Can machine learning predict the accuracy of preoperative planning for total hip arthroplasty, basing on patient-related factors? An explorative investigation on Supervised machine learning classification models.

Background: The success of Total Hip Arthroplasty (THA) is influenced by preoperative planning, with traditional 2D approaches displaying varied reliability as well. The present study investigates the use of Supervised Machine Learning (SML) models with patient-related features to improve accuracy. Methods: Preoperative and perioperative data, as well as planning and final implant information, were obtained from 800 consecutive cementless primary THA, which was performed uniformly by a specialized surgical team. Six Supervised Machine Learning models were trained and validated using patient characteristics and implant data: Logistic Regression (LR), Linear Discriminant Analysis (LDA), K-Nearest Neighbors (KNN), Decision Tree (CART), Gaussian Naive Bayes (GN), and Support Vector Classifier (SVC). The models' ability to predict planning reliability and leg length disparity was evaluated. Results: KNN performed better on the cup model (97.9 %), femur model (96.7 %), and femur size (99.2 %). SVM emerged as the model with the highest accuracy for cup size (60.4 %) and head size (62.1 %). CART had the best accuracy (99 %) when determining leg length discrepancy. Conclusion: The study demonstrates the utility of Supervised Machine Learning models, specifically KNN, in predicting the accuracy of preoperative planning in THA. The accuracy of these models, which are driven by patient-related characteristics, provides useful information for optimizing patients' selection and improving surgical outcome.

Prognostic factors for return to work in patients affected by chronic low back pain: a systematic review.

Chronic low back pain (LBP) represents a leading cause of absenteeism from work. An accurate knowledge of complex interactions is essential in understanding the difficulties of return to work (RTW) experienced by workers affected by chronic LBP. This study aims to identify factors related to chronic LBP, the worker, and the psycho-social environment that could predict and influence the duration of an episode of sick leave due to chronic LBP.Studies reporting the relation between prognostic factors and absenteeism from work in patients with LBP were included. The selected studies were grouped by prognostic factors. The results were measured in absolute terms, relative terms, survival curve, or duration of sick leave. The level of evidence was defined by examining the quality and the appropriateness of findings across studies in terms of significance and direction of relationship for each prognostic factor.A total of 20 studies were included. Prognostic factors were classified in clinical, psycho-social, and social workplace, reaching a total of 31 constructs. Global conditions with less favorable repercussions on worker's lives resulted in a delay in time to RTW. Older age, female, higher pain or disability, depression, higher physical work demands, and abuse of smoke and alcohol have shown strong level of evidence for negative outcomes.High global health well-being, great socioeconomic status, and good mental health conditions are decisive in RTW outcomes. Interventions that aim at RTW of employee's sick-listed with LBP should focus on psycho-social aspects, health behaviors, and workplace characteristics.

Simultaneous vs staged bilateral hip arthroplasty: monocentric analysis of satisfaction rate and complications.

PURPOSE: Interest in bilateral total hip arthroplasty (THA) has been increasing over the past decade. This study aims to compare postoperative local and systemic complications, hospital readmissions, and satisfaction assessment in patients undergoing simultaneous versus staged bilateral THA. METHODS: A retrospective observational study was conducted among patients who underwent simultaneous or staged bilateral THA between 2017 and 2020. Data on perioperative parameters, local and systemic complications, and 30-day hospital readmissions were collected. Patient satisfaction was assessed using Forgotten Joint Score (FJS). The comparison of continuous variables with normal distribution of variance was performed by ANOVA; for variables with abnormal distribution, the nonparametric test Mann-Whitney U was adopted. The distribution of dichotomous variables was analyzed by chi-square test, and statistical significance was calculated by Fisher exact test. RESULTS: The study included 199 patients, of whom 156 underwent staged and 43 simultaneous bilateral THA. A total of 44 patients developed complications (21 systemics, 12 locals, and 20 postoperative anemia). There were no significant differences regarding local (simultaneous 5% vs. staged 6%; p = 0.999) or systemic complications (simultaneous 14% vs. staged 10%; p = 0.408). Only the incidence of postoperative anemia was significantly higher in simultaneous group compared with staged group (p = 0.003). There were no significant differences in FJS between the two groups (p = 0.258). CONCLUSION: No differences in local or systemic complications nor readmission rates were observed following simultaneous or staged bilateral THA. Simultaneous bilateral THA is non-inferior to staged implants in terms of safety and patient satisfaction.

Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications.

PURPOSE: The exponential increase in total hip arthroplasty (THA) has led to acute and chronic surgery-related complications. Common chronic and local complications are represented by hip ossification (HO). The aim of our study was to assess the clinical and radiological correlates of patients undergoing surgical removal of heterotopic ossifications after THA and the possible association between HO and prosthetic joint infection. METHODS: Data of 26 patients who underwent surgical removal of periprosthetic calcifications after THA from 2000 to 2022 were analyzed and compared with characteristics of 156 subjects without HO. RESULTS: The preoperative radiographs of patients showed a high-grade Brooker, 3 or 4, later reduced to 1 or 2 in the postoperative radiographs. Ten (38.5%) patients underwent radiotherapy prophylaxis, administered as a single dose 24 h before surgery. In 19 (73%) patients, pharmacological prophylaxis with indomethacin was added in the 30 postoperative days. Only one patient who underwent radiotherapy had a recurrence, while new ossifications were found in three patients without prophylaxis (11.5%). Intraoperative cultures were performed for suspected periprosthetic infection in 8 study group patients. In logistic regression, the presence of HO was significantly and inversely associated with the ASA score (OR = 0.27, 95% CI = 0.09-0.82; P = 0.021) after adjusting. CONCLUSION: Surgical HO removal in symptomatic patients with high-grade disease produces good clinical and radiographic results. Radiotherapy was a good perioperative and preventive strategy for recurrence, also associated with NSAIDs and COX-2 inhibitors.

Failure rate analysis and clinical outcomes of two different femoral tunnel positions using anteromedial portal technique in anterior cruciate ligament reconstruction.

AIM: To analyze two different femoral tunnel positions and to evaluate their correlation with clinical, functional outcomes and surgical revision rate in patients who underwent primary arthroscopic anterior cruciate ligament (ACL) reconstruction with anteromedial (AM) portal technique. METHODS: From January 2015 to October 2018, we recruited 244 patients that underwent primary single-bundle ACL reconstruction, using four strand-semitendinosus graft and AM portal technique for femoral tunnel placement. Patients were divided into two groups based on the different femoral tunnel positions: 117 patients of group A had ACL footprint center femoral tunnel position compared with 127 patients of group B, with femoral tunnel placement close to the AM bundle footprint. Preoperatively and at last follow up, all patients were assessed subjectively by Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores, while Lachman, Pivot-shift, and KT-1000 tests were performed to evaluate knee joint stability. RESULTS: Group B patients showed significantly better results in Lysholm, objective, and subjective IKDC scores compared with patients of group A (P < 0.001). A significantly higher surgical failure rate was found in group A than in group B (10.26% vs. 2.3%; P < 0.001). A higher anterior knee laxity was recorded in patients of group A than in patients of group B (1.9 ± 1.1 vs. 1.3 ± 1 mm; P < 0.001); a reduction in mean anterior tibial translation from preoperative to final follow up was found in group B compared with group A (3.5 ± 1.2 vs. 2.7 ± 1.1 mm; P < 0.001). No significant differences in the Tegner scale were found between the two groups. CONCLUSION: ACL reconstruction performed using the AM portal technique showed better and more satisfactory clinical and functional outcomes associated with a lower failure rate when the femoral tunnel had been placed more eccentrically in the footprint, in the AM bundle center position.

Adipose-derived stromal vascular fraction processed with different systems for the treatment of knee osteoarthritis: a pilot study on cell proliferation and clinical results.

