Dual-Energy Computed Tomography in Urological Diseases: A Narrative Review.

Dual-Energy computed tomography (DECT) with its various advanced techniques, including Virtual Non-Contrast (VNC), effective atomic number (Z-eff) calculation, Z-maps, Iodine Density Index (IDI), and so on, holds great promise in the diagnosis and management of urogenital tumours. In this narrative review, we analyze the current status of knowledge of this technology to provide better lesion characterization, improve the staging accuracy, and give more precise treatment response assessments in relation to urological tumours.

Innovative Experimental Ultrasound and US-Related Techniques Using the Murine Model in Pancreatic Ductal Adenocarcinoma: A Systematic Review.

Pancreatic ductal adenocarcinoma (PDAC) is a cancer with one of the highest mortality rates in the world. Several studies have been conductedusing preclinical experiments in mice to find new therapeutic strategies. Experimental ultrasound, in expert hands, is a safe, multifaceted, and relatively not-expensive device that helps researchers in several ways. In this systematic review, we propose a summary of the applications of ultrasonography in a preclinical mouse model of PDAC. Eighty-eight studies met our inclusion criteria. The included studies could be divided into seven main topics: ultrasound in pancreatic cancer diagnosis and progression (n: 21); dynamic contrast-enhanced ultrasound (DCE-US) (n: 5); microbubble ultra-sound-mediated drug delivery; focused ultrasound (n: 23); sonodynamic therapy (SDT) (n: 7); harmonic motion elastography (HME) and shear wave elastography (SWE) (n: 6); ultrasound-guided procedures (n: 9). In six cases, the articles fit into two or more sections. In conclusion, ultrasound can be a really useful, eclectic, and ductile tool in different diagnostic areas, not only regarding diagnosis but also in therapy, pharmacological and interventional treatment, and follow-up. All these multiple possibilities of use certainly represent a good starting point for the effective and wide use of murine ultrasonography in the study and comprehensive evaluation of pancreatic cancer.

Do prior intra-articular injections impact on the risk of periprosthetic joint infection in patients undergoing total hip arthroplasty? A meta-analysis of the current evidences with a focus on the timing of injection before surgery.

Purpose: Intra-articular injection is a well-established and increasingly used treatment for the patient with mild-to-moderate hip osteoarthritis. The objectives of this literature review and meta-analysis are to evaluate the effect of prior intra-articular injections on the risk of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA) and to try to identify which is the minimum waiting time between hip injection and replacement in order to reduce the risk of infection. Methods: The database of PubMed, Embase, Google Scholar and Cochrane Library was systematically and independently searched, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To assess the potential risk of bias and the applicability of the evidence found in the primary studies to the review, the Newcastle-Ottawa scale (NOS) was used. The statistical analysis was performed by using the software 'R' version 4.2.2. Results: The pooling of data revealed an increased risk of PJI in the injection group that was statistically significative (P = 0.0427). In the attempt to identify a 'safe time interval' between the injection and the elective surgery, we conducted a further subgroup analysis: in the subgroup 0-3 months, we noted an increased risk of PJI after injection. Conclusions: Intra-articular injection is a procedure that may increase the risk of developing periprosthetic infection. This risk is higher if the injection is performed less than 3 months before hip replacement.

Usefulness of modular neck adapter in partial hip revision.

Background and Objective: Modular neck adapters allow different length and offset changes to reach a stable total hip arthroplasty (THA) and permit a quick partial hip revision procedure without removing the existing components. The literature is poor on this matter and about the long-term related outcomes. This narrative review summarizes the most recent literature about these devices as an option of surgical treatment in partial total hip arthroplasty revision (THAr) focusing on indications, clinical and radiological outcomes, and related complications. Methods: The narrative review of the current available literature was conducted in December 2022 through electronic database. The terms used were: "Head neck taper" OR "Merete BioBall" AND "revision Total Hip Arthroplasty (MeSH Terms)". The timeframe was limited between 01/01/2000 and 01/12/2022. The studies regarding the clinical use of the Merete BioBall® system in hip revision surgery were included, while all the papers concerning modular stem prosthesis were excluded. Key Content and Findings: The surgical procedure is safe, quick and allows the surgeon to correct a well-fixed stem version, length and offset, besides retensioning soft tissues. Clinical and radiological outcomes are good with low complications rates. Conclusions: The modular neck adapter system seems to be a good surgical procedure for recurrent dislocation of THA, especially in case of a second THAr surgery. However, the main indication of adapter use remains the isolated acetabular cup revision. The related complications are rare: the worst is the re-dislocation due to an insufficient stem version and length correction. Re-dislocation rates reported in literature vary from 5.2% to 15%. Corrosion or fretting of the modular system are not reported in literature.

