"Single-use peripheral" vs "conventional" reaming in total hip arthroplasty: how to respect native centre of rotation and acetabular offset? A CT study.

PURPOSE: The respect of native hip offset represents a mainstay for satisfying results in total hip arthroplasty (THA). Historically, a great interest has been focused on restoration of femoral offset, while only in recent years, acetabular offset (AO) has been considered. The purpose of the current study was to compare the "single-use peripheral" reaming technique with the "conventional" one for the maintenance of the native COR of the hip and AO in patients undergoing to primary THA. METHODS: Eighty patients affected from primary hip osteoarthritis were prospectively enrolled in the study and were divided in two groups (Group A "single-use peripheral" and Group B "conventional" reaming technique). Pre- and post-operatively, AO, acetabular floor distance (AFd) and acetabular version (AV) were assessed through a CT scan. A comparison between groups for the radiological parameters, surgical time and complications was performed. RESULTS: The demographic data were similar in both groups. The complications rate and the AV did not differ statistically between groups. Group A presented a statistically significant shorter surgical time and lower variation between pre- and post-operative AO and AFd. Statistical significance was defined as p < 0.05. CONCLUSIONS: The "single-use peripheral" reaming technique demonstrated to be more reliable in reproducing the native COR and AO of patients undergoing to primary THA than the "conventional" one. The operative time was significantly reduced, and it may lead to a reduction in the infection risk even though it was not observed in the current study. Further research could be useful to validate such findings and to assess clinical impact and long-term survival of the implant.

Long-Term Outcomes of Extent of Revascularization in Complex High Risk and Indicated Patients Undergoing Impella-Protected Percutaneous Coronary Intervention: Report from the Roma-Verona Registry.

OBJECTIVE: To investigate the effect of extent of revascularization in complex high-risk indicated patients (CHIP) undergoing Impella-protected percutaneous coronary intervention (PCI). BACKGROUND: Complete revascularization has been shown to be associated with improved outcomes. However, the impact of more complete revascularization during Impella-protected PCI in CHIP has not been reported. METHODS: A total of 86 CHIP undergoing elective PCI with Impella 2.5 or Impella CP between April 2007 and December 2016 from 2 high volume Italian centers were included. Baseline, procedural, and clinical outcomes data were collected retrospectively. Completeness of coronary revascularization was assessed using the British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) derived revascularization index (RI). The primary end-point was all-cause mortality. A multivariate regression model was used to identify independent predictors of mortality. RESULTS: All patients had multivessel disease and were considered unsuitable for surgery. At baseline, 44% had left main disease, 78% had LVEF ≤ 35%, and mean BCIS-JS score was 10±2. The mean BCIS-JS derived RI was 0.7±0.2 and procedural complications were uncommon. At 14-month follow-up, all-cause mortality was 10.5%. At follow-up, 67.4% of CHIP had LVEF ≥ 35% compared to 22.1% before Impella protected-PCI. Higher BCIS-JS RI was significantly associated with LVEF improvement (p=0.002). BCIS-JS RI of ≤ 0.8 (HR 0.11, 95% CI 0.01- 0.92, and p = 0.042) was an independent predictor of mortality. CONCLUSIONS: These results support the practice of percutaneous Impella use for protected PCI in CHIP. A more complete revascularization was associated with significant LVEF improvement and survival.

First Metatarsal Bilateral Stress Fracture: A Case Report.

Introduction: Metatarsal stress fractures typically occur in the second and third metatarsus metaphysis, with only rare cases in the fourth and first. The main factors influencing its onset are repetitive stress from prolonged training, biomechanical factors and bone weakness. There is only a paucity of literature documenting first metatarsal stress fractures; the authors present a rare bilateral first metatarsal stress fracture. Case Report: A Caucasian 52-years-old amateur female runner with no other risk factors or medical condition was admitted in our institute with complaints of severe bilateral forefoot pain for 2 weeks arisen after a 20 km run of an amateur race. The patient presented bilateral hallux valgus (HVA) and advanced osteoarthritis of the first metatarsal-phalangeal joint, which is not usually considered a biomechanical risk factor for metatarsal stress fractures. Radiographs of both feet showed linear sclerosis, perpendicular to the diaphysis of the first metatarsal, approximatively in the half of the bone. Signs of osteoarthritis of the first metatarsal-phalangeal were also detected bilaterally.The patient was treated with rest, bilateral post-operative rocker sole shoes that she has worn for 6 weeks, cryotherapy, analgesics as needed and pulsed electromagnetic fields for 8 h per day for 40 days with a complete resolution of symptoms and the previous radiological findings. Conclusion: The authors believed that the bilateral HVA condition could be considered an indirect sign of overuse, and it may be investigated and eventually treated as a responsible for this pathologic condition.

Spontaneous healing of a ruptured anterior cruciate ligament: a case series and literature review.