In recent years, the interest in stromal vascular fraction (SVF) therapy for conservative treatment of osteoarthritis has grown significantly. This study aims to assess three different processing systems (micro-fragmentation, filtration, or slow centrifugation) in terms of cell proliferation in vitro and clinical results of intraarticular injections for the treatment of knee OA. From December 2017 to June 2018, 25 procedures were performed using three different systems. A considerable improvement of the clinical condition in almost all patients already one month after the treatment with a stable effect at 6 and 12 months was recorded. Patients treated with SVF, obtained by the micro-fragmentation system, had better outcomes one month after the treatment with a mean improvement of the symptomatology higher than that found in patients treated with the filtration or slow centrifugation system. The SVF product from the same system had a higher cell proliferation capacity in vitro.

The combined use of platelet rich plasma and hyaluronic acid: prospective results for the treatment of knee osteoarthritis.

Osteoarthritis represents an important social economic burden with a high incidence worldwide. Conservative management of knee OA consists in several therapeutic options: pharmacologic therapy such as analgesics, non-steroid and steroid anti-inflammatory drugs, physical therapy, and injective therapy with hyaluronic acid (HA) and platelet-rich plasma injections (PRP). The aim of our study is to evaluate the effect of combined autologous PRP and HHA (Hybrid Hyaluronic Acid) viscosupplementation on clinical outcomes of patients with knee OA, by assessing the subjects before and after injective treatment. The study was conducted on 60 patients with an age between 40 and 70 years old affected by unilateral symptomatic knee osteoarthritis (stage II and III of Kellgren-Lawrence scale) nonresponsive to pharmacologic and rehab treatment. We divided the patients in two groups, and we treated the group A with injection of HHA and group B with HHA+PRP. Each patient received 3 injections at an interval of 1 week for 3 consecutive weeks. The patients were evaluated by the Knee Injury and Osteroartrhitis Outcome Score (KOOS) and Visual Analog Scale (VAS) at 3, 6 and 12 months after treatment. Statistical comparison between groups showed a significantly better result for the group B concerning the KOOS value, at 3 months and at 6 months. This difference, although clinically relevant, lost the statistical significance at 12 months. The VAS trend differently showed a significant difference at 3 and 12 months, while at 6 months the superiority of group B did not achieve statistical significance. Few studies investigated the effects of HA+PRP combined treatment for knee OA. Numerous studies demonstrated the efficacy of HA injection therapy in knee OA for a clinical point of view, reducing the pain and improving the quality of life. PRP preparations also improved functional outcome scores compared to hyaluronic acid and placebo in patients affected by knee OA. Based on our results we can conclude that the combined PRP and HHA treatment is not only a safe and efficacious procedure which can provide functional benefit but is also significantly better than HHA injective therapy alone, as demonstrated by the comparison within our cohort.

Sport activity as risk factor for early knee osteoarthritis.

There is wide discussion about the association between sport activity and musculoskeletal disorders, as sports-related joint loading increases the risk of osteoarthritis (OA). The present article reviews the current available literature on the connections between participation in several sports and athletic activities and prevalence of knee OA, especially focusing on early knee OA. The study was based on an electronic search through web databases including Medline, Cochrane and Google Scholar. Articles were retrieved and evaluated, and case series, retrospective studies, case-control studies, prospective cohort studies and randomized controlled trials were considered for inclusion. The main data were extracted and summarized in tables and text. Athletic individuals do show an increased prevalence of knee OA, especially for professional athletes when compared to general population or non-professional athletes. Furthermore, several features related to sport activity were associated to increased risk of early knee OA, such as knee ligamentous injury, concussion, high-impact sports and different team roles. Methodology and results of the included studies are barely comparable, thus preventing the authors to carry out an accurate and systematic comparison of the results of the included studies. Only low level evidence studies are available, and better designed studies, with radiological and functional evaluation of the knee based on internationally validated measures, should be planned. Also, follow-up of patients during and after their life-period of sport involvement should be considered.

