Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study.

PURPOSE: The aim of this study was to evaluate the relationship between the Löwenstein Lateral view and the True Lateral view for the positioning of the cephalic hip screw, through a cadaveric study. MATERIALS AND METHODS: We placed two Kirschner wires in eight femur specimens using an Antero-Posterior view, Löwenstein Lateral view and True Lateral view. The distances between the Kirschner wires and the anterior, posterior, superior and inferior cortex were measured in all projections. The head of the femur was then sectioned, and the same macroscopic distances were measured. Finally, we could calculate the accuracy of the two radiographic lateral projections. RESULTS: When the Kirschner wire was placed in the center of the head using the Antero-Posterior and the True Lateral view, the accuracy of Antero-Posterior view was 0.9705 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1479 and 1.1584, respectively. When the Kirschner wire was placed superior on the Antero-Posterior and centrally on the True Lateral view, the accuracy of Antero-Posterior view was 0.9930 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1159 and 0.7224, respectively. CONCLUSION: When the Kirschner wire was positioned proximal in Antero-Posterior view and central in True Lateral view, only the True Lateral view showed high accuracy.

Controversies in ACL revision surgery: Italian expert group consensus and state of the art.

BACKGROUND: Revision ACL reconstruction is a complex topic with many controversies and not-easy-to-make decisions. The authors' aim is to provide some feasible advice that can be applied in daily clinical practice with the goal of facilitating the decision-making process and improving the outcomes of patients subjected to revision ACL reconstruction. METHODS: A national survey with seven questions about the most controversial topics in revision ACL reconstruction was emailed to members of two societies: SIOT and SIAGASCOT. The participants' answers were collected, the most recent literature was analyzed, and a consensus was created by the authors, according to their long-term surgical experience. CONCLUSIONS: The decision-making process in revision ACL reconstruction starts with a standardized imaging protocol (weight-bearing radiographs, CT scan, and MRI). One-stage surgery is indicated in almost all cases (exceptions are severe tunnel enlargement and infection), while the choice of graft depends on the previously used graft and the dimensions of the tunnels, with better clinical outcomes obtained for autografts. Additional procedures such as lateral extra-articular tenodesis in high-grade pivot-shift knees, biplanar HTO in the case of severe coronal malalignment, and meniscal suture improve the clinical outcome and should be considered case by case. LEVEL OF EVIDENCE: V (Expert opinion).

Patients Following Revision Total Hip Arthroplasty With Modular Dual Mobility Components and Cobalt-Chromium Inner Metal Head are at Risk of Increased Serum Metal Ion Levels.

BACKGROUND: Modular dual-mobility (MDM) total hip arthroplasty (THA) is designed with a cobalt-chromium liner inserted into a titanium acetabular component. The purpose of this study is to investigate the potential risks for fretting corrosion at this junction, by measuring serum metal ions, after MDM acetabular revision. METHODS: Thirty-seven patients with well-functioning revision THAs participated in a cross-sectional study at mean 5.1 (2-10) years after surgery. All received a trabecular titanium MDM acetabular component. The serum levels of cobalt and chromium were measured using mass spectrometry. RESULTS: The mean values of chromium and cobalt were 2.08 µg/L (95% confidence interval 0.9-3.2, range 0.02-11.8) and 1.99 µg/L (95% confidence interval 0.81-3.17, range 0.07-16.05), respectively. Eleven patients (29, 7%) had ion levels above the normal range, with 6 (16.2%) above 5 µg/L and 5 (13.5%) between 1 and 5 µg/L. A significant correlation was found between an elevated serum metal ion level and University of California Los Angeles score (P = .016). CONCLUSION: We conclude that serum metal level elevation may occur secondary to metal debris resulting from corrosion of the index MDM THA. This potential risk should be included in the decision-making process when dealing with revision arthroplasty in young and active patients.

Bone integration in acetabular revision hip arthroplasty using equine-derived bone grafts: a retrospective study.

PURPOSE: During the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction. METHODS: Records of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed. RESULTS: Of the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components. CONCLUSIONS: Results of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

Partial rupture of anterior cruciate ligament: preliminary experience of selective reconstruction.

