The correlates of post-surgical haematoma in older adults with proximal femoral fractures.

BACKGROUND: Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients. AIMS: This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients. METHODS: Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma. RESULTS: Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.

The treatment of knee cartilage lesions: state of the art.

The management and repair of knee cartilage lesions currently represents a challenge for the orthopaedic surgeon. Identifiable causes are the characteristics of the involved tissues themselves and the presence of poor vascularization, which is responsible for overall reduced repair capacity. The literature reports three types of cartilage lesions' treatment modalities: chondroprotection, chondroreparation and chondrogeneration. The preference for one or the other therapeutic option depends on the pattern of the lesion and the clinical conditions of the patient. Each treatment technique is distinguished by the quality of the restorative tissue that is generated. In particular, the chondrorigeneration represents the last frontier of regenerative medicine, as it aims at the complete restoration of natural cartilage. However, the most recent literature documents good results only in the short and medium terms. In recent years the optimization of chondroregeneration outcomes is based on the modification of the scaffolds and the search for new chondrocyte sources, in order to guarantee satisfactory long-term results.

Prosthetic joint infection diagnosis applying the three-level European Bone and Joint Infection Society (EBJIS) approach.

Sensitive and specific tests for the diagnosis of prosthetic joint infection (PJI) are lacking. The aim of this study was to report clinical and microbiological findings of consecutive patients diagnosed with PJI at the University Hospital of Perugia, Perugia, Italy, and to validate these diagnoses utilizing the European Bone and Joint Infection Society (EBJIS) three-level diagnostic approach from 2021. Patients with a PJI diagnosis were included in this study and examined retrospectively. Overall, 133 patients were diagnosed with PJI: mean age 72 years, 54.9% female, and 55.6% with more than one comorbidity. The most frequent involved joints were hip 47% and knee 42%. Aetiology was identified in 88/133 (66.2%): staphylococci resulted the most frequent microorganisms and over 80% (45/54) resulted rifampin susceptible. Applying the EBJIS approach, PJI diagnosis resulted: confirmed in 101 (75.9%), likely in 25 (18.8%), and unlikely in 7 (5.3%). Likely PJIs aetiology was Staphylococcus aureus 11/25, coagulase-negative staphylococci 8/25, Streptococcus agalactiae 3/25, viridans group streptococci 2/25, and Pseudomonas aeruginosa 1/25. No statistically significant differences were detected among the three diagnosis groups with regard to clinical characteristics with the exception of a higher number of confirmed PJIs occurring < 3 months after implantation. The logistic regression analysis did not disclose any independent predictor of confirmed PJIs. We recommend using all the diagnostic tests available to approach PJI diagnosis, and suggest caution before rejecting PJI diagnosis in the presence of highly virulent microorganisms from a single sample, in patients without sinus tract, and in those receiving antimicrobial at the time microbiologic samples are collected. Study approved by Umbrian Regional Ethical Committee, Perugia, Italy, Prot. N. 23,124/21/ON of 10.27.2021.

Osteolysis in total hip arthroplasty in relation to metal ion release: Comparison between monolithic prostheses and different modularities.