Case report of a tibial fracture in a patient suffering from gout: An atypical site, the importance of differential diagnosis.

We present the case of a 60-year-old man with a history of severe tophaceous gout with polyarticular involvement who came to the emergency room due to direct trauma to the right forearm and knee. The knee X-ray and CT scan showed a lateral tibial plateau fracture characterized by the presence of a lytic bone lesion. The presence of a solid neoplasm was ruled out and a CT-guided biopsy was performed. Histological evaluation revealed findings typical for an advanced intraosseous gout. As there was no significant risk of progression of the lytic lesion, the fracture site was treated conservatively. This case is unique in the literature in terms of location and should be considered as an atypical site of intraosseous gout. Proper differentiation of a pathological fracture on an intraosseous gout location from a neoplastic lesion is essential to choose the correct therapy.

Clinical Activities, Contaminations of Surgeons and Cooperation with Health Authorities in 14 Orthopedic Departments in North Italy during the Most Acute Phase of Covid-19 Pandemic.

Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors' viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study.

BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.

Posterior Shoulder Dislocation with Engaging Reverse Hill-Sachs Lesion: A Retrospective Study of Ten Patients Treated with Arthroscopy or Open Reduction and Stabilization.

This study compares two surgical techniques used to treat patients with posterior shoulder dislocation with an engaging reverse Hill-Sachs lesion. We assessed ten patients who were treated at the Surgical Orthopedic and Traumatological Institute (ICOT) of Latina and the Clinic of Orthopedic and Traumatological Surgery of the ASST Sette Laghi of Varese between 2016 and 2019. The patients were divided into two groups: the first comprising six patients who underwent the open surgery McLaughlin procedure as modified by Neer, the second including four patients who underwent the arthroscopic McLaughlin procedure. All patients received postoperative rehabilitation to achieve the best possible functional recovery of the affected shoulder. We then assessed the shoulder range of motion, the pain level, and the impact on quality of life with four tests: the Constant Scale, the Simple Shoulder Test (SST), the OXFORD Scale, and The University of California-Los Angeles (UCLA) Shoulder Scale. The mean scores of the first group were: 81.3 ± 9.8 SD (Constant Scale), 10.8 ± 1.06 SD (SST), 42.5 ± 5.4 SD (Oxford Scale), 30.8 ± 3.02 SD (UCLA Shoulder Scale); we calculated the following mean scores in the second group: 80.25 ± 4.1 SD (Constant Scale), 11.5 ± 0.8 SD (SST), 42 ± 4.06 SD (Oxford Scale), 32 ± 2.9 SD (UCLA Shoulder Scale). We found no significant differences between the two groups.

Active septic arthritis of the hip in adults: what's new in the treatment? A systematic review.

Treatment of bacterial septic arthritis in the native adult hip joint can be challenging. Prompt diagnosis and treatment decisions can reduce the associated morbidity and mortality.For this systematic review of the literature, we asked: (1) What are the treatment options? (2) What are the success rates and the outcomes after treatment? (3) Which antibiotic and duration of therapy are optimal?We searched the electronic databases PubMed, Scopus, and Embase using the search terms "hip" or "native hip" and "septic arthritis" or "coxitis". Studies were included if they reported on: (1) bacterial infection of the hip, (2) treatment, (3) success rate/outcomes, (4) follow-up. The final review included 19 studies. The quality of study reporting was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.Three treatment options are: arthroscopy, single open surgery, and two-stage total hip arthroplasty (THA). A high success rate in infection eradication was reported for all three. Intravenous antibiotic therapy should be promptly initiated to eradicate septic arthritis and minimize potential sequelae and complications.Arthroscopy, single open or two-stage THA were reported to be effective in treating bacterial septic arthritis of the native hip. The key to optimal outcome is early diagnosis and timely treatment. Cite this article: EFORT Open Rev 2021;6:164-172. DOI: 10.1302/2058-5241.6.200082.

