Clinical and radiological outcomes and analysis of failures of modular revisions stems at long-term follow-up: a systematic review and meta-analysis.

Background: Increasingly hip replacements at young age exposes the patient to an increased risk of failure of the implant over the years. In case of failure, revision specific stems were designed to overcome bone loss. Modularity of these devices is an important resource for the surgeon as they allow the new implant to be better adapted to the patient's anatomy. The purpose of this systematic review is to provide data about the outcome at long-term follow-up (>8 years) of hip modular revision femoral stems. Methods: This systematic review and meta-analysis were conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines. PubMed and Google Scholar databases were systematically and independently searched, according to the inclusion and exclusion criteria. Two reviewers performed the data extraction independently. In case of disagreement, the senior authors were sought to resolve the divergences. Quality of the involved studies was evaluated with National Institute for Health and Care Excellence (NICE) guidelines (eight-item list) and the Newcastle-Ottawa scale (NOS). Primary and secondary outcomes were evaluated. The statistical analysis of this meta-analysis was performed by using Excel Microsoft and the software STATA. Results: The primary outcome was the re-revision rate of modular revision stems at long-term follow-up. It ranged from 1.4% to 45.6%: random effect pooled estimate was 5.5% [95% confidence interval (CI): 4% to 7%], with a I2 of 12.3% (P=0.332). Mean Harris Hip Score (HHS) was 83 [min: 79; max: 87.6; standard deviation (SD): 3.55]. Secondary evaluated outcomes were: subsidence >5 mm, rate of periprosthetic infection or fractures (intra- and post-operative) and dislocations. The mean value for the NICE tool was 5.5 (SD: 1.13) and 7.3 (SD: 0.79) for the NOS tool. The survival rate was >90% at long-term follow-up (min: 60%; max: 97%). Conclusions: The modular femoral revision stems have demonstrated good long-term reliability and efficacy. This meta-analysis demonstrates that the re-revision rate after 8 years of follow-up is low and 90% of the implants did not fail.

Do prior intra-articular injections impact on the risk of periprosthetic joint infection in patients undergoing total hip arthroplasty? A meta-analysis of the current evidences with a focus on the timing of injection before surgery.

Purpose: Intra-articular injection is a well-established and increasingly used treatment for the patient with mild-to-moderate hip osteoarthritis. The objectives of this literature review and meta-analysis are to evaluate the effect of prior intra-articular injections on the risk of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA) and to try to identify which is the minimum waiting time between hip injection and replacement in order to reduce the risk of infection. Methods: The database of PubMed, Embase, Google Scholar and Cochrane Library was systematically and independently searched, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To assess the potential risk of bias and the applicability of the evidence found in the primary studies to the review, the Newcastle-Ottawa scale (NOS) was used. The statistical analysis was performed by using the software 'R' version 4.2.2. Results: The pooling of data revealed an increased risk of PJI in the injection group that was statistically significative (P = 0.0427). In the attempt to identify a 'safe time interval' between the injection and the elective surgery, we conducted a further subgroup analysis: in the subgroup 0-3 months, we noted an increased risk of PJI after injection. Conclusions: Intra-articular injection is a procedure that may increase the risk of developing periprosthetic infection. This risk is higher if the injection is performed less than 3 months before hip replacement.

Pentraxin 3, a new biomarker for the diagnosis and management of PJI in primary and revision hip arthroplasty.

Background/Aim of the study: The periprosthetic or superficial site infections are one of the most catastrophic and difficult to manage complications following total hip arthroplasty. Recently, in addition to well know systemic markers of inflammation, the blood and synovial fluid biomarkers are focused to have a possible role in the infection diagnosis. The long Pentraxin 3 (PTX3) seems to be a sensitive biomarker of acute phase inflammation. The objectives of this prospective and multicentre study were (1) to establish the plasma trend effectiveness of PTX3 in patients undergoing primary hip replacement, and (2) to evaluate the diagnostic accuracy of blood and synovial PTX3 in patients undergoing prosthetic revision of infected hip arthroplasty. METHODS: Human PTX3 was measured by ELISA in two cohorts of patients, 10 patients undergoing primary hip replacement for osteoarthritis and 9 patients with infected hip arthroplasty. RESULTS: The Authors were able to demonstrate that PTX3 is a viable biomarker for acute phase inflammation. CONCLUSIONS: An increase in PTX3 protein concentration in the synovial fluid of patients undergoing implant revision has a strong diagnostic capacity for periprosthetic joint infection, showing 97% specificity.