BACKGROUND: Among the various complications associated with total hip arthroplasty (THA) periprosthetic osteolysis and wear phenomena due to the release of metal particles, are two of the most common and have been reported to be correlated because of inflammatory responses directed towards released particles that generally activate macrophagic osteolytic effects. Therein, new masses known as pseudotumors can appear in soft tissues around a prosthetic implant. To date, there is paucity of reliable data from studies investigating for any association between the above mentioned adverse events. AIM: To investigate for the existence of any association between serum and urine concentrations of metal-ions released in THA and periprosthetic osteolysis for modular neck and monolithic implants. METHODS: Overall, 76 patients were divided into three groups according to the type of hip prosthesis implants: Monoblock, modular with metal head and modular with ceramic head. With an average f-up of 4 years, we conducted a radiological evaluation in order to detect any area of osteolysis around the prosthesis of both the femur and the acetabulum. Moreover, serum and urinary tests were performed to assess the values of Chromium and Cobalt released. Statistical analysis was performed to determine any association between the ion release and osteolysis. RESULTS: For the 3 study groups, the monolithic, modular ceramic-headed and modular metal-headed implants had different incidences of osteolysis events, which were higher for the modular implants. Furthermore, the most serious of these (grade 3) were detected almost exclusively for the modular implants with metal heads. A mapping of the affected areas was performed revealing that the highest incidences of osteolysis were evidenced in the pertrochanteric region at the femur level, and in the supero-external region at the acetabular level. Regarding the evaluation of the release of metals-ions from wear processes, serum and urinary chromium and cobalt values were found to be higher in cases of modularity, and even more so for those with metal head. Statistical linear correlation test results suggested positive correlations between increasing metal concentrations and incidences areas of osteolysis. However, no cases of pseudo-tumor were detected. CONCLUSION: Future studies are needed to identify risk factors that increase peri-prosthetic metal ion levels and whether these factors might be implicated in the triggering of local events, including osteolysis and aseptic loosening.

Effectiveness of ankle arthroscopic debridement in acute, subacute ankle- bimalleolar, and trimalleolar fractures.

BACKGROUND: The purpose of this retrospective study was to evaluate the usefulness of ankle arthroscopy at the time of ORIF or after six months in patients with residual symptoms. The hypothesis was that in patients treated arthroscopically at the time of ORIF, there were faster and better clinical results than those treated after or untreated with arthroscopy. METHODS: In this retrospective study, we compared three homogeneous groups of selected patients with specific inclusion criteria (144 in total, mean age 38.2 years). They have been surgically treated for an ankle fracture (bimalleolar or trimalleolar without frank syndesmotic injuries) with open technique (ORIF) or arthroscopic ORIF (AORIF), between 2013 and 2017. The AO classification system was used for each patient. The clinical assessment was based on the Foot and Ankle Outcome Score (FAOS). RESULTS: At the final follow-up (mean 38 months), both patients treated with ankle arthroscopic debridement at the time of ORIF and patients treated with arthroscopic debridement after ORIF showed a significant improvement of the FAOS, which reported 84 and 85 respectively at final follow-up. CONCLUSION: Through minimally invasive visualization of intra-articular structures, ankle arthroscopy can offer an essential option for selected patients both in acute and in sequelae after an ankle fracture. More studies are needed to understand the real effectiveness of the procedure, especially in acute at the same time of osteosynthesis.

Role of positioning of femoral component in the anterior-posterior direction on postoperative anterior pain in TKA.

INTRODUCTION AND PURPOSE: The patellofemoral joint has proved to be the most problematic element of modern TKA for postoperative anterior knee pain; the positioning of the femoral component constitutes a critical phase in this issue. The objective of our study was to evaluate the possible role of either anterior positioning or posterior positioning of the femoral shield compared to the reference plane represented by the anterior cortex, on the anterior knee pain after knee arthroplasty. METHODS: Forty-eight patients treated with TKA were followed up approximately 12 months. None of them have been submitted to any patellar treatment. We observed the position of femoral shield with respect to the anterior cortical line of femur dividing patients into three groups: patients with significant notching, patients with no notching (shield corresponding to anterior cortical line) and patients with anterior positioning of shield. We evaluated clinical and functional outcomes with KSS, anterior knee pain with Kujala's score and adverse events such as periprosthetic fractures. RESULTS: We found a better clinical and functional result for patients with femoral shield positioned in line with anterior cortical cortex with respect to both TKAs with femoral notching and to protruding anterior femoral components; there were no main differences in anterior postoperative score by Kujala's system. We observed a periprosthetic fracture in a patient with an important femoral notching. CONCLUSIONS: We cannot consider our study as an objective conclusion to the argument. We need more RCTs in order to study the proper influence of either notching or protrusion of femoral shield component onto anterior postoperative pain. Anyway positioning of femoral shield in anterior-posterior direction could be an interesting new critical object of study about anterior knee pain after TKA.

Effects of Weekly Supplementation of Cholecalciferol and Calcifediol Among the Oldest-Old People: Findings From a Randomized Pragmatic Clinical Trial.

