Autologous osteochondral transplantation for osteochondral lesions of the talus: high rate of return to play in the athletic population.

PURPOSE: (1) To determine the rate of return to play following autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLT) and (2) report subsequent rehabilitation protocols. METHODS: A systematic review of the PubMed, Embase, and The Cochrane Library databases was performed according to the PRISMA guidelines based on specific eligibility criteria. Return to play data was meta-analysed and subsequent rehabilitation protocols were summarised. Level of evidence and quality of evidence (Zaman's criteria) were also evaluated. RESULTS: Nine studies that totalled 205 ankles were included for review. The mean follow-up was 44.4 ± 25.0 (range 16-84) months. The mean OLT size was 135.4 ± 56.4 mm2. The mean time to return to play was 5.8 ± 2.6 months. The mean rate of return to play was 86.3% (range 50-95.2%), with 81.8% of athletes returning to pre-injury status. Based on the fixed-effect model, the rate of return to play was 84.07%. Significant correlation was found between increase age and decrease rate of return to play (R2 = 0.362, p = 0.00056). There was no correlation between OLT sizes and rate of return to play (R2 = 0.140, p = 0.023). The most common time to ankle motion post-surgery was immediately and the most common time to full weight-bearing was 12 weeks. CONCLUSIONS: This systematic review indicated a high rate of return to play following AOT in the athletic population. Size of OLT was not found to be a predictor of return to play, whereas advancing age was a predictor. Rehabilitation protocols were largely inconsistent and were primarily based on individual surgeon protocols. However, the included studies were of low level and quality of evidence. LEVEL OF EVIDENCE: Level IV.

Surgical prevention of femoral neck fractures in elderly osteoporotic patients. A literature review.

Fragility fractures of the femur are one of the major causes of morbidity and mortality worldwide. The incidence of new contralateral hip fractures in elderly osteoporotic patients ranges from 7 to 12% within 2 years after the first fracture. Secondary prevention can be divided in: pharmacological therapy based on the prescription of anti-osteoporotic drugs with different mechanism of action and non-pharmacological therapy which is based on modification of environmental risk factors, on a healthy diet with daily supplements of calcium and vitamin D and calcium and on the use of hip protectors. Recently a new form of prevention is becoming achievable: surgical prevention; the rationale of surgical reinforcement is the need to increase the resistance of the femoral neck to the compression and distraction forces acting on it. In this paper we analyse all the experimental and "on the market" device available for the surgical prevention of femoral neck fracture.

Subcutaneous injection of diclofenac for the treatment of pain following minor orthopedic surgery (DIRECT study): a randomized trial.

OBJECTIVES: Parenteral diclofenac is frequently used for analgesia following minor orthopedic interventions. Currently available diclofenac formulations are for intramuscular (IM) or intravenous injection. A new 1 mL volume formulation of diclofenac containing hydroxypropyl-ß-cyclodextrin (HPßCD) allows both SC and IM administration. The objective of this open-label, randomized, parallel group, active-controlled study was to assess the safety and efficacy of 75 mg diclofenac HPßCD, administered SC or IM, compared with IM Voltaren® 75 mg in inpatients undergoing minor orthopedic surgeries with moderate-to-severe postoperative pain. METHODS: A total of 325 patients were randomized to treatment. Surgery-related pain was comparable between groups before treatment and rapidly declined in all patients following diclofenac injection. The primary endpoint was investigator-assessed local tolerability up to 18 hours postinjection (redness, swelling, and hardening at the injection site each scored on a 4-point scale where 0 = none, 1 = mild, 2 = moderate, and 3 = severe). RESULTS: Local tolerability was found to be optimal for all the injected formulations, with mean overall scores (0 to 9) of 0.57, 0.31, and 0.26, for diclofenac HPßCD SC, diclofenac HPßCD IM, and Voltaren® IM, respectively. Consistently, the overall tolerability as judged by the patients and investigators was reported as good or excellent in more than 90% of cases in all groups. CONCLUSIONS: Overall, the study results indicate that safety and efficacy were similar irrespective of the diclofenac formulation used; thus, the new SC diclofenac HPßCD has an acceptable tolerability profile and may be considered a valid alternative to IM-delivered diclofenac formulations.

How do metal ion levels change over time in hip resurfacing patients? A cohort study.

