A Two-Step Approach to the Surgical Treatment of Soft-Tissue Sarcomas.

Background: Nowadays, limb-sparing procedures are the gold standard in the treatment of soft-tissue sarcomas of the limbs. Wide tumor resection with appropriate oncological margins, reconstruction, and stabilization of the involved bone and joint and restoration of the soft tissue lost are essential in order to obtain good clinical and functional outcomes. Tumor excision and soft-tissue reconstruction performed in one-step surgery is chosen by many centers as the preferred approach; however, according to our experience in some selected patients, two-step surgery performed using a dermal regeneration template first and then a margin revision, taking into account the definitive results of the anatomopathological exam conducted over the surgical specimen from the previous surgery, associated with definitive reconstruction surgery over a healthy bed of granulated tissue, showed many potential benefits. Methods: A retrospective observational study was conducted on thirteen patients who underwent a two-step reconstruction procedure using dermal substitution after soft-tissue sarcoma excision. Results: Clinically, the enrolled patients achieved excellent contour and cosmesis of their surgical wounds, with a mean VSS value of 3.07. During the follow-up period, no local recurrences were observed in any patient. Conclusions: Two-step surgery represents the most suitable solution to allow surgical radicality with minimal recurrency and adequate soft-tissue reconstruction, avoiding the possibility of wasting autologous tissue. Our patients generally embraced this approach and the management that followed.

Current Evidence Using Pulsed Electromagnetic Fields in Osteoarthritis: A Systematic Review.

(1) Background: Osteoarthritis (OA) significantly impacts patients' quality of life and negatively affects public healthcare costs. The aim of this systematic review is to identify the effectiveness of pulsed electromagnetic fields (PEMFs) in OA treatment across different anatomical districts, determining pain reduction and overall improvement in the patient's quality of life. (2) Methods: In this systematic review following PRISMA guidelines, PubMed and Google Scholar were searched for randomized controlled trials involving patients with osteoarthritis undergoing PEMF therapy. Seventeen studies (1197 patients) were included. (3) Results: PEMF therapy demonstrated positive outcomes across various anatomical districts, primarily in knee osteoarthritis. Pain reduction, assessed through VAS and WOMAC scores, showed significant improvement (60% decrease in VAS, 42% improvement in WOMAC). The treatment duration varied (15 to 90 days), with diverse PEMF devices used. Secondary outcomes included improvements in quality of life, reduced medication usage, and enhanced physical function. (4) Conclusions: Diverse PEMF applications revealed promising results, emphasizing pain reduction and improvement in the quality of life of patients. The variability in the treatment duration and device types calls for further investigation. This review informs future research directions and potential advancements in optimizing PEMF therapies for diverse osteoarthritic manifestations.

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series.

BACKGROUND: Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock. METHODS: A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields. RESULTS: Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures. CONCLUSIONS: The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

Stress-Induced Hyperglycemia is a Risk Factor for Surgical-Site Infections in Nondiabetic Patients with Open Leg Fractures.