Vitamin D inadequacy is pervasive in the oldest-old. Many vitamin D metabolites are available for supplementation, their effects on the recovery of adequate serum levels remain unknown. We investigate the effects of supplementation with cholecalciferol (D3) and calcifediol (25D3) on serum levels of 25(OH)D, 1-25(OH)D, bone and inflammatory markers, ultimately identifying clinical predictors of successful treatment. Sixty-seven oldest-old individuals were randomized to weekly administration of 150 mcg of 25D3 or D3, from hospital admission to 7 months after discharge. Supplementation of 25D3 and D3 were associated with increasing serum levels of 25(OH)D (p < 0.001) and 1-25(OH)D (p = 0.01). Participants on 25D3 experienced a steeper rise than those on D3 (group*time interaction p = 0.01), after adjustment for intact parathyroid hormone (iPTH) levels the differences disappeared (intervention*iPTH interaction p = 0.04). Vitamin D supplementation was associated with a decreasing trend of iPTH and C-reactive protein (CRP) (p < 0.001). Polypharmacy and low handgrip strength were predictors of failure of intervention, independent of vitamin D metabolites. In conclusion, D3 and 25D3 supplementation significantly increase vitamin D serum levels in the oldest-old individuals, with a tendency of 25D3 to show a faster recovery of acceptable iPTH levels than D3. Polypharmacy and low muscle strength weaken the recovery of adequate vitamin D serum levels.

Treating Primary Arthroprosthesis Infection Caused by Mycobacterium abscessus subsp. abscessus.

Prosthetic joint infections (PJI) caused by nontuberculous mycobacteria are very rare, and results of treatment can be unpredictable. A 72-year-old female underwent hip replacement after an accidental fall in a local hospital in Santo Domingo. The postoperative period was uneventful except for a traumatic wound near the surgical scar. PJI caused by Mycobacterium abscessus subsp. abscessus was diagnosed 6 months later. A two-stage reimplantation was performed after a 3-month period of aetiology-directed therapy, including amikacin, imipenem, and clarithromycin. M. abscessus isolate was reported to be resistant to clarithromycin when incubation was protracted for 14 days and to harbour the gene erm(41). The patient manifested major side effects to tigecycline. At reimplant, microbiologic investigations resulted negative. Overall, medical treatment was continued for a 7-month period. When discontinued and at 6-month follow-up, the patient was clinically well, inflammatory markers were normal, and the radiography showed well-positioned prosthesis. Mycobacterium abscessus subsp. abscessus is a very rare cause of PJI, yet it must be included in the differential diagnosis, especially when routine bacteria cultures are reported being negative. Further investigations are needed to determine any correlations between clinical results and in vitro susceptibility tests, as well as the clinical implications of M. abscessus subsp. abscessus harbouring the functional gene erm(41). Moreover, investigations are needed for determine optimal timings of surgery and lengths of medical therapy to improve patient outcome.

The Challenge of Managing the "Third-Space" in Total Knee Arthroplasty: Review of Current Concepts.

Total knee arthroplasty (TKA) is the best treatment for advanced knee osteoarthritis and it has proven to be durable and effective. Anterior knee pain (AKP) is still one of the most frequent complications after TKA, but sometimes no recognized macroscopic causes can be found. The correct treatment of patella is considered the key for a proper management of AKP. The inclusion of patellar resurfacing during TKA has been described as a potential method for the reduction of AKP. After surgeons started to resurface the patella, new complications emerged, such as component failure, instability, fracture, tendon rupture, and soft tissue impingement. Patelloplasty has been proposed as a good alternative to resurfacing but whether or not to resurface the patella is still a controversial topic in the literature. Therefore, patellofemoral joint is a complex critical aspect in TKA and choosing between the several options of treatment of patella could not be sufficient. In this review, evidence-based studies do not succeed in resolving this difficult argument. The accurate management of the so-called "third space" should include an accurate assessment of cartilage layers, balance of soft tissue, preoperative anterior tracking, and positioning of the femoral and tibial components. In fact, the selection of suitable implants and adherence to proper surgical technique are the fundamental principles for the success of TKA.

