Cementless Primary Stems in Revision Hip Arthroplasty: A Narrative Review.

Cementless primary stems in revision hip arthroplasties may be conservative options to preserve bone stock and provide adequate reconstruction of the hip biomechanics. However, there is still little evidence about indications, limitations, and outcomes. This narrative review showed that conventional standard stems were adopted in different revision settings, up to Paprosky IIIA grade bone defects. In cases of acceptable metaphyseal bone stock, when a scratch fit of at least 4 cm can be achieved, a conventional cementless stem may be an adequate solution. Mid-term clinical and radiographic outcomes and survival rates were similar to long revision stems, whereas complications, surgical time, and costs were lower among conventional stems. However, unsuitable contexts for conventional stems included canal diameters larger than 18 mm and failed revision stems with cortical weakening. Even short stems can be considered in revisions, in order to preserve bone stock and stay proximal to femoral remodeling zones and bone/cement plugs. Short stems were successfully adopted up to Paprosky IIIA bone defects, achieving mid-term survival rates not inferior to long revision stems. Ageing, osteoporosis, and intraoperative femoral fractures were the main negative prognostic factors. In very select cases, a downsizing technique (from longer to shorter stems) may be adopted to simplify the procedure and reduce complications.

Arthrodesis versus dynamic neutralization: A short/mid- and long-term retrospective evaluation in degenerative disk disease treatment.

Study Design: This was a retrospective comparative study. Objectives: The aim of this study was to perform a clinical and radiological retrospective evaluation of the most used techniques for the lumbar degenerative disk disease (DDD) treatment: arthrodesis versus dynamic neutralization (DN)-Dynesys dynamic stabilization system. Methods: The study included 58 consecutive patients affected by lumbar DDD, 28 treated with rigid stabilization and 30 with DN at our department between 2003 and 2013. The clinical evaluation was performed through the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). The radiographic evaluation was performed through standard and dynamic X-ray projections and magnetic resonance imaging. Results: Both techniques determined a clinical improvement in the postoperative period compared to the preoperative one. There were no significant differences between the postoperative VAS of the two techniques. The DN group postoperative ODI percentage showed a significant improvement (P = 0.026) compared to the arthrodesis group. During the follow-up, no clinically significant differences were highlighted between the two techniques. At a long term follow up period, radiographic results showed, in both groups, a L3-L4 disk mean height reduction and an increase of segmental and lumbar lordosis without significant differences between the two techniques. During an average of 96-month follow-up period, 5 (18%) patients developed an adjacent segment disease in the arthrodesis group and 6 (20%) patients developed this syndrome in the DN group. Conclusions: We are confident in recommending arthrodesis and DN as effective techniques for lumbar DDD treatment. Both techniques are potentially burdened, with similar frequency, by the development of long-term adjacent segment disease.

Unstable lesions of the forearm: Terminology, evaluative score and synoptic table.

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.

Is Dual Mobility Total Hip Arthroplasty Surgery More Aggressive than Hemiarthroplasty when Treating Femoral Neck Fracture in the Elderly? A Multicentric Retrospective Study on 302 Hips.

INTRODUCTION: Bipolar hemiarthroplasty (BHA) and total hip arthroplasty (THA) are validated treatments for displaced femoral neck fractures (DFNFs). BHA seldomly needs conversion to THA, but the latter has higher dislocation rate in FNFs. Dual Mobility THA offers a reduced dislocation rate and eliminates the risk of conversion. This study looks for differences between BHA and DMTHA in terms of surgical time, blood loss and transfusion, dislocation rate, mortality, and thromboembolic events. MATERIAL AND METHODS: All patients were ≥75yo. Recorded data included use of anticoagulant/antiplatelet drugs, ASA, operative time, intra-operative complications, pre/post-operative hemoglobin values, transfusions, hospitalization time, DVT/PE, glomerular filtration rate, Charlson Comorbidity Index (CCI), dislocation at 60 days, and mortality at 30 days and 6 months. A secondary analysis compared the subgroups in different age range (75-85 and ≥ 86yo). RESULTS: In the cohort of 302 DFNF (93 BHA and 209 DMTHA) differences in mean age, CCI, and ASA score were significant. Once divided by age, the subgroups resulted comparable in terms of age and CCI, with no significant difference. A significant difference in surgical times showed DMTHA being an average 12 minutes longer than BHA. Significant was the ΔHB in the DMTHA subgroup which resulted lower compared to the BHA one. Difference in mean number of post-operative transfusion were not statistically significant. CONCLUSIONS: From our data, DMTHA did not lead to an increase in mortality, morbidity, bleeding, or dislocation rate when compared to BHA and could be considered as treatment of choice for DFNFs especially in healthy and active patients.

