MPFL reconstruction and tibial tuberosity transposition in patients with patellar instability: May it troubleshots also trochlear dysplasia?

PURPOSE: This study aimed to highlight short- and medium-term outcomes of combined medial patello-femoral ligament (MPFL) reconstruction and anterior tibial tuberosity (ATT) transposition surgery in patients with recurrent patellar instability and different degrees of trochlear dysplasia. METHODS: Between January 2014 and May 2019, 25 patients with patellar instability underwent a surgical procedure combining the lowering/transposition of the ATT and the MPFL reconstruction. Each patient were preoperative assessed by Kujala score, International Knee Documentation Committee (IKDC), Tegner activity level scale. The assessment of instability predisposing factors was carried out with patellar height, tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, sulcus angle, patellar tilt and MPFL injuries. Functional outcomes were evaluated with Kujala, IKDC and Tegner scores at 3, 6 and 12 months after surgery. RESULTS: The average age of the patients was 20 years (range 13-43 years). Pre- operative Caton-Deschamps index was pathological in 10 (40%). Sulcus angle was elevated in 13 patients (52%) and TT-TG distance was irregular in 17 patients (68%). Trochlear dysplasia was present in 13 patients (9 type A, 3 type B, 1 type C according to Dejour's Classification). No re-dislocation occurred during the follow-up. There was a significant increase in the Kujala, IKDC and Lysholm scores after 3, 6 and 12 months, and the results were compared for the different follow-up times and patient's trochlear dysplasia degree. CONCLUSION: This prospective observational longitudinal study identified good clinical outcomes in patients who underwent MPFL reconstruction and ATT transposition for patellar instability. Finally, the different risk factors for patellar instability examined, particularly the presence of trochlear dysplasia, did not significantly influence the final functional results, which range from good to excellent without re-dislocation episodes.

The role of six biomarkers in diagnosis of hemophilic arthropathy: review of the literature.

The aim of our narrative review of the literature is to identify the role of six important biomarkers: synovial fluid thrombomodulin, fibroblast-like synoviocytes, synovial tissue growth factor , vascular endothelial growth factor in synovium and peripheral blood, urinary C-terminal telopeptide of type II collagen, and synovial fluid tumor necrosis factor alpha. These urinary, serum and synovial biomarkers illustrated should be evaluated in patients with hemophilic arthropathy for early diagnosis of hemophilic arthropathy, because they have important implications in the development of arthrofibrosis, altered inflammatory response and bleeding. Moreover, better knowledge of their biological activity is important to identify possible new biological treatment options.

Knee arthroplasty system with medialized keel: Seven-year follow-up of a pioneer cohort.

BACKGROUND: In this clinical investigation, a new design with a progressive increased keel medialization according to the size was implanted. The cohort of patients was followed up for seven years. METHODS: From May 2012 to November 2012, we implanted 70 total knee arthroplasties in 69 patients. The mean age of the patients was 76.2 years. We followed up 56 patients for seven years; we evaluated the patients at six and 60 months after surgery by Patient Reported Outcome Measures score. During the seven-year follow-up, all patients were clinically re-evaluated using the Knee Society Score and the Forgotten Joint Score. All patients underwent a preoperative and postoperative radiographic investigation. At the last follow-up the presence of any radiolucency lines was checked using the Knee Society Total Knee Arthroplasty Radiographic Evaluation and Scoring System. RESULTS: The patients defined the surgical results as excellent in 66% of the cases, very good in 23%, good in five percent. The analysis of the functional data at seven years, performed by administering the Forgotten Joint Score, showed average values of 70.4. The clinical analysis, performed through the Knee Society Score at the same follow-up, showed average values of 90.4. The seven-year radiological analysis revealed the presence of radiolucency lines in 20 implants. The sum of the line widths never exceeded the critical value of nine millimeters, always remaining below four millimeters. Only one patient was revised. CONCLUSIONS: The results showed an excellent outcome of this design. The medialization of the tibial keel showed good bone fixation and component alignment at seven-year follow-up.

Interobserver and intraobserver reliability of a new radiological classification for femoroacetabular impingement syndrome.

