Use of ceramic bearings in hip arthroplasty: correct implantation and review of clinical and radiographic results.

Ceramic materials are widely used in hip prosthetic surgery. Faced with important developments in the design and characteristics of the materials, ceramic-on-ceramic (CoC) are today the bearings in Total Hip Replacement (THR) showing the minimal wear rate. Moreover, ceramic wear debris demonstrated the absence of local and systemic toxicity. This makes ceramic bearing particularly suitable for active patients, whatever their age. The results show excellent survival rates of THRs with ceramic components and excellent clinical and radiographic scores with follow-up close to 20 years. However, the excellent outcomes of THRs with ceramic bearings are depending on appropriate and correctly performed surgical technique.

A rare case of post-traumatic infected pilomatricoma of the finger of the hand diagnosed after performing radioiodine therapy.

We present the clinical case of a young woman with pilomatricoma of the finger, a very rare location. The patient got infected after receiving radioiodine therapy to treat a thyroid carcinoma. Given the patient's high functional requirements we choose a minimal treatment which allowed her to maintain a sufficient functionality.

Biomechanical study of shaft fracture with the butterfly fragment: software simulation.

The specific traumatic mechanism that leads to the formation of the butterfly fragment is debated in literature. The aim of the present study is to analyze the biomechanics of fractures with a "butterfly" fragment, using a software that simulates the movement of the lines of force (and related iso-displacement points) that occur on the bone, when traumatic forces are applied on it. We have shown that the formation of the butterfly fragment derives from the application of three forces (compression, torsion and bending) with the bending force that acts by increasing the curvature of the long bone.

Predictable risk factors for infections in proximal femur fractures.

Proximal femur fractures are increasing, together with the aging of world population. One of the complications worsening this condition is infection. In this study, we try to identify risk factors that can lead to infection. We identified 122 patients with femoral neck fracture. The occurrence of infectious events were recorded (respiratory, urinary, superficial wound and periprostethic infection). There were 15 infections, mostly urinary and pulmonary, and all were treated using antibiotics. No statistical differences were found between infection and control group regarding waiting time for surgery, mean time of surgery, age, kind of fracture, type of surgery. Fever onset >38° within 72 hours from surgery was statistically correlated with early infections. Future studies must be led to identify risk factors for infection and to create a strategy to prevent this possibly lethal complication.

Vascular endothelial growth factor expression as a biomarker of prognosis in patients with chondrosarcoma, Ewing's sarcoma and osteosarcoma. Current concepts.

With the advent of the molecularly targeted therapies, identifying molecular therapeutic targets and molecolar marker is increasingly important, especially in neoplastic diseases. Several studies show VEGF is involved in neo-angiogenesis in many solid cancers, as breast, lung, renal, gastric carcinomas, through promoting endothelial cell growth and migration. Conversely the relationship between VEFG and tumours of the musculoskeletal system is yet unclear, in particular the role of VEGF has not yet been completely understood in these tumours. Chondrosarcoma, Ewing's Sarcoma and Osteosarcoma are the tumours of the musculoskeletal system in which the activity of VEGF has been closely studied. The present study aims to give an overview focused on the relationship between VEGF and these three cancers.

Single dose cefazolin is safe and effective for pre-operative prophylaxis in orthopaedic oncology.

Surgical site infections (SSI) are a common potentially preventable complication after surgical procedures. A standardized antibiotic prophylaxis in elective orthopaedic surgery plays a major role in lowering SSI. At present, there is little published evidence regarding standardized antibiotic prophylaxis in orthopaedic oncological surgery. We introduced a prophylactic antibiotic protocol for orthopaedic oncological surgery in our hospital. The proposed protocol consists in "one-shot" intravenous administration of Cefazolin 2g, 30 min before surgery. In our setting, this preoperative antibiotic prophylaxis regimen was associated with a markedly lower rate of SSI's. There is no current evidence in favour of greater effectiveness of prophylaxis beyond 24/48 h after surgery compared to our pre-surgical "one-shot" administration; by contrast, prolonged post-surgical prophylaxis is likely to undermine the patient's bacterial flora and select resistant pathogens. These results are preliminary and should be used to start planning a standardised prophylactic protocol to prevent SSI's after orthopaedic oncological surgery.

