Application and advantages of monoenergetic reconstruction images for the reduction of metallic artifacts using dual-energy CT in knee and hip prostheses.

OBJECTIVE: The study aimed to assess image quality when using dual-energy CT (DECT) to reduce metal artifacts in subjects with knee and hip prostheses. METHODS: Twenty-two knee and 10 hip prostheses were examined in 31 patients using a DECT protocol (tube voltages 100 and 140 kVp). Monoenergetic reconstructions were extrapolated at 64, 69, 88, 105, 110, 120, 140, 170, and 190 kilo-electron volts (keV) and the optimal energy was manually selected. The B60-140 and Fast DE reconstructions were made by CT. The image quality and diagnostic value were subjectively and objectively determined. Double-blind qualitative assessment was performed by two radiologists using a Likert scale. For quantitative analysis, a circular region of interest (ROI) was placed by a third radiologist within the most evident streak artifacts on every image. Another ROI was placed in surrounding tissues without artifacts as a reference. RESULTS: The inter-reader agreement for the qualitative assessment was nearly 100%. The best overall image quality (37.8% rated "excellent") was the Fast DE Siemens reconstruction, followed by B60-140 and Opt KeV (20.5 and 10.2% rated excellent). On the other hand, DECT images at 64, 69 and 88 keV had the worse scores. The number of artifacts was significantly different between monoenergetic images. Nevertheless, because of the high number of pairwise comparisons, no differences were found in the post hoc analysis except for a trend toward statistical significance when comparing the 170 and 64 keV doses. CONCLUSIONS: DECT with specific post-processing may reduce metal artifacts and significantly enhance the image quality and diagnostic value when evaluating metallic implants.

Update on mitochondria and muscle aging: all wrong roads lead to sarcopenia.

Sarcopenia is a well-known geriatric syndrome that has been endorsed over the years as a biomarker allowing for the discrimination, at a clinical level, of biological from chronological age. Multiple candidate mechanisms have been linked to muscle degeneration during sarcopenia. Among them, there is wide consensus on the central role played by the loss of mitochondrial integrity in myocytes, secondary to dysfunctional quality control mechanisms. Indeed, mitochondria establish direct or indirect contacts with other cellular components (e.g. endoplasmic reticulum, peroxisomes, lysosomes/vacuoles) as well as the extracellular environment through the release of several biomolecules. The functional implications of these interactions in the context of muscle physiology and sarcopenia are not yet fully appreciated and represent a promising area of investigation. Here, we present an overview of recent findings concerning the interrelation between mitochondrial quality control processes, inflammation and the metabolic regulation of muscle mass in the pathogenesis of sarcopenia highlighting those pathways that may be exploited for developing preventive and therapeutic interventions against muscle aging.

Correlation Between Hump Dimensions and Curve Severity in Idiopathic Scoliosis Before and After Conservative Treatment.

STUDY DESIGN: Prospective study in 150 consecutive outpatients affected by adolescent idiopathic scoliosis (AIS). OBJECTIVES: The purposes were to (1) identify a correlation between hump dimensions and the severity of scoliotic curve, and (2) evaluate how the treatment influenced the main parameters of scoliosis. SUMMARY OF BACKGROUND DATA: The existence of a relationship between clinical deformities and curve severity in AIS is still debated. Furthemore, only a few studies have investigated the effectiveness of conservative treatment for idiopathic scoliosis taking into account both clinical and radiologic factors. METHODS: 150 consecutive outpatients (mean age 12.8 ±â€Š1.9 years) affected by AIS were subjected to conservative brace-based treatment. 134 participants completed the treatment protocol. Two parameters were considered to evaluate the treatment progress: the hump and the Cobb angle. Measurements were determined at the beginning and the end of treatment. Statistical analyses were performed in the whole sample and after dividing the study participants into 4 subgroups: patients with lumbar (n = 66) or thoracic curves (n = 68), patients ranging in age between 6 and 13 years (n = 89) and patients ≥ 14 years of age (n = 45). RESULTS: A positive correlation was detected between the hump dimension and curve severity at the beginning and the end of treatment, except for lumbar curves at baseline. The deformity was effectively corrected by the orthotic treatment (Cobb angle: 29.4 ±â€Š8.5° at baseline and 19.3 ±â€Š9.8° at the end of treatment; hump severity: 11.6 ±â€Š5.6 mm at baseline and 6.2 ±â€Š4.6 mm at the end). In addition, our data indicate that the hump correction is more evident than that of the curve registered in Cobb degrees. CONCLUSION: A significant correlation exists between the hump dimension and curve severity both at the beginning and the end of treatment, except for lumbar curves at baseline. The brace treatment confirmed its effectiveness in arresting the deformity progression and inducing a remodeling both of the scoliotic curve and the hump.