Iliac bone graft for the treatment of bone loss and non-union of the distal radius.

Background/Aim of the work: Open distal radius fractures are rare compared to closed ones. They mainly affect young people with high-energy trauma and are burdened with a high number of complications, including non-union. In this case report, we describe the technique used to manage bone loss and non-union of the distal radius of a polytraumatized patient with an open Gustilo IIIB fracture of the wrist. CASE REPORT: 58-year-old man, suffering from head trauma and open right wrist fracture after motorcycle accident, underwent emergency damage control with debridement, antibiotic prophylaxis and stabilization in an external fixator. Then, he developed infection and bone loss, associated with an injury of the median nerve.  Non-union were treated with iliac crest bone graft, open reduction and internal fixation (ORIF). OUTCOMES: At the follow-up 6 months after the bone graft and ORIF procedure and 9 months after the trauma, the patient was clinically healed, with good performance status. CONCLUSIONS: Treatment of non-union in open distal radius fractures with iliac crest bone graft is a viable, safe and easy surgical choice.

Could Short Stems THA Be a Good Bone-Saving Option Even in Obese Patients?

Short femoral stems, with preservation of the femoral bone stock, are commonly used in recent years for hip replacement in younger and more active patients. Obesity is increasingly spreading even in the younger population. The aim of this case-series study is to evaluate short stems compared to traditional hip prostheses in the obese population. A total of 77 consecutive patients with a BMI greater than or equal to 30 Kg/m2 were enrolled in this prospective study and were divided into two groups: 49 patients have been implanted with short stems while 28 patients were implanted with traditional stems. All the patients were treated for primary osteoarthritis or avascular necrosis and all the stems were implanted by the same surgeon using a posterior approach. Clinical (Harris Hip Score­HHS, Western Ontario and McMaster Universities Osteoarthritis Index­WOMAC, visual analogue scale­VAS, 12-item Short Form Health Survey­SF-12) and radiographic outcomes were recorded. Radiological evaluations were carried out by three different blinded surgeons. A statistical analysis was performed (chi-square, t-test, Wilcoxon Rank Sum Test, 2-factor ANOVA). At a mean follow-up of 42.6 months both groups showed a marked improvement in pain and in the clinical scores between pre- and post-surgical procedures (p < 0.05) with no significant differences between the two groups at last follow-up (p > 0.05). The radiological evaluations, with high concordance correlation between the three blinded surgeons (ICC consistently >0.80), showed good positioning and osseointegration in all cases, with no significant differences in the restoration of the joint geometry and complications. No revisions were recorded during the follow-up period. In conclusion, short stems appear to be a good option for bone preservation even in obese patients, showing comparable results to traditional implants.

Is Fibrinogen a Reliable Biomarker in the Diagnosis of Peri-Prosthetic Joint Infection? A Systematic Review and Meta-Analysis.