Correlation of pre-operative planning to surgical correction of opening wedge HTO: a radiographic study utilizing a manual measurement method.

High tibial osteotomy (HTO) utilizing a medial opening wedge has become a common and effective surgical technique for treatment of isolated medial compartment knee osteoarthritis secondary to varus malalignment. To reduce the risk of under- or overcorrection, accurate preoperative planning is important. This is a radiographic study to evaluate the reliability of preoperative measurement on full-length weight-bearing X-rays (FLWBXr) compared to post-operative X-rays after healing. In addition, we calculated if the intraoperative opening wedge performed was consistent with the preoperative calculation and the postoperative correction. Three independent observers measured preoperative and postoperative FLWBXr at three different times. The angle of varus deformity; the angle to correct and the wedge needed to achieve desired alignment: the angle achieved postoperatively, and the postoperative mechanical axis deviation were measured. Intra- and inter-rater reliability showed high values for all the investigated parameters. The discrepancy between the calculated wedge and the wedge actually used in surgery ranged from 1 mm of over-correction to 3 mm of undercorrection, averaging -1.3 mm. The mechanical axis crossed the tibial plateau an average of 53% ±12.7. Clustering the data by the plate type statistically significant differences were found for preoperative varus alignment, advocated correction, intraoperative correction and post-op alignment. The Dugdale method can be considered highly reliable. Possible factors affecting the final correction are: surgeon's desire not to overcorrect in young patients and minimal osteoarthritis; measurement errors; variability in the method the FLWBXr is performed. In addition, the under correction could be the result of some collapse with time or the correction could be affected by the fixation system. Further investigation should include complete post-operative evaluation of outcomes and assess the role of these potential factors and their relationship to correction. Level of Evidence: Level III, Retrospective study.

Talar exostosis (epiphyseal dysplasia): case report of posterior arthroscopic excision.

Posterior ankle impingement is a syndrome characterized by discomfort or pain at the hind foot during plantarflexion. The etiology can be divided into three main categories: overuse, trauma and anatomic abnormalities. Regarding overuse, usually patients that complain of posterior ankle pain are ballet dancers, downhill runners, field athletes and soccer players secondary to flexor hallucis tendinitis.

Advances in management of periprosthetic joint infections: an historical prospective study.

OBJECTIVE: The purpose of our study is to assess the incidence of prosthetic joint infection (PJI) after total Knee arthroplasty (TKA), total Hip arthroplasty (THA) and total Shoulder arthroplasty (TSA), to identify risk factors, determine the microbial spectrum and management's outcome. PATIENTS AND METHODS: A case-control, retrospective observational study was performed analyzing patients who developed a PJI after TKA, THA, and TSA from 2000 to 2017 at our hospital. The patient's risk profile was defined extracting from clinical records the following data: sex, age, BMI, type of implant, comorbidity, year of surgery, year of infection, previous intra-articular injection, microbial isolation, medical and surgical management outcome. We include in the "control group" for each "case" at least 3 patients who didn't have a PJI after TJA. RESULTS: 28 patients met all inclusion and exclusion criteria. Comparing the "cases" with "controls" demographics parameters, medical comorbidities and previous intra-articular injection were not associated with an increased risk of PJI. Comparing the "early/delayed group" with "late group", BMI was associated with an increased risk of early/delayed PJI, while demographics parameters, medical comorbidities, and previous intra-articular injection did not significantly increase the risk of PJI. Logistic regression showed that for each BMI unit there was a 20-fold increased risk of early prosthetic infection (OR 1.19, IC 1.03-1.38, p=0.01). Staphylococci were isolated most frequently from pre-operative and intra-operative cultures. Two-stage arthroplasty exchange and surgical debridement resulted in the most performed surgical treatment with a success rate of 88 and 87%. CONCLUSIONS: Obesity is a risk factor for "early/delayed infection" of TJA. Two-stage arthroplasty exchange, debridement, antibiotics, and implant retention in patients are treatments with a high rate of success in terms of reinfection.