Complex tibial plateau fractures: a retrospective study and proposal of treatment algorithm.

INTRODUCTION: Complex tibial plateau fractures are characterized by compression and sinking of one or both the articular surfaces. In this study, we evaluated clinical and radiological outcomes in patients with 41.C1,41.C2,41.C3 fractures according to AO classification. We also provide a specific therapeutic algorithm for each type of fracture. MATERIAL AND METHODS: The study was conducted in 43 patients who underwent surgical treatment for complex tibial plateau fractures and were followed for a minimum of 12 months. Outcome measures included: range of motion (ROM) recovery, Short Form 36 Health Survey (SF36), Knee injury and Osteoarthritis Outcome Score (KOOS), tibial plateau angle (TPA), and posterior angle (PA). RESULTS: Analyses were performed in 38 patients after excluding 5 cases because of missing imaging evaluations at follow-up. All patients showed good quality of life in all areas considered by SF36 and KOOS as well as satisfactory recovery of ROM. Average TPA and PA values were 87.9° and 0.6°, respectively. DISCUSSION: In complex tibial plateau fractures, surgical treatment is instrumental to obtain full restoration of the joint surface and fast functional recovery. Results are highly related to the type of treatment adopted for different kinds of fracture. In our case series, the best results were obtained when 41.C1 fractures were treated with a single plate. In 41.C2 fractures, clinical and imaging outcomes were independent of the number of plates used. In contrast, in 41.C3 fractures, optimal results were achieved with double plates. CONCLUSIONS: Based on our findings, as also supported by the literature, 41.C1 fractures should be treated with single plate, which reduces the surgical time, soft tissue damage and infection risk. On the other hand, 41.C3 fractures have best outcomes in stability, consolidation and recovery time when treated with double plate.

Mitochondrial dynamics signaling is shifted toward fusion in muscles of very old hip-fractured patients: Results from the Sarcopenia in HIp FracTure (SHIFT) exploratory study.

BACKGROUND: Mitochondrial quality control (MQC) is crucial for maintaining mitochondrial fitness. We investigated MQC signaling in muscle of old hip-fractured patients. METHODS: Twenty-three patients, enrolled in the Sarcopenia in HIp FracTure (SHIFT) study, were categorized into old (OL; n=8) and very old groups (VOL; n=15) using 85years as the cut-off. The expression of a set of MQC signaling proteins was assayed in vastus lateralis muscle biopsies. RESULTS: The content of lysosome-associated membrane protein 2, microtubule-associated protein 1 light chain 3B, optic atrophy protein 1, fission protein 1 (Fis1), peroxisome proliferator-activated receptor-γ coactivator-1α, and forkhead box O3 was unvaried between groups. Conversely, the protein expression of mitofusin 2 (Mfn2) as well as the fusion index (Mfn2/Fis1) was increased in VOL patients. CONCLUSIONS: Muscle mitochondrial dynamics appear to be shifted toward fusion in very advanced age. Whether this phenomenon represents an adaptation to cope with age-dependent mitochondrial dysfunction warrants further investigation.

Titanium elastic nailing in diaphyseal femoral fractures of children below six years of age.