Soft tissue adhesion patterns over Trevira tube on modular endoprosthesis for malignant bone tumours: an in vitro study.

A reliable and effective technique in case of limb salvage surgery after resection of extensive bone tumors is represented by the implant of modular or custom-made megaprosthesis. Fixation of the residual surrounding soft tissue on the implant represent a challenge for the surgeon and the use of a polyethylene terephthalate (PET) tube over it, also known as Trevira, is currently a common choice for reattachment with good clinical outcomes. We compared fibroblastic cell culture potential over simple titanium coating vs titanium surrounded by Trevira and evaluated cell viability and replication at 24, 48 and 72 h using MTT cell growth assay and scanning electron microscopy to determine if there was any difference in the potential of cell growth associated to the material used. No significant difference was found at different timings in terms of total cell count for cultures over the two materials, but the absolute cell count was slightly higher in the Trevira group in the early time points, reversing the trend at 72 h of incubation. Ninety-four % of the cells analyzed were vital, regardless of the materials involved in the experiment, confirming the biocompatibility of titanium and PET. According to the results shown, we are able to confirm the in vitro safety and efficacy, in terms of newly formed cells extension and adhesion pattern, of using an attachment tube made from Trevira fibers surrounding an oncological megaprosthesis in order to achieve the most anatomical reinsertion of remaining soft tissue following resection.

Evaluation of accuracy of bone cuts and implant positioning in total knee arthroplasty using patient specific instrumentation.

In the last years new surgical techniques are developing to improve prosthesis positioning, increasing clinical and functional results and reducing invasiveness. In this scenario patient-specific instrumentations have been introduced in order to enhance surgical accuracy and ease of implantation. The purpose of this study was to assess the compliance of the pre-operative planning data with bone resections measured intraoperatively and to evaluate prosthesis positioning in patients undergoing total knee arthroplasty (TKA) using an MRI-based pin-guides instrumentation. Thirty consecutive patients (20 women and 10 men) undergoing 30 total knee replacements (20 right- and 10 left-sided knees) were included in this study. The same cemented cruciate ligament sacrificing prosthesis (NexGen LPS, Zimmer, Warsaw, Indiana, USA) was implanted in all patients by a single surgeon using Patient-Specific Instruments (PSI, Zimmer, Warsaw, Indiana, USA). Femoral and tibial bone resections were measured using a manual caliper intra-operatively and compared with the corresponding pre-operative values. Each patient underwent A CT examination following surgery in order to investigate individual component positioning. None of the cases was converted from PSI technique to conventional TKA and adequate femoral and tibial bone cuts were performed without the need for intraoperative adjustments. Two outliers were detected among the intra-operative bone cuts measurements. In all patients the size of femoral and tibial prosthetic components, hypothesized at preoperative planning, was confirmed intra-operatively. Two outliers were detected among post-operative CT measurements as for components positioning. PSI system can assist in obtaining good component positioning with reduction of outliers. Despite the small number of patients, our data demonstrate the validity of this patient-specific pin-guides system in TKA and may support repeatable improvements in surgical accuracy. Level of evidence: IV.

QUALITY OF LIFE FOLLOWING SURGICAL TREATMENT OF LOWER LIMB METASTASES IN LONG BONE.

Pathological fractures have a high incidence in musculo-skeletal oncology, and localization in long bone causes severe pain, disability and poor quality of life. The aim of this retrospective case series is to evaluate the clinical results, in particular regarding the quality of life, in patients affected by lower long bone pathological fractures surgically treated. We analyzed 93 patients with pathological fractures of tibia and femur surgically treated in our Orthopaedic Department and followed up for at least 3 years or until their death. Intramedullary nailing or endoprosthetic reconstruction for pathologic fractures located in the metadiaphyseal and diaphyseal or proximal regions in advanced-stage cancer patients are suitable methods for a stable fixation or reconstruction. These approaches guarantee a good mechanical stability, a faster mobilization, a better control of pain with an overall improvement in quality of life in all patients, confirmed also by the trend of the ECOG performance status and QOL-ACD.