Background: Nondiabetic patients with open leg fractures who have elevated blood glucose levels on arrival in the emergency department have an increased risk of surgical-site infections (SSIs). Objective: This study evaluates the association between the incidence of SSIs in nondiabetic patients with an open leg fracture and blood glucose levels registered on arrival in the ER. We also analyzed the correlation between patients' days of hospital stay and the incidence of SSIs and the time elapsed between the damage control with external fixation and final fixation and the incidence of SSI. Methods: We retrospectively studied nondiabetic patients admitted to our emergency unit from 2017 to 2021 with a diagnosis of open leg fracture consecutively treated. Based on the diagnosis of SSIs, all enrolled patients were divided into two groups based on the developed (group A) or not developed (group B) SSIs within 1 year after surgery. All patients enrolled in the study underwent damage control within 24 hours after admission to the ER. At stabilization of general clinical and local wound conditions, all patients underwent definitive surgery. Results: We enrolled 80 patients. In group A, glycemia on arrival in the ER was on average 148.35 ± 19.59 mg/dl, and in group B, it was 122.61 ± 22.22 mg/dl (p value: 0.0001). In group A, glycemia in the first postoperative day was on average 113.81 ± 21.07 mg/dl, and in group B, it was 99.02 ± 17.60 mg/dl (p value: 0.001). In group A, the average hospitalization was 57.92 ± 42.43 days, and in group B, it was 18.41 ± 14.21 days (p value: 0.01). Through Youden's J, we therefore analyzed the value with the highest sensitivity and specificity which proved to be 132 mg/dl. Conclusion: Our findings show that nondiabetic patients with SIH have a significantly increased risk of SSIs compared to patients without SIH within 1 year after surgery. Patients with open leg fractures with SIH have a significantly higher average hospital stay than patients without SIH. Further studies are needed to confirm 132 mg/dl of blood glucose levels as a value to stratify the risk of SSIs in these patients.

MENISCAL ALLOGRAFT TRANSPLANTATION COMBINED WITH ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A SYSTEMATIC REVIEW.

Introduction: To evaluate the clinical and functional outcomes of meniscal allograft transplantation (MAT) with anterior cruciate ligament reconstruction (ACLR) in a single surgical stage through a systematic review of the currently available evidence. Methods: A systematic search of the PubMed and Google Scholar databases, with no publication date limit, until December 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Follow-up studies and case series published in English involving patients undergoing a combination of ACLR and MAT were included. The quality of these studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist. A systematic review of the International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores was conducted. Results: Seven studies involving 154 patients were included. The mean follow-up was 5,3 years. The mean age at the time of the surgery was of 35.3 years. All studies used the Lysholm Knee score, IKDC score or Tegner activity score to measure clinical outcomes post-operatively and the mean improvements were 26.7, 24.7, and 1.8 respectively. The rate to return to sport was 75.5 %. No intra-operative complications were reported. The post-operative complication rate was 11.6%. Conclusions: MAT combined with ACLR procedure showed good clinical results up to an average of 5 years of follow-up. More studies need to be conducted that can better understand the long-term effects of this combined procedure.

Predictive Factors of Poor Outcome in Sanders Type III and IV Calcaneal Fractures Treated with an Open Reduction and Internal Fixation with Plate: A Medium-Term Follow-Up.

BACKGROUND: Consensus on the treatment for severely comminuted calcaneus fractures has yet to be found. This study aims to analyze the functional and radiological short- and medium-term outcomes of displaced calcaneus fractures of type III and IV treated with ORIF, and to identify, if present, the early predictors of unfavorable outcomes. METHODS: Thirty-three calcaneal fractures were included, 23 type III and 10 type IV, according to Sanders classification. AOFAS scales for ankle and hindfoot and SF-12 were used. Böhler and Gissane angles were analyzed before and after surgery. RESULTS: The minimum follow-up was six years. The mean AOFAS score at six months was 16.5 points (24.2 ± 10.8 vs 10.8 ± 9.5; p = 0.03) with better outcomes in patients with Sanders type III fractures. This difference decreased in the subsequent follow-up. Likewise, the mental and physical score of SF-12 had the same trend. Two wound infections and no deep infections were recorded in the Sanders type III fracture group. Instead, in the Sanders type IV group, there were four wound infections and one deep infection. CONCLUSIONS: Clinical and radiological outcomes in Sanders Type III and Type IV calcaneus fractures treated with plate and screws were very similar in long-term follow-up. If ORIF provided better short- to medium-term follow-up in Sanders type III fracture, these benefits have been lost in six years. Polytrauma and psychiatric patients showed significantly lower clinical outcomes in long-term follow-up, appearing as the most reliable negative predictors.

Plate Augmentation in Aseptic Femoral Shaft Nonunion after Intramedullary Nailing: A Literature Review.