PURPOSE: The anterior cruciate ligament is probably one of the ligaments with the lowest healing potential. Many authors have reported cases of spontaneous healing but nowadays it is difficult to predict successful healing of an anterior cruciate ligament rupture and, even more, residual functionality and capability to return to sport. The aim of this study was to investigate cases of spontaneous healing in a population that received non-surgical treatment after anterior cruciate ligament rupture and to perform an updated review of contemporary literature. METHODS: The authors retrospectively reviewed patients who suffered from an acute complete anterior cruciate ligament rupture and underwent non-surgical treatment. No specific rehabilitation protocol was prescribed. A new magnetic resonance imaging study was conducted 6 months after the injury for all patients. A literature review was conducted regarding spontaneous healing of the anterior cruciate ligament. The papers included in the analysis were reports of any level of evidence, written in English, Italian, or French languages; articles were excluded if they reported non-human studies, histological studies, studies conducted without magnetic resonance imaging or arthroscopic second look, or partial anterior cruciate ligament tear. RESULTS: Case series: Six patients were enrolled in the study. All patients had a proximal anterior cruciate ligament lesion. The minimum follow-up was 13 months (range 6-20 months). At the last follow-up the mean score on the Lysholm scale was 97, the mean IKDC score was 94, and the mean KOOS score was 96. All patients returned to their own sport activities; no one reported significant differences. The magnetic resonance imaging study at 6 months revealed an end-to-end continuous anterior cruciate ligament with homogeneous signal. No one had any new knee injury at last follow-up. LITERATURE REVIEW: A search of comprehensive databases retrieved 1057 articles; 8 full-text articles met the eligibility criteria. The studies were heterogeneous regarding the populations analysed, sport activity level, treatment applied, healing definition, and follow-up. The failure rate of non-surgical management ranged among the papers from 0 to 73%. CONCLUSIONS: The study findings show that spontaneous anterior cruciate ligament healing is possible and there are chances of clinical recovery for patients not suitable for surgery. However, there is still a lack of evidence about predictors, clinical outcomes, and adequate rehabilitation protocols.

A Modified Technique for Two-Stage Revision in Knee PJI Treatment.

Knee PJIs represent one of the most important complications after joint replacement surgery. If the prerequisites for implant retention do not subsist, the surgical treatment of these conditions is performed using one-stage and two-stage revision techniques. In this study, an implemented two-stage revision technique was performed, adopting antibiotic calcium sulfate beads and tumor-like debridement guided by methylene blue, such as described for the DAPRI technique. The aim of the present study is to compare the implemented two-stage revision technique with the standard technique in order to assess its effectiveness. METHODS: Twenty patients affected by knee PJIs were prospectively enrolled in the study and underwent an implemented two-stage revision technique (Group A). Data collected and clinical results were compared with a matched control group treated with a standard two-stage technique (Group B). For each patient, the time of the reimplantation and length of antibiotic systemic therapy were recorded. Each patient underwent routine laboratory tests, including inflammatory markers. RESULTS: In Group A and in Group B, inflammatory markers normalized at 6.5 ± 1.1. weeks and 11.1 ± 2.3 weeks, respectively (p < 0.05). Also, the difference in length of antibiotic therapy and time to reimplantation were significantly shorter in Group A (p < 0.05). No recurrence of infection was found in Group A at the last follow-up. DISCUSSION: The implemented two-stage revision technique demonstrated a faster normalization of inflammatory markers, as well as a decrease in reimplantation time and duration of antibiotic therapy, compared to the traditional technique. The use of calcium sulfate antibiotic beads and tumor-like debridement seems to improve the results and reduce the time of healing. CONCLUSION: The implemented two-stage revision technique seems to improve the results and reduce the time of healing. This leads to a more rapid and less stressful course for the patient, as well as a reduction in health care costs.

In-office needle arthroscopic assessment after primary ACL repair: short-term results in 15 patients.

PURPOSE: In-office needle arthroscopy has been reported as a diagnostic tool for different knee pathologies. In addition, ACL repair has seen a resurgence with the advent of innovative orthopedic devices. The aim of this study was to assess clinical, radiological, and in-office needle arthroscopic findings in 15 adult patients who underwent acute (within 14 days from injury) anterior cruciate ligament (ACL) repair. METHODS: Fifteen patients voluntarily participated in the study. A second-look arthroscopy was performed with an in-office needle arthroscopy at an average of 7.2 months after the primary repair. The parameters included in the investigation were the continuity of the anatomical footprint of the repaired ACL, subjective assessment of the ACL tension with the probe, and synovial coverage of the ACL. All patients had a Magnetic Resonance Imaging (MRI) at 6 months after repair and an arthrometric evaluation with the KT-1000. Clinical evaluation with the scores, Tegner Lysholm Knee Scoring Scale (TLKSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) was performed at the final follow-up of 2 years. Moreover, a correlation between the characteristics of ACL appearance at the time of the second look in-office needle arthroscopy, MRI and KT-1000 was performed. RESULTS: The mean TLKSS was 97.86, the mean KOOS was 98.08 and the mean subjective IKDC was 96.71. The objective IKDC was A in 10 patients and B in 5 patients. ACL healing was graded as A in 11 patients and B in 4 patients. Synovial coverage was graded as good in 10 patients and fair in 5 while MRI assessment showed a type I ACL in 10 patients, type II in 4 patients and type III in 1 patient. CONCLUSION: In-office needle arthroscopy is a reliable tool to assess the condition of a repaired ACL. In addition, ACL repair performed in acute proximal tears demonstrated excellent clinical results.