A silent massive ossification of Achilles tendon as a suspected rare late effect of surgery for club foot.

We report the case of a 66-year-old male patient with massive ossification of the distal portion of the Achilles tendon, as a late consequence of a surgical release for club foot conducted in his childhood. The singularity of the case report derives from its clinical features: the bone mass was of abnormal dimensions, almost substituting the entire tendon; the condition had always been asymptomatic, without deficits in range of motion, in absence of either pain or biomechanical defects with age. In fact, the condition was diagnosed just recently as a consequence of a tear. Despite an ultrasound diagnosis after the injury, only during the surgical treatment, a proper evaluation of the entity of the pathology was possible. Although the ossification of Achilles tendon is a rare clinical condition with a complex multifactorial etiology, in our case report, some of the elements in the patient's medical history could be useful for the pathogenesis and early diagnosis of the disease. The aim of this case report is to emphasize the importance both of a correct evaluation of clinical history and of an accurate diagnosis, in order to conduct a proper management of this pathology.

Acute patellofemoral instability in children and adolescents.

Patellofemoral problems are considered to be among the most frequent causes of knee pain in children and adolescents. Correcting bone abnormalities through specific and targeted interventions is mandatory in skeletally immature patients. Medial patellofemoral ligament (MPFL) reconstruction is the preferred procedure, but there are several important precautionary considerations that the surgeon must take into account. It must always be remembered that MPFL rupture is the result, not the cause, of an altered extensor mechanism; therefore, patellar stabilization with MPFL reconstruction is only the first step to be accomplished in the management of an MPFL rupture. If other anatomical alterations are encountered, alternative/additional surgical procedures should be considered. If MPFL rupture occurs without associated anatomical or functional knee alterations, an appropriate rehabilitation program after MPFL reconstruction should be sufficient to achieve a good outcome. In conclusion, an acute patellar dislocation should be managed conservatively unless there is evidence of osteochondral damage or medial retinaculum lesions. Osseous procedures are contraindicated in children, while MPFL anatomical reconstruction with "physeal sparing" is the primary surgical option.

Post-operative blood loss in total knee arthroplasty: knee flexion versus pharmacological techniques.

PURPOSE: To compare the blood loss and the blood transfusion between a control group and a group of patients following either a local administration of tranexamic acid or a mechanical post-operative knee flexion, a controlled randomized study was performed. METHODS: Sixty patients affected by primary knee osteoarthritis and candidates to receive a primary unilateral total knee arthroplasty were enrolled in a prospective, randomized, controlled study. Exclusion criteria were the following: tranexamic acid allergy, the use of pharmacological anticoagulant therapy, previous knee surgery and renal failure. For each patient, the following parameters were investigated: the blood loss volume, the haemoglobin and haematocrit concentrations and the blood transfusion needs. RESULTS: Compared to the control group, the administration of systemic tranexamic acid significantly reduces (p < 0.05) both the blood loss (average reduction 39.8%) and the blood transfusion needs (64%). Furthermore, the tranexamic acid group shows a significant reduction (p < 0.05) compared to the knee flexion group of the blood loss (average reduction 31.8%) and the transfusion needs (65%). However, even if the knee flexion technique slightly reduces the blood loss (average reduction 11.6%) compared to the control group, this difference is not statistically significant (n.s.). Moreover, this treatment did not reduce the transfusion needs compared to the control group (n.s.). Incidence of complications was not influenced by any of the treatments. CONCLUSIONS: The use of tranexamic acid compared to knee flexion and to control group significantly reduces blood loss and transfusion needs, without wound complications or symptomatic deep vein thrombosis. LEVEL OF EVIDENCE: Prospective therapeutic study, Level I.

Ultrasound morphology of the Achilles in asymptomatic patients with and without diabetes.