BACKGROUND: Femoral shaft fractures (FSFs) are a frequent injury in traumatology for which intramedullary nailing (IMN) is considered the gold standard treatment. Nonunion (NU) is one of the most frequent complications in FSF treated with IMN, with a percentage from 1.1% to 14%. Plate augmentation (PA), the addition of a compression plate and screws, with or without bone graft has been described as an effective option for the treatment of NU, improving the biomechanical conditions at the fracture site. The aim of this review was to analyze the literature relating to the use of PA in NU after IMN in FSFs to assess the efficacy of the technique. METHODS: An electronic search on PubMed, Google Scholar, and Web of Science was conducted to search for all studies concerning PA of femoral shaft NUs after IMN. RESULTS: Twenty-four studies were included in the review comprising a total of 502 patients with a mean age of 39.5 years. Of these, 200 hundred patients had atrophic pseudoarthrosis and 123 had hypertrophic pseudoarthrosis, while in 179, the type of pseudoarthrosis was not reported. The most frequently used plate for PA was the dynamic compression plate (DCP); in 87.1% of the cases, the authors added a bone graft to the plate fixation. In 98.0% of the patients, a complete bone union was achieved in a mean time of 5.8 ± 2.12 months. CONCLUSION: The patients treated with PA included in this review showed a good rate of consolidation in the femoral shaft NUs, with good functional recovery and a low incidence of complications.

Intramedullary nailing vs modular megaprosthesis in extracapsular metastases of proximal femur: clinical outcomes and complication in a retrospective study.

BACKGROUND: Extracapsular proximal femur metastasis could be treated by synthesis or resection and megaprosthesis. No universal accepted guidelines are present in the literature. The aim of our study is to analyze of patients with metastases in the trochanteric region of the femur treated by a single type of intramedullary nailing or hip megaprosthesis. METHODS: We retrospectively reviewed all patients affected by extracapsular metastases of proximal femur. Anthropometric and anamnestic data, routine blood exams and complications were collected. VAS score and MSTS score was administered before the surgery, ad 1-6-12 months after surgery. An un-paired T test and Chi-square were used. Multiple linear regression and logistic regression was performed. Significance was set for p < 0.05. RESULT: Twenty patients were assigned in intramedullary Group, twenty-five in megaprostheses Group. The mean operative time is shorter in intramedullary group. Differential shows a higher anemization in megaprostheses group (2 ± 2 vs 3.6 ± 1.3; p = 0.02). The patients of intramedullary group showed malnutrition (Albumin: 30.5 ± 6.5 vs 37.6 ± 6 g/L; p = 0.03) and pro-inflammatory state (NLR: 7.1 ± 6.7 vs 3.8 ± 2.4; p = 0.05) (PLR: 312 ± 203 vs 194 ± 99; p = 0.04) greater than megaprostheses group. The patients in intramedullary groups shows a higher functional performance score than megaprostheses group at 1 month follow-up (MSTS: 16.4 ± 6.3 vs 12.2 ± 3.7; p = 0.004). A multivariate analysis confirms the role of type of surgery (p = 0.001), surgery duration (p = 0.005) and NLR (p = 0.02) in affecting the MSTS. Globally eight complications were recorded, no statistical difference was noticed between the two groups (p = 0.7), no predictor was found at logistic analysis. CONCLUSION: Intramedullary nailing guarantees a rapid functional recovery, compared to patients undergoing hip megaprosthesis who instead improve gradually over time. The selection of patients with poor prognosis allows the correct surgical indication of nailing, while in the case of a more favorable prognosis, the intervention of hip megaprosthesis is to be preferred.

Three-Dimension-Printed Custom-Made Prosthetic Reconstructions in Bone Tumors: A Single Center Experience.