Outcomes of neck modularity in total hip arthroplasty: an Italian perspective.

BACKGROUND: The aim of this study is to conduct a systematic review of clinical outcomes and complications of modular neck THA among Italian cohorts. METHODS: Only reviewed publications focused on Italian cohort patients in English language were considered for inclusion. Studies were included if they involved patients who underwent total hip replacement surgery with modular necks, and reported aetiology or survival rate or bone stability or clinical scores or complications. RESULTS: The studies included in our search reported data on 3714 patients and 3856 hips. Most of the studies were from high-volume surgery centres. The most frequent diagnosis was osteoarthritis that occurred in 2910 cases (75.9%). The average survival rate and average bone stability were 97.20% and 99.37%, respectively. The average HHS improved from 42.1 prior to surgery to 89.52 after surgery. Studies included in our search reported 40 complications. The most frequently reported complication was dislocation (40%). CONCLUSION: This review showed excellent survival rate and bone stability and good clinical outcomes in Italian cohort patients treated with modular neck THA, and these clinical results are comparable with international cohort rates. This review suggests that modular implants represent a very satisfying choice when practised by expert orthopaedic joint surgeons.

Comparing hybrid hyaluronic acid with PRP in end career athletes with degenerative cartilage lesions of the knee.

Cartilage lesions are very common causes of chronic knee pain in athletes. Current treatment options consist in conservative strategies, such as viscosupplementation and platelet-rich plasma injections. This randomized controlled trial aims to investigate the effect of intra-articular Hybrid Hyaluronic Acid injections compared to PRP for the treatment of cartilage lesions among athletes at the end of their career. Since March 2015, 48 professional soccer players were randomized into two groups: 24 patients received 3 injections of HHA and 23 patients received 3 intra-articular injections of PRP. All patients achieved a statistically significant clinical improvement from preoperative to postoperative time in both groups. Patients in the HHA group showed a significant superiority compared to PRP group at 3 and 6 months. Intergroup differences decrease gradually until loss of significance at 12 months follow-up. Athletes with chronic degenerative cartilage lesions of the knee responded positively both to HHA and PRP until last follow up.

The management of osteomyelitis in the adult.

BACKGROUND AND PURPOSE: Osteomyelitis (OM) is considered one of the most challenging medical conditions an orthopaedic surgeon has to face. Much debate is present concerning diagnosis and treatment, especially about differences between acute and chronic forms of the condition. The main aim of the present work is to show the key points where research should be implemented. METHODS: Online database were searched to find evidence about the clinical management of osteomyelitis. Clinical randomized trials, case series, prospective cohort studies reporting on diagnosis and treatment of acute and chronic osteomyelitis were taken into consideration. Cadaveric studies, laboratory studies, case reports, review articles and meta-analyses were excluded. Furthermore, studies concerning implant related OM were excluded. Studies in English, Spanish and French were considered in this process of inclusion. The cohorts of all the included studies were composed of adult patients. RESULTS: The main growpoints concerning OM are the identification of a correct laboratory test array to allow a prompt diagnosis and provide a sensitive and specific detection of the bacterial species involved, along with antibiotic drug resistance; optimal imaging techniques, according to the phase of the infection, have to be performed, to avoid unnecessary medical expenses; the identification of a suitable compromise between intravenous and oral drugs administration. A flow chart is proposed for optimal clinical management of this pathology. CONCLUSION: More work should be carried out to clarify the main issues concerning the clinical management of osteomyelitis in adult patients.

Sarcopenia and its relationship with osteoarthritis: risk factor or direct consequence?

