Distinctive Geometrical Traits of Proximal Femur Fractures-Original Article and Review of Literature.

Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson's χ2 criterion was used, while Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur.

Posterior hip dislocation in a non-professional football player: a case report and review of the literature.

The majority of injuries during a football game are contusions, sprains and/or strains in the thigh, knee and ankle. Hip dislocations account for 2-5% of total hip dislocations, and they can be posterior or anterior. Major complications of traumatic hip dislocation include avascular necrosis of femoral head, secondary osteoarthritis, sciatic nerve injury and heterotopic ossification. On the occasion of a case of a 33-year-old football player, who suffered a posterior hip dislocation, associated with a posterior wall fracture of the acetabulum, while playing football, we review the literature and analyze the various mechanisms of injury, the possible complications and the management including surgery and rehabilitation.

Comparing return to sport activities after short metaphyseal femoral arthroplasty with resurfacing and big femoral head arthroplasties.

OBJECTIVES: Young patients feel that maintaining sport activities after total hip arthroplasty constitutes an important part of their quality of life. The majority of hip surgeons allow patients to return to low-impact activities, but significant caution is advised to taking part in high-impact activities. The purpose of this study is to compare and evaluate the post-operative return to daily living habits and sport activities following short-metaphyseal hip and high functional total hip arthroplasties (resurfacing and big femoral head arthroplasties). MATERIAL AND METHODS: In a study design, 48 patients (55 hips) were enrolled in three different comparative groups, one with the short-metaphyseal arthroplasties, a second with high functional resurfacing arthroplasties and a third of big femoral head arthroplasties. Each patient experienced a clinical examination and evaluated with Harris Hip Score, WOMAC, Sf-36, UCLA activity score, satisfaction VAS, anteroposterior and lateral X-rays of the hip and were followed in an outpatient setting for 2 years. RESULTS: Statistical analysis revealed no notable differences between the three groups regarding their demographic data however significant differences have been found between preoperative and postoperative clinical scores of each group. Also, we fail to reveal any significant differences when comparing data of all three groups at the final 2 years postoperative control regarding their clinical scores. The overall outcome of all three groups was similar, all the patients were satisfied and returned to previous level of sport activities. CONCLUSION: Short metaphyseal hip arthroplasties in young patients intending to return to previous and even high impact sport activities, similar to high functional resurfacing, big femoral head arthroplasties. Short stems with hard on hard bearing surfaces might become an alternative to standard stems and hip resurfacing.

Evaluation of TLICS for thoracolumbar fractures.

PURPOSE: Thoracolumbar Injury Classification and Severity Score (TILCS), facilitates the communication between physicians, and guides to treatment decision with better outcome. A composite injury severity score is calculated from these characteristics stratifying patients into operative and non-operative treatment. Aim of this study is to identify the effectiveness of TLICS scoring for thoracolumbar vertebral fractures without neurological deficits and the efficacy of conservative treatment in patients with TILCS 4. METHODS: 58 patients with thoracolumbar fracture were included. 38 patients with TLICS 1-3 (group A) and 20 patients with TLICS 4 (group B) treated conservatively, were evaluated with traditional two-plain radiographic examination, CT-scan and MRI. The pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Mean follow-up period was 28 months. Post-fracture and follow-up values were compared. Functional scores and clinical outcomes of the groups were compared. RESULTS: The mean pain (1 = worse pain, reverse-VAS) and functional scores at the final follow-up were 8.2 and 86 points, respectively (group A), 6.4 and 76 points (group B). The mean period for returning to work was 3.2 (group A) and 3.8 months (group B). Comparing the two groups did not demonstrate any statistical difference of their clinical and functional outcomes. CONCLUSION: The study's results demonstrate that conservative treatment for TLICS 4 thoracolumbar fractures can be safely applied. The conservative treatment of cases scoring TLICS 4 is equally effective to those scoring ≤3.

Salvage of failed hip osteosynthesis for fractures with modular hip prosthesis.