BACKGROUND: Partial lesions of the anterior cruciate ligament (ACL) are more common than is generally thought, accounting for about 10-12% of ACL injuries. Selective reconstruction may be considered as an option in isolated bundle rupture. The purpose of this study is to evaluate both subjective and objective clinical results, as well as functional recovery time, after selective arthroscopic single-bundle reconstruction in a consecutive series of patients affected by partial ACL rupture. MATERIALS AND METHODS: Thirty-six patients undergoing selective reconstruction of a single ACL bundle were retrospectively evaluated from a series of 354 ACL reconstructions performed over a 3-year period. Although the suspicion of partial lesions was present at clinical and magnetic resonance imaging (MRI) evaluation, final diagnosis was obtained during arthroscopy. All patients were operated using the same technique and type of fixation, and undergoing the same functional recovery protocol. RESULTS: Mean follow-up was 64 months (48-84 months). All patients but one achieved good functional recovery and returned to their sports within a mean period of 6.1 months. A single patient complained of postoperative instability 1 year after the index operation and needed further surgery. No complications were recorded. CONCLUSIONS: Selective reconstruction of partial ACL injury is a method to bear in mind because it offers quick functional recovery. Specific technical and diagnostic steps should be performed and discussed with patients preoperatively. LEVEL OF EVIDENCE: Level 4, retrospective study.

Total Knee Arthroplasty in Patients With Extra-Articular Deformity: Restoration of Mechanical Alignment Using Accelerometer-Based Navigation System.

BACKGROUND: Total knee arthroplasty (TKA) in patients with post-traumatic extra-articular deformity (EAD) is difficult to manage using conventional instrumentation techniques. In this study, we evaluate whether accelerometer navigation system can be a valuable option to make accurate bone resections and restore the neutral mechanical axis in complex TKA patients with EAD. METHODS: From May 2015 to June 2017, 18 consecutive TKA were performed in 18 patients with knee osteoarthritis with associated EAD. An accelerometer-based navigation system was used to guide tibial and femoral resection in the coronal and sagittal plane. Postoperative lower limb alignment in coronal plane and component position in coronal and sagittal plane was measured through full-leg weight-bearing X-ray. Clinical score were recorded using the Knee Society Score at the final follow-up. RESULTS: The mean hip-knee-ankle angle was 0.9° ± 1.4° varus alignment. The coronal alignment of the femoral component was 89.2° ± 1.9°, and the coronal alignment of the tibial component was 89.4° ± 2.1°. The sagittal alignment of the femoral component was 93.2°± 1.9°, and the sagittal alignment of the tibial component was 84.4° ± 3.1°. At the final follow-up, the Knee Society Score was 89 points (range, 82-100), and the functional score was 86.7 points (range, 60-100). No intraoperative and postoperative surgical complications were reported using this technology. CONCLUSION: Accelerometer-based navigation is accurate in achieving neutral mechanical alignment and optimal implant position after TKA in patients with EAD. This system should be considered a valuable option to the more complex technique of computer navigation or robotic surgery.

The anterior-based muscle-sparing approach to the hip: the "other" anterior approach to the hip.

PURPOSE: The purpose of this study was to evaluate safety, efficacy, and learning curves of anterior-based muscle-sparing total hip arthroplasty (ABMS-THA) in the supine position. Furthermore, early functional outcome was evaluated and compared to direct anterior approach (DAA) by measuring surface electromyography (sEMG). METHODS: We present a prospective cohort study of 343 hips. The safety and learning curve were assessed by recording operative time and peri-operative adverse events. For assessment of efficacy, functional and radiological outcomes were evaluated. A selected group of 32 patients have been studied by sEMG and compared to a matched group of 32 patients who received a THA using DAA approach. RESULTS: There was one dislocation (0.3%); two (0.6%) patients had an intra-operative fractures of the greater trochanter; two patients (0.6%) experienced a self-limited femoral nerve palsy. Physical therapy milestones for hospital discharge were reached on an average of 1.7 days. sEMG showed that ABMS and DAA have a similar muscle recruitment pattern and functional recovery after THA. One patient was revised for infection, 16 were lost, and 326 hips were available with a median follow-up of 42 months (range 24-60). The mean Harris Hip Score (HSS) increased from 44.3 to 91.9. Ninety-six percent of the hips had a leg length discrepancy (LLD) < 5 mm. There were no radiological signs of mechanical loosening or osteolysis. CONCLUSIONS: The ABMS approach in the supine position is clinically effective and safe; special advantages include a very low dislocation rate and a great control of LLD.

Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement.

PURPOSE: To evaluate the feedback from post-operative three-dimensional computed tomography (3D-CT) on femoral tunnel placement in the learning process, to obtain an anatomic anterior cruciate ligament (ACL) reconstruction. METHODS: A series of 60 consecutive patients undergoing primary ACL reconstruction using autologous hamstrings single-bundle outside-in technique were prospectively included in the study. ACL reconstructions were performed by the same trainee-surgeon during his learning phase of anatomic ACL femoral tunnel placement. A CT scan with dedicated tunnel study was performed in all patients within 48 h after surgery. The data obtained from the CT scan were processed into a three-dimensional surface model, and a true medial view of the lateral femoral condyle was used for the femoral tunnel placement analysis. Two independent examiners analysed the tunnel placements. The centre of femoral tunnel was measured using a quadrant method as described by Bernard and Hertel. The coordinates measured were compared with anatomic coordinates values described in the literature [deep-to-shallow distance (X-axis) 28.5%; high-to-low distance (Y-axis) 35.2%]. Tunnel placement was evaluated in terms of accuracy and precision. After each ACL reconstruction, results were shown to the surgeon to receive an instant feedback in order to achieve accurate correction and improve tunnel placement for the next surgery. Complications and arthroscopic time were also recorded. RESULTS: Results were divided into three consecutive series (1, 2, 3) of 20 patients each. A trend to placing femoral tunnel slightly shallow in deep-to-shallow distance and slightly high in high-to-low distance was observed in the first and the second series. A progressive improvement in tunnel position was recorded from the first to second series and from the second to the third series. Both accuracy (+52.4%) and precision (+55.7%) increased from the first to the third series (p < 0.001). Arthroscopic time decreased from a mean of 105 min in the first series to 57 min in the third series (p < 0.001). After 50 ACL reconstructions, a satisfactory anatomic femoral tunnel was reached. CONCLUSION: Feedback from post-operative 3D-CT is effective in the learning process to improve accuracy and precision of femoral tunnel placement in order to obtain anatomic ACL reconstruction and helps to reduce also arthroscopic time and learning curve. For clinical relevance, trainee-surgeons should use feedback from post-operative 3DCT to learn anatomic ACL femoral tunnel placement and apply it appropriately. LEVEL OF EVIDENCE: Consecutive case series, Level IV.

Clinical and instrumental evaluation of two different regimens of tranexamic acid in total hip arthroplasty: a single-centre, prospective, randomized study with 80 patients.

PURPOSE: The use of tranexamic acid (TXA) in total hip arthroplasty (THA) can significantly reduce blood losses with many clinical and economical advantages. However, no consensus has been reached regarding the optimal regimen for TXA administration. The aim of this study is to analyse and compare the haemostatic effect of two different intravenous (IV) regimens of TXA. MATERIALS AND METHODS: We planned a single-centre, prospective, randomized study including 80 patients who underwent primary unilateral minimally invasive THA because of a hip osteoarthritic degeneration. We divided patients into two groups: the G10 group received two IV doses of 10 mg/kg of TXA, and the G20 group received two doses of 20 mg/kg. RESULTS: No significant differences in mean minimum levels of Hb and HcT stratified by days after surgery were uncovered between the two groups despite the use of two different dosages of TXA. Also the mean blood volume loss was statistically similar between two groups. No differences were also observed regarding the occurrence of adverse effects. CONCLUSIONS: In two IV bolus regimens of TXA administration, the use of a dose of 10 or 20 mg/kg provides statistically similar results in blood loss sparing. Therefore, the use of two 10 mg/kg doses could be considered more advisable in order to reduce the potential thromboembolic risks related to this drug.