Background: In recent years, several studies have identified closed correlations between the coagulation cascade and inflammatory mechanisms in infective diseases. Fibrinogen (PF) is emerging as promising biomarker for the diagnosis of peri-prosthetic joint infection (PJI). This study aims to investigate the diagnostic value of PF in diagnosing PJI and to explore potential causes influencing the diagnostic value of PF. Materials and Methods: PubMed, Embase, and Cochrane Library were searched regarding the role of fibrinogen as a biomarker in the diagnosis of PJI. Studies in English were included in the meta-analysis if they determined the diagnostic value of fibrinogen for PJI detection after hip or knee arthroplasty, applying the recognized diagnostic criteria for PJI. A quality evaluation of the studies included was performed. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratio (DOR) and the area under the receiver operating characteristic curve (AUROC) were obtained using the statistical software STATA, version 17 (StataCorp, College Station, TX). Results: Ten studies (9 retrospective) were included in the study. Low publication bias was detected, but with high heterogeneity among them. Plasma fibrinogen showed a good diagnostic accuracy and clinical utility in PJI (sensitivity, 0.81 [95% confidence interval {CI}, 0.75-0.86]; specificity, 0.82 [95% CI, 0.76-0.86]; AUROC, 0.88 [95% CI, 0.85-0.91]; DOR, 19 [95% CI, 14-26]). Conclusions: The attempt to find an "ideal" biomarker is crucial to improve the sensitivity and specificity of the current diagnostic algorithms for PJI. The analysis performed in the current study indicates that plasma fibrinogen test is a valid biomarker for PJI diagnosis.

WHICH SURGICAL TREATMENT IS PREFERABLE IN HUMERAL DIAPHYSEAL FRACTURES? A SYSTEMATIC REVIEW.

Introduction: Humeral diaphyseal fractures are very common. Many treatments have been proposed but the choice of the best one is often complex. Objective: The aim of the proposed study is to analyze the data in the literature in order to define the risks, advantages and disadvantages of the alternative surgical treatments (anterograde/retrograde intramedullary nailing, ORIF, MIPO). Methods: PubMed / Medline and Google Scholar were searched for prospective randomized or case-control retrospective studies about surgical treatment of humeral diaphyseal fractures with nailing, ORIF and MIPO, according to PRISMA guidelines. The primary outcome considered was the fracture healing time by comparing nailing-ORIF, nailing-MIPO and ORIF-MIPO. Differences in the rate of post-operative complications, patient satisfaction, intra-operative blood loss and surgical time were considered secondary outcomes. Results: 506 studies were identified, but only 10 studies were valid for the systematic review. No differences between nailing, ORIF and MIPO were recorded in terms of healing and surgical times. Intra-operative blood loss was significantly higher during ORIF (p 0.024). No differences were found in the restoration of function evaluated using clinical scales. The rate of complications was 27.4% for nailing, 21.2% for ORIF and 13.8% for MIPO. The difference was statistically significant only by comparing nailing with MIPO (p 0.012), probably because anterograde nailing is more often correlated to shoulder impairment. ORIF was at higher risk of infection compared to nailing (p 0.007). Conclusion: Humeral diaphyseal fractures require careful pre-operative planning, ensuring reduced healing time, less soft tissue damage and low rate of complications. The lower exposure of the fracture allows for excellent results with reduced bleeding and lower risk of complications.

Reduction in the Duration of Postoperative Fever during the COVID-19 Pandemic in Orthopedic and Traumatic Surgery Due to PPE and Cautions.

The Italian government on the 8th of march in response to the increased global prevalenceof severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) stated a national quarantine. In this period the absence of rapid and sure screening tests for COVID-19 made necessary more attention for presence of fever in hospitalized patients, like continuous use of surgical, FFP2, and FFP3 masks (PPE) by nurses, physicians, and patients; moreover, patients visits were restricted. In this period, during the daily activities in our orthopedic department we observed an empirical decreased incidence of post-operative fever in patients admitted for trauma surgery. The aim of this study is to compare the prevalence of post-operative fever in this period with the same period in 2019. We analyzed the presence of post-operative fever in 110 patients admitted in 2020 and 129 admitted in 2019. The results show a significant decrease of the prevalence and duration of post-operative fever in patients admitted in 2020. This study evidenced that the use of PPE and limitation in external access to the hospital decrease postoperative fever in hospitalized patients undergone surgery for fracture.

Ceramic-on-metal coupling in THA: long term clinical and radiographic outcomes using two different short stems.