The Effect of Shelter-In-Place on Orthopedic Trauma Volumes in Italy During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 outbreak heavily attacked Italy, putting a strain for an extended time on the National healthcare system.  Hospitals fastly rearranged the activity to cope with the crisis. This retrospective comparative study intended to investigate the impact of the lockdown imposed in Italy, in two different periods, during the COVID-19 outbreak on acute orthopedic trauma, in order to identify significant issues for improvement and future preparation. MATERIALS AND METHODS: We obtained data on total trauma access to a single University hospital DEA (Department of Emergency and Acceptance) in Rome during two periods of the COVID-19 pandemic lockdown in Italy: from March 9th, 2020 to May 4th, 2020(Phase 1), from May 10th, 2020 to June 30th, 2020(Phase 2) and then comparing them with the analogous period in 2019. We recorded demographic data; the characteristics of the lesion, including the anatomical area, fracture, sprain, dislocation, contusion, laceration, whether the lesion site was exposed or closed, where the trauma occurred and polytrauma. We also reported the waiting time in the emergency room and the mode of transport. RESULT: The study sample was composed of 1655 patients, 894 (54%) males and 761 (46%) females. The overall number of admissions in 2019 (pre-COVID-19 period) was 995; then it was 204 during Phase 1 and increased again to 456 during Phase 2. The average age of the Phase 1 group was 51.9 ± 24.8 years, significantly higher than that of the 2019 group (41.4 ± 25.7) and Phase 2 group (42.2 ± 22.5 years) (p<0.0001). In particular, elderly patients (>=65 years) were the most commonly involved in the Phase 1 group, while in the pre-COVID-19 period and in Phase 2 they were middle-aged adults (15-44 years) (p<0.0001). The injury occurred at home in 66.2% of cases in the Phase 1 group, in 32.3% of cases in the Phase 2 group and in 32.3% of patients in the 2019 group. Concerning the injury type, in all groups, the most frequent injury was a fracture (45.1% in 2019; 62.7% in Phase 1; 50% Phase2) (p<0.0001). The most injured anatomical section during Phase 1 was the upper limb (43.1%), while in the pre-COVID-19 group and in Phase 2 group the most frequent injury location was the lower limb (48.3% and 40.8% respectively). CONCLUSION: Despite the decrease of overall acute trauma referral rates during the COVID-19 outbreak in Italy, the incidence of fractures in elderly people remained constant, indicating that not all trauma presentations would inevitably decrease during such circumstances.

The impact of COVID-19 on orthopaedic trauma: A retrospective comparative study from a single university hospital in Italy.

The COVID-19 outbreak strongly affected Italy, putting a strain on the National healthcare system. Hospitals quickly reorganized the activity to cope with the emergency. This retrospective comparative study aimed to analyze the impact of the lockdown imposed in Italy during the COVID-19 outbreak on acute orthopedic trauma, in order to identify critical issues for improvement and future planning. We collected data on all the trauma admissions to a single University hospital DEA (Department of Emergency and Acceptance) in Rome during the COVID- 19 pandemic lockdown in Italy, comparing them with the corresponding period in 2019. We reported demographic data; the characteristics of the injury, including the anatomical location, fracture, sprain, dislocation, contusion, laceration, whether the injury site was exposed or closed, where the injury occurred, and polytrauma. We also recorded the waiting time in the emergency room and mode of transportation. The study sample was composed of 1199 patients, 636 (53.04%) males and 563 (46.96%) females. The overall number of admissions in 2019 (pre-COVID-19 period) was 995; then it was 204 during COVID-19 outbreak in 2020. The average age of the 2020 group was 51.9 ± 24.8 years, significantly higher than that of the 2019 group (41.4 ± 25.7) (p<0.0001). In particular, elderly patients (≥65 years) were the most commonly involved in the COVID-19 group, while in the pre- COVID-19 period they were middle-aged adults (15-44 years) (p<0.0001). The injury occurred at home in 65.7% of cases in the 2020 group, and in 32.3% of patients in the 2019 group. Concerning the injury type, in both groups, the most common injury was a fracture (45.1% in 2019; 62.7% in 2020) (p<0.0001). The most injured anatomical location during COVID-19 lockdown was the hand (14.2%), while in the pre-COVID- 19 group the most frequent injury type was polytrauma (22.8%). Despite the decrease of overall acute trauma referral rates during the COVID-19 outbreak in Italy, the incidence of fractures in elderly individuals remained stable, indicating that not all trauma presentations would necessarily decrease during such times.