The kinetics of remodeling of a calcium sulfate/calcium phosphate bioceramic.

In the last years considerable research and development activity have been expended to find new ceramic bone substitutes for the treatment of bone defects. However in many cases the drawback of synthethic bone substitutes are the slow graft incorporation and remodelling into the host bone. The purpose of this study was to analyze the kinetics of resorption and new bone formation of new calcium sulfate (CaSO4)/calcium phosphate (CaPO4) bioceramic engineered to enhance its bone forming properties. We prospectively evaluated the results of a series of 15 hips with osteonecrosis of the femoral head (ONFH) treated at with core decompression and injection of the CaSO4/CaPO4 composite. In all hips, a quantitative computed tomography (QTC) scan was taken within one week after the surgery, at 12 months, 2 years and finally with a minimum of 4 years follow-up. The mean HU in the immediate post-operative period was 1445 (Range 1388-1602); At one year the mean HU strongly decrease at 556.6 HU (P < 0.01); The mean HU at 2 years follow-up further decreased to 475.1. The mean HU at 4 years was unchanged. The quantitative and qualitative CT scan data of this series indicates that the CaSO4-CaPO4 ceramic composite resorbs over a narrow timeframe and the gradual resorption of the graft within the defect provides an ideal environment for the direct new bone growth that propagates across the defect.

Resorbable screw and sheath versus resorbable interference screw and staples for ACL reconstruction: a comparison of two tibial fixation methods.

PURPOSE: The anterior cruciate ligament (ACL) reconstruction is one of the most performed and successful orthopaedic procedures. The results are considered independent by the choice of the graft and the fixation devices. A growing interest on resorbable non-metallic fixation devices versus standard metallic fixation devices has been noted over recent years with few clinical experiences reported in the literature. The aim of this study is to compare the clinical and radiological outcomes of patients undergoing ACL reconstruction using autologous hamstring tendons with tibial fixation by a centrally placed resorbable screw and sheath to a combination of an eccentrically placed resorbable interference screw and supplementary staple fixation. METHODS: Ninety patients undergoing an isolated, single-bundle, primary ACL reconstruction with autologous hamstring tendons, using the same femoral fixation, were randomized to a tibial fixation with a centrally placed resorbable screw and sheath, BioIntrafix (group A), or an eccentrically placed resorbable interference screw, BioRCI, and two non-resorbable staples (group B). The latter has represented for many years our standard fixation method. Clinical evaluations (KOOS, IKDC, KT-2000™ side-to-side difference) and radiological analyses were conducted in both groups with a minimum follow-up of 2 years. RESULTS: We assisted in a satisfactory pain relief and functional improvements, without significant clinical and radiological differences in both groups. No further surgery was needed in patients with the screw/sheath tibial fixation. Seven patients with the screw/staples tibial fixation needed the surgical removal of the fixation devices due to pes anserinus irritation or local infection years after the index operation. Other parameters such as the tunnel enlargement were not statistically different in the two groups. CONCLUSIONS: Good clinical and radiological outcomes of ACL reconstruction by a screw/sheath tibial fixation have been reported showing comparable results with respect to screw/staples fixation. There were no failures associated with loss of fixation with either of tibial fixation methods. A fewer number of surgical removals of tibial devices were also recorded in patients treated by the screw/sheath fixation system, related to the absence of local intolerance or infection compared to subjects with a standard tibial fixation.

The use of a dual mobility cup in the management of recurrent dislocations of hip hemiarthroplasty.

