Bi-cruciate retaining total knee arthroplasty is here to stay: A consecutive series transitioning from manual instrumentation to enabling technologies.

BACKGROUND: Bicruciate-retaining (BCR) total knee arthroplasty (TKA) has seen renewed interest due to the potential for more natural knee kinematics with anterior cruciate ligament (ACL) retention. OBJECTIVE: The present study attempts to determine differences in the 2-year survivorship and patient-reported outcomes between two surgical strategies (traditional instrumentation versus robotics) applied to the extensive use of a modern, 2nd generation BCR TKA design. METHODS: We performed a retrospective study with prospectively collected data of 113 patients who underwent primary TKA between 2018 and 2020 using a 2nd generation BCR TKA implant. Patient demographics, PROMS, and intra/post-operative complications were collected. Patients were also evaluated according to the use or not of robotics. A Kaplan-Meier analysis was used to evaluate revision-free survival at follow up. RESULTS: 102 patients were enrolled: 90 received traditional surgery and 12 robotic-assisted surgery. The mean age was 68 years (SD 7.76) with an average BMI of 29.6 kg/m2 (SD 3.56). The mean follow up (FU) was 32.4 ± 6.2 months (range 24-45 months). Survivorship at 2 years was 98% (95% CI: 92.4-99.5). Revisions/reoperations were performed for anterior cruciate ligament (ACL) tear (1/4), pain (1/4), arthrofibrosis (1/4) and acute periprosthetic joint infection (PJI) (1/4). At final FU, 92 patients (90.2%) considered themselves satisfied, showing a mean OKS of 40.6 (SD 5.1) and a mean FKS of 76.7 (SD 11.8). No differences in the outcome were found between traditional and robotic-assisted procedures. CONCLUSION: The modern BCR design evaluated in this study achieved excellent results in terms of implant survivorship, low rate of reoperation and clinical results, independently from the use of enabling technologies.

CRISPR-Cas9-mediated somatic correction of a one-base deletion in the Ugt1a gene ameliorates hyperbilirubinemia in Crigler-Najjar syndrome mice.

(AAV)-mediated episomal gene replacement therapy for monogenic liver disorders is currently limited in pediatric settings due to the loss of vector DNA, associated with hepatocyte duplication during liver growth. Genome editing is a promising strategy leading to a permanent and specific genome modification that is transmitted to daughter cells upon proliferation. Using genome targeting, we previously rescued neonatal lethality in mice with Crigler-Najjar syndrome. This rare monogenic disease is characterized by severe neonatal unconjugated hyperbilirubinemia, neurological damage, and death. Here, using the CRISPR-Staphylococcus aureus Cas9 (SaCas9) platform, we edited the disease-causing mutation present in the Ugt1a locus of these mice. Newborn mice were treated with two AAV8 vectors: one expressing the SaCas9 and single guide RNA, and the other carrying the Ugt1a homology regions with the corrected sequence, while maintained in a temporary phototherapy setting rescuing mortality. We observed a 50% plasma bilirubin reduction that remained stable for up to 6 months. We then tested different Cas9:donor vector ratios, with a 1:5 ratio showing the greatest efficacy in lowering plasma bilirubin, with partial lethality rescue when more severe, lethal conditions were applied. In conclusion, we reduced plasma bilirubin to safe levels and partially rescued neonatal lethality by correcting the mutant Ugt1a1 gene of a Crigler-Najjar mouse model.

Relationship between Middle Cerebral Artery Pulsatility Index and Delayed Neurocognitive Recovery in Patients undergoing Robot-Assisted Laparoscopic Prostatectomy.

A steep Trendelenburg (ST) position combined with pneumoperitoneum may cause alterations in cerebral blood flow with the possible occurrence of postoperative cognitive disorders. No studies have yet investigated if these alterations may be associated with the occurrence of postoperative cognitive disorders. The aim of the study was to evaluate the association between an increased middle cerebral artery pulsatility index (Pi), measured by transcranial doppler (TCD) 1 h after ST combined with pneumoperitoneum, and delayed neurocognitive recovery (dNCR) in 60 elderly patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Inclusion criteria were: ≥65 years; ASA class II-III; Mini-Mental Examination score > 23. Exclusion criteria were: neurological or psychiatric pathologies; any conditions that could interfere with test performance; severe hypertension or vascular diseases; alcohol or substance abuse; chronic pain; and an inability to understand Italian. dNCR was evaluated via neuropsychological test battery before and after surgery. Anesthesia protocol and monitoring were standardized. The middle cerebral artery Pi was measured by TCD, through the trans-temporal window and using a 2.5 MHz ultrasound probe at specific time points before and during surgery. In total, 20 patients experiencing dNCR showed a significantly higher Pi after 1 h from ST compared with patients without dNCR (1.10 (1.0-1.19 95% CI) vs. 0.87 (0.80-0.93 95% CI); p = 0.003). These results support a great vulnerability of the cerebral circulation to combined ST and pneumoperitoneum in patients who developed dNCR. TCD could be used as an intraoperative tool to prevent the occurrence of dNCR in patients undergoing RALP.

Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial.

Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS: Parallel-group, randomized trial. SETTING: Operating room of a university hospital, Italy. PATIENTS: Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS: Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS: Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS: Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS: In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION: Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.

Modified Dunn procedure versus percutaneous pinning in moderate/severe stable slipped capital femoral epiphyses.