Retrospective multi-centre study on head adapters in partial revision hip arthroplasty.

BACKGROUND: Instability and dislocation after total hip arthroplasty (THA) is a common reason for revision surgery. THA head-neck adapters promise the reconstruction of optimal femoral offset and leg length in revision THA (rTHA) while retaining stable implants. The aim of this retrospective multi-centre study is to report on the results achieved with the use of head adapters in partial rTHA, to avoid the instability of the implant. METHODS: 55 cases of partial rTHA performed between February 2015 and April 2017 in 3 different hospitals using the Bioball Head Adapter (BHA) (Bioball Merete, Medical GmbH, Berlin, Germany) were retrospectively recorded. All patients were evaluated from a radiological point of view at an average follow-up of 3.5 years. Failure was defined as re-revision surgery for any cause as well as a subjective feeling of instability of the joint. RESULTS: One failure was registered in an extreme case and radiological findings show no suggestive signs of radiolucencies or loosening and therefore all implants have been considered stable. CONCLUSIONS: Despite some limitations of this retrospective study and according to the relevant literature, our data confirms that BHA is a safe system that allows the flexibility to restore femoral offset and version, to adjust leg length, to minimise instability, to avoid unnecessary removal of otherwise well-fixed components thus improving tribology and reducing the risk of taper junction issues without major complications in partial rTHA.

Effect of the versatile bifunctional chelator AAZTA5 on the radiometal labelling properties and the in vitro performance of a gastrin releasing peptide receptor antagonist.

BACKGROUND: Gastrin Releasing Peptide receptor (GRPr)-based radioligands have shown great promise for diagnostic imaging of GRPr-positive cancers, such as prostate and breast. The present study aims at developing and evaluating a versatile GRPr-based probe for both PET/SPECT imaging as well as intraoperative and therapeutic applications. The influence of the versatile chelator AAZTA5 on the radiometal labelling properties and the in vitro performance of the generated radiotracers were thoroughly investigated. The GRPr-based antagonist D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH2 was functionalized with the chelator 6-[Bis (carboxymethyl)amino]-1,4-bis (carboyxmethyl)-6-methyl-1,4-diazepane (AAZTA5) through the spacer 4-amino-1-carboxymethyl-piperidine (Pip) to obtain AAZTA5-Pip-D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH2 (LF1). LF1 was radiolabelled with gallium-68 (PET), indium-111 (SPECT, intraoperative applications) and lutetium-177 (therapy, SPECT). In vitro evaluation included stability studies, determination of lipophilicity, protein-binding studies, determination of Kd and Bmax as well as internalization studies using the epithelial human prostate cancer cell line PC3. In vitro monotherapy as well as combination therapy studies were further performed to assess its applicability as a theranostic compound. RESULTS: LF1 was labelled with gallium-68, indium-111 and lutetium-177 within 5 min at room temperature (RT). The apparent molar activities (Am) were ranging between 50 and 60 GBq/µmol for the 68Ga-labelled LF1, 10-20 GBq/µmol for the 111In- and 177Lu-labelled LF1. The radiotracers were stable for a period of 4 h post labeling exhibiting a hydrophilic profile with an average of a LogDoctanol/PBS of - 3, while the bound activity to the human serum protein was approximately 10%. 68/natGa-LF1, 177/natLu-LF1 and 111/natIn-LF1 exhibited high affinity for the PC3 cells, with Kd values of 16.3 ± 2.4 nM, 10.3 ± 2.73 nM and 5.2 ± 1.9 nM, respectively, and the required concentration of the radiotracers to saturate the receptors (Bmax) was between 0.5 and 0.8 nM which corresponds to approximately 4 × 105 receptors per cell. Low specific internalization rate was found in cell culture, while the total specific cell surface bound uptake always exceeded the internalized activity. In vitro therapy studies showed that inhibition of PC3 cells growth is somewhat more efficient when combination of 177Lu-labelled LF1 with rapamycin is applied compared to 177Lu-laballed LF1 alone. CONCLUSION: Encouraged by these promising in vitro data, preclinical evaluation of the LF1 precursor are planned in tumour models in vivo.