BACKGROUND: Dislocation is one of the most frequent causes of failure of hemiarthroplasties of the hip, which is the most common treatment for femoral neck fractures in elderly patients. A revision with conversion to total hip arthroplasty is the gold standard in case of failure of closed reduction: however, the use of standard or modular components shows variable outcomes. The use of a dual mobility cup has been evaluated in patients with unstable implants, given the good outcomes obtained in primary and revision surgery. The aim of this study was to assess the results of revisions by dual mobility cups in unstable hemiarthroplasties. MATERIALS AND METHODS: Thirty-one patients (mean age 75.4 years) were retrospectively evaluated between 2006 and 2010 after conversion to total hip arthroplasty with dual mobility cups for recurrent dislocations. The mean number of dislocations was 2.6 (range 2-5). The evaluation was performed by the American Society of Anesthesiologists physical function score (ASA) and the Harris hip score, and several radiologic criteria. RESULTS: The mean follow-up was 3.8 years. No recurrence of dislocation was recorded. The ASA score remained unchanged, and the mean Harris hip score improved from 62.2 before dislocation to 76.0 points postoperatively. CONCLUSIONS: Dual mobility cups may be a useful option in the treatment of a hemiarthroplasty dislocation. No risk of a new revision due to instability after insertion of dual mobility cups resulted in our experience, and this option may be strongly considered in cases of revisions of unstable hemiarthroplasties.

Preliminary results of an early vs delayed timing of surgery in the management of proximal femur fragility fractures.

INTRODUCTION: The appropriate surgical timing for the treatment of proximal femur fractures is still debated. Advantages of a delayed surgery may be: stabilization of systemic diseases, decrease of the risk of perioperative mortality and morbidity. An early timing of surgery may allow: early mobilization, reduction of the risks of disability and hospital stays, early return to home of the patients. However, the effects on mortality are still discussed. PURPOSE: The purpose of this study is to assess the influence of the surgical timing on clinical outcomes, complications, and mortality in a preliminary experience of the early management of these fractures vs the delayed surgery. METHODS: A series of 176 patients was retrospectively evaluated. 132 patients were followed-up for one year after surgery. The evaluation was performed by the assessment of the comorbidities, preoperative wait for surgery, type of fracture and procedures, hospital stay, and functional outcomes: 33 patients were operated with an early timing, 99 with a delayed surgery. RESULTS: The mean mortality rate was 18.2% in the early timing (6/33 patients), and 23.2% in the delayed timing (23/99 patients): no significant difference was recorded in the preliminary analysis. Postoperative complications were recorded in 28 patients (21.2%): 4 patients were operated within 48 hours (12.1%) and 24 after 48 hours (24.2%) with no substantial differences. The postoperative hospital stay showed no correlation with the timing of surgery, as no evidence was found on the functional recovery and postoperative disability. CONCLUSIONS: No significant differences were found on the evaluated parameters in the two groups in the present preliminary study. A correlation between male sex and mortality, and male sex and postoperative complications was assessed. An enlargement of the study population is needed to surely clarify any effective differences, given the fact that recent studies seem to identify in the early treatment the better strategy to ensure the best recovery and the lower rate of mortality and complications.

Range of motion after total knee arthroplasty: the effect of a preoperative home exercise program.

PURPOSE: Preoperative range of motion (ROM) is the most important variable to determine final flexion after total knee arthroplasty (TKA). The purpose of this study was to determine whether a preoperative home exercise program could improve ROM in the arthritic knee and whether this influenced ROM and functional recovery following primary TKA. METHODS: During the period between 2005 and 2006, one hundred and twenty-two patients with gonarthrosis were included in a prospective study and randomly allocated to either the control or the treatment group. The sixty-one subjects in the treatment group underwent a 6-week home-based exercise program before TKA surgery. All one hundred and twenty-two patients were assessed before and after this exercise intervention. Postoperative assessments were at 6 weeks, 6 months and 1 year. Each evaluation included knee ROM and the Knee Society Clinical Rating System. Length of hospital stay and postoperative duration before achieving 90° of knee flexion were also recorded. RESULTS: Exercise program improves knee motion in the presence of gonarthrosis. After TKA, the patients in the exercise group achieved 90° of knee flexion faster and had a shorter hospital stay. There is no prolonged effect on knee motion or patient function between 6 weeks and 1 year postoperatively. CONCLUSION: Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA. LEVELS OF EVIDENCE: Therapeutic study, Level I.

Total knee arthroplasty in patients with hypersensitivity to metals.