BACKGROUND: Hip prosthetic replacement surgery is the gold standard for patients affected by symptomatic osteoarthritis. The ceramic-on-metal hybrid hard-on-hard bearing was initially launched on the market with the purpose of reducing adhesive and corrosion wear, loss of metal debris and ions and risk of fracture and squeaking. However, this bearing was withdrawn from the market, in the apprehension of local and systemic toxicity. The aim of this study is to evaluate the reliability and safety of ceramic-on-metal bearing at long term follow-up. METHODS: From 2 cohorts of patients suffering of hip osteoarthritis who underwent total hip arthroplasty using ceramic-on-metal bearing with two different short stems, 19 of the GROUP A and 25 of the GROUP B were suitable for this study. All patients were compared clinically using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS), 12-item Short Form Health Survey (SF12P/M), and radiographically. Blood samples were collected in order to evaluate chromium and cobalt ions level. The two groups were compared in terms of metal ions blood levels, and finally all the implanted prostheses were compared with a healthy control group. RESULTS: All the implanted stems were well-positioned and osseointegrated at a mean follow-up of 114 months. Improvements were observed for all clinical scores comparing preoperative and postoperative values in both groups. Radiographic evaluation showed a good ability to restore proper articular geometry. Chromium and cobalt ion analysis revealed values below the safety threshold except for 1 case in GROUP A (cup malposition) and 2 cases in GROUP B (6.1%). No revision occurred. CONCLUSIONS: Ceramic-on-metal bearing is safe and reliable at long term follow-up in association to short stems arthroplasty, if the implant is correctly positioned. Chromium and cobalt metal ions blood levels evaluation should be performed annually.

Pain Management Optimisation by an Ultrasound-Guided Analgesic Technique in Outpatients with Plantar Fasciitis during High-Energy Extracorporeal Shock Wave Therapy.

OBJECTIVE: Several studies have demonstrated the efficacy of high-energy extracorporeal shock wave therapy (HESWT) for the treatment of painful foot diseases. A crucial complication of HESWT is the appearance of pain with the subsequent interruption of the procedure. The aim of this study was the evaluation of ultrasound (US)-guided posterior tibial nerve block (PTNB) efficacy in outpatients who discontinued the first application of HESWT due to surge of moderate-severe pain. METHODS: Twenty-one patients, scheduled for HESWT due to plantar fasciitis, who interrupted the treatment for surge of pain (numeric rating scale [NRS] 5), were enrolled. After interruption of the first treatment, the patients received US-guided PTNB for every subsequent HESWT session. The same skilled anaesthesiologist performed an US-guided PTNB all the times. Once the nerve was identified, the needle was inserted and 5ml mepivacaine 1% were injected. Intensity of pain during each procedure by NRS and evaluation of patient's adherence to the treatment were detected. RESULTS: The HESWT was split into only three applications giving in average about 0.25 mJ mm-2, and all patients completed the treatment sessions. US-guided PTNB showed a significant reduction of NRS (P < 0.01) between the first HEWST without anaesthesia and the three subsequent treatments under peripheral block. CONCLUSION: US-guided PTNB resulted a valid support for the HEWST in outpatients with plantar fasciitis because it reduced the pain during the procedure, allowing to minimise the patient discomfort and to give the therapeutic doses just in three sessions.

SAFETY AND RELIABILITY OF CARBON-PEEK PLATE FOR THE TREATMENT OF DISTAL RADIUS FRACTURES: A REVIEW OF THE LITERATURE.

