Anterior cruciate ligament reconstruction in association with medial unicompartmental knee replacement: a retrospective study comparing clinical and radiological outcomes of two different implant design.

PURPOSE: Unicompartmental knee arthroplasty (UKA) combined with anterior cruciate ligament (ACL) reconstruction has recently been suggested as a feasible treatment option for young and active patients with medial compartment osteoarthritis (OA) and ACL deficiency. The aim of this study is to evaluate retrospectively the outcomes of two different implant designs in patients with medial OA secondary to traumatic ACL rupture, who underwent combined ACL reconstruction and unicompartmental knee replacement. METHODS: From January 2007, to December 2013, 24 patients with medial OA secondary to ACL rupture underwent medial unicompartmental knee arthroplasty (UKA) and ACL reconstruction. Nine patients received a mobile bearing UKA (Group 1) and fifteen a fixed-bearing one (Group 2). The mean follow-up was 53 ± 8.3 months for Group 1 and 42 ± 6.7 months for Group 2. Knee Society Score (KSS), Western Ontario and McMaster Index of Osteoarthritis (WOMAC) index and radiological evaluation used to assess the implant loosening alignment of the knee joint and tibial slope were recorded pre-operatively and at the last follow-up. RESULTS: At the final follow-up, all patients showed statistically significant clinical improvements with respect to the pre-operative values (p < 0.05). No significant difference was observed in WOMAC index and KSS both objective and functional between groups at the last follow-up (KSS obj. 73.4 ± 9.3 vs 77.3 ± 10.5; KSS funct. 86.2 ± 6.2 vs 84.7 ± 5.9; WOMAC 79.3 ± 7.3 vs 81.3 ± 7.6 for Group 1 and 2, respectively). No differences in radiolucent lines were found between the groups. CONCLUSION: The use of different prosthesis design (fixed- or mobile-bearing) during a combined procedure of ACL reconstruction and medial unicompartmental arthroplasty does not affect the middle-term clinical