PURPOSE: We evaluated the risk of hypersensitivity to metals in a population of consecutive subjects undergoing a total knee arthroplasty (TKA). We also proposed a diagnostic pathway to address any sensitivity to metals. We finally presented the mid-term outcomes of a full non allergenic knee implant. METHODS: We developed a protocol based on the medical history, patch testing, and on specific laboratory assays, in order to assess a sensitization to metals. Twenty-four patients (25 knees) with referred or suspected allergy to metals were found in more than 1,000 treated patients, with a mean age of 72.9 years. We proceeded to a radiologic study, a clinical evaluation by the visual analogic scale (VAS), and Knee Society rating system (KSS). In all cases a full anallergic cemented implant with an oxidized zirconium femoral component and an all-polyethylene tibial baseplate was chosen. RESULTS: Four (16.6%) of the 24 patients were considered to be hypersensitive to metals. The mean follow-up was 79.2 months. No patient reported any reaction related to hypersensitivity or complications after TKA. The VAS improved from a mean preoperative value of 7.2 to 1.8 postoperatively; the KSS and the functional score increased from 38 to 91 points and from 39 to 88 points, respectively. CONCLUSIONS: We consider careful research of medical history for metals hypersensitivity crucial, and we perform patch testing and lab assays in case of doubtful sensitization. The choice of a modern hypoallergenic implant may prevent any kind of potential reactions.

A New Entity of Ramp Lesion Combined with Posterior Root Tear of the Medial Meniscus: A Case Report.

CASE: This report describes a new pattern of meniscal tear in an 18-year-old man after a knee sprain; he had undergone anterior cruciate ligament revision (ACL-R) 3 years earlier. He was diagnosed with an anterior cruciate ligament (ACL) graft rupture, a ramp lesion (Thaunat type 4), and a posterior root avulsion fracture of the medial meniscus (MM) (LaPrade type 5). He was treated successfully with an all-inside repair of the ramp lesion, a transtibial pull-out repair of the root tear, and ACL graft revision and anterolateral stabilization. CONCLUSION: This specific meniscal injury pattern should be recognized and documented, potentially warranting consideration as a new addition to Thaunat and LaPrade classifications as type 6.

Computer Patient-Specific 3D Modeling and Custom-Made Guides for Revision ACL Surgery.

Revision anterior cruciate ligament reconstruction (ACLR) is a challenging surgery occurring in 3 to 24% of primary reconstructions. A meticulous planning to study the precise size and location of both femoral and tibial bone tunnels is mandatory. The aim of the study was to evaluate the intra- and interoperator differences in the decision-making process between experienced surgeons after they were asked to make preoperative planning for ACL revision reconstruction with the use of both the computed tomography (CT) scan and a three-dimensional (3D)-printed model of the knee. Data collected from 23 consecutive patients undergoing revision of ACLR for graft failure at a single institute between September 2018 and February 2020 were prospectively reviewed. The double-blinded collected data were presented to three board-certificate attending surgeons. Surgeons were asked to decide whether to perform one-stage or two-stage revision ACLR based on the evaluation of the CT scan images and the 3D-printed custom-made models at two different rounds, T0 and T1, respectively, 7 days apart one from the other. Interoperator consensus following technical mistake was 52% at T0 and 56% at T1 using the CT scans, meanwhile concordance was 95% at T0 and 94% at T1 using the 3D models. Concordance between surgeons following new knee injury was 66% at T0 and 70% at T1 using CT scans, while concordance was 96% both at T0 and T1 using 3D models. Intraoperative variability using 3D models was extremely low: concordance at T0 and T1 was 98%. McNemar test showed a statistical significance in the use of 3D model for preoperative planning (p < 0.005). 3D-printed model reliability resulted to be higher compared with CT as intraoperator surgery technique selection was not modified throughout time from T0 to T1 (p < 0.005). The use of 3D-printed models had the most impact when evaluating femoral and tibial tunnels, resulting to be a useful instrument during preoperative planning of revision ACLR between attending surgeons with medium-high workflow.

Multicenter survey about leg length discrepancy and total hip arthroplasty: preoperative and intraoperative management.