Non-specific spondylodiscitis: a new perspective for surgical treatment.

PURPOSE: Pyogenic spondylodiscitis is a relatively rare spinal disease; non-specific spondylodiscitis (NSS) cases are increasing. This study aims to identify if changes of inflammatory markers under antibiotic therapy can be used to determine which NSS patients can benefit from surgical indication earlier than others. METHODS: Two groups of patients with NSS were examined. Group A underwent surgery, while Group B was treated conservatively. Group B was also subdivided in patients undergoing antibiotic therapy for > 6 weeks (B1) and < 6 weeks (B2). Groups were compared for age, gender, BMI, blood levels of ESR and CRP and VAS scale. RESULTS: There were no differences (P = 0.06) in reduction in ESR at 4 weeks between two main groups. A reduction in CRP, with < 2.7 mg/dl at 4 weeks, was observed in Group A (P = 0.01). Comparing Group B1 to B2, a reduction (P = 0.0001) in VAS, ESR and CRP at 4 weeks was observed in Group B2. It was possible to isolate the pathogen in 52.8% of Group B, without any differences on VAS, ESR and CRP values and on length of the antibiotic therapy. CONCLUSIONS: The surgical treatment should be considered for patients who, after 4 weeks of conservative therapy, do not show a reduction in the ESR < 50 mm/h and of the CRP < 2.7 g/dl. The comparison between groups underwent surgically and those treated conservatively showed a reduction in the CRP at 4 weeks and better VAS for pain at 3 months in Group A.

Elbow hemiarthroplasty for acute distal humeral fractures and their sequelae: medium- and long-term follow-up of 41 cases.

BACKGROUND: The earliest distal humeral hemiarthroplasty (or elbow hemiarthroplasty [EHA]) implants, which date back to the late 1940s, were performed in patients with severe elbow joint injuries as an alternative to arthrodesis. After some clinical reports and case studies with a short follow-up, published in the 1990s, a new "anatomically convertible" EHA model was introduced in 2005 and became a common surgical option to treat complex elbow fractures and their sequelae. We describe the mid- and long-term outcomes of EHA performed to treat acute intra-articular fractures or their sequelae. METHODS: From 2006 to 2017, 51 patients underwent EHA for acute intra-articular fractures or their sequelae. A total number of 41 patients (80.5% female) with a minimum follow-up of 2 years, 24 with acute lesions and 17 with sequelae, were identified retrospectively. Clinical evaluation was according to the Disabilities of the Arm, Shoulder, and Hand (DASH) score (subjective), and the Oxford Elbow Score (OES) and Mayo Elbow Performance Score (MEPS) (objective). Radiographic follow-up was with standard radiographs. RESULTS: Mean follow-up was 92.2 months (range, 24-151). Mean patient age at surgery was 62.8 years (range, 45-81). The mean MEPS was 87.1 points, with excellent results in 26 cases, good results in 9 cases, fair in 2, and poor results in 4. The mean DASH score was 15.9 and the mean OES was 40.5, with satisfactory results in 30 cases. Twenty patients experienced complications and 2 required revision surgery. DISCUSSION: EHA is a valuable surgical option in selected patients with comminuted distal humeral joint fractures that cannot be reconstructed with stable fixation and in those with malunion of the articular surface of the humerus. EHA offers potential advantages, especially in active elderly patients and in those aged less than 70 years. It is essential to achieve joint stability, restoring medial and lateral ligament function besides the integrity of the coronoid process. An intact olecranon surface without signs of degenerative changes is also critical for EHA success. CONCLUSION: Our mid- and long-term experience with EHA is favorable, with a high proportion of satisfactory results and long survival rates for both lesion types. In selected patients with acute and post-traumatic injuries, EHA is a valuable surgical option.

Iatrogenic intraprosthetic dislocation after closed reduction of dual mobility total hip arthroplasty: Report of two cases.