BACKGROUND/PURPOSE: Treating options of failed internal fixation include revision fixation and salvage arthroplasty. The purpose of this study was to evaluate the results, complications and the final functional outcome associated with modular hip arthroplasty. METHODS: Modular arthroplasty was performed in 11 patients due to failed treatment of peritrochanteric fracture. Each patient examination included Trendelenburg test, Harris Hip Score, SF-36, and X-rays of the hip. Examinations were recorded and a paired t test was applied for further statistic analysis. RESULTS: Two years postoperatively, four patients referred no hip pain, seven patients claimed for slight or mild pain, and three patients presented with moderate pain. Statistical analysis revealed a statistically significant difference equally for Harris Hip Score and SF-36. CONCLUSION: The use of modular stems during salvage arthroplasty can decrease the risk of intraoperative and postoperative complications. The final outcome for the patient is satisfactory with functional improvement of the hip.

The complexity of the IGF1 gene splicing, posttranslational modification and bioactivity.

The insulinlike growth factor-I (IGF-I) is an important factor which regulates a variety of cellular responses in multiple biological systems. The IGF1 gene comprises a highly conserved sequence and contains six exons, which give rise to heterogeneous mRNA transcripts by a combination of multiple transcription initiation sites and alternative splicing. These multiple transcripts code for different precursor IGF-I polypeptides, namely the IGF-IEa, IGF-IEb and IGF-IEc isoforms in humans, which also undergo posttranslational modifications, such as proteolytic processing and glycosylation. IGF-I actions are mediated through its binding to several cell-membrane receptors and the IGF-I domain responsible for the receptor binding is the bioactive mature IGF-I peptide, which is derived after the posttranslational cleavage of the pro-IGF-I isoforms and the removal of their carboxy-terminal E-peptides (that is, the Ea, Eb and Ec). Interestingly, differential biological activities have been reported for the different IGF-I isoforms, or for their E-peptides, implying that IGF-I peptides other than the IGF-I ligand also possess bioactivity and, thus, both common and unique or complementary pathways exist for the IGF-I isoforms to promote biological effects. The multiple peptides derived from IGF-I and the differential expression of its various transcripts in different conditions and pathologies appear to be compatible with the distinct cellular responses observed to the different IGF-I peptides and with the concept of a complex and possibly isoform-specific IGF-I bioactivity. This concept is discussed in the present review, in the context of the broad range of modifications that this growth factor undergoes which might regulate its mechanism(s) of action.

Management and outcome of diaphyseal aseptic non-unions of the lower limb: a systematic review.

OBJECTIVES: To review current treatments utilising biological enhancement modalities and their efficacy for the management of lower limb long bone aseptic non-unions. MATERIALS & METHODS: A systematic review of English articles using PubMed Medline; Ovid Medline; Embase; and the Cochrane Library was performed, supplemented by a manual search of bibliographies. RESULTS: Thirteen manuscripts met the inclusion criteria reporting on 428 patients. The overall healing had a pooled estimate of effect size at 94.3%. The calculated summarised estimate of effect size for deep infection rate (413 patients) was 2.3%. Three subgroups were then created on the basis of the exact type of graft used at the non-union site (ABG, BMP-7, BMP-7 + ABG). Comparison between the above subgroups revealed that ABG resulted in approximately 3-fold increase of the odds of healing compared with the use of BMP-7. Combined use of ABGs and BMP-7 improved the odds of healing by 3.5 times compared with BMP-7 alone. However, the previous median operations prior to the implantation of ABG or BMP-7 treatment was 1.09 versus 2.3 respectively (p = 0.02). Although the implantation of ABG was associated with a greater incidence of infection the documented differences did not reach significance. CONCLUSIONS: Although ABG was found to have a higher success rate compared to BMP-7 (95% Vs 87%), patients treated with BMP-7 had a higher number of previous failed interventions, statistically significantly so (BMP-7 is used for the treatment of more recalcitrant non-unions). It is the surgeon's judgement that should determine the most suitable treatment modality, depending on the nature and characteristics (personality) of the non-union and the patient.

Role of Dithiothreitol in Detection of Orthopaedic Implant-Associated Infections.

