate a local immune response in the periprosthetic tissue that eventually lead to implant loosening and failure. There are many causes of the primary aseptic loosening inside the periprosthetic microenvironment, but the most important elements are the wear debris and the cell-particle interactions. Together with implant position, micromotion, bearings, joint fluid pressure, and increased load on the joints drive the pathogenesis of the disease. This narrative review aims to summarise recent studies describing the biological and mechanical factors in the pathogenesis of osteolysis and some of the current pharmacological attempts to "rescue" a failing implant.

Hamstring grafts are tenogenic constructs for ACL reconstruction and Pulsed Electromagnetic Fields improve tendon specific markers expression. An in-vitro study.

Hamstring tendons represent one of the commonest autologous graft used during ACL reconstruction. The harvest of the tendon and the time of tendon processing on the operating table, together with the pretensioning maneuvers and the permanence out of the joint during the time of surgery, might impair tendon derived cells (TCs) viability. The aim of the study was: i) to assess the effective viability of the TCs at the end of the surgical procedure; ii) to investigate if TCs viability and the expression of tendon specific markers may be improved through exposure to prolonged pulsed electromagnetic fields (PEMF) similar to that of clinical practice. Remnants of semitendinosus and gracilis tendons (discarded at the end of the ACL reconstruction) were collected from 13 healthy donors. To isolate TCs, the tendon tissue was minced and digested enzymatically with 0.3% type I collagenase in DMEM with continuous agitation for 15 h at 37°C. The isolated nucleated cells were then plated at 5x103 cells/cm2 in a complete medium composed of DMEM, 10% fetal bovine serum, 50 U/ml Penicillin, 50 mg/ml Streptomycin, 2 mM L-glutamine, and supplemented with 5 ng/ml basic fibroblast growth factor (b-FGF). They were maintained at 37 °C in a humidified atmosphere with 5% CO2, changing culture medium every 3 days. When they reached 80-90% of confluence, the cells were detached by incubation with trypsin/EDTA and then cultured at a density of 5x103 cells/cm2. TCs were cultured in complete medium for 7, 14, 21 days (in chamber slides, to optimize the final immunofluorescence analysis). The following cell cultures were set up: i) TCs cultured with differentiation medium + exposure to PEMF 8 h/day; ii) TCs cultured with differentiation medium without exposure to PEMF. The stimulation with PEMF was generated by a pair of electrical coils, connected with the generator of pulsed electromagnetic fields (PEMF generator system IGEA, Carpi, Italy, intensity of magnetic field = 1.5 mT, frequency = 75 Hz). At day 0, day 7, day 14 and day 21 immunofluorescence analysis was performed to evaluate the expression of tendon specific markers (collagen type I, collagen type VI, scleraxis) and proliferative markers (PCNA, beta-catenin). The TCs from the hamstring tendon fragments at the end of the ACL reconstruction were alive and they expressed markers of proliferation and tendon phenotype at the end of the culture period. The TCs in the presence of PEMF 8h/day showed a greater production of collagen type I, collagen type VI and scleraxis than TCs cultured without PEMF (p<0.05). The expression of these markers increased from 7 to 21 days of culture. The expression of proliferative markers in the presence of PEMF stimulus was significantly lower (p<0.05) than that of TCs cultured without PEMF. Hamstring tendons are not simple "tenoconductive" scaffolds but biologic alive tenogenic constructs rich in cells that can sustain tenogenic behavior and tendon matrix synthesis. Prolonged exposure to PEMF improves their phenotype. Thus, from a clinical perspective, the use of PEMF may represent a possible future strategy to positively influence the early phase of graft remodeling and, ultimately, improve the ligamentization process. Following these concepts, further studies might also exploit the anabolic role of PEMF as an adjunctive postoperative strategy in different tendon pathologies.

Tips and tricks for writing a scientific manuscript.

An original scientific manuscript is the target for any researchers whose aim is to show the innovative results arising from the original intuitions that drove all their experiments. Time and patience are essential to decide how to present the data, how to conceive the tables and figures representing the main outcomes of the research, and how to read and mention the necessary references. Few basic rules may help in this difficult task. The first basic rule is: "do not follow the sequence of the paper". On the opposite, i) start writing the "Materials and Methods (or Patients and Methods when dealing with a clinical study)", ii) then write the "Results" section, iii) then, write the "Discussion" paragraph, in which the principal investigator explains the results and the innovations proposed, iv) then, write the "Introduction", which should be clear and concise. The last element to be written should be the "Abstract", which is the "interface" between the authors and the readers. The second basic rule is that any of the central chapters of the manuscript, i.e. "Materials and Methods" (MM), "Results" (R) and "Discussion" (D), should follow a methodical and sequential description of the topics in a "corresponding sequence of paragraphs". In other words, in the R and the D chapter sequence of the paragraphs should be linked to the sequence of the concepts described and discussed in the paragraphs of the MM chapter. Thus, a sequential description of concepts will be easily followed by the writers, facilitating both the authors in the organization of the data and the reader in finding a reasonable "answer" to all the aspects of the study mentioned in the MM chapter. In this article, these two rules are extensively described and several tips and tricks for each chapter are suggested to ease the composition of a scientific paper. Indeed, it may be possible to solve the complex problem of "writing a scientific paper" by means of separating it in main sections (chapters) and subsections (paragraphs) and dealing with them one by one. Naturally, this takes time and passion, but, as affirmed by Steve Jobs, "the only way to do great work is to love what you do".

Bilateral THA in the same sitting for avascular necrosis of the head of the femur in sickle cell patient: our African experience.

Sickle cell anemia is protective against the malaria protozoan. The heterozygous form of the disease is not fatal, and may cause musculoskeletal disorders when sickling occurs, and small vessels are occluded. When the head of the femur is involved, this may result in hip arthritis, often bilateral, at a young age. This article describes three patients in whom bilateral total hip arthroplasty (THA) was performed in the context of a humanitarian mission in Togo, Africa.