PURPOSE: The aim of this review is to evaluate the clinical role of sarcopenia in patients affected by osteoarthritis (OA) of major joints. METHODS: An online database research was performed, in order to retrieve all articles investigating the relationship between sarcopenia and OA. No peer-reviewed journal was excluded. Papers in English, French, Spanish and Italian language were considered. After consulting the full-text article, five studies have been included in the review. RESULTS: Of the five studies included, four are prospective studies and only one is a cross-sectional study which retrieved data retrospectively. A total of 4,231 patients, presenting a mean age of 62.0 years, were studied. Three studies evaluated only female subjects. Weight, height and body mass index were reported in all the articles. Knee OA has been assessed using the Kellgren-Lawrence grading system and the American college of rheumatology criteria. Alterations of the lean body mass on body weight ratio have been reported to be as a significant predictive parameter in two studies. Relationship between radiographic OA and an increase in the leg lean mass has been observed in one study. CONCLUSIONS: We cannot support neither the thesis of a direct effect of sarcopenia on OA development nor the opposite relation, because the up-to-date literature lacks basic science studies concerning these topics. The absence of clinical studies regarding measurements and tools to compare sarcopenia and OA do not allow to definitely clarify this relationship.

Structural properties of a new fixation strategy in double bundle ACL reconstruction: the MiniShim.

INTRODUCTION: Double-bundle reconstruction of the ACL has become the focus of scientific and clinical interest in the last years. However, there is still a discussion about the most appropriate technique for graft fixation. Both, extracortical fixation systems like the Endobutton and aperture fixation by interference screws have advantages as well as disadvantages. Aim of this study was to analyze the biomechanical properties of a new small wedge shaped implant (MiniShim, Karl Storz, Germany) for the fixation of a soft tissue graft in double bundle ACL reconstruction and to compare it to an aperture fixation by interference screw and an extracortical fixation. METHODS: Porcine knees and flexor tendons were used for this study. 5 and 6 mm tunnels were drilled. The following fixation strategies were tested: 4 and 5 mm MiniShim (Karl Storz Germany), 6 mm interference screw (MegaFix, Karl Storz, Germany), hybridfixation by FlippTack (FlippTack, Karl Storz, Germany) and MiniShim and hybridfixation by FlippTack and 6 mm interference screw. All fixation strategies were tested with a 5 and 6 mm tendon graft. Maximum load, yield load and stiffness were recorded using a material testing machine. Load was applied in line with the bone tunnel. Grafts were cyclically preconditioned between 0 and 20 N for 10 cycles before the graft-bone-complex was loaded to failure. Statistical evaluation was performed using SPSS Version 11.0. RESULTS: Load to failure for the 5 mm graft was 81.1 and 118.0 N for the 4 and 5 mm MiniShims. Fixation by interference screw reached 237.4 N. The extracortical fixation resulted in a load to failure of 471.7 N. Load to failure for the 6 mm tendon grafts was 52.0 and 92.8 N for the 4 and 5 mm MiniShims. Fixation by interference screw resulted in a load to failure of 214.0 N. Extracortical fixation failed at 451.7 N. The difference between MiniShim and interference screw was statistically significant. Load to failure was significantly higher for extracortical fixation compared to fixation by MiniShim or interference screw. Hybrid fixation showed higher fixation strength compared to fixation by interference screw or MiniShim alone. This difference was statistically significant. Stiffness was significantly higher for fixation by interference screw compared to extracortical fixation and fixation by MiniShim. Four different modes of failure could be seen. All 4 mm MiniShims failed by slippage of the tendon past the MiniShim. In the 5 mm group the fixation failed by pullout of the MiniShim or the tendon past the MiniShim. Hybrid fixation failed by rupture of the linkage material. When the graft was fixed by an interference screw failure occurred by rupture of the tendon at the fixation side. CONCLUSION: Hybrid fixation using the MiniShim provides biomechanical properties strong enough to withstand the forces occurring during rehabilitation and comparable to the fixation strength provided by interference screw. While fixation by MiniShim alone does not provide sufficient fixation strength in double bundle ACL reconstruction, hybridfixation using a cortical fixation by FlippTack is an alternative to aperture fixation by interference screw concerning primary stability.