PURPOSE: Radiological evaluation of femoroacetabular impingement is based on single-plane parameters such as the alpha angle or the center edge angle, or complex software reconstruction. A new simple classification for cam and pincer morphologies, based on a two-plane radiological evaluation, is presented in this study. The determination of the intraobserver and interobserver reliability of this new classification is the purpose of this study. METHODS: We retrospectively reviewed the three-view hip study in patient undergoing hip arthroscopy for FAI syndrome between October 2015 and April 2016. Any case having protrusio acetabuli, coxa profunda or which has undergone previous osteotomic surgery was excluded. Five observers used our proposed classification to identify three different stages for the cam and pincer morphologies. Inter- and intraobserver agreement of classification was determined using average pairwise Cohen's kappa coefficient. RESULTS: The interobserver agreement for the pincer and cam morphologies was excellent. For the pincer morphology classification, the average Kappa agreement was 0.838 (range 0.764-0.944). For the cam morphology, the average pairwise Cohen's kappa coefficient was 0.846 (range 0.734-0.929). The intraobserver agreement was excellent as well. The average percent pairwise agreement was 0.870 and 0.845 for pincer and cam type, respectively. CONCLUSIONS: The new classification system shows excellent levels of inter- and intraobserver agreement for both deformities. This classification is demonstrated to be a useful tool in planning hip arthroscopy. Further studies are needed to correlate the classification itself with specific intraoperative findings.

Acute treatment of medial collateral ligament tears: short to mid-term results.

The aim of this study is to describe the results of a consecutive set of patients treated in acute for the surgical repair of medial collateral ligament (MCL) tears with a mean follow up of 63.78±43.25 months (4- 136). This is a retrospective observational study. From January 2011 to December 2016, 56 patients within the average of 31.75±13.27 (13-55) years old at the time of injury underwent medial compartment repair in an acute setting. The sample size of our study is therefore made up of 26 patients. Patients have been evaluated with functional scores: IKDC (international knee documentation committee evaluation form), the KOOS (Knee injury and osteoarthritis outcome score) and clinical assessment. The Tegner Activity Score was evaluated retrospectively at the 12 months follow-up. The mean KOOS value at the final follow-up were 91.25±9.65 (72-100) for pain, 85.68 ± 12.34 (57-100) for the symptoms category, 94.5±8,07 (75-100) for the activity of daily life, 71.87±22.86 (35-100) for the sport category and 76.37±18.55 (38-100) for the quality of life. At the last follow up the mean IKCD value was 77.68±15.95 (55-98). The mean difference in the Tegner Activity Score between the preoperative time and the postoperative time was 1.06±1.12 with a 95% Confidence Interval 0.46-1.66. The functional outcomes underline how the surgical approach to the medial capsule-ligament compartment of the knee is a reliable treatment to restore excellent joint function. Level of evidence III retrospective observational study.

PEEK versus metal cages in posterior lumbar interbody fusion: a clinical and radiological comparative study.

BACKGROUND: Low back pain and sciatica represent a common disabling condition with a significant impact on the social, working and economic lives of patients. Transforaminal lumbar interbody fusion (TLIF) is a surgical procedure used in degenerative spine conditions. Several types of cages were used in the TLIF procedure. PURPOSE: To determine whether there is a difference in terms of symptomatology improvement, return to daily activities and fusion rate between metal cages and polyetheretherketone (PEEK) cages. METHODS: We have retrospectively reviewed 40 patients who have undergone TLIF from October 2015 to May 2016. All patients were clinically evaluated with questionnaires and were assessed with CT scan and standing X-ray films of the full-length spine. RESULTS: We found no significant functional differences in the two groups. At 1-year follow-up, osteolysis was present in 50% of cases of the PEEK cages and in 10% cases of the metal cages. The degree of fusion at 1  year was evaluated as complete in 40% cases of the metal cages and 15% cases of the PEEK cages. CONCLUSIONS: We have found a better fusion rate and prevalence of fusion in the group treated with metal cages, reflecting the well-known osteoinductive properties of titanium and tantalum.

Musculoskeletal hydatid disease: report of a rare case with primary and exclusive localization in right hemi-pelvis and femur.