BACKGROUND: The prevalence of tendinopathies is increased in subjects with diabetes mellitus. However, there are few data on the structural abnormalities of Achilles tendons in asymptomatic diabetic patients. The aim of the study was to assess the morphologic characteristics of the Achilles tendon in subjects with diabetes in comparison with controls without diabetes. METHODS: Participants were consecutively recruited from an outpatient population. Ultrasound longitudinal and transverse scans were performed bilaterally along the full length of Achilles tendon from the musculotendinous junction to the insertion. Degenerative features (abnormal fibrillar pattern, hypo-hyperechoic areas), signs of enthesopathy (bony erosion, enthesophytes, and bursitis), and intratendinous neovessel formation were recorded. RESULTS: Asymptomatic sonographic abnormalities (ASA) were significantly increased in subjects with diabetes (35/136 [25.7%] vs 32/273 [11.7%], P = .0003). Sixty tendons with ASA were observed in the first group and 45 in the latter because ASA were bilateral in 25 and in 13 subjects, respectively. ASA were more frequently localized at the enthesis (32/60 [53.3%] vs 9/45 [20%], P = .0005) in the diabetes group, whereas, on the contrary, they were more prevalent at the midportion in controls (38/45 [84.4%] vs 36/60 [60%], P < .006). CONCLUSION: Diabetes may predispose to Achilles tendinopathy and particularly to Achilles enthesopathy. Longitudinal studies, evaluating the progression of the lesions not only in the midportion of the tendon but also at the insertion are needed to support this conclusion. LEVEL OF EVIDENCE: Level III, comparative series.

Meniscus repair and regeneration: review on current methods and research potential.

Meniscus regeneration is an unsolved clinical challenge. Despite the wide acceptance of the degenerative consequences of meniscectomy, no surgical procedure has succeeded to date in regenerating a functional and long-lasting meniscal fibrocartilage. Research proposed a number of experimental approaches encompassing all the typical strategies of regenerative medicine: cell-free scaffolds, gene therapy, intra-articular delivery of progenitor cells, biological glues for enhanced bonding of reparable tears, partial and total tissue engineered meniscus replacement. None of these approaches has been completely successful and can be considered suitable for all patients, as meniscal tears require specific and patient-related treatments depending on the size and type of lesion. Recent advances in cell biology, biomaterial science and bioengineering (e.g., bioreactors) have now the potential to drive meniscus regeneration into a series of clinically relevant strategies. In this tutorial paper, the clinical need for meniscus regeneration strategies will be explained, and past and current experimental studies on meniscus regeneration will be reported.

Stimulation of CCL2 (MCP-1) and CCL2 mRNA by substance P in LAD2 human mast cells.

Chemokines are cytokines with chemotactic properties on inflammatory cells and other cell types. Chemokine (C-C motif) ligand 2 (CCL2), which is also called monocyte chemotactic protein 1 (MCP-1), is a potent chemotactic molecule that attracts lymphocytes, monocytes, mast cells, and memory T cells, but not neutrophils. CCL2/MCP-1 represents a link between the activation of monocytes, lymphocytes, basophils, mast cells, and eosinophils in inflammatory disorders, such as the late-phase allergic reaction. This C-C chemokine also plays a role in regulating Th-cell cytokine production and leukocyte trafficking. Laboratory of allergic diseases (LAD) cells is the first reported human mast cell line that closely resembles a primary culture of CD34+-derived human mast cells. These cells were cultured in vitro and treated with different concentrations of substance P (SP) for the production of CCL2/MCP-1. We used calcium ionophore as a positive control for stimulating transcription and translation of CCL2/MCP-1. The stimulation of SP on CCL2/MCP-1 was statistically significant (P < 0.05) compared with the control (untreated cells). In this study, we determined the expression and secretion of CCL2/MCP-1 from SP-activated LAD2 human mast cells in vitro. The levels of CCL2/MCP-1 from SP-activated LAD2 human mast cells were higher at 10 microM and at 18 h incubation compared with controls. This effect was also revealed on CCL2/MCP-1 messenger RNA (mRNA) expression, as determined by reverse transcriptase polymerase chain reaction (RT-PCR) analysis. Our data suggest that SP is an important neurotransmitter that can stimulate the chemokine CCL2, which plays a fundamental role in inflammation by recruiting inflammatory cells to specific cites.