Custom-made implants for massive acetabular bone loss: accuracy with CT assessment.

BACKGROUND: Custom-made implants are a valid option in revision total hip arthroplasty to address massive acetabular bone loss. The aim of this study was to assess the accuracy of custom-made acetabular implants between preoperative planning and postoperative positioning using CT scans. METHODS: In a retrospective analysis, three patients who underwent an acetabular custom-made prosthesis were identified. The custom-made designs were planned through 3D CT analysis considering surgical points of attention. The accuracy of intended implants positioning was assessed by comparing pre- and postoperative CT analyzing the center of rotation (CoR), anteversion, inclination, screws, and implant surface in contact with the bone. RESULTS: The three cases presented satisfactory accuracy in positioning. A malpositioning in the third case was observed due to the posterization of the CoR of the implant of more than 10 mm. The other CoR vectors considered in the third patient and all vectors in the other two cases fall within 10 mm. All the cases were positioned with a difference of less than 10° of anteversion and inclination with respect to the planning. CONCLUSIONS: The current case series revealed promising accuracy in the positioning of custom-made acetabular prosthesis comparing the planned implant in preoperative CT with postoperative CT.

Tricalcium Phosphate as a Bone Substitute to Treat Massive Acetabular Bone Defects in Hip Revision Surgery: A Systematic Review and Initial Clinical Experience with 11 Cases.

The use of tricalcium phosphate (TCP) as a bone substitute is gaining increasing interest to treat severe acetabular bone defects in revision total hip arthroplasty (rTHA). The aim of this study was to investigate the evidence regarding the efficacy of this material. A systematic review of the literature was performed according to the PRISMA and Cochrane guidelines. The study quality was assessed using the modified Coleman Methodology Score (mCMS) for all studies. A total of eight clinical studies (230 patients) were identified: six on TCP used as biphasic ceramics composed of TCP and hydroxyapatite (HA), and two as pure-phase ceramics consisting of TCP. The literature analysis showed eight retrospective case series, of which only two were comparative studies. The mCMS showed an overall poor methodology (mean score 39.5). While the number of studies and their methodology are still limited, the available evidence suggests safety and overall promising results. A total of 11 cases that underwent rTHA with a pure-phase ceramic presented satisfactory clinical and radiological outcomes at initial short-term follow-up. Further studies at long-term follow-up, involving a larger number of patients, are needed before drawing more definitive conclusions on the potential of TCP for the treatment of patients who undergo rTHA.

Comparison of a Minimally Invasive Tissue-Sparing Posterior Superior (TSPS) Approach and the Standard Posterior Approach for Hip Replacement.

Purpose: The purpose of this study is to compare the functional and clinical outcomes, blood loss, complication rate, and hospital length of stay (LOS) of total hip replacement (THR) using a minimally invasive tissue-sparing posterior superior (TSPS) approach and the standard posterior approach. Materials and Methods: This retrospective, observational, double-centered study included 38 patients undergoing hip replacement. The patents were divided into two groups: control group (19 patients), who underwent surgery with the standard posterior approach, and treatment group (19 patients), who received the same type of implant with ceramic-on-ceramic bearing via the TSPS approach. Hemoglobin level was assessed preoperatively, on first and second postoperative days, and on discharge day. Harris hip score and Western Ontario and McMaster Universities Arthritis Index were used to measure the clinical and functional outcomes. Hospital LOS and incidence of early and late complications were assessed in both groups. Postoperative anteroposterior pelvis X-ray was performed to assess the correct positioning of implants. Results: Better early clinical outcomes (p = 0.0155), lesser blood loss (p < 0.0001), and reduced hospital LOS (p < 0.0001) were observed in the TSPS group than in the control group. No major adverse effects occurred in both groups, and a satisfactory implant orientation was achieved in all patients. Conclusions: The TSPS approach is a reliable minimally invasive procedure for THR as it allows an accurate orientation of the components and provides better early postoperative functional outcomes, faster recovery, significantly lower blood loss, and shorter hospital LOS than the standard posterior approach. However, further research is needed to confirm the promising results and cost-effectiveness of the TSPS approach in larger cohorts with a longer follow-up period.

Hamstring grafts for anterior cruciate ligament reconstruction show better magnetic resonance features when tibial insertion is preserved.