Bone can be affected by different neoplastic conditions. Limb salvage surgery has become the preferred treatment strategy for most malignant tumors of the extremities. Advanced 3D printing technology has transformed the conventional view of oncological surgery. These types of implants are produced by electron beam melting (EBM) technology by sintering titanium powder in a scaffold shape designed following a project designed from HRCT and MRI. The aim of our study was to evaluate the outcomes and the mid-term follow-up of a population treated with 3D-printed custom-made prosthesis implantation in major oncological bone resection or after failure of primary implants. The primary outcome was the general patient satisfaction one year after surgery. The secondary outcomes were: mortality rate, treatment related complication rate, functional and clinical outcomes (KPS, ADL and IADL). Eight patients were included, five females and two males, with a mean age of 50.3 (±23.72) years at the surgery. The enrolled patients reported a mean satisfaction rate after surgery of 7.38 (±2) where 10 was the maximum value. There were no changes between pre- and postoperative mean KPS (81.43 +/−10.69). Mean preoperative ADL and IADL score was in both cases 4.86 (±1.07), while postoperative was 5 (±0.82), with a delta of 0.13 (p > 0.05). Custom-made prosthesis permits reconstructing bone defects caused by large tumor resection, especially in anatomically complex areas, restoring articular function.

Surgical management of tibial metastases: a systematic review.

BACKGROUND: Tibia is a rare location among all skeletal metastases. Those lesions are often discovered in an advanced stage of disease and are mainly reported to the orthopedic surgeon to reduce pain, to improve the patient quality of life and his functional status. Current literature on the surgical management of metastases and/or pathological tibial fractures shows mostly few case reports, case series or at most retrospective studies on very small and heterogeneous groups of patients. The purpose of this study is to analyze those articles highlighting epidemiology and discussing surgical options and relative outcomes. METHODS: Studies were searched on PubMed, Google Scholar and Web of Knowledge from inception to September 2020 and 30 articles discussing tibial metastasis surgical treatment were included. RESULTS: Results discuss age and sex of patients, location of tibial metastases, origin of metastases, type of lesion and spread of disease, surgical treatment, outcomes in terms of pain evolution, gain of function and general status, complication and relapse, and survival of patients. CONCLUSIONS: Despite the lack of randomized trials and the absence of high-level studies, guidelines suggest different types of treatments depending on location and stage of disease. The analysis of the articles included in this review confirms the heterogeneity of possible treatments, assuring, independently of the chosen techniques, good and similar results, leading to the conclusion that the choice of the surgical technique must take in consideration each patient's characteristics and the surgeon's experience.

Uncoated vs. Antibiotic-Coated Tibia Nail in Open Diaphyseal Tibial Fracture (42 according to AO Classification): A Single Center Experience.

Implant-associated infections remain one of the main problems in the treatment of open tibia fractures. The role of systemic antibiotic prophylaxis is now agreed and accepted; nevertheless, recent literature also seems to emphasize the importance of local antibiotic therapy at the fracture site. Several therapeutic strategies have been proposed to overcome this new need. Antibiotic-coated nails play crucial role in this, allowing both infection prevention and favoring the fracture stabilization. We describe the outcome of patients with open diaphyseal tibia fracture treated either with a standard uncoated nail or a gentamicin-coated nail from January 2016 to December 2018 at our second level emergency-urgency department. Primary outcomes were infection rate and bone union rate. Other outcomes reported are reoperation rate, time between injury and nailing, and safety of antibiotic nail. Numerical variables were tabulated using mean, standard deviation, minimum, maximum, and number of observations. Categorical variables were tabulated using number of observations. 23 patients treated with uncoated nail and 23 patients treated with antibiotic-coated tibia nail were included in the study and were evaluated for a minimum follow-up of 18 months. Among the 46 patients, 9 were Gustilo-Anderson type I, 21 type II, and 16 type III open fracture. Regarding the bone healing rate at 12 months, 16 fractures in the first group and 18 in the second were completely healed. 4 infections were found in the first group (3 superficial surgical site infection and 1 osteomyelitis) and 3 superficial infections in the second one. No adverse events have been recorded with antibiotic-coated nails. In this unicentric retrospective study observed no deep wound infections and good fracture healing in the use of antibiotic-coated nails. Antibiotic nails have been shown to play a role in the treatment of fractures in critically ill patients with severe soft tissue damage.