SILVER COATED PROSTHESIS IN ONCOLOGICAL LIMB SALVAGE SURGERY REDUCE THE INFECTION RATE.

Silver coatings, used in many surgical devices, have demonstrated good antimicrobial activity and low toxicity. Oncological musculoskeletal surgery have a high risk of infection, so in the last decades, silver-coated mega-prostheses have been introduced and are becoming increasingly widespread. In this study, a retrospective analysis of 158 cases of bone tumors, primary or metastatic, treated between 2005- 2015 with wide margins resection and tumor implants reconstruction, was performed. The average age was 59 years (range 11-78 years), the same surgeon with antibiotic prophylaxis according to a standard protocol treated all patients. Silver-coated prostheses were implanted in 58.5% of patients and uncoated tumor prostheses in the remaining 41.5%. Patients were re-evaluated annually and complications were recorded, focusing analysis on infective complications. The average follow-up was 39.7 months: 23.4% of patients died at a median time of 35.3 months after surgery; 18.4% developed complications that required new surgery, of which 12.6% of these were due to infection. Patients treated with silver-coated implants developed early infection in 2.2% of cases against the 10.7% of the patients treated with standard tumor prosthesis. This difference between the two groups was statistically significant. The percentage of late infections occurring from 6 months after surgery was similar in both groups. Silver blood level taken in a sample of patients at different times after surgery, always showed values well below the threshold of toxicity and no patient showed any sign of local or general toxicity secondary to silver. Our study demonstrates that tumor silver-coated implants have a rate of early infection significantly lower than traditional implants, while there were no differences in the rate of late infections as described also in the literature. We recommend the use of silver–coated prosthesis as primary implants for limb salvage surgery in primary or metastatic bone tumors, considering the absence of toxicity and the lower rate of early infection.

Collatamp sponges in the management of open fractures.

Open fractures are at high risk of infection and the prompt treatment of these injuries is critical to the success and is crucial to reduce the rate of complications. The basic steps of treatment include the immediate administration of systemic antibiotics, early surgical stabilization of the fracture associated with copious irrigation and radical debridement of the site of exposure, and when possible adequate soft tissue coverage. The systemic antibiotic therapy significantly improves the prognosis and reduces the occurrence of complications. However, in order to ensure adequate and sustained local concentration of antibiotic agent, high doses and for a long time are necessary. This increases the risk of side effects and bacterial resistance. The introduction of the antibiotic-loaded collagen sponges offers the advantages of a high local concentrations of antibiotic carrier delivering system with reduced systemic drug diffusion (less risk of side effects and resistance rate). Sponges are also biodegradable and fully resorbable and do not require additional surgery for their removal.

Survivorship of proximal femoral replacement in neoplastic and non-neoplastic elderly patients.

OBJECTIVE: Massive bone loss is a serious problem in the elderly. Joint replacement with modular prostheses represents the most common reconstructive technique after oncological and non-oncological resections. Megaprostheses are broadly available, adaptable and versatile and allow early mobilization and rehabilitation. Although segmental endoprosthetic implants are now widely used and despite innovations, complications remain far high. Our purpose is to establish what happens to megaprostheses of a specific anatomical site in the long term in a population with oncologic and non-oncologic indications treated at a single center solely by a few skilled surgeons. MATERIALS AND METHODS: We retrospectively reviewed our institutional database. We collected 35 patients who underwent endoprosthetic reconstruction exclusively of the proximal femur for neoplastic and non-neoplastic disease between 2008 and 2021. The minimum follow-up was 12 months. Complications were collected and classified, and also adapted to the non-oncological setting. RESULTS: Taking into consideration the entire population, 94% of this survived the follow-up at 6 months, subsequently 85% at 1 year and 82% at 2 years. At follow-ups after 5 years, 79% of megaprostheses showed no mechanical failure. Analyzing prosthetic survival in the two groups, this was >50% at 24 months after surgery in both groups, with better survival for the oncological one. CONCLUSIONS: Proximal femur replacement can be a valid option in treatment of oncological and non-oncological cases. Due to the high complication rate, only selected cases should undergo this kind of surgical procedure.