PURPOSE: Comparing the MRI features of the grafts between a group of patients treated with an over-the-top anterior cruciate ligament reconstruction technique that preserves the hamstring attachment and a control group with a classical reconstruction technique. METHODS: Patients were assigned to a standard reconstruction technique or an Over-the-top plus lateral plasty technique. All patients underwent preoperative, 4-months and 18-months MRI; together with a clinical evaluation with KOOS and KT1000 laxity assessment. MRI study involved different parameters: the "Graft" was evaluated with the continuity, Howell Grading system, presence of liquid and signal noise quotient. The "Tibial Tunnel" was evaluated with the signal noise quotient, presence of edema or liquid and tunnel widening. All points assigned to each parameter formed a composite score ranging from 0-10. Tunnel and graft positioning were evaluated. RESULTS: At 18-month 20 MRIs (10 each group) were available, demographics were not significantly different between groups. The non-detached group showed significantly less liquid within the graft at 4-months (p = 0.008) and 18-months (p = 0.028), the tunnel was significantly smaller (p < 0.05) and less enlarged at both follow-ups (p < 0.05), signal noise quotient of the intra-tunnel graft was lower at 18-months (p < 0.05). The total score of the non-detached group saw a significant improvement at 4-months (p = 0.006) that remained stable at 18-months (n.s.). CONCLUSIONS: Hamstring grafts, which tibial insertions were preserved, showed better MRI features at 4-and 18-months follow-up, especially in terms of liquid effusion, tunnel enlargement and signal noise quotient. LEVEL OF EVIDENCE: IV.

Difficult primary total knee arthroplasty requiring a varus-valgus constrained implant is at higher risk of periprosthetic infection.

PURPOSE: The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs. METHODS: 74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis). RESULTS: Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence. CONCLUSIONS: Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Packing for damage control of nontraumatic intra-abdominal massive hemorrhages.

BACKGROUND: The Damage Control Surgery (DCS) approach to massive intraperitoneal hemorrhage has been shown to significantly reduce the morbidity and mortality in severely injured trauma patients. We applied the same principles to patients who developed a massive hemorrhage and the "lethal triad" (acidosis, hypothermia, coagulopathy) during a surgical procedure in order to assess feasibility and efficacy of DCS on nontraumatic grounds. METHODS: A retrospective analysis of eight consecutive cases was performed aimed at collecting information on laboratory parameters, fluids requirements, operative times, APACHE II score, damage control surgery procedure, angioembolization, morbidity, mortality, and need for repacking. RESULTS: Average APACHE II score was 25.5 (predicted mortality rate = 54%); overall and early mortality in the nontraumatic group was nil, while the intra-abdominal septic (packing-related) complication rate was 12.5%. CONCLUSIONS: Intra-abdominal packing was shown to be feasible, safe, and effective for patients with intra-abdominal nontraumatic massive hemorrhage, and the application of the principles of DCS may improve survival in cases of surgical hemorrhage with development of the lethal triad.

[Penetrating abdominal trauma: 20 years experience in a Western European Trauma Center]. / Traumi penetranti dell'addome. Esperienza di 20 anni in Trauma Center dell'Europa Occidentale.

BACKGROUND: The incidence of penetrating abdominal trauma in Western Europe is low. While non-operative management of blunt trauma has become the gold standard, the management of penetrating trauma is still controversial. Nonoperative management (NOM) and laparoscopy are currently used in selected patients, reducing the rate of unnecessary laparotomy. METHODS: We retrospectively reviewed a 20-years period from the Trauma Registry of our Trauma Center. 6523 patients were admitted for thoraco-abdominal trauma (5861 blunt vs 662 penetrating). We sorted the 114 patients with penetrating abdominal trauma in 2 groups for period (1989-2000 vs 2001-08, before and after the establishment of dedicated trauma unit) analyzing their demographics, clinical, therapeutic characteristics and the outcome in comparison. RESULTS: In the latest period a significant increase in the incidence of penetrating trauma has been observed (doubled from 4.17/year up to 8.53/year, accounting now for 13.95% of all trauma laparotomies vs 7.8% in the past decade). A reduction of GSW (30% vs 12.5%, p = ns) occurred while no differences have been recorded in sex, age, prognostic parameters at arrival such as mean GCS (11.8 vs 13.2), ISS (22 vs 18), pH, BE and blood transfusion (6.4 vs 4.3 U) requirement. Interestingly a markedly significant change has been observed in the demographics of the victims (67.2% were of extra-EU origin vs 8% in the previous decade, p < 0.01). Recently the use of NOM spread widely in selected stable patients (21.9%). The failure rate of NOM was 14.3%. The percentage of unnecessary laparotomies decreased from 36% to 21.1% (p = ns). The introduction of laparoscopy was helpful in achieving a reliable, less invasive exploration, allowing detection of the peritoneal penetration and complete visceral exploration. Two GSW (4%) vs 3 (5.8%) cases of the latest years required Damage Control Surgery. A recent significant reduction in mortality and morbidity rate has been recorded (respectively 3.85% vs 18%, p < 0.05; 20% vs 39%, p = ns). CONCLUSION: The recent immigration phenomenon and social changes contributed towards a significant rise in the incidence of penetrating trauma in Italy in the last decade associated to changes in the mechanism of injury. The increased use of NOM and laparoscopy contributed in decreasing the incidence of unnecessary laparotomies as well as overall morbidity and mortality.

