Histological study of atraumatic periprosthetic fractures: does atypical periprosthetic fracture exist?

PURPOSE: Is it possible a correlation between some periprosthetic femoral fractures and atypical fractures? CASE: We present a case of a 77-year-old woman with atypical periprosthetic femoral fracture. The patient had a history of long-term bisphosphonate use. We performed an open reduction, a synthesis of the fracture and a histological exam. The patient stopped the bisphosphonate (BF) therapy. Three months later, before starting the teriparatide treatment, the patient had a re-fracture so we did a second osteosynthesis and began a teriparatide therapy. After six months, the radiography showed a bone healing at the fracture site. RESULT: The histological examination confirmed the diagnosis of atypical femoral fracture. CONCLUSION: At first, the fracture showed a delayed union which led to a new surgery, as often happens in BF-related atypical fractures. Appropriate treatment (BF suspension and teriparatide beginning) permitted fracture healing. The atypical characteristic of the fracture was confirmed by histological exam.Some periprosthetic femoral fractures in patients treated with BF, especially in long time therapies, should be suspected as atypical fractures and a specific medical treatment should be performed, as well as a correct surgical treatment.

Underdiagnosis of osteoporotic vertebral fractures in patients with fragility fractures: retrospective analysis of over 300 patients.

Osteoporosis (OP) is a silent disease unless a fracture occurs; it is a major health problem, mainly due to fragility fractures, that occur at vertebral and peripheral sites. Vertebral fractures (VF) are probably the most common fragility fractures, but they go often unrecognized. The main clinical symptoms of VF are acute and chronic back pain, spinal deformity, reduced mobility and impaired quality of life. They are frequently associated with other fragility fractures. We examined 478 patients at our outpatient clinic, who were referred for fragility fracture occurrence. The most common fragility fractures was hip fractures. However, after execution of spine X-rays in patients who had sustained hip fracture, we found that a large proportion of them had VF, which had not been reported in their medical history.

Algodystrophy: complex regional pain syndrome and incomplete forms.

The algodystrophy, also known as complex regional pain syndrome (CRPS), is a painful disease characterized by erythema, edema, functional impairment, sensory and vasomotor disturbance. The diagnosis of CRPS is based solely on clinical signs and symptoms, and for exclusion compared to other forms of chronic pain. There is not a specific diagnostic procedure; careful clinical evaluation and additional test should lead to an accurate diagnosis. There are similar forms of chronic pain known as bone marrow edema syndrome, in which is absent the history of trauma or triggering events and the skin dystrophic changes and vasomotor alterations. These incomplete forms are self-limited, and surgical treatment is generally not needed. It is still controversial, if these forms represent a distinct self-limiting entity or an incomplete variant of CRPS. In painful unexplained conditions such as frozen shoulder, post-operative stiff shoulder or painful knee prosthesis, the algodystrophy, especially in its incomplete forms, could represent the cause.

Efficacy of a specific rehabilitation protocol in postural control of a young woman with multiple fragility vertebral fractures: a case report.

The fragility vertebral fractures have a considerable impact on an individual's health-related quality of life due to pain, limitations in activity, social participation, altered mood and balance impairment. Physiotherapy interventions may have an important role in improving quality of life, balance and reducing the fracture risk in people with osteoporotic vertebral fractures. In literature there are only a few studies that examine exercise interventions in osteoporotic populations with vertebral fracture and few studies that examine the effects on balance with instrumental measurements. In this paper we present a case of a woman with fragility vertebral fractures and a related balance impairment and the effects of a specific rehabilitation program using both clinical evaluations that instrumental measurements.

Grafting of Expanded Mesenchymal Stem Cells without Associated Procedure in a Healed Case of Ulna Pseudarthrosis: A Case Report.

BACKGROUND: The surgical management of pseudoarthrosis is often a challenge. The use of mesenchymal multipotent cells expanded and manipulated in the laboratory is an interesting treatment of pseudoarthrosis, because they can lead to differentiation into osteocytes and thus the formation of bone tissue. CASE DESCRIPTION: We present a case of a 47-years-old man with isolate ulna fracture, treated with plate and screws and evolved in non-union. The patient underwent an expanded stem cells graft on the site of non-union with a small incision of approximately 3cm, without changing the synthesis system. After one year, the X-ray showed a complete fracture consolidation. DISCUSSION: In our opinion, this case is interesting because it highlights the cellular action that is the only healing factor; it is an important demonstration of the biological action of expanded mesenchymal stem cells (MSCs). CONCLUSION: To validate the use of MSCs, it is necessary to perform comparative studies for age, sex, general condition, location, and mechanism of injury as a further clinical validation of the efficiency of this cell line.