Orthopaedic implant-associated infections (OIAIs) represent a notable complication of contemporary surgical procedures, exerting a considerable impact on patient outcomes and escalating healthcare expenditures. Prompt diagnosis holds paramount importance in managing OIAIs, with sonication widely acknowledged as the preferred method for detecting biofilm-associated infections. Recently, dithiothreitol (DTT) has emerged as a potential substitute for sonication, owing to its demonstrated ability to impede biofilm formation. This study aimed to compare the efficacy of DTT with sonication in identifying microorganisms within implants. Conducted as a prospective cohort investigation, the study encompassed two distinct groups: patients with suspected infections undergoing implant removal (Group A) and those slated for hardware explantation (Group B). Hardware segments were assessed for biofilm-related microorganisms using both sonication and DTT, with a comparative analysis of the two methods. A total of 115 patients were enrolled. In Group A, no statistically significant disparity was observed between DTT and sonication. DTT exhibited a sensitivity of 89.47% and specificity of 96.3%. Conversely, in Group B, both DTT and sonication fluid cultures yielded negative results in all patients. Consequently, this investigation suggests that DTT holds comparable efficacy to sonication in detecting OIAIs, offering a novel, cost-effective, and readily accessible diagnostic modality for identifying implant-associated infections.

Molecular Mechanisms of Biofilm Formation on Orthopaedic Implants: Review of the Literature.

Orthopaedic implant-associated infections (OIAIs) is one of the most catastrophic complications following joint arthroplasty or fracture fixation. Given the increasing number of orthopaedic implants which are used annually, periprosthetic infections emerge as a global problem. Their diagnosis and consequent therapeutic management remain challenging for clinicians. Biofilm formation is a complex and only partially understood process that has not been extensively studied. Understanding the underlying mechanisms involved in biofilm formation is crucial in the amelioration of both diagnosis and therapeutic management of OIAIs. We performed a literature review of the molecular mechanisms of biofilm formation and discussed the four most common and thoroughly researched microbes of biofilm-related OIAIs.

Technical note for intraoperative determination of proper acetabular cup size in primary total hip arthroplasty.

BACKGROUND: Selecting the optimal size of components is crucial when performing a primary total hip arthroplasty. Implanting the accurate size of the acetabular component can occasionally be exacting, chiefly for surgeons with little experience, whilst the complications of imprecise acetabular sizing or over-reaming can be potentially devastating. AIM: To assist clinicians intraoperatively with a simple and repeatable tip in elucidating the ambivalence when determining the proper acetabular component size is not straightforwardly achieved, specifically when surgeons are inexperienced or preoperative templating is unavailable. METHODS: This method was employed in 263 operations in our department from June 2021 to December 2022. All operations were performed by the same team of joint reconstruction surgeons, employing a typical posterior hip approach technique. The types of acetabular shells implanted were: The Dynasty® acetabular cup system (MicroPort Orthopedics, Shanghai, China) and the R3® acetabular system (Smith & Nephew, Watford, United Kingdom), which both feature cementless press-fit design. RESULTS: The mean value of all cases was calculated and collated with each other. We distinguished as oversized an implanted acetabular shell when its size was > 2 mm larger than the size of the acetabular size indicator reamer (ASIR) or when the implanted shell was larger than 4 mm compared to the preoperative planned cup. The median size of the implanted acetabular shell was 52 (48-54) mm, while the median size of the preoperatively planned cup was 50 (48-56) mm, and the median size of the ASIR was 52 (50-54) mm. The correlation coefficient between ASIR size and implanted acetabular component size exhibited a high positive correlation with r = 0.719 (P < 0.001). Contrariwise, intraoperative ASIR measurements precisely predicted the implanted cups' size or differed by only one size (2 mm) in 245 cases. CONCLUSION: In our study, we demonstrated that the size of the first acetabular reamer not entering freely in the acetabular rim corroborates the final acetabular component size to implant. This was also corresponding in the majority of the cases with conventional preoperative templating. It can be featured as a valid tool for avoiding the potentially pernicious complications of acetabular cup over-reaming and over-sizing in primary total hip arthroplasty. It is a simple and reproducible technical note useful for confirming the predicted acetabular cup size preoperatively; thus, its application could be considered routinely, even in cases where preoperative templating is unavailable.