[The continuing medical education in the management of trauma (corrected)]. / Percorsi educazionali nella chirurgia dei trauma [corrected]

BACKGROUND: The continuous medical education constitutes a great institutional project for the improvement of the relief quality in which he is affirming a variety of formative methodologies. Particularly must be uses specific systems for the adult education. MATERIALS AND METHODS: The project that is introduced it concerns a post-university formative run on the trauma with courses of target multidisciplinare or specialistic that answers to the need of specific knowledges on the whole run of clinical continuity of the patient. 236 students have currently participated, in non systematic way, developing interactive courses with a 40% of the hours devoted to the practical activity. RESULTS: The initial results of this activity show the validity of the model to increase his/her own abilities and to answer to the professional needs. CONCLUSIONS: The formative application appears directed to the development of coherent and systematic trials "problem directed" with strong involvement of the participants in practical activity and clinical experiences comparison.

[The damage control surgery]. / Damage control surgery: orientamenti attuali.

AIM OF THE STUDY: To evaluate our experience in the treatment of complex abdominal injuries with the principles of Damage Control Surgery (DCS). METHOD: A retrospective review was conducted of 55 patients with multiple abdominal injuries and severe haemorrhage induced hypothermia and acidosis admitted to the "Ospedale Maggiore Trauma Center" in Bologna from 1989 to June 2005. RESULTS: All the patients but one had major blunt trauma. Mean age was 40.1; mean ISS 42; mean RTS 4.11; extimated loss of blood was greater than 4000 ml. Packing provide definitive control of bleeding in 44 patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery (2) or arterial embolization (8). Twenty eights patients (50.9%) died. Survival was strongly associated with the ISS, GCS, the loss of blood and acidosis. CONCLUSION: The Authors concluded that in selected circumstances the traditional approach to severe abdominal injuries is not appropiate. In this situation, alternative and aggressive treatment such as the Damage Control Surgery has been recommended as the procedure of choice.

[The education of the trauma surgeon: the "trauma surgery course" as advanced didactic tool]. / Modelli educazionali in chirurgia del trauma: il "Corso Teorico-Pratico di Chirurgia del Politrauma" come proposta di didattica avanzata.

BACKGROUND: The consequences of low incidence of penetrating injuries in Europe and of the increasing in nonoperative management of blunt trauma are a decrease in surgeons' confidence for managing traumatic injuries. The Corso Teorico Pratico di Chirurgia del Politrauma was developed as model for teaching operative trauma techniques. The aim of this retrospective study is to evaluate the effectiveness of the course and compare it with other similar courses. METHOD: The Corso Teorico Pratico di Chirurgia del Politrauma is a two day course and consists of lecture on trauma topics and porcine operative experience. Data on the first 124 participants were collected and analyzed. RESULTS: One hundred twenty general surgeons and 2 pediatric surgeons had participated at the course. All the participants judged the course an efficient model to improve knowledge on surgical treatment of trauma. CONCLUSION: A two days course, focused on trauma, with didactic lectures and operative life-like situations, can be a model for simulated education and useful to improve surgeons' confidence in trauma patients.

Initial evaluation of the "Trauma surgery course".

BACKGROUND: The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy. METHOD: the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed. RESULTS: All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma. CONCLUSION: A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses.

[Diagnosis and treatment of retroperitoneal traumatic injuries. Our experience on 221 patients]. / Le lesioni traumatiche del retroperitoneo: inquadramento diagnostico e terapeutico. Nostra esperienza su 221 pazienti.

BACKGROUND: The management of traumatic retroperitoneal injuries is still confusing to many surgeons. The presence of injuries of retroperitoneum generally worsens the prognosis in trauma patients and need more attention both the diagnosis and treatment and mortality is high comparated to abdominal traumati injuries. METHOD: A retrospective review was conducted of 221 patients with retroperitoneal injuries admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to March 2005. RESULTS: Two hundred seven were blunt traumas and 14 penetrating. Mean age was 40.3; 25 patients died in operating room and 25 were treated with Damage Control Surgery for both abdominal and retroperitoenal injuries. The mortality rate was 15%. Data about surgical treatments, associate treatments for abdominal injuries, and need of reoperation are reported. CONCLUSION: Retroperitoneal traumatic injuries are challenging emergencies and need of attention and expertise by the suorgeon. Only with a careful judgement on the tactics and the procedure to carry on it is possible to gain valid results, which often means to safe the patients life.