Metal-on-metal hip resurfacing (MOM-HR) is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting increase in metal ion levels. We evaluated three cohorts of patients with Birmingham hip resurfacing (BHR) at an average follow-up of 2, 5, and 9 years. We asked whether there would be differences in ion levels between the cohorts and inside the gender. Nineteen patients were prospectively analyzed. The correlation with clinical-radiographic data was also performed. Chromium, cobalt, nickel, and molybdenum concentrations were measured by atomic absorption spectrophotometry. Chromium and cobalt levels demonstrated a tendency to decrease over time. Such tendency was present only in females. An inverse correlation between chromium, implant size, and Harris hip score was present at short term; it disappeared over time together with the decreased ion levels. The prospective analysis showed that, although metal ion levels remained fairly constant within each patient, there was a relatively large variation between subjects, so mean data in this scenario must be interpreted with caution. The chronic high exposure should be carefully considered during implant selection, particularly in young subjects, and a stricter monitoring is mandatory.

Ankle fractures in elderly patients.

The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner's wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.

Autograft, allograft and bone substitutes in reconstructive orthopedic surgery.

Reconstruction of bone defects is a challenge for all orthopedic surgeons worldwide; to overcome this problem there are different options: the use of autografts, allografts and bone substitutes (BSs) to enhance and accelerate bone repair. Autografts have excellent biological properties but are associated with morbidity of the donor site and are restricted in volume. Allografts are available in adequate quantity but concerns still remain about the risk of infections, moreover they do not have osteogenetic properties. Bone substitutes have different indications and are very attractive for orthopedic surgeons. The present paper briefly reviews the advantages and disadvantages of autografts, allografts and BSs for bone reconstruction.

Do ion levels in metal-on-metal hip resurfacing differ from those in metal-on-metal THA at long-term followup?

BACKGROUND: Metal-on-metal hip resurfacing arthroplasty (MOM HR) has become an established alternative to traditional metal-on-metal total hip arthroplasty (MOM THA) for younger, more active patients. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting systemic metal ion distribution. QUESTIONS/PURPOSES: We therefore asked whether (1) serum ion concentrations in patients with MOM HR at the time of long-term followup were higher than concentrations in a control population with no hip implants; (2) the ion concentrations in patients with MOM HR were different from those in patients with MOM THA; and (3) sex would influence ion levels with regard to implant type. METHODS: The MOM HR and MOM THA groups consisted of 25 patients (evaluated at a minimum of 96 months) and 16 patients (evaluated at a minimum of 106 months), respectively. Forty-eight healthy donors were recruited for reference values. Cobalt, chromium, nickel, and molybdenum were measured by furnace graphite atomic absorption spectrophotometry. RESULTS: Ion concentrations of cobalt, chromium, and molybdenum in MOM HR were higher than in controls. Chromium and cobalt release were higher in MOM HR than in MOM THA. The sex-based analysis showed the difference was because women had higher concentrations in the MOM HR group than in the MOM THA group, whereas there was no difference between the men in the two groups. CONCLUSIONS: In MOM HR, high metal ion release persists for the long term. Consequently, it is important to implement strict biomonitoring for patients who have received these implants. The sustained high levels of chromium in females within the MOM HR group are concerning and merits strong consideration when choosing implants in this patient group.

Can a combination of different risk factors be correlated with leg fracture healing time?

BACKGROUND: A multicenter retrospective analysis of patients treated for leg fractures was conducted to develop a score that correlates with fracture healing time and to identify the risk gradient for delayed healing. METHODS: Fifty-three patients were analyzed and considered healed when full weight bearing was possible. Patients were divided into those who healed within 180 days and those who took longer to heal. Risk factors associated with delayed healing, fracture morphology, and orthopedic treatments were recorded. The available literature was used to weight the relative risk associated with each factor; values were combined into a score evaluating the risk of delayed healing: L-ARRCO (a literature-based score where the risk of delayed bone healing is calculated using a specific algorithm). Other risk factors associated with delayed healing were then considered in order to calculate a new score, ARRCO. Continuous variables were compared between groups using Student's heteroschedastic two-tail t test. Receiver operating characteristic (ROC) curves and the areas under the curves were calculated to determine the ability of this score to discriminate subjects with delayed healing. RESULTS: The mean L-ARRCO scores of the patients who healed within and after 180 days were significantly different (5.78 ± 1.59 and 7.05 ± 2.46, respectively). The mean ARRCO scores of the patients who healed within and after 180 days were also significantly different (5.92 ± 1.78 and 9.03 ± 2.79, respectively). However, the area under the ROC curve was significantly smaller for L-ARRCO than for ARRCO (0.62 ± 0.09 versus 0.82 ± 0.07). CONCLUSIONS: The ARRCO score is significantly associated with fracture healing time and could be used to identify "fractures at risk," allowing early intervention to stimulate osteogenesis.

Atypical femoral fractures.