Bone mineral density, vitamin D and osseous metabolism indices in neurofibromatosis type 1: A systematic review and meta-analysis.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a genetic autosomal neurocutaneous syndrome correlated with skeletal dysplasia and defects in the osseous microarchitecture. The physiological mechanism for the development of NF1-related bone abnormal turnover is still unclear. OBJECTIVES: A meta-analysis was performed to investigate the effects of NF1 on bone mineral density (BMD) and osseous metabolic indices in order to provide clinical evidence for the pathogenesis of the associated skeletal deformities. METHODS: A systematic literature review search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in the PubMed/Medline and Web of Science databases from the date of inception of each database through to 10 September 2023. Specific inclusion and exclusion criteria were applied for the identification of studies examining the effects of NF1 on bone strength and metabolism. The Newcastle-Ottawa and Jadad scales were applied to assess the quality of the included studies. RevMan 5.3 software was used for the analysis of the data, and MedCalc was applied to examine publication bias. RESULTS: Overall, 13 studies met the inclusion criteria comprised of 5 cross-sectional, 6 case-control and 2 retrospective studies. 703 patients and 973 healthy subjects formed the NF1 and control group, respectively. The results of the meta-analysis displayed that lumbar (SMD = -3.85, 95%CI = -7.53 to -0.18, Z = 2.05, p = 0.04) and femoral (SMD = -4.78, 95%CI = -8.86 to -0.69, Z = 2.29, p = 0.02) BMD was reduced in the NF1 group. Both in children and adults the serum levels of 25 hydroxyvitamin D3 were also decreased in NF1 group, but without any statistical significance (SMD = -0.62, 95%CI = -1.34 to -0.11, Z = 1.66, p = 0.10). Serum Parathyroid hormone (PTH) (SMD = 0.73, 95%CI = 0.31 to 1.15, Z = 3.43, p = 0.0006) and C-telopeptide of type 1 collagen (CTX) (SMD = 0.82, 95%CI = 0.33 to 1.30, Z = 3.29, p = 0.001) were elevated in NF1 patients, while serum calcium (SMD = -0.10, 95%CI = -0.74 to 0.53, Z = 0.32, p = 0.75) phosphorous (SMD = 0.33, 95%CI = -0.38 to 1.05, Z = 0.92, p = 0.36), alkaline phosphatase (ALP) (SMD = -0.36, 95%CI = -0.77 to 0.05, Z = 1.71, p = 0.09), osteocalcin (SMD = 1.81, 95%CI = -0.37 to -3.98, Z = 1.63, p = 0.10) and bone formation markers (SMD = 0.28, 95%CI = -0.37 to -0.94, Z = 0.85, p = 0.39) were not. CONCLUSION: NF1 is associated with decreased BMD at the lumbar spine and femur. Taking into account that the serum levels of PTH, CTX were increased whereas the concentrations of vitamin D, calcium, phosphorous, ALP, osteocalcin and bone formation markers were not altered significantly in the NF1 patients compared with the healthy subjects, a vitamin D independent dysregulated bone cellular activity could be considered. STUDY REGISTRATION: Registered on PROSPERO (CRD42023424751).

Porous Tantalum Acetabular Cups in Primary and Revision Total Hip Arthroplasty: What Has Been the Experience So Far?-A Systematic Literature Review.

BACKGROUND: The global population, especially in the Western world, is constantly aging and the need for total hip arthroplasties has rocketed, hence there has been a notable increase in revision total hip arthroplasty cases. As time has passed, a considerable developments in science and medicine have been attained which have also resulted in the evolution of both surgical techniques and implants. Continuous improvements have allowed large bore bearings to be utilized which provide an increased range of motion, with ameliorated stability and a very low rate of wear. The trend for almost the last two decades has been the employment of porous tantalum acetabular cups. Several studies exist comparing them with other conventional methods for total hip arthroplasties, exhibiting promising short and midterm results. METHODS: The Preferred Reporting Items for Systematic Reviews and a Meta-Analysis (PRISMA) were used to identify published studies in a comprehensive search up to February 2023, and these studies were reviewed by the authors of the article. Specific rigorous pre-determined inclusion and exclusion criteria were implemented. RESULTS: Fifty-one studies met our inclusion criteria and were involved in the systematic review. Sixteen studies examined postoperative clinical and radiological outcomes of using a tantalum cup in primary and revision total hip arthroplasty, whilst four biomechanical studies proved the superiority of tantalum acetabular components. Five articles provided a thorough comparison between tantalum and titanium acetabular cups, while the other studies analyzed long-terms results and complication rates. CONCLUSIONS: Porous tantalum acetabular cups appear to be a valuable option in revision total hip arthroplasty, providing clinical improvement, radiological stability, and promising long-term outcomes. However, ongoing research, longer follow-up periods, and careful consideration of patient factors are essential to further validate and refine the use of tantalum in various clinical scenarios.