AIM: To report the clinical and radiographic results of titanium elastic nail (TEN) in diaphyseal femoral fractures of children below age of six years. METHODS: A retrospective analysis of 27 diaphyseal femoral fractures in children younger than six years treated with TEN between 2005 and 2015 was conducted. Patients were immobilized in a cast for 5 wk and the nails were removed from 6 to 12 wk after surgery. Twenty-four cases were clinically and radiographically re-evaluated using the Flynn's scoring criteria, focusing on: Limb length discrepancy, rotational deformity, angulation, hip and knee range of motion (ROM), functional status, complications, and parent's satisfaction. RESULTS: Sixteen males and eight females with a mean age of 3.2 years at the time of treatment were re-evaluated at an average follow-up of 58.9 mo. No cases of delayed union were observed. The mean limb lengthening was 0.3 cm. Four cases experienced limb lengthening greater than 1 cm and always minor than 2 cm. Twelve point five percent of the cases showed an angulation < 10°. Complete functional recovery (hip and knee ROM, ability to run and jump on the operated limb) occurred in 95.7% of cases. Complications included two cases of superficial infection of the TEN entry point, one case of refracture following a new trauma, and one TEN mobilization. According to the Flynn's scoring criteria, excellent results were obtained in 79.2% of patients and satisfactory results in the remaining 20.8%, with an average parent's satisfaction level of 9.1/10. CONCLUSION: TEN is as a safe, mini-invasive and surgeon-friendly technique and, considering specific inclusion criteria, it represents a useful and efficacy option for the treatment of diaphyseal femoral fractures even in patients younger than six years of age.

Association between myocyte quality control signaling and sarcopenia in old hip-fractured patients: Results from the Sarcopenia in HIp FracTure (SHIFT) exploratory study.

BACKGROUND: Sarcopenia has been proposed as a potentially amenable factor impacting the clinical outcomes of hip-fractured elderly. The identification of specific biological targets is therefore crucial to developing pharmacological interventions against age-related muscle wasting. The present work reports promising preliminary data on the association between alterations of myocyte quality control (MQC) signaling and sarcopenia in old patients with hip fracture. METHODS: Twenty-five elderly hip-fractured patients (20 women and 5 men; mean age 84.9±1.65years) were enrolled as part of the Sarcopenia in HIp FracTure (SHIFT) study. Intraoperative biopsies of the vastus lateralis muscle were obtained and assayed for the expression of a set of MQC signaling proteins. The presence of sarcopenia was established according to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, with bioelectrical impedance analysis used for fat-free mass estimation. RESULTS: Sarcopenia was identified in 10 patients (40%). Protein expression of the mitochondrial fusion factor mitofusin (Mfn) 2 and the autophagy mediator microtubule-associated protein 1 light chain 3B (LC3B) was significantly lower in patients with sarcopenia compared with non-sarcopenic controls. No differences between groups were observed for Mfn1, optic atrophy protein 1 (OPA1), fission protein 1 (Fis1), and the master regulator of mitochondrial biogenesis peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α). CONCLUSION: Data from this exploratory study show that a reduced expression of the mitochondrial fusion factor Mfn2 and the autophagy mediator LC3B is associated with sarcopenia in old hip-fractured patients. Future larger-scale studies are needed to corroborate these preliminary findings and determine whether MQC pathways may be targeted to improve muscle health and promote functional recovery in old patients with hip fracture.

Fixation techniques for the anterior cruciate ligament reconstruction: early follow-up. A systematic review of level I and II therapeutic studies.

The purpose of our study was that to systematically review the fixation techniques for the ACL reconstruction and associated clinical outcomes at the early follow-up. Systematic search on three electronic databases (Cochrane register, Medline and Embase) of fixation devices used for primary ACL reconstruction with doubled semitendinosus and gracilis and bone-patellar tendon-bone autografts in randomized clinical trials of level I and II of evidence published from January 2001 to December 2011. Therapeutic studies collected were with a minimum 12-month follow-up, and the clinical outcomes were evaluated by at least one of International Knee Documentation Committee, Lysholm and Tegner functional scales and at least one of the following knee stability tests: arthrometric AP tibial translation, Lachman test and pivot-shift test. Nineteen articles met the inclusion criteria. At the femoral side cross-pin, metallic interference screw, bioabsorbable interference screw, and suspensory device were used in 32.3, 27.3, 24.8, 15.5% of patients, respectively. At the tibial side fixation was achieved with metallic interference screw, bioabsorbable interference screw, screw and plastic sheath, screw post and cross-pin in 38.7, 31, 15.7, 12.8, and 1.7% of patients, respectively. Side-to-side anterior-posterior tibial translation was 1.9 ± 0.9, 1.5 ± 0.9, 1.5 ± 0.8, 2.2 ± 0.4 mm for metallic interference screw, bioabsorbable screw, cross-pin and suspensory device, respectively. At least two-third of all the patients achieved good-to-excellent clinical outcomes. Rate of failure was 6.1, 3.3, 1.7 and 1.2% for bioabsorbable interference screw, metallic interference screw, cross-pin and suspensory device, respectively. Clinical outcomes are good to excellent in almost two-third of the patients but several pitfalls that affect the current fixation techniques as graft tensioning such as graft-tunnel motion are still unaddressed.