Bisphosphonates (BPs) represent the most widely used therapy for osteoporosis. Recently, a relationship between long-term treatment with BPs and a subset of atypical femoral fractures (AFFs) from below the lesser trochanter to the sovracondilar line has been described. Many etiopathogenetic theories have been invoked to explain AFFs: reduced bone turnover and increased osteoblast bone apposition with accumulation of microdamage and decreased bone toughness with subsequent increased risk of micro-cracks and duration fractures, collagen fiber cross-linking and vascularization impairment. Based on published studies, a task force of the American Society for Bone and Mineral Research has redacted the diagnostic criteria of AFFs by classifying them according to their major and minor criteria. The treatment for displaced AFFs is osteosynthesis, but there is a lack of evidence for undisplaced AFFs and the duration of fracture treatment. BPs have a proven efficacy in osteoporotic fracture reduction as well as in the treatment of other bone diseases caused by the downregulation of osteoclast activity. BPs have an excellent benefit-to-risk ratio; however, minor adverse events, such as AFFs, occur in a variable percentage of patients treated over a long period of time.

Conservative versus surgical treatment of osteogenesis imperfecta: a retrospective analysis of 29 patients.

The aim of our study was to compare the surgical and conservative treatment of patients affected by fragility fractures and deformities of long bones in osteogenesis imperfecta (OI).Our series consisted of 29 consecutive OI patients treated at our Institute. The series comprised 14 females and 15 males of different ages. The mean age at the time of the first treatment was 8 years (median 6 years; SD ± 15; range 1 to 75). The mean follow-up was 88 months. The Sillence classification was used to classify OI. Fifteen patients were classified as Type I; five as Type III and nine as Type IV.A total number of 245 procedures were recorded. Of these, 147 were surgical (pinning; intramedullary nailing and plating) while 98 were conservative (cast, braces and bandages). Bisphosphonate use was a major variable in the study. Clinical charts and radiographic films were analyzed for complications (delayed union, nonunion, malunion, hardware loosening). We recorded 58 complications: 13 in Type I; 28 in Type III and 17 in Type IV OI. The rate of each complication was: 15/245 nonunions (6.1%), 14/245 delayed unions (5.7%), 14/245 malunions (5.7%) and 15/245 hardware loosenings (6.1%).We found no statistically significant differences between surgical and conservative treatments. Type III OI, which is a very crippling form of the disease, was associated with radiographically poorer results than the other types. In our analysis, the two groups were unbalanced and only five patients were treated with bisphosphonates. Nevertheless, bisphosphonate use can be considered a good adjuvant to both the conservative and surgical treatment of OI in order to reduce the rate of complications.

Surgical prevention of femoral neck fractures in elderly osteoporotic patients: a randomised controlled study on the prevention nail system device.

INTRODUCTION:: Hip fractures represent an enormous challenge for our health care system. The aim of this randomised controlled trial was to assess both efficacy and safety of a novel device called Prevention Nail System (PNS) and developed for the surgical prevention of a contralateral femoral neck fracture (FNF) in elderly osteoporotic patients. METHODS:: Primary outcome was to evaluate, in patients suffering from osteoporotic FNF, the effectiveness of PNS in reducing the incidence of a contralateral hip fracture. Secondary outcome was to evaluate the safety of this device therefore intra- and postoperative complications were recorded. RESULTS:: 72 patients, with an age ⩾65 years old, were enrolled (38 study group (group A) and 34 control group (group B). 3 and 5 contralateral FNF were recorded respectively in group A and B. An interim analysis showed a non-effectiveness of the device therefore enrollment was suspended. DISCUSSION:: In all group A failures a difficult positioning of the PNS was recorded: surgical techniques errors may have affected the result. Nevertheless, it is improbable to hypothesise that, without substantial modifications to the PNS design, this could significantly reduce the incidence of FNF. Considering that current pharmacological approach can achieve, at best, a marginal reduction in FNF especially in patients at high risk, complementary approaches to provide immediate prevention of hip fractures may need to be developed. CLINICAL TRIAL PROTOCOL:: N° 263. 03 June 2008.

Hip resurfacing arthroplasty: a series of 140 consecutive hips with a minimum five year follow-up. A clinical, radiological and histological analysis.

We reviewed the clinical and radiological outcome at a minimum of five years of 140 consecutive metal-on-metal hip resurfacing (HR) arthroplasties in 132 patients. The mean follow-up was 73 months (62 to 105). Revision of either component was defined as failure. The average Harris hip score (HHS) was 58.6 (25 to 88) preoperatively and 94.4 (60 to 100) at the latest follow-up (p<0.0005). Average University of California Los Angeles (UCLA) activity score was 3.1 (1 to 9) pre-operatively and 6.7 (2 to 10) post-operatively (p<0.0005). The survival after 6 years was 97.8% overall and 98.5% (excluding a post traumatic femoral neck fracture). These good medium-term results suggest that HR is an effective procedure in young and active patients.