The Role of Interleukin-10 in the Pathogenesis and Treatment of a Spinal Cord Injury.

Spinal cord injury (SCI) is a devastating condition that often leads to severe and permanent neurological deficits. The complex pathophysiology of an SCI involves a cascade of events, including inflammation, oxidative stress, and secondary injury processes. Among the myriad of molecular players involved, interleukin-10 (IL-10) emerges as a key regulator with the potential to modulate both the inflammatory response and promote neuroprotection. This comprehensive review delves into the intricate interplay of IL-10 in the pathogenesis of an SCI and explores its therapeutic implications in the quest for effective treatments. IL-10 has been found to regulate inflammation, oxidative stress, neuronal apoptosis, and glial scars after an SCI. Its neuroprotective properties have been evaluated in a plethora of animal studies. IL-10 administration, either isolated or in combination with other molecules or biomaterials, has shown neuroprotective effects through a reduction in inflammation, the promotion of tissue repair and regeneration, the modulation of glial scar formation, and improved functional outcomes. In conclusion, IL-10 emerges as a pivotal player in the pathogenesis and treatment of SCIs. Its multifaceted role in modulating inflammation, oxidative stress, neuronal apoptosis, glial scars, and neuroprotection positions IL-10 as a promising therapeutic target. The ongoing research exploring various strategies for harnessing the potential of IL-10 offers hope for the development of effective treatments that could significantly improve outcomes for individuals suffering from spinal cord injuries. As our understanding of IL-10's intricacies deepens, it opens new avenues for innovative and targeted therapeutic interventions, bringing us closer to the goal of alleviating the profound impact of SCIs on patients' lives.

Is Regional Bone Mineral Density the Differentiating Factor Between Femoral Neck and Femoral Trochanteric Fractures?

Background Osteoporosis is globally recognized as a prevalent bone disease, and proximal femoral fractures constitute a serious complication associated with it. In recent years, the frequency of hip fractures has increased rapidly, with ramifications that extend into the social and economic aspects of both patients' lives and healthcare systems. The primary goal of this study is to discover whether bone mineral density (BMD) in specific regions of the hip could be related to femoral neck or trochanteric fractures. Methodology This prospective cohort study employed dual-energy X-ray absorptiometry (DEXA) measurements on 70 individuals with proximal femoral fractures. The participants sought treatment at the emergency department of our unit for hip fractures and adhered to our predefined eligibility criteria. These criteria primarily included (i) age exceeding 60 years and (ii) a diagnosis of either femoral neck or trochanteric fracture attributed to (iii) a low-energy lateral fall and (iv) a previously established state of complete ambulation before the occurrence of the fracture. In this context, we recorded the BMD of the hip, as well as the BMD values of the upper and lower halves of the neck, trochanteric region, and diaphysis. For the comparison of the categorical variables, Pearson's χ2 criterion was used, whereas Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results No statistical differences were identified when comparing regional BMDs and T-scores with the fracture type. This conclusion was also reconfirmed concerning age, gender, and Tonnis classification. Only a moderate correlation was observed, demonstrating lower values of regional BMDs in women compared to men. Conclusions The inability of our study to establish a direct correlation between BMD measurements across diverse areas of the proximal femur underlines the imperative need for subsequent investigations. These studies should not only integrate more precise techniques for measuring and mapping the BMD of different hip regions but should also encompass a comprehensive examination that would consider both intrinsic and extrinsic characteristics of the proximal femur.

A Comprehensive Review of COVID-19-Infection- and Steroid-Treatment-Associated Bone Avascular Necrosis: A Multi-Study Analysis.