Single-Use Instrumentation Technologies in Knee Arthroplasty: State of the Art.

The surgical site contamination and the resulting periprosthetic infections are an important cause of morbidity and socio-economic impact. In total knee arthroplasty, the single-use instrumentation is developed to simplify the surgical procedure, reduce the chance of instrument contamination, improve the operating room efficiency, and reduce overall costs (low cost of instrument washing and sterilization as well as personnel management). Surgical single-use instrumentations on the market are complete with all you need for the surgical procedure-cutting guides, conventional or PSI (patient-specific instrumentation), femoral cutting block, re-cutting block, trials components, alignment rods, inserts, and impactors. In recent years, PSI (patient-specific instrumentation) was introduced. It decreases operative time and blood loss without violating the intramedullary canal. It also allows the surgeon to preoperatively plan the patient's component size, position, and alignment. We reported an average of 30 minutes saved for each surgical procedure, a saving of 60€ for each surgical tray. Moreover, we avoided surgery cancellation or delay due to un-sterile, missing, or dysfunctional instruments. We think that this technology is the first step in developing implants that are entirely customized for each patient, and we believe that it will have a more relevant role in knee surgery in the future.

Giant Schwannoma of the Saphenous Nerve in The Distal Thigh: A Case Report.

CASE: Schwannomas are benign nerve myelin sheath tumors that can occur anywhere in the peripheral nervous system. It is very rare for Schwannomas to become malignant, but surgery is still the principal treatment to eliminate symptoms and to correctly diagnosis the tumor. We report an interesting case of a schwannoma of the saphenous nerve at the distal third of the posteromedial thigh: the patient complained of muscle weakness at left lower limb and vague anteromedial knee pain, mimicking a meniscal tear. Magnetic resonance images of the thigh showed a well-defined and oval mass lesion measuring 8.5 cm x 4.5 cm. Before investigating for a possible meniscal tear, we decided to remove the mass from the thigh, because we felt that it could itself be the cause of the mild pain complained about by the patient. Post-surgery, histological analysis conducted confirmed that this was a benign schwannoma. DISCUSSION: Schwannomas generally can be asymptomatic or present as a mass. The clinical presentation of this rare tumor makes the diagnosis difficult. CONCLUSION: This reported case is particularly interesting because of the rarity of the lesion localization along the course of the saphenous nerve. The combination of the location, and especially the large size of the tumor, led us to believe that there is a correlation with the particular clinical presentation.

Stemless humeral component in reverse shoulder prosthesis in patient with Parkinson's disease: a case report.

INTRODUCTION: In patients with Parkinson's disease falling is very common and for this reason, the prosthetic surgical indication in shoulder is reserved for special cases. PD has been linked to several interrelated factors that may contribute to failure of shoulder arthroplasty. CASE PRESENTATION: A 65-year-old woman with PD, severe pain, recurrent bursitis, swelling and functional limitation to all movements in left shoulder presented to our attention. Radiographic and CT exams show cuff-tear arthropathy. The patient was submitted to implantation of a Reverse Shoulder Comprehensive Nano cementless modular system (Biomet(®), Warsaw, IN, USA) with anterosuperior surgical approach. We chose this kind of solution of stemless humeral component after bone mineral consideration. DISCUSSION: Reverse shoulder arthroplasty represents an option in the management of glenohumeral arthritis. Poor functional results of RTSA in patients with PD have been attributed to increased muscle tone, severity of tremor and an increased mortality rate. In general, post operative complications related to the humeral component are dominated by fractures (between 1 and 3%): in patients with PD this percentage is higher because of falls often occur. With a stemless implant revisions can be performed easily. Overall, the anterosuperior surgical exposure gives a low risk of postoperative instability. CONCLUSION: In selected cases of patients with PD, after carefully analysis of bone quality, the use of a stemless component is of benefit in the possible revision cases for periprosthetic fractures and the use of an anterosuperior exposure reduces the percentage of instability. The results obtained about the pain relief are excellent in contrast with functional outcomes that remain poor.