Prosthetic surgery in fragility osteopathy.

Elderly osteoporotic patients with a femoral neck fractures should undergo hip prosthesis replacement. Nevertheless, there is still debate about the best choice of treatment (Total Hip Replacement (THR) vs HemiArthroplasty (HA)). The aim of our study is to compare functional results of new polycarbonate- urethane (PCU) cup coupled with large diameter femoral head THR and bipolar HA. To verify our hypothesis, a consecutive series of 60 patients were randomized either to receive a bipolar HA or a THR. No statistically significant difference was found between the two groups in terms of age, surgical time and blood loss. Splitting the Harris Hip Score into two categories, pain and function, a trend for a better functional score was found in THR either at 3 and 12 months when compared to HA. Our study suggests that the use of a PCU acetabular cup with large diameter femoral head is an effective solution for osteoporotic patient and may provide a better hip function to this patient population. These positive results should be confirmed at a longer follow-up in a large cohort of patients.

Osteosynthetic improvement of osteoporotic bone: prevention surgery.

A prior osteoporotic femoral neck fracture (FNF) doubles the risk of a second, contralateral hip fracture. Pharmacological prevention of osteoporotic fractures is cost-effective but medication compliance and persistence rates are suboptimal.The aim of our study was to evaluate the safety and effectiveness of a device developed for the surgical prevention of an additional contralateral FNF in elderly osteoporotic patients.Only patients with a T score ≤ -2.5 were enrolled and randomized either to receive (Group A) or not receive (Group B) surgical prevention. Sixty-seven patients were enrolled. The mean follow-up was 16 months (range 1 to 22). To date, no contralateral FNF has been reported in either group. In Group A, no device-related complications were recorded. Twelve patients reported one or more falls and in four cases a non-femoral fragility fracture occurred.The main problem with pharmacological prevention is therapy adherence and the extensive period needed for only a slight improvement in bone strength.Surgical prevention is a potential solution for avoiding the occurrence of a second contralateral FNF. Nevertheless, a longer follow-up and a larger cohort of patients is necessary in order to verify the true effectiveness of the surgical prevention in elderly osteoporotic patients.

Bone mineral density of the proximal femur recovers after metal-on-metal hip resurfacing.

Bone resorption of the proximal femur is a frequent complication of total hip replacement. As hip resurfacing (HR) may load the bone more physiologically, we measured proximal femur bone mineral density (BMD) in 21 patients with HR. DEXA analysis was performed in the 7 Gruen zones and in the femoral neck pre-operatively and at 3, 9, and 24-months post-operatively. In Gruen zone-2 the BMD ratio decreased to 90±18.8% (p=0.0009) at 3-months and completely restored at 24-months to 100±17.7% (p=0.01). In Gruen zone-7 the BMD ratio decreased to 93±15.3% (p=0.05) by 3 months and surpassed the baseline to 105±14.8% (p=0.01) at 24-months. A positive correlation was observed between valgus positioning of the femoral component and BMD in Gruen zone-2 and 7 respectively. HR preserves the bone-stock of the proximal femur. When the femoral component is implanted in a valgus position BMD is further enhanced, thus potentially reducing the risk of femoral neck fractures.

Viscosupplementation for grade II osteoarthritis of the ankle: a prospective study at 18 months' follow-up.

BACKGROUND: Viscosupplementation, with hyaluronan derivates injected into the intra-space of osteoarthritic joints, is now widely used for the treatment of knee osteoarthritis. This study evaluates the results in terms of pain and disability of intra-articular injections of hyaluronan derivates into the ankle joint in patients suffering from grade II primary or secondary osteoarthritis of the ankle. METHODS: Twenty-one patients with a painful ankle and radiographic evidence of grade II osteoarthritis had three weekly intra-articular injections of 2 ml of hylan G-F 20 (10 mg/ml) into the ankle joint. The primary clinical outcome measurement was the ankle osteoarthritis score (AOS) at the baseline, and at 6, 12 and 18 months. RESULTS: Significant improvement of the AOS from baseline was seen after 6 months (p=0.0001). This improvement was maintained over time with no further changes at 12- and 18-month follow-ups. Regarding pain, the AOS improved over time from the baseline to the 18-month follow up and became statistically significant at the 12- and 18-month follow-ups (p<0.05).