Introduction: Distal radius fractures are one of the most common injuries. Open reduction and internal fixation (ORIF) are the most diffused between surgical treatments. Carbon-fiber reinforced (CFR) polyetheretherketone (PEEK) plates have been proposed to prevent effects linked to stainless steel or titanium alloy traditional plates, such as radio-opacity, mismatch of bone-plate elasticity modulus, corrosion, limited fatigue life, osseointegration. Objective: This review aims to evaluate the actual safety and reliability of CFR- PEEK plates to treat distal radius fractures. Methods: Electronic databases PubMed, Google Scholars, and Cochrane Library were searched in December 2020. Eligible studies were published in peer-reviewed journals. Three authors independently selected relevant articles and discussed those. Searching identified 13 titles and abstracts, 11 manuscripts were considered eligible for the full-text analysis. Of these 11 papers, 7 studies were included in our review. Results: 215 patients were analyzed in this systematic review. The mean age of enrolled patients was 52,8 years. 34% were males and 66% were females. Fractures were classified according to AO/ASIF classification system. We reported 12 cases of complications specific to this device, such as intraoperative plate and screws rupture, erosive flexor tendons synovitis, and loosening. Conclusion: CFR-PEEK distal radius plates are potentially an alternative to traditional ones. But we believe that the use of this device does not entail a significant advantage in the treatment of distal radius fractures, as safe and low-cost traditional devices are available. Further comparative studies are needed to demonstrate the superiority of carbon devices.

Isolated compression of the ulnar motor branch due to carpal joint ganglia: clinical series, surgical technique and postoperative outcomes.

The entrapment of the ulnar nerve in Guyon's canal (GC) is a well-known wrist canalicular syndrome which is usually followed by a gradual combination of both sensitive and motor symptomatology. However, GC nerve compression could also cause a pure hand motor dysfunction. This condition, less frequent than the classic Guyon's syndrome, can be difficult to diagnose. Authors report a case series of eight patients affected by isolated compression of the ulnar nerve motor branch, due to piso-triquetrum or triquetro-hamate joint ganglia. Surgical technique and postoperative outcomes are discussed in this paper. The isolated compression of the ulnar nerve motor branch is a very rare clinical condition which is often linked to several causes. The rarity of the pathology is probably due to lack of knowledge and therefore to the difficulty in formulating a correct diagnosis. Surgical treatment appears to be decisive in most cases, although late diagnosis often leads to incomplete functional recovery.

Ceramic-on-metal bearing in short stem total hip arthroplasty: ions, functional and radiographic evaluation at mid-term follow-up.

INTRODUCTION: The aim of this study is to evaluate clinical, radiographic and laboratory results of ceramic-on-metal (CoM) (hybrid hard bearing) in total hip arthroplasty (THA), associated with a short stem implant. METHODS: From a cohort of 37 patients suffering from primary or secondary hip osteoarthritis who underwent THA using CoM bearing, 19 were suitable for this study. All procedures were performed by the same surgeon using a posterior-lateral approach. All patients were compared clinically using the Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS), 12-item Short Form Health Survey (SF12F/M), and radiographically (offset, CD angle, limb length discrepancy, cup inclination and anteversion, subsidence, osseointegration, heterotopic ossification). Blood samples were collected in order to evaluate chromium (Cr) and cobalt (Co) ions level. Radiographic evaluations were carried out by 3 different blinded surgeons. A statistical analysis was performed. RESULTS: At a mean follow-up of 97 (73-125) months all implanted stems were well-positioned and osseointegrated. Clear improvements were observed for clinical scores comparing preoperative and postoperative values. Radiographic evaluation showed a good ability to restore proper articular geometry. Cr ion analysis revealed values below the safety threshold except for 1 case. Serum levels of Co were below the threshold in all patients. There was a statistically significant correlation only between Cr metal ions and length of follow-up. CONCLUSIONS: CoM bearing has proven to be reliable and safe at a mean 8-year follow-up for patients in whom the components were correctly implanted. The rise of blood metal ions was minimal and involved neither systemic or local toxicity nor influenced clinical results.

Surgical approach for fracture of distal humerus: Posterior vs lateral.