Up-to-date Review and Cases Report on Chondral Defects of Knee Treated by ACI Technique: Clinical-instrumental and Histological Results.

The limited regenerative potential of a full thickness defect of the knee joint cartilage has certainly conditioned the development of therapeutic strategies that take into account all the aspects of the healing process. The most common treatments to repair chondral and osteochondral lesions are bone marrow stimulation, osteochondral autograft transplantation, autologous matrix-induced chondrogenesis, and autologous chondrocyte implantation. We like to emphasize the difference between a chondral and an osteochondral lesion because the difference is sometimes lost in the literature. In the context of treatment of injuries of the knee joint cartilage, the second-generation autologous chondrocyte transplant is a consolidated surgical method alternative to other techniques. Our experience with the transplantation of chondrocytes has had exceptional clinical results. We report 2 complete cases of a group of 22 in knee and ankle. These 2 cases had histological and instrumental evaluation. We cannot express conclusions, but can only make considerations, stating that, with the clinical functional result being equal, we obtained an excellent macroscopic result in both cases of second look. Autologous chondrocyte implantation (ACI) is a multiple surgical procedure with expensive chondrocyte culture, but even with this limitation, we think that it must be the choice in treating chondral lesions, especially in young patients.

Treatment of Tendon Injuries of the Lower Limb with Growth Factors Associated with Autologous Fibrin Scaffold or Collagenous Scaffold.

Tendon injuries are an increasing problem in orthopedics as we are faced with a growing demand in sports and recreation and an aging population. Tendons have poor spontaneous regenerative capacity, and often, complete recovery after injury is not achieved. Once injured, tendons do not completely re-acquire the biological and biomechanical properties of normal tendons due to the formation of adhesions and scarring, and often these abnormalities in the arrangement and structure are risk factors for re-injury. These problems associated with the healing of tendon injuries are a challenge for clinicians and surgeons. This study examined 9 cases of subcutaneous injuries including quadriceps tendon (2 cases), patellar tendon (1 case), and Achilles tendon (6 cases), incomplete and complete, treated consecutively. The surgical technique has provided, as appropriate, the termino-terminal tenorraphy, techniques of plastics of rotation flap, reinsertion with suture anchors, and in one case tendon augmentation with cadaver tissue. In cases where we needed mechanical support to the suture, we used preloaded growth factors on porcine collagen scaffold; in cases where we needed only one biological support, we used fibrin scaffold.

Hip replacement in femoral head osteonecrosis: current concepts.

Osteonecrosis of the femoral head is a destructive disease that usually affects young adults with high functional demands and can have devastating effects on hip joint. The treatment depends on extent and location of the necrosis lesion and on patient's factors, that suggest disease progression, collapse probability and also implants survival. Non-idiopathic osteonecrosis patients had the worst outcome. There is not a gold standard treatment and frequently it is necessary a multidisciplinary approach. Preservation procedures of the femoral head are the first choice and can be attempted in younger patients without head collapse. Replacement procedure remains the main treatment after failure of preserving procedures and in the late-stage ONFH, involving collapse of the femoral head and degenerative changes to the acetabulum. Resurfacing procedure still has good results but the patient selection is a critical factor. Total hip arthroplasties had historically poor results in patients with osteonecrosis. More recently, reports have shown excellent results, but implant longevity and following revisions are still outstanding problems.

Three-dimensional parametric mapping in quantitative micro-CT imaging of post-surgery femoral head-neck samples: preliminary results.

Osteoporosis and pathological increased occurrence of fractures are an important public health problem. They may affect patients' quality of life and even increase mortality of osteoporotic patients, and consequently represent a heavy economic burden for national healthcare systems. The adoption of simple and inexpensive methods for mass screening of population at risk may be the key for an effective prevention. The current clinical standards of diagnosing osteoporosis and assessing the risk of an osteoporotic bone fracture include dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) for the measurement of bone mineral density (BMD). Micro-computed tomography (micro-CT) is a tomographic imaging technique with very high resolution allowing direct quantification of cancellous bone microarchitecture. The Authors performed micro-CT analysis of the femoral heads harvested from 8 patients who have undergone surgery for hip replacement for primary and secondary degenerative disease to identify possible new morphometric parameters based on the analysis of the distribution of intra-subject microarchitectural parameters through the creation of parametric images. Our results show that the micro-architectural metrics commonly used may not be sufficient for the realistic assessment of bone microarchitecture of the femoral head in patients with hip osteoarthritis. The innovative micro-CT approach considers the entire femoral head in its physiological shape with all its components like cartilage, cortical layer and trabecular region. The future use of these methods for a more detailed study of the reaction of trabecular bone for the internal fixation or prostheses would be desirable.