Arthrodesis in the Charcot foot: a systematic review.

The Charcot foot is a condition characterized by a progressive derangement of the foot. The type of deformity and patient clinical conditions will lead to the proper surgical approach among exostectomy, arthrodesis (through external and/or internal fixation) and amputation. Many authors report good clinical outcomes performing the arthrodesis in Charcot foot; however, the choice of the most appropriate hardware is still an issue. The aim of this study is to analyze the outcomes of different hardware in midfoot and hindfoot Charcot arthrodesis.

Bifocal parosteal osteoma of femur: A case report and review of literature.

Osteoma is a benign, slowly growing, asymptomatic, bone-forming tumor arising from cancellous or compact bone. Osteoma usually is a solitary lesion, but in patients with Gardner's Syndrome it may be multiple. osteoma may rarely have a parosteal localization. Parosteal osteoma has peculiar radiographic, histologic and clinical features. We describe a case report of a 51- years old man with a bifocal parosteal osteoma of the femur in a non-syndromic patient. This is the first described patient with a bifocal lesion. In literature only 24 cases of paraosteal osteoma are found. Our patient underwent surgery and the lesions were fully excised. At one year follow-up there was no evidence of recurrence.

Foot metastasis: Current knowledge.

Foot metastasis are rare and often overlooked due to non-specifical symptoms. This often leads to misdiagnosis delaying the right diagnosis. Metastatic disease of the foot is rare. Foot pain and swelling may be the presenting symptom of an occult malignancy. If metastatic disease is not kept in the differential diagnosis of foot pain, diagnosis and treatment will be delayed. The purpose of this study was to analyze articles presenting cases of foot metastasis to provide a more accurate incidence of symptomatic foot acrometastasis as well as to review the clinical course and outcomes. Studies were searched on PubMed/Medline from the inception to February 2020. All studies included in the review presented foot metastasis either with or without a known primary tumor. Most of the articles were case reports, to which we added two case reports of foot acrometastasis produced by our Institute. Forty-three studies with a total of 45 patients were included in this review. The literature published mostly concerning case reports about old patients (average age: 63,2), in a late phase of their disease. Lung cancer appeared to be the most common primary tumor, followed by endometrial and breast cancer. In the 36% of the cases foot metastasis were found when the primary site was still unknown. Calcaneus and metatarsal bones were the most common bones involved. Surgical solution is rare, the chosen treatments are often of palliative care. Prognosis was often poor, death occurred within 2 years since the discovery of foot metastasis in about 50% of cases.

A rare case of Bacillus megaterium soft tissues infection.

BACKGROUND AND AIM OF THE WORK: To report the history and clinical presentation of a 60-year-old male who developed a rare soft tissue infection of the right leg caused by Bacillus megaterium and to perform a Literature review focusing on clinical manifestations and diagnostic difficulties of the aforementioned bacterium. METHODS: Medical history and clinical presentation suggested the infectious etiology, which led to the surgical procedure of fistulectomy and to further histological and microbiological investigations with bacterial cultures. RESULTS: The histological report tested negative for osteomyelitis. Bacterial cultures revealed Bacillus megaterium, which was sensitive to all antibiotics against which it was tested. The oral antibiotic therapy was set for 12 days with benefits. The patient has always been apyretic, inflammation indexes and white cells count have been within normal limits.  Conclusions: This was a rare case of soft tissue infection caused by Bacillus megaterium known to be a "non-pathogenic" bacterium. The infection was likely acquired by the penetration through the injury wound. The combination of surgical and antibiotic therapy lead to complete skin healing and infection resolution at the 6-months follow up.