Hemodynamics and its predictors during Impella-protected PCI in high risk patients with reduced ejection fraction.

BACKGROUND: Percutaneous ventricular-assistance by Impella (IMP) represents an emerging strategy to manage patients with reduced left-ventricular (LV) ejection-fraction (EF) undergoing percutaneous-coronary-intervention (PCI). The hemodynamic behave during IMP-protected PCI has been scarcely investigated. METHODS: We reviewed the IMP console's function and hemodynamic data (which are continuously recorded during assistance) in a consecutive series of 37 patients who underwent elective IMP-protected PCI in two high-volume centers. All patients had multivessel disease and impaired LVEF. Coronary artery disease burden was graded using the British-Cardiovascular-Intervention-Society jeopardy-score (BCIS-JS) score. IMP motor speed and pressure signals (systolic blood pressure, SBP, and mean blood pressure, MBP) were analyzed. Primary hemodynamic end-points were "critical systolic blood pressure (SBP) drop" (SBP decrease ≥ 20 mm Hg reaching ≤90 mm Hg values) and "critical mean blood pressure (MBP) drop" (MBP decrease reaching ≤60 mm Hg). RESULTS: Over mean assistance duration of 254 ±â€¯549 min, no IMP motor drop occurred. During PCI, SBP and MBP significantly decreased but all patients had SBP values >78 mm Hg. Critical SBP and MBP drops occurred in 10.8% of patients. Among all baseline and procedural characteristics, BCIS-JS was the only significant predictor of SBP drop (p = 0.001) while BCIS-JS and LV end-diastolic volume significantly predicted MBP drop (p = 0.001 for both). CONCLUSIONS: In patients with reduced EF undergoing IMP-protected PCI, a significant pressure decrease occurs during PCI but pressure is systematically maintained at levels warranting vital organ perfusion. Critical pressure drops during PCI occur in some patients with higher jeopardized myocardium and left ventricular diastolic volumes.

Definitions and clinical impact of revascularization completeness.

The completeness of revascularization in patients with multivessel coronary artery disease (CAD) remains an unanswered question. Despite 20 years of investigation there are still major doubts in this topic, reaching as far as to the lack of a standardized definition. The employment of different definition and the multiplicity of confounding variables that in general favor patients who receive a complete revascularization (CR) are the reason of difficult comparisons between studies. The complexity of coronary anatomy diseases and the clinical features play important role in the revascularization strategy. However, the clinical impact of CR is different in particular clinical subsets, such as diabetes, ST-segment elevation myocardial infarction, cardiogenic shock, ischemic heart failure. The CR is a desirable objective, but it is not mandatory and sometimes a reasonable incomplete revascularization (IR) offers comparable results. Clinical variables, including patient's age, life expectancy, the severity of symptoms at presentation, comorbidities (particularly diabetes mellitus), left ventricular function and myocardial viability, as well as coronary anatomy should be considered in the decision making whether to attempt CR or to follow a reasonable IR strategy, for both percutaneous coronary intervention and coronary artery bypass graft surgery, in patients with multivessel CAD.

Impella: pumps overview and access site management.

The Impella left ventricular support system consists of two main components: a family of different ventricular support catheters with a microaxial pump to be placed across the aortic valve and a single external controller which is connected to activate and control the pump function. Four Impella left ventricular support catheters are available: Impella 2.5, Impella CP, Impella 5.0 and Impella LD. Impella 2.5 and Impella CP are designed for percutaneous peripheral insertion, have respectively a 12F and 14F maximal diameter at the pump level and are capable of providing up to 2.5 and 4.1 liters per minute, respectively. Impella 5.0 and Impella LD have 21F maximal diameter at the pump level and are designed for surgical insertion through, respectively, a peripheral artery (femoral or axillary) or the aorta. The Impella CP or 5.0 are commonly selected for cardiogenic shock patients. The femoral approach represents the most adopted access site for percutaneous Impella insertion. Yet, it requires the presence of suitable aorto-iliac-femoral arterial axis for retrograde advancement of the Impella pump. The axillary artery is usually the main alternative approach for surgical insertion in the patients with unfavorable peripheral anatomy or for patients requiring prolonged assistance. When adopting Impella pumps, maximal attention should be paid to the access site management before, during and after cardiac assistance in order to minimize the risk of vascular complications.