Total hip replacement in osteoarthritis: the role of bone metabolism and its complications.

Osteoarthritis is one of the most common joint disorder. For treatment of hip symptomatic osteoarthritis, when conservative medical therapy has failed, total hip arthroplasty (THA) is a successful orthopaedic procedures that reduces pain and improves function and quality of life. Incidence of osteoarthritis is constantly increasing with raising life expectancy. This aging process also has led to an increasing number of patients with osteoporosis who need hip replacement for osteoarthritis. Osteoporosis have 3 major potential complications in total hip arthroplasty: perioperative fracture, an increased risk of periprosthetic fracture, and late aseptic loosening. The purpose of the present study was to examine the effects of osteoporosis on total hip replacement procedure outcome and highlight the importance of adequate study of calcium-phosphorus metabolism in patient candidate for hip surgery, and the need to start a suitable therapy to recover the bone mass before surgery. Bone quality of the hip joint has become an important risk factor limiting the durability of THA.

The role of external fixation in the treatment of humeral shaft fractures: a retrospective case study review on 85 humeral fractures.

There is no consensus among surgeons on the treatment for humeral fractures: the best it is still a matter of some debate. The aim of our work was to demonstrate that external fixation may be considered a valid method not only in emergencies but also for the definitive treatment of such fractures. We perform a retrospective case study review on 85 humeral fractures, 62 shaft fractures, and 23 extrarticular distal third fractures treated with external fixation. Clinical (Disabilities of the Arm, Shoulder and Hand (DASH) score and SF-36) and radiographic follow-up lasted on average 30 months (minimum 12 to maximum 36). Complete healing of fractures was achieved in 97.6% of cases (83 patients), with an average consolidation time of about 12 weeks (83.2 days). One case of delayed union and one case of refracture were encountered. Eighty-one patients demonstrated SF-36 scores at or above the national average and an average DASH score of 8.9. External fixation of humeral shaft fractures is considered a valid treatment method as it provides good results in terms of stability of reduction, tolerability, healing times, and functional recovery.

Cement extractor device in revision prosthesis of the humerus.

In revision arthroplasty the surgeon is often faced with the problem of removal of residual cement in the medullary canal. Conventional manual cement removal by hand or power-driven instruments can be time-consuming, can require osteotomy, and can be associated with complications such as cortical perforation, fracture, or bone loss. Ultrasonic devices offer an alternative method of cement removal, but the potential for thermal injury exists, in particular for the humerus and the radial nerve. Considering these problems with the use of ultrasound, and whereas the old cement mantle may be left in place in the hip or knee but not in the shoulder, we tried this new mechanical cement extractor also in the humerus. We utilized this extractor in 5 cases, and we eliminated all residual resin in an accurate and complete way without bone loss and without iatrogenic fractures in all cases. We believe this system, which was designed for revisions of hip and knee surgery, is also suitable for the shoulder.

Osteoporosis with vertebral fractures associated with pregnancy: two case reports.

Pregnancy and lactation-associated osteoporosis (PAO) is a rare condition characterized by the occurrence of fragility fractures, most commonly vertebral, in late pregnancy or the early postpartum period. The prevalence, etiology and pathogenesis of this osteoporosis are unknown, although there are several hypotheses attempting to explain the etiopathogenesis of pregnancy associated osteoporosis. In this paper we present two cases of young women who developed severe PAO with vertebral fractures: a 42-year-old woman with a family history of osteoporosis, and a 21-year-old woman affected with myasthenia gravis. The case 1 presented fragility fracture of D12, L2, and L3. She did not have any disease causing osteoporosis. However, she had a positive familial history for osteoporosis and during pregnancy (12th week) she had a detached placenta, so bed rest was prescribed for two months. The case 2 presented multiple vertebral fracture. She was affected by myasthenia gravis, which was diagnosed two years before pregnancy, and treated with corticosteroid. In summary, pregnancy and lactation-induced osteoporosis, although it is a rare disorder, should be kept in mind when pregnant women or women in postpartum period develop persistent back pain and it is important to monitor the patients with risk factors or secondary causes of osteoporosis.