BACKGROUND: We created a multicenter survey for Italian orthopedic surgeons on how they approach leg length discrepancy (LLD) when dealing with primary total hip arthroplasty. Aim of the study was to show how surgeons manage LLD and follow the literature recommendations during clinical practice. METHODS: The survey was composed of 25 questions divided into four sections: 1-surgeon's profile, 2-preoperative and 3-intraoperative evaluation, and 4-postoperative management. In this paper, we report results to answer Sects. 1 and 2. Absolute and relative frequencies of answers to Sects. 2 and 3 are reported. We divided the participants in subgroups based on the "surgeon's profile" and evaluated difference in the answers given. RESULTS: Absolute and relative frequencies demonstrate low agreement among participants in all phases of LLD management. We demonstrated a statistically significant difference based on the surgeon's profile regarding these questions: radiographic measure of LLD depending on working experience, p = 0.008; digital planning based on surgeons' age, p < 0.001, and workplace, p = 0.026; intraoperative anatomical landmarks based on numbers of procedures per year, p = 0.020; and use of intraoperative X-rays based on working experience, p = 0.002. CONCLUSIONS: LLD is a debated topic with no definitive recommendations. Many decisions still depend on tradition and surgeons' preference.

Displaced fragility fractures of proximal humerus in elderly patients affected by severe comorbidities: percutaneous fixation and conservative treatment.

BACKGROUND AND AIMS: Proximal humerus is a common site of fracture in elderly patients, mainly related to bone fragility. Comorbidities are often present in these patients and may limit the surgical options. Not or minimal invasive treatments are commonly indicated however with variable results. The authors present their experience with conservative approach and percutaneous fixation by K-wires, focusing on their indications and main advantages on this population: mini-invasivity, acceptable reduction and recovery, and low costs. METHODS: A study group of 51 consecutive patients with a mean age of 75.5 and affected by severe comorbidities (mainly cardiac, circulatory, pneumologic, neurologic, metabolic, and nephrologic pathologies) were evaluated clinically (ASA score, VAS, muscular strength, Constant-Murley score), and with radiologic analysis: 28 patients were treated by percutaneous fixation, while 23 subjects were treated conservatively. RESULTS: Fractures treated by K-wires fixation healed after a mean interval of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score (up to 80.6 points), in mean VAS (2.9), in muscular strength (4.1), and in range of motion. Fractures treated by brace healed in a mean time of 10.2 weeks. Mean Constant-Murley score improved to 76.4 points, VAS to 3.0, muscular strength to 3.8 points, and significant recovery of range of motion. CONCLUSIONS: Results of the study confirm that both percutaneous fixation and conservative treatment may represent suitable options for proximal humerus fragility fractures in elderly patients, not candidated to open surgery for severe associated comorbidities. LEVEL OF EVIDENCE: IV (case series study).

A novel technique to preserve range of motion in two-stage revision of infected total knee arthroplasty.

PURPOSE: Two-stage revision represents the gold standard in the treatment of infected total knee arthroplasty. Different techniques have been proposed, mostly not preserving range of motion. An articulated antibiotic-loaded cement spacer made in association with two unicompartmental implants has been used as an alternative to a static spacer in an effort to retain as much movement as possible between the stages in young, high-demand patients with preserved ROM. METHODS: We evaluated nine consecutive patients with a mean age of 66.5 years. The second stage was performed after lab tests returned to normal and culture proved negative. Mean follow-up was 4.6 years. RESULTS: Mean ROM from a preoperative value of 105.6° was 103.5° after the first stage, and improved to 110.0° after the definitive implant. Mean Knee Society score was 27.6 preoperatively improving to 86.4 points postoperatively. WOMAC score showed that six patients were very satisfied with the overall result of their reimplanted knee, three subjects were somewhat satisfied. No recurrence of infection, no significant radiolucent lines or osteolysis were recorded at clinical and radiological follow-up and the patients were satisfied with the outcome. CONCLUSIONS: Results indicated that this technique may ensure the advantages of a static spacer, but allow a greater ROM and better functional recovery. It may be considered as a viable option in selected cases even though the higher costs of two unicompartmental implants should be considered in the light of other aspects, such as prolonged hospital stay and rehabilitation in revision of infected total knee arthroplasty.