Treatment of osteochondritis dissecans of the knee with a biomimetic scaffold. A prospective multicenter study.

PURPOSE: the aim of the present study was to evaluate the clinical outcome of the treatment of osteochondritis dissecans (OCD) of the knee with a type-I collagen-hydroxyapatite nanostructural biomimetic osteochondral scaffold. METHODS: twenty-three patients affected by symptomatic knee OCD of the femoral condyles, grade 3 or 4 of the International Cartilage Repair Society (ICRS) scale, underwent biomimetic scaffold implantation. The site of the defect was the medial femoral condyle in 14 patients, whereas in 9 patients the lateral femoral condyle was involved. The average size of the defects was 3.5±1.43 cm(2). All patients were clinically evaluated using the ICRS subjective score, the IKDC objective score, the EQ-VAS and the Tegner Activity Score. Minimum follow-up was two years. MRI was performed at 12 and 24 months after surgery and then every 12 months thereafter. RESULTS: the ICRS subjective score improved from the baseline value of 50.93±20.6 to 76.44±18.03 at the 12 months (p<0.0005) and 82.23± 17.36 at the two-year follow-up (p<0.0005). The IKDC objective score confirmed the results. The EQ-VAS showed a significant improvement from 3.15±1.09 to 8.15±1.04 (p<0.0005) at two years of follow-up. The Tegner Activity Score improvement was statistically significant (p<0.0005). CONCLUSIONS: biomimetic scaffold implantation was a good procedure for treating grade 3 and 4 OCD, in which other classic techniques are burdened by different limitations. This open one-step surgery gave promising stable results at short-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Joint line tenderness and McMurray tests for the detection of meniscal lesions: what is their real diagnostic value?

OBJECTIVES: To assess the interobserver concordance of the joint line tenderness (JLT) and McMurray tests, and to determine their diagnostic efficiency for the detection of meniscal lesions. DESIGN: Prospective observational study. SETTING: Orthopedics outpatient clinic, university hospital. PARTICIPANTS: Patients (N=60) with suspected nonacute meniscal lesions who underwent knee arthroscopy. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patients were examined by 3 independent observers with graded levels of experience (>10y, 3y, and 4mo of practice). The interobserver concordance was assessed by Cohen-Fleiss κ statistics. Accuracy, negative and positive predictive values for prevalence 10% to 90%, positive (LR+) and negative (LR-) likelihood ratios, and the Bayesian posttest probability with a positive or negative result were also determined. The diagnostic value of the 2 tests combined was assessed by logistic regression. Arthroscopy was used as the reference test. RESULTS: No interobserver concordance was determined for the JLT. The McMurray test showed higher interobserver concordance, which improved when judgments by the less experienced examiner were discarded. The whole series studied by the "best" examiner (experienced orthopedist) provided the following values: (1) JLT: sensitivity, 62.9%; specificity, 50%; LR+, 1.26; LR-, .74; (2) McMurray: sensitivity, 34.3%; specificity, 86.4%; LR+, 2.52; LR-, .76. The combination of the 2 tests did not offer advantages over the McMurray alone. CONCLUSIONS: The JLT alone is of little clinical usefulness. A negative McMurray test does not modify the pretest probability of a meniscal lesion, while a positive result has a fair predictive value. Hence, in a patient with a suspected meniscal lesion, a positive McMurray test indicates that arthroscopy should be performed. In case of a negative result, further examinations, including imaging, are needed.