INTRODUCTION: Among hip arthroplasty, dual mobility aims to improve ROM and reduce dislocation rates, however this particular implant can fail in specific ways. Iatrogenic intraprosthetic dislocation (IPD) is a rare occurrence that can happen during closed reduction of a dislocated dual mobility total hip arthroplasty. PRESENTATION OF CASE: #1 - A 34-year-old male who came to our attention with an undiagnosed IPD. He had experienced a classic dislocation 6 days earlier, which was treated with closed reduction. CT-scan confirmed decoupling of the metal head and PE liner. #2 - An 89-year-old male came to our attention for THA dislocation. During closed reduction manouvers he suffered IPD of the implant. Both patients were treated with revision surgery. DISCUSSION: Despite being already reported in literature, IPD are still not well known to practitioners and sometimes overlooked even by orthopaedic specialists. Given the good results and diffusion of this kind of implant, iatrogenic IPD in the contest of a classic dislocation might become more frequent in the clinical practice. CONCLUSION: When performing reduction maneuvers for a dislocated dual mobility total hip arthroplasty, X-rays must be carefully inspected for signs of IPD which, if undiagnosed, can lead to major implant damage and the need for extensive revision surgery.

Can Elastosonography Be Useful in Improving Diagnosis and Prognosis of Acute Muscle Injuries?

Purpose The objective of this study was to investigate the ability of elastosonography (USE) in the identification of different grades of muscular injuries, comparing its effectiveness with traditional ultrasound (US) survey and by relating the results to the clinical classification of muscular pain. Methods In the period between August 2014 and May 2016, we conducted a prospective cohort study on a population of 34 young male professional athletes belonging to the same under-17 football club (Ancona 1905). Injuries were recorded according to location, type, mechanism, recurrence, and whether they occurred with or without contact. Muscle pain was classified, after a physical examination, according to the classification of Mueller-Wohlfahrt et al. All athletes were evaluated by musculoskeletal US and USE in hours following the trauma/onset of pain. Results Seventy injuries were documented among 19 players. Muscle/tendon injuries were the most common type of injury (49%). USE showed areas of edema in nine lesions that were negative at the US examination and previously classified as fatigue-induced muscle disorders. These nine players took more time to return to physical activity compared with others with injuries classified into the same group, but negative at USE evaluation. Conclusion USE is a valuable aid in the diagnosis and prognostic evaluation of muscle injury, as it detects pathologic changes that are not visible with the B-mode US. Level of Evidence This is a Level III, observational cohort study.

Survivorship and clinical outcomes of 147 consecutive isolated or combined arthroscopic bone plug free meniscal allograft transplantation.

PURPOSE: To present the results of a survival analysis of a series of 147 arthroscopic MAT procedures. METHODS: One-hundred and forty-seven patients (117 males and 30 females) underwent arthroscopic MAT without bone plugs (82 medial MAT and 65 lateral MAT) using fresh-frozen, non-irradiated grafts. They were retrospectively reviewed at a mean of 4.0 ± 1.9-year follow-up. Mean age at surgery was 40.9 ± 11.2 (range 16.7-68.8) years; 70 patients (48 %) underwent combined procedures. Clinical evaluation was performed with KOOS, Lysholm and a 0-100 VAS for pain. Survival analysis was performed using two endpoints: surgical failure (revision procedure with direct relation to MAT) and clinical failure (revision procedure or poor Lysholm score, <65). RESULTS: There was a significant (p < 0.05) and clinically relevant decrease in the VAS and increase in KOOS and Lysholm from pre-operative mean score to post-operative mean score. Seven (5 %) patients (two medial and five lateral) experienced surgical failure (five meniscectomies, one lateral graft peripheral suture and one unicompartmental knee arthroplasty). The mean overall survival time was 9.7 years (CI 9.1-10.3). As 16 (11 %) patients presented poor Lysholm score, a total of 23 (16 %) patients were considered clinical failures. The mean overall survival time was 8 years (CI 7.1-8.8). No statistically significant differences in failure and survival rate were present between medial and lateral MAT, isolated or combined MAT, patients >50 or <50 years old and patients with body mass index <25 or >25. CONCLUSIONS: MAT, eventually associated with other needed procedures, was able to significantly relieve pain and improve function of the knee joint at midterm follow-up, with a survival rate from 9.7 to 8.0 years based on failure criteria. Most additional procedures were done in the first 2 post-operative years. MAT eventually associated with other needed procedures could represent an effective treatment for post-meniscectomy syndrome. LEVEL OF EVIDENCE: Therapeutic study, retrospective case series, Level IV.