A case of bilateral stress fractures in an old woman: three years of pain.

In elderly patients frequent episodes of joint pain of lower limbs exacerbated by stress and resistant to treatment occur frequently. This paper reports a case of a long lasting bilateral atraumatic knee pain with a final diagnosis of bilateral stress fractures of proximal tibia in osteoporotic postmenopausal woman. The distinctive trait of this case is that the fracture has set in bilaterally and associated with an isthmic L4-L5 spondylolisthesis in a patient afflicted by a decline in mood. This particular clinical picture has delayed the diagnosis and the suitable treatment for 3 years. Therapy for this type of patients must aim in the acute phase at pain relief and only after must be settled in a long term antiosteoporotic therapy. We choose clodronate acyd for pain relief and after strontium ranelate for osteoporosis prevention.

Study of the porcine dermal collagen repair patch in morpho-functional recovery of the rotator cuff after minimum follow-up of 2.5 years.

Tendon augmentation grafts have the potential to facilitate the repair of massive or otherwise unrepairable rotator cuff tears. In our clinic, between 2009 and 2013, 25 patients underwent surgery to treat massive symptomatic rotator cuff tears with porcine dermal collagen patch. This study is a clinical and instrumental assessment of 9 patients with the longest follow-up. These patients were evaluated with Constant score, the American Shoulder and Elbow Surgeons Evaluation Form, ultrasound imaging, magnetic resonance imaging, and electromyography. The clinical evaluations have shown good outcomes. The magnetic resonance imaging results were comparable with those of the ultrasound scan. In all cases, we found covering of humeral head, centering of the humeral head, maintenance of the tropism of the supraspinatus, no appearance of fatty degeneration, no worse in cases with fatty degeneration. With the electromyographic examination a complete functional recovery was observed with the possibility of performing maximal contraction against resistance in all cases. We believe that porcine dermal collagen is effective as an augmentation graft in the treatment of chronic extensive rotator cuff tears, providing excellent pain relief with an improvement in active ranges of motion and strength.

The hip prosthesis in lateral femur fracture: current concepts and surgical technique.

The third proximal femur fractures are divided into medial and lateral ones. For medial fractures already exists unanimity of thought for the choice of treatment that involves the prosthetic replacement of the hip joint in patients over 60 without indications to the synthesis. Regarding the lateral femur fractures this unanimity does not exist yet even if the majority of surgeons practice treatment with osteosynthesis. We want to highlight if there are any types of lateral fractures associated with patient's clinical condition in which it might be more useful to a prosthetic replacement with the aim of being able to allow a total load and earlier deambulation, reducing complications related to a possible patient immobilization.

Current medical treatment strategies concerning fracture healing.

The morbidity and socioeconomic costs associated with bone healing are considerable. A number of fractures are complicated by impaired healing. This is prevalent in certain risk groups such as elderly, osteoporotics, post-menopausal women, and in people with malnutrition. The biologic process of fracture healing is complex and impacted by multiple factors. Some of them, such as the nutritional and health conditions, are patient-dependent, while others depend on the trauma experienced and stability of the fracture. Fracture healing disorders negatively affect the patient's quality of life and result in high health-care costs, as a second surgery is required to stabilize the fracture and stimulate bone biology. Future biotechnologies that accelerate fracture healing may be useful tools, which might also prevent the onset of these disorders. We list the characteristics of the drugs used for osteoporosis, but we point out in particular the use of strontium ranelate and teriparatide in our clinical practice in elderly patients, especially females, who reported fractures with risk of nonunion. This medical treatment could impaired fracture healing however, most of the evidence is obtained in animal studies and very few studies have been done in humans. Thus one could hypothesize the possibility of a medical treatment both as a preventive and as support to the synthesis. However, no clinical studies are available so far, and such studies are warranted before any conclusions can be drawn. A positive effect of osteoporosis treatments on bone healing is an interesting possibility and merits further clinical research.