Vancouver B2 and B3 periprosthetic femoral fractures treated by ORIF. Mid to long-term follow-up study in 28 patients.

OBJECTIVE: Periprosthetic femoral fractures (PFF) are a serious complication in patients who have undergone hip arthroplasty. Some authors consider revision arthroplasty as the gold standard in the surgical treatment of Vancouver type B2 and B3 PFF. Others, however, prefer treating PFF by open reduction and internal fixation (ORIF), without revising loose stems, especially in elderly patients. In the present retrospective study, we report mid/long-term results in a series of patients affected by B2 or B3 PFF surgically treated by ORIF, using a locking compression plate (LCP), thus avoiding the need of revision arthroplasty. MATERIALS AND METHODS: We reviewed 28 patients affected by B2 or B3 PFF surgically treated between 2010 and 2017 by ORIF using a LCP, after an average follow-up of 5.5 years. The average age of the patients at diagnosis was 78 years; in 17 patients, the femoral stem was uncemented while in 11, cemented. The mean interval time between hip arthroplasty and PFF was 6.7 years. Clinical results were assessed using Harris Hip Score (HHS), while radiographic results according to Beals and Tower criteria. RESULTS: At follow-up, HHS ranged from 72 to 96 points; 8 patients had an excellent result, 12 got a good result and 8 a fair result. According to Beals and Tower criteria, all the radiographic results were excellent (9 patients) or good (19 patients). The majority of our patients returned to their previous ambulatory levels. CONCLUSIONS: According to our results, in elderly patients affected by Vancouver type B2 or B3 PFF, surgical treatment by ORIF using a locking compression plate, without a stem revision, seems to be associated with satisfactory outcome.

The effect of combined drug therapy in lateral fragility fractures of the femur: a prospective observational study.

OBJECTIVE: Due to a growing number of lateral fragility fractures, and their high economic and social impact, we evaluated the combined drug therapy effectiveness in lateral fragility femur fractures treated by intramedullary nailing surgery comparing the clinical and radiological results of two groups of patients. PATIENTS AND METHODS: From May 2019 to March 2020, we carried out a prospective observational study comparing the results of patients with femoral lateral fractures treated by the same intramedullary nail (PFNA Synthes®) using Clodronic acid and Vitamin D (study group, 25 patients) compared to patients with the same fractures treated with Vitamin D alone (control group, 25 patients). The evaluations were based on bone biochemical markers (serum calcium level, serum phosphate level, parathyroid hormone, Vitamin D, serum C-terminal telopeptide), Visual Analogic Scale and HHS (Harris Hip Score) score, and femur densitometric views. In order to evaluate the femur neck mineral bone density (BMD), two areas have been identified on the Anterior-Posterior view: the Region of Interest (ROI)1 (under the head screw) and the ROI2 (above the femoral screw). The BMD has been calculated using femur densitometric views at T0 (1st day post-surgery) and at T1 (12 months later). RESULTS: As far as the BMD average of ROI1 is concerned, we found a significant statistical increase at T1 in the study group (0.93±0.07 gr/cm2) vs. control group (0.88±0.08 gr/cm2), p=0.04. Both biochemical and densitometric values were statistically increased in the study group from T0 to T1 (p<0.05), while control group showed an improvement in the biochemical values only. CONCLUSIONS: Thanks to a one year follow-up, we are able to demonstrate that the administration of an adequate drug therapy after surgery can lead to a better control of the bone remodeling and reabsorption process.

COVID-19 lockdown and hip arthroplasty rehabilitation changes: mid-term clinical outcomes.