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war.

BACKGROUND: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed. METHODS: The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). RESULTS: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. CONCLUSIONS: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Internal fixation of intracapsular femoral neck fractures in elderly patients: mortality and reoperation rate.

BACKGROUND: A significant increase in the prevalence of intracapsular femoral neck fractures in the elderly population was reported but the best treatment is still debated. AIM: To evaluate the mortality rate and the reoperation rate of stable neck fractures treated with cannulated screw fixation in elderly patients. METHODS: This was a retrospective study of patients older than 60 years with a Garden I or II femoral neck fractures treated with cannulated screw fixation without capsulotomy. A total of 244 patients (246 hips) who underwent surgery between 2008 and 2018 were included. The average age at the time of surgery was 80 years (range 60-99 years). The mean ASA score was 2.64 (range 1-4). Mortality rate, complications, reoperation rate, the time elapsed between surgeries were recorded. RESULTS: The mortality rate was 50.0%. There were 16 mortalities (6.6%) in the first-month follow-up. We observed higher mortality rates in ASA 4 (80.8%). In 22 patients (8.9%), complications after surgery were observed, and in 11 patients (4.5%) underwent conversion surgery to hemiarthroplasty at a mean of 14.6 months (range 2-48 months) after the femoral screw fixation. Two patients were treated with hardware removal and Gamma Nail for a peri-implant subtrochanteric femur fracture. INTERPRETATION: Cannulated screw fixation should be considered a valid option in intraarticular femoral Garden I-II fractures in elderly patients. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Adverse reaction to metal debris after small-head diameter metal-on-metal total hip arthroplasty: an increasing concern.

INTRODUCTION:: Failures due to adverse reaction to metal debris (ARMD) have become an area of common focus among surgeons performing hip replacements. Several authors have reported data on the prevalence of these masses, in both symptomatic and asymptomatic patients after either large-diameter head metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing arthroplasty, with a large variability of rate. To our knowledge, few data are reported on the association of this lesion with the use of small-head diameter MoM. METHODS:: 15 hips that were revised for ARMD in small-head MoM THA were included in this study. We focused our attention on the difficulties of diagnosis and treatment and also on the histologic aspects of the harvested pathologic tissue. RESULTS:: The histological examination of our cases showed a presence of lymphocytic infiltrate suggesting a delayed hypersensitivity reaction to the metal of type IV (ALVAL), but different from each other in term of the prevalence of the cellular component. Osteolysis and severe soft tissue damage were also observed. Revision resulted in remission of the lesion and successful implant. CONCLUSIONS:: Our observation suggests that the evidence of ARMD should be considered even in case of small-head MoM arthroplasty and therefore these patients should be followed scrupulously with 2nd level diagnostic tools such as magnetic resonance imaging with metal artifact reduction sequence (MARS-MRI) and metal ion levels at least once. Further investigations are necessary to establish the real prevalence of this phenomenon in the whole population of small-head MoM THAs.

Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis of Risk Factors at 7 to 10 Years Follow-up.

BACKGROUND: Dislocation of primary THA (total hip arthroplasty) is one of the most undesirable complications with an incidence ranging from 2% to 5%. Several risk factors are described, related to the patient, surgery, or prosthetic design. The aim of the study was to assess risk factors and their potential influence on dislocation. MATERIALS AND METHODS: 387 primary THA were performed between September 2005 to December 2008 at our institute (Varese, Italy) through a modified posterior-lateral approach. Clinical evaluation was based on range of motion (ROM) and Harris Hip Score; femoral offset, acetabular inclination, and anteversion were measured on plain radiograms. Data were analyzed by SPSS software (SPSS, Inc., Chicago, Illinois). RESULTS: Excellent ROM and Harris Hip Scores were achieved in more than 95% of patients (p<0.05). The offset was restored in all patients. Most of the cases had their cup positioned in the "safe zone" (both inclination and anteversion). Six dislocations (1.87%) occurred: significant correlation was found between dislocation and preoperative diagnosis of femoral neck fracture. CONCLUSIONS: THA dislocation rate appears not to be related to patient biometric parameters and prosthesis design. Femoral neck fracture is reported as the major risk factor for this complication, probably caused by higher preoperative activity and lesser compliance of the patient.