Humeral fractures have an incidence of 3-5% and a bimodal age distribution. They may occur in young patients after highenergy traumas or in elderly osteoporotic patients after low-energy injuries. In nondisplaced fractures or in elderly patients, humeral fractures are treated by conservative methods. Open reduction and internal fixation (ORIF) should be the treatment of choice in case of multi-fragmentary fractures associated with radial nerve palsy or not. ORIF is usually regarded as the gold standard treatment, but, depending on the different types of fracture, the surgical approach can change. In this review, we compare results and complication rates between lateral and posterior surgical approaches in the management of extraarticular distal humeral shaft fractures. An internet-based literature research was performed on Pubmed, Google Scholars and Cochrane Library. 265 patients were enrolled: 148 were treated by lateral or antero-lateral approach, while 117 by posterior or postero-lateral approach. The literature shows that no differences between the posterior and lateral approach exist. Certainly, the posterior approach offers undoubted advantages in terms of exposure of the fracture and visualization of the radial nerve. In our opinion, the posterior approach may also allow better management of complex and multi-fragmentary fractures.

Recurrent postoperative delirium in spinocerebellar ataxia type 2: a case report.

BACKGROUND: Postoperative delirium is a relatively uncommon condition in middle aged patients, but very widespread in patients with psychiatric and neurological diseases undergoing general anesthesia. Few studies are currently available in the literature on the perioperative anesthesiological management of patients suffering from spinocerebellar ataxia. CASE PRESENTATION: A 58-year-old Caucasian woman affected by spinocerebellar ataxia type 2 underwent total hip arthroplasty for advanced osteoarthritis. One month later, debridement, antibiotics, and implant retention was performed for periprosthetic hip infection. Both times she underwent general anesthesia and developed an early postoperative delirium treated successfully with chlorpromazine. CONCLUSIONS: This case report highlights the need to correctly manage patients at high risk of developing postoperative delirium, especially if suffering from degenerative neurological diseases. On the other hand, further studies will be needed in order to evaluate if spinocerebellar ataxia is an independent risk factor for the development of this acute and transient pathological condition.

Early failure of a locked titanium plate in a proximal humeral fracture: Case report and metallurgic analysis.

Angular stability locking plates are commonly used in proximal humeral fractures, especially in old patients with osteoporotic bones. These implants show good results in short and midterm follow-up, but complications are not uncommon. Here we present a case report to describe a case of early failure of a proximal angular stability plate implanted in a 72 years old female with a highly unstable two part proximal humeral fracture. An optical and metallurgic analysis was also conducted to study the modalities of failure. We concluded that anatomic reduction and restoration of the medial cortical support are crucial in order to minimize the mechanical load on the bone-metal interface and to prevent mechanical failure, in particular when the fracture rim drop in the weak point of the plate that was found in the proximal two symmetric holes (Holes E).

Stemless hip arthroplasty versus traditional implants: a comparative observational study at 30 months follow-up.

INTRODUCTION:: The aim of this retrospective case-control study is to evaluate clinical and radiographic results of short stems compared with traditional hip prostheses. METHODS:: 46 short stems (SS) and 50 traditional stems (TS) were selected. All the stems were implanted by the same surgeon using posterior approach because of primary osteoarthritis, post-traumatic osteoarthritis and avascular necrosis. All the patients were compared clinically by Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS), 12-item Short Form Health Survey (SF-12F/M) and radiographically (offset, CD angle, limb length discrepancy, cup inclination, subsidence, osseointegration, heterotopic ossification). Radiographic evaluations were carried out by 3 different blinded surgeons. A statistical analysis was performed (chi-square, t-test, Mann-Whitney). RESULTS:: At a mean follow-up of 30 months all the implanted stems were well-positioned and osseointegrated. In both groups there was a marked improvement in pain ( p < 0.001) with a statistically significant advantage in the SS group for WOMAC (90.8 vs. 87.5; p = 0.02) and in part for HHS (93 vs. 91.7; p = 0.18). The radiographic evaluations, with high concordance correlation between the 3 blinded surgeons (ICC consistently >0.80), showed no significant differences in the restoration of the articular geometry, with a reduction of cortical hypertrophy (2% SS vs. 7% TS) and periprosthetic stress-shielding ( p < 0.05) in the SS group. On the other hand, SS were more related to limb length discrepancy (61% vs. 33%; p < 0.05). No major complications were recorded in the 2 groups. CONCLUSION:: Short stems were shown to be comparable or better than traditional implants at short-term follow-up.