OBJECTIVE: Hip arthroplasty is one of the most performed surgeries in orthopedics. Rehabilitation process after surgery allows rapid recovery of joint functions in absence of pain in most patients. During COVID-19 pandemic, rehabilitation clinics have reduced the number of beds available. Thus, an increasing number of patients were forced to home rehabilitation programs. Our study aimed at determining any significant differences in clinical and functional outcomes between those patients who underwent a home rehabilitation program and those others who were granted a place in a Rehabilitation clinic during COVID-19 pandemic, at mid-term follow-up. PATIENTS AND METHODS: An observational retrospective single-center study was designed. The patients included were 63, divided into two groups: Group A (29 patients) for home rehabilitation, and Group B (34 patients) for clinic rehabilitation. Follow-up was performed at 1, 6 and 12 months after surgery. Clinical evaluation was assessed through Oxford Hip Score for hip function, Visual Analogue Scale (VAS) for pain and hip range of motion (ROM) to evaluate joint recovery. RESULTS: ROM was compared at follow-up with significant differences 12 months after surgery (107.93° group A vs. 104.7° group B; p=0.0168). Pain felt by patients according to the VAS scale showed no significant differences at follow-up (1 month 3.27 vs. 3.65 p=0.1489; 6 months 1.89 vs. 2.18 p=0.105; 12 months 0.58 vs. 0.68 p=0.6263). Regarding the Oxford Hip score, significant differences emerged at 1-month follow-up (38.75 group A vs. 37.94 group B; p=0.0498). CONCLUSIONS: At mid-term follow-up, little differences were found between patients who went through home rehabilitation and those who went to a rehabilitation clinic. Therefore, decreasing the number of beds available in rehab clinics during COVID-19 pandemic was not an obstacle for elective surgery for orthopedic surgeons.

Medial gastrocnemius flap for the treatment of infected knee prostheses.

OBJECTIVE: Muscular flaps may represent a valid treatment option for prosthetic infection after knee arthroplasty. PATIENTS AND METHODS: We present the results of 20 consecutive patients treated with the use of medial gastrocnemius flap for the management of different types of injuries or integumentary defects after total knee arthroplasty. Tissue necrosis or dehiscence occurred within 1 and 2 months after arthroplasty. The mean follow-up was 23.4 (12-60) months. Clinical outcome was evaluated according to the infection control rate and post-operative Knee Society Score (KSS). RESULTS: Prosthesis salvage and complete restoration of skin coverage were achieved in all patients. Functional assessment was performed using the KSS score. The final knee KSS score was classified as excellent (score: 80-100) in 0 patients, good (score: 70-79) in 17 patients, fair (score: 60-69) in 2 patients, and poor (score: 60) in 1 patient. Residual Extension Deficit: 0-20°; Very Satisfactory in 17 patients. 30-70° Satisfactory in 2 patients, 80-90° Unsatisfactory in 1 patient. Patients who successfully underwent flap treatment experienced a much greater increase in both components of the KSS score. CONCLUSIONS: The results highlight the effectiveness of medial gastrocnemius muscular flap for the treatment of prosthetic knee infection, in terms of function, limb salvage, cost-effectiveness and post-surgery quality of life. Further larger studies may consolidate these findings.

Megaprosthesis in articular fractures of the lower limbs in fragile patients: a proposal for the therapeutic algorithm.

OBJECTIVE: The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to identify the patients suitable to megaprosthetic implants in the treatment of lower limbs fractures, as well as periprosthetic fractures. PATIENTS AND METHODS: From January 1st, 2015, to December 31st, 2021, all patients affected by femoral fractures with severe bone loss or previous surgery failure were retrospectively reviewed. ADL, IADL, SF-12 values pre- and post-operative were recorded. Hemoglobin value, NLR, PLR were recorded pre- and peri-operatively for all patients. Complications were recorded. All patients underwent a radiological follow-up. Significance was set at p ≤ 0.05. RESULTS: 23 patients were considered eligible, 10 males and 13 females; the mean age was 72.87 years old (± 12.33), while the mean BMI was 27.2 points (± 5.2). The mean follow-up was 2 years (± 1.4). The mean preoperative ADL and IADL scores were correlated with a positive independence of the patient, while the mean postoperative scores corresponded to a moderate-low independence. Also the mean Mental and Physical SF12 scores saw a decrease in values. NLR values were higher in the first group of patients with complications. CONCLUSIONS: A careful multiparametric and multidisciplinary patient selection is required to identify the suitable patient to this treatment.

Correlation between Neutrophil-to-lymphocyte ratio and Euthyroid Sick Syndrome in elderly patients with proximal femur fractures.