BACKGROUND: The modified Dunn procedure (MDP) has risen enthusiasm in treating slipped capital femoral epiphyses (SCFE) due to the anatomic reduction and high patients' satisfaction rates at long-term follow-up. Main aim of this study is to compare clinical and radiographic outcomes of 2 cohorts with moderate to severe stable SCFE treated by MDP and in situ fixation. METHODS: Medical records were analysed to collect demographic data, comorbidities and time from slip to surgery. The collected postoperative data were: avascular necrosis (AVN); complications; progression of osteoarthritis and subsequent procedures. Southwick angles (SA), alpha angles and Klein line were measured on the preoperative x-rays, on the immediate postoperative period and at the latest follow-up. Outcomes scores were recorded by the following questionnaires: the Harris Hip Score, the Hip disability and Osteoarthritis Outcome Score, the Merle d'Aubigné and Postel score and the Western Ontario and McMaster Universities Arthritis Index. Kaplan-Meier survivorship curve was calculated. RESULTS: We compared 81 hips treated by MDP with 22 hips treated by in situ pinning (PS) for moderate/severe stable SCFE. No significant differences were found between the 2 groups in terms of age, BMI, comorbidities and preoperative slip angles. At the latest follow-up, postoperative anteroposterior mean slip angles were respectively 6.2 and 19.9° in MDP and PS group (p = 0.3). Slip angles in frog lateral view were 11° in the MDP group and 39.7° in the PS group (p = 0.2). MDP group achieved better correction angles on frog leg view (11° vs. 39.7°; p < 0.001). There was no statistically significant difference in the occurrence of AVN among both groups (19.7% MDP group vs. 31.8% PS group) (p = 0.2). CONCLUSIONS: The MDP in treating severe stable SCFE showed the best deformities corrections in conjunction with the highest functional scores at long-term follow-up and similar rates of osteonecrosis compared to in situ fixation.

Hip morphology in slipped capital femoral epiphysis.

Several mechanical factors have been related to slipped capital femoral epiphysis (SCFE). Main aim of this study is to investigate the acetabular coverage and acetabular version in unilateral SCFE hips in order to detect a potential pincer-type deformity as predisposing factor; second, we compared those measurements either to the contralateral, uninvolved hips either to a matched healthy control population. A total of 85 patients treated for unilateral SCFE were retrospectively reviewed. The lateral center-edge angle (LCEA) and the Tönnis angle were used to assess acetabular coverage, whereas acetabular retroversion was defined by positive prominent ischial spine (PIS), cross-over sign (COS) and posterior wall sign (PWS). Angles and signs of the affected hips were compared to the contralateral hips and to a matched cohort undergoing an abdominal/pelvic computed tomography for nonorthopedic-related diseases. Affected and unaffected hips of patients with unilateral SCFE had similar morphology in terms of LCEA 28.7° vs. 28° (P = 0.4), Tönnis angle 9° vs. 9° (P = 0.1) and retroversion signs with concomitant rate of PWS and COS 57.6% vs. 50.5% (P = 0.4), PIS 56.4% vs. 49.4% (P = 0.4). Matched healthy controls vs. the affected hips showed a lower LCEA (P < 0.001) and higher Tönnis angle (P < 0.001) in conjunction with a lower incidence of acetabular retroversion: PWS and COS 40% vs. 57.6% (P = 0.01), PIS 43% vs. 56.4% (P = 0.07). A significant retroversion and increased overcoverage were observed in SCFE patients compared to matched healthy controls. In unilateral SCFE, the involved and uninvolved hips showed a substantial symmetry.

Minimal Damage to the Supinator Muscle After the Double-Incision Technique for Distal Biceps Tendon Repair.

BACKGROUND: The effect of the double-incision technique on the supinator muscle is unclear. PURPOSE: The aim of this study was to quantify fatty atrophy of the supinator muscle and map the area of muscle damage. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 19 male patients (median age, 43 years) who underwent distal biceps tendon repair were included in the analysis. Patients with a minimum of 12 months of follow-up were included. The following variables were analyzed: range of motion; shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Summary Outcome Determination (SOD) score; and isokinetic peak force and endurance in supination. Quantitative analysis and mapping of fatty infiltration of the supinator muscle were based on the calculation of proton density fat fraction on magnetic resonance imaging scans of both elbows using the IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) sequence. RESULTS: At an average follow-up of 24 months (range, 12-64 months), the median SOD score was 9.0 (95% CI, 7.8-9.4), and the mean QuickDASH score was 6.7 (95% CI, 0.0-14.1). A difference of 17% in peak torque was measured between repaired and nonrepaired elbows (repaired elbow: 9.7 N·m; nonrepaired elbow: 11.7 N·m; P = .11). Endurance was better in the repaired elbow than the nonrepaired elbow (8.4% vs 14.9% work fatigue, respectively; P = .02). The average fat fraction of the supinator muscle was 19% (95% CI, 16%-21%) in repaired elbows and 14% (95% CI, 13%-16%) in contralateral elbows (P = .04). The increase in fat fraction was located in a limited area between the radius and ulna at the level of the bicipital tuberosity. CONCLUSION: The assessment of the supinator muscle showed a limited increase in fat fraction between the radius and ulna at the level of the bicipital tuberosity. No significant effect on supination strength was highlighted.

Unexpected Listeria monocytogenes detection with a dithiothreitol-based device during an aseptic hip revision.

Prosthetic joint infection diagnosis is often difficult since biofilm-embedded microorganisms attach well to the prosthetic surfaces and resist their detection by conventional methods. DL-dithiothreitol has been described as a valid method for biofilm detachment on orthopedic devices. We report the case of an occasional detection of Listeria monocytogenes in a non immuno-compromised patient with a preoperative diagnosis of aseptic loosening. The infection diagnosis due to such rare bacteria was made postoperatively, thanks to a DL-dithiothreitol-based device. This may be considered a feasible approach for the microbiological analysis of prosthetic joint infection, considering that a prompt diagnosis of such biofilm-associated infections could bring some advantages, such as an early and appropriate antibiotic therapy administration and a reduction of undiagnosed infections.