The Use of an Electronic System for Soft Tissue Balancing in Primary Total Knee Arthroplasties: Clinical and Radiological Evaluation.

The eLibra® Dynamic Knee Balancing System (Synvasive Technology, Zimmer, Warsaw, IN) is an instrument designed to address the flexion stability during a TKA. It provides an objective measurement of the soft-tissue forces in the two compartments before the final cuts are made, allowing to obtain patient-specific rotational orientation of the femoral component. Between March 2010 and March 2012, the eLibra® system was used during the implantation of 75 TKAs in 75 patients at the author's institution. Preoperative and postoperative clinical assessment were evaluated using the Knee Society Score (KSS) and the Visual Analogical Scale (VAS). Radiographic evaluation was performed with weight-bearing radiographs in antero-posterior and lateral views in order to study the presence of radiolucencies. In a sample of 20 patients, representative of the population studied, the rotation of the femoral component was measured by two independent observers using the C-arm Cone Beam CT scan (XperCT/Allura FD20 angiography system; Philips, Best, Netherlands). At a mean follow-up of 42.3 months (29-54 months), three patients died from causes not related to the surgery. We had one case of aseptic loosening three years after surgery. None of the patients reported complications peri- or postoperatively. Clinical evaluation showed an improvement in KSS scoring, from preoperative means of 48.35 and 47.53 points for clinical and functional aspects, respectively, to postoperative means of 88.03 and 91.2 points, respectively (p<0.001 for both aspects). The current study demonstrates that the use of the eLibra® device is simple and reproducible. It could help surgeons objectively quantify ligament balance and perform soft tissue-guided resection in a reproducible way, resulting in better post-operative stability and reduced complications. The use of the postoperative cone beam computed tomography (CBCT), in a representative sample of patients, revealed a specific and optimal orientation of the femoral component with a mean of 2.18° of external rotation.

Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies.

Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.

Revision in cemented and cementless infected hip arthroplasty.

Infection is a frequent cause of failure after joint replacement surgery. The infection rate after total hip arthroplasty (THA) has been reduced to 1-2% in the last years. However, it still represents a challenging problem for the orthopedic surgeon. Difficulty of therapeutic approach, and poor functional outcomes together with length of treatment and overall cost are the main burden of this issue. Even the diagnosis of an infected hip could be challenging although it is the first step of an accurate treatment. At the end, many cases require removing the implants. Afterwards, the treatment strategy varies according to authors with three different procedures: no re-implantation, immediate placement of new implants or a two-stage surgery re-implantation. Based on the most recently systematic review there is no suggestion that one- or two-stage revision methods have different re-infection outcomes. The two-stage implant-exchange protocol remains the gold standard. It is considered as the most efficacious clinical approach for the treatment of periprosthetic infection, especially in patients with sinus tracts, swelling, extended abscess formation in depth and infection of Methicillin Resistant Staphylococcus Aureus (MRSA), and other multidrug-resistant bacteria as reported in recent consensus documents.

The use of cementless acetabular component in revision surgery without pelvic discontinuity.

Reconstruction of the failed acetabular component in total hip arthroplasty (THA) can be challenging. Although there are multiple reconstructive options available, a cementless acetabular component inserted with screws has been shown to have good intermediate-term results and is the reconstructive method of choice for the majority of acetabular revisions This reconstruction is feasible provided at least 50% of the implant contacts host bone. When such contact is not possible, and there is adequate medial and peripheral bone, techniques using alternative uncemented implants can be used for acetabular reconstruction. An uncemented cup can be placed at a "high hip center." Alternatively, the acetabular cavity can be progressively reamed to accommodate extra-large cups. Oblong cups, which take advantage of the oval-shaped cavity resulting from many failed acetabular components, can also be used. The success of these cementless techniques depends on the degree and location of bone loss. The correct indication to revision and the choice of the correct implant is the keystone for the success of this type of surgery and follows an accurate preoperative planning in order to understand the specific pathologic scenario. The aim of this paper is to review some technical options for the revision of the acetabular component also taking into account our personal experiences and series.