Hydatid Disease (HD), also called Echinococcosis or Hydatidosis, is a parasitic infection caused by the larval stage of the tapeworm Echinococcus: E. granulosus or E. multilocularis. HD occur most frequently in liver or lungs, rarely in brain, skeletal muscles, bones, kidneys, spleen. Bone infestation of Echinococcosis hydatid cysts occurs respectively by haematogenous seeding and progressive invasion into bone by lesions in the adjacent soft tissues. Patients with musculoskeletal HD clinically show the disease in adulthood because the lesions develop very slowly. In some cases, HD is an uncommon cause of soft tissue mass, pain and neurovascular symptoms due to compression or to secondary infection. Diagnostic imaging plays an important role in the diagnosis of HD and in the differential diagnosis with soft tissue tumors. We present a rare case of male patient of 42 year-old with diagnosis of HD with primary and exclusive localization in right hemi-pelvis and femur.

A rare case of Hoffa's fat pad herniation in a young patient: dynamic ultrasound and MRI diagnosis.

Hoffa's fat pad (HFP) is part of the knee structure interposed between the joint capsule and the synovium. Recent studies have classified infrapatellar fat pad (IFP) disorders on a pathogenesis-based classification: traumatic disorders, post-traumatic disorders, lesions secondary to adjacent disorders. Masses or pseudo-masses may also be found within the IFP, however these alterations are much less frequent. Diagnostic imaging plays an important role in the diagnosis of masses and pseudo-masses of IFP and the first choice exam is a dynamic ultrasound study. We presented a rare case of Hoffa's fat pad herniation through the joint capsule, in a young child without history of knee injuries that has never been described before in the literature.

Aggressive hemangioma starting from l5 body, treated with mass embolization and radiation therapy with protons: a case report.

A hemangioma is a benign tumor of endothelial cells, multiplying into the medullary spaces of the cancellous bone. This tumor is in most cases not symptomatic, and in this case, they do not require any specific treatment. Pain and neurological symptoms derived from hemangiomas as shown in 2-11% of the cases. The 55% of these cases presents low back pain, while the 45% presents neurological deficit from compression of the spinal cord, peripheral nerves or both. We present a clinical case report of a young woman, affected by aggressive L5 hemangioma causing a spinal canal stenosis with associated sciatalgic symptoms. We performed a review of the current literature on the treatment options, giving the rationale of our treatment choice (mass embolization and radiation therapy with protons).

Primary total knee replacement in hemophiliacs: experience of a single institution over fourteen years of surgical procedures.

This retrospective study reports clinical and functional orthopedic outcomes and complications after 14 primary total knee replacement (TKR) performed between 2000 and 2014. The mean age at surgery was 42 years (range 26-59), with a removal-free survival of 100% at the end of follow-up (months 109.85). The KSS score was 49.64 pre-operatively (range 31-63) and 78.14 at final follow-up (range 45-90), the KSS function score was 64.64 pre-operatively (range 35-80) and 84.57 at final follow-up (range 45-100). According to this study, there are three main factors that can influence long-term and early surgical outcomes: post-operative fibrosis, a previous synovectomy and presence of inhibitors. Even if our results are slightly suboptimal compared to those obtained in non-hemophilic patients, this study shows that TKR is an effective surgical procedure in hemophiliacs.

How to obtain better results, choice of implant or surgical technique? A new surgical technique with an extramedullary referenced cutting guide and a blended alignment method.

Measured resection and ligament balancing techniques are the most used in TKA; both require, in the majority of knee arthroplasty systems, a femoral intramedullary canal referencing for the distal femoral cut. Fat embolism, activation of coagulation and bleeding may occur from the reamed canal; this can be avoided with different solutions such as navigation, patient specific instruments or the use of an extramedullary device. The FuZionTM tensor was created as a blended method with the purpose to overcome the downsides of both techniques by fusing them. The aim of our study is to present the technique and the preliminary results of a cohort of patients where this instrument was customized and used as an extramedullary cutting guide for the distal femur, matching the distal femoral cut with the proximal tibial cut in order to obtain a guided, kinematically adjusted, alignment and a reduction of post-op blood loss.