BACKGROUND: The COVID-19 pandemic has presented numerous challenges to the global healthcare system and emerging evidence suggests a potential link between COVID-19 treatment, specifically steroid therapy, and the development of avascular necrosis (AVN) of the hip. This review aims to provide a comprehensive overview of recent studies and case reports investigating the relationship between COVID-19, corticosteroid therapy, and the development of AVN. Understanding the nuances of AVN in the context of COVID-19 is crucial for healthcare professionals to navigate treatment decisions and mitigate potential complications. MATERIALS AND METHODS: The Preferred Reporting Items for Systematic Reviews and a Meta-Analysis (PRISMA) were used in the systematic review until 1 September 2023. The full texts of the remaining twenty-three (n = 23) articles were independently reviewed by the authors of this review. CONCLUSIONS: The association between steroid therapy for COVID-19 and the development of hip AVN is a noteworthy concern even though no relationship is evident between the duration of treatment, cumulative dosage of medication, maximum daily dosage received, and presence of AVN. Further research with larger cohorts and long-term follow up is needed to better understand the causative relationship and optimal management strategies for hip AVN in the context of COVID-19 and steroid therapy.

Unraveling the Link of Altered TGFß Signaling with Scoliotic Vertebral Malformations in Osteogenesis Imperfecta: A Comprehensive Review.

Osteogenesis Imperfecta (OI) is a genetic disorder caused by mutations in genes responsible for collagen synthesis or polypeptides involved in the formation of collagen fibers. Its predominant skeletal complication is scoliosis, impacting 25 to 80% of OI patients. Vertebral deformities of the scoliotic curves in OI include a variety of malformations such as codfish, wedged-shaped vertebrae or platyspondyly, craniocervical junction abnormalities, and lumbosacral spondylolysis and spondylolisthesis. Although the precise pathophysiology of these spinal deformities remains unclear, anomalies in bone metabolism have been implicated in the progression of scoliotic curves. Bone Mineral Density (BMD) measurements have demonstrated a significant reduction in the Z-score, indicating osteoporosis and a correlation with the advancement of scoliosis. Factors such as increased mechanical strains, joint hypermobility, lower leg length discrepancy, pelvic obliquity, spinal ligament hypermobility, or vertebrae microfractures may also contribute to the severity of scoliosis. Histological vertebral analysis has confirmed that changes in trabecular microarchitecture, associated with inadequate bone turnover, indicate generalized bone metabolic defects in OI. At the molecular level, the upregulation of Transforming Growth factor-ß (TGFß) signaling in OI can lead to disturbed bone turnover and changes in muscle mass and strength. Understanding the relationship between spinal clinical features and molecular pathways could unveil TGFß -related molecular targets, paving the way for novel therapeutic approaches in OI.

Current Progress and Future Perspectives in Contact and Releasing-Type Antimicrobial Coatings of Orthopaedic Implants: A Systematic Review Analysis Emanated from In Vitro and In Vivo Models.

Background: Despite the expanding use of orthopedic devices and the application of strict pre- and postoperative protocols, the elimination of postoperative implant-related infections remains a challenge. Objectives: To identify and assess the in vitro and in vivo properties of antimicrobial-, silver- and iodine-based implants, as well as to present novel approaches to surface modifications of orthopedic implants. Methods: A systematic computer-based review on the development of these implants, on PubMed and Web of Science databases, was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Overall, 31 in vitro and 40 in vivo entries were evaluated. Regarding the in vitro studies, antimicrobial-based coatings were assessed in 12 entries, silver-based coatings in 10, iodine-based in 1, and novel-applied coating technologies in 8 entries. Regarding the in vivo studies, antimicrobial coatings were evaluated in 23 entries, silver-coated implants in 12, and iodine-coated in 1 entry, respectively. The application of novel coatings was studied in the rest of the cases (4). Antimicrobial efficacy was examined using different bacterial strains, and osseointegration ability and biocompatibility were examined in eukaryotic cells and different animal models, including rats, rabbits, and sheep. Conclusions: Assessment of both in vivo and in vitro studies revealed a wide antimicrobial spectrum of the coated implants, related to reduced bacterial growth, inhibition of biofilm formation, and unaffected or enhanced osseointegration, emphasizing the importance of the application of surface modification techniques as an alternative for the treatment of orthopedic implant infections in the clinical settings.

Fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan contributes to the diagnosis and management of brucellar spondylodiskitis.

BACKGROUND: Limited data suggest that fluorine-18 fluoro-2-deoxy-D-glucose (F-18 FDG) positron emission tomography combined with computed tomography (PET/CT) scan may be useful for diagnosing infections of the spine. Brucellar spondylodiskitis might be devastating and current imaging techniques lack sensitivity and specificity. The aim of this prospective study was to determine the role of F-18 FDG PET/CT scan in the diagnosis of brucellar spondylodiskitis and in monitoring the efficacy of its treatment. METHODS: Ten consecutive patients with brucellar spondylitis were prospectively evaluated with PET/CT. Baseline evaluation included also magnetic resonance imaging (MRI) of the affected spine, indices of inflammation, the slide agglutination test (SAT), and the standard hematology and biochemistry. All cases were treated with suitable antibiotics until resolution or significant improvement of clinical and radiological (MRI) findings. Upon completion of treatment, they were re-evaluated with follow-up PET/CT scan. The maximum standardized uptake values (SUV) were measured and compared with SAT. RESULTS: In all patients there was an increased F-18 FDG activity in the infected spine region detected by the initial MRI. F-18 FDG PET/CT provided additional information, compared to MRI, in 4 (40%) patients. More specifically it revealed additional spine lesions (in 3 patients), lymphadenitis, arthritis, organomegaly, as well as new paravertebral soft tissue involvement and epidural masses. This additional information had an impact on the duration of treatment in these patients. At the end of treatment all patients had a complete clinical response; 5 patients had positive serology, 6 patients had residual MRI findings, while 9 had a positive PET/CT but with significantly decreased FDG uptake compared to baseline (median 2.6, range 1.4 - 4.4 vs. median 5.5, range 2.8 - 9.4, p = 0.005). During the follow up period (median 12.5 months) no relapses have been observed. No significant association was observed between the SUV and SAT. CONCLUSIONS: Our study suggests that in patients with brucellar spondylodiskitis F-18 FDG PET/CT scan can provide additional information on the spread of the infection, compared to MRI. Successful treatment is associated with a significant decrease in SUVmax values; thus, PET/CT scan may be a complementary method for determining the efficacy of treatment.

Congenital variations of the upper cervical spine and their importance in preoperative diagnosis. A case report and a review of the literature.

Several variations of the bony and vascular anatomy around the first and second cervical vertebrae have been reported. Failure to recognise these variations can complicate operations on the upper cervical spine. We present a patient with recent onset of cervical myelopathy due to stenosis at the C3-4 level. Preoperative evaluation identified Klippel-Feil syndrome with cervical fusion of C2-3, aplasia of posterior arch of C1, anomalous vertebral artery course and a "ponticulus posticus" of C2. The combination of these variations in a Klippel-Feil syndrome patient has never been reported. Thus, we recommend a thorough preoperative imaging evaluation, with CT scan and CT angiography or DSA, in addition to plain radiographs. This evaluation is imperative, before a cervical spine surgery, allowing a better understanding of the anatomy, in order to minimise the risks of misplacement of cervical instrumentation especially in such patients.

Tibiofemoral dislocation after total knee arthroplasty treated successfully with an external fixation device.

Tibiofemoral dislocation after primary total knee arthroplasty (TKA) is a rare but potentially devastating complication with various patient-related and surgeon-related predisposing factors. We present the case of an obese 86-year-old woman who sustained an atraumatic posterior tibiofemoral dislocation 3 days after a primary medial-pivot design TKA. The knee remained unstable after reduction, owing to significant hamstring hypertonia. The administration of botulinum toxin injections in the hamstrings resulted in no clinical improvement. The periprosthetic infection workup was negative and the neurological impairment of the patient was excluded. The patient was reoperated with extensive hamstring release and the application of a lateral external fixator. The external fixator was removed 6 weeks postoperatively, and physical therapy was initiated. At 1-year follow-up, the patient had a painless, stable knee with a 0-100° range of motion, without any neuromuscular impairment.