OBJECTIVE: Proximal femur fractures are among the most common type of trauma in elderly patients, and Euthyroid sick syndrome has already been related to fractures and trauma. The evidence of a consistent inflammatory state occurring during hip fracture, made us consider as a potential marker also the neutrophil-to-lymphocyte ratio (NLR), which is already in use to measure the prognosis and guide the therapeutic management in various conditions. PATIENTS AND METHODS: A retrospective observational analysis on patients affected by proximal femur fractures was conducted. Patients were divided between affected and non-affected by Euthyroid Sick Syndrome (ESS). Standard follow up was conducted at 1, 3, 6 and 12 months. RESULTS: 79 patients were enrolled in this study. There were 19 males and 60 females, the mean age was 83.8 ± 6.5 y.o., and 44 patients were affected by ESS. Affected patients showed higher NLR values (10.2 ± 9.4 vs. 6.9 ± 3.9; p= 0.001) and higher decrease in fT3 values in the 1st post-operative day (1.8 ± 0.4 vs. 2.2 ± 0.3; p= 0.001), higher values of PTH (97.9 ± 46.2 vs. 70.1 ± 36.2; p=0.004) and lower levels of Vitamin D (18.8 ± 7.8 vs. 23.5 ± 12.9; p= 0.04). As regards complications, we found them in 27% of patients in group A, while only in 8% in Group B, with a statistically significant difference (p= 0.03). CONCLUSIONS: ESS and NLR are promising prognostic markers in PFF in the elderly patients. If used together, they could help in the pre- and post-operative management of the patients.

Proximal humerus fractures treatment in adult patients with bone metastasis.

OBJECTIVE: The humerus is the second long bone most affected by pathological fractures. According to Capanna and Campanacci criteria, surgical choice is based on bone metastasis location, on the patient's status and on the residual functional capacity. Metadiaphysis is an area of conflict in the choice between megaprosthesis implant and intramedullary nail osteosynthesis. This study compares these two surgical procedures in terms of reacquired functionality and local control of metastasis. PATIENTS AND METHODS: Thirty-eight patients (17 males and 21 females; mean age: 66 years old) treated in our institution between January 2010 and December 2020 for pathological humeral metadiaphyseal fractures caused by metastasis, were included in this study. We choose the Musculoskeletal Tumor Society rating system (MSTS) and the Quick Disability of Arm-Shoulder-Hand (QuickDASH) scores for the evaluation of the upper limb function after surgery. RESULTS: Eighteen (47%) pathological fractures were treated by resection and megaprosthesis implantation, twenty (53%) were treated by medullary nail osteosynthesis. A reduction in pain and greater mechanical stability in the immediate post-operative period was found in all patients. Twenty-two patients died (58%) and sixteen survived (42%). Long-term functional recovery of patients undergoing osteosynthesis is greater than megaprothesis group. CONCLUSIONS: Both medullary nail osteosynthesis and resection and megaprosthesis implantation guarantee excellent recovery at 72 months after surgery, improvement in quality of life and pain relief.  Patients treated with osteosynthesis showed a great short-term functional recovery since the joint portion of the limb is not involved, whereas patients treated with megaprosthesis showed better local oncologic control. It is therefore possible to define the type of treatment not only on the localization of the fracture (diaphysis or epiphysis) but above all on the conditions and characteristics of the patient.

The use of collatamp in total hip arthroplasty.

Total Hip Arthroplasty (THA) is one of the most common orthopedic operations in the world. The number of THA is expected to grow and with it the number of associated complications. Although improved surgical technique and the development of more scrupulous asepsis has decreased the incidence of periprosthetic joint infection (PJI), it remains one of the most feared complications of joint arthroplasty. The purpose of this study is to present the use of antibiotic-loaded collagen sponges (Collatamp EG) in the prophylaxis and treatment of PJI. For this scope a case report is described. The advantages offered by the antibiotic loaded sponges in terms of high and sustained concentration of antibiotic at the site of infection, diffused by the fully reabsorbable carrier, showed to be a an important adjuvant therapy in the treatment of PJI. Low systemic concentration of the drug and a wide versatility in surgical application are other advantages of this dispositive.