Hydatid cyst in the spine. The alliance between surgeon and infectivologist is winning: a case report.

Hydatid Cyst is a protozoal disease, whose spinal localization may be cause of pain and severe inability due to neurological symptoms and instability. Treatment combines the difficulties to eradicate the cyst with the spine regional constraints. The case of a 45-year-old woman is reported, affected by hydatid cyst in the spine, submitted to combination of medical treatment and surgery (double approach gross total excision and reconstruction) and followed up for 6 years. The treatment strategy allowed an excellent quality of life without pain and neurological symptoms at the latest follow-up. This case supports the validity to combine anthelmintic medical treatment and excisional surgery in the treatment of hydatid cyst of the spine. The medical treatment makes surgery more effective maintaining the result over long term. Subtotal or total excision of the cysts can be performed, including decompression of neural structures and adequate spine reconstruction.

Treatment of Vancouver B1, C periprosthetic hip fractures with periprosthetic polyaxial locking plate system: A 3-year follow-up.

The incidence of periprosthetic fractures after primary knee and hip arthroplasty is around 2.5% and is increasing after revision surgery up to 4%. Management of these fractures is often particularly demanding and expensive. The primary aim of the presented study is to describe our experience in using a precontoured periarticular polyaxial standard plating system in a cohort of patients with homogeneous fracture type (Vancouver B1, C), comparing our experience with other surgical solutions. In stable implants, the primary strategies aim for fracture stabilization, leaving the original prosthesis in place. The results of conventional non-locking implants have been mostly poor with complication rates up to 53%. Therefore, today, monoaxial locking plates are strongly recommended. From May 2013 to December 2014, 30 "non-contact bridging plate" (NCB-PP®) were implanted. All fractures were periprosthetic Vancouver B1 or C fractures. In 24 patients, NCB-PP® plating was performed after periprosthetic femoral fracture as primary treatment, in 6 patients, it was performed as secondary fracture treatment after primary plating failure. All surgeons performed lateral femoral approach with ORIF. Average follow up was 36 months. Bony consolidation was confirmed in all patients, bar one, in an average time of 4 months; none of the patients bar one developed mechanical failure or implant breakage. The GOS at 52 weeks was back to the preoperative level in 18 patients and it did not improve at 24 months. The Harris Hip Score at 52 weeks showed a mean score of 80.14 points. Full weight bearing was allowed at mean time of 100 days. None of the patients developed complications that needed subsequent surgery. The use of NCBPP plates has given excellent results in our clinical practice, allowing early postoperative mobilization and recovery.

Simulation of the flue gas cleaning system of an RDF incineration power plant.

Because of the stringent pollutant emission standards introduced with the European Union guidelines for waste incineration, it is very important to optimize the flue gas cleaning systems which are able to result in a low environmental impact according to the emission limits. In this paper a thermochemical model has been proposed for the simulation of the flue gas cleaning system of an RDF incineration plant. The model simulates the operation of the flue-gas treatment section and the combustion section by using a simplified approach. The combustion includes the grate incinerator and the post-combustion chamber, while the cleaning section includes the NO(x) reduction process (urea injection) and the scrubbing of SO(2) and HCl (Ca(OH)(2) as sorbent). The modelling has been conducted by means of ASPEN PLUS code. The simulation results have been validated with the operating data. The model proposed by the authors can be a useful tool in both evaluating the efficiency of the gas cleaning system by verifying the environmental pollution of an incinerator power plant in nominal operating conditions and in forecasting the efficiency of the cleaning system in off-design operating conditions.

The surgical treatment of recurrent anterior dislocation of the shoulder.

The authors analysed the results obtained in 94 recurrent dislocations of the shoulder submitted to surgery between 1979 and 1988 according to the Latarjet method. After considering the reasons for selecting this method, they discuss some aspects of the physiopathology of recurrent dislocation and instability of the shoulder. the principles of the Latarjet method are described and the Patte modification, used by the authors since 1986, is briefly illustrated. The long-term results were evaluated according to the walch and Duplay evaluation scheme. Sixty-nine patients with a follow-up ranging from a minimum of 1 year to a maximum of 9 were reviewed. The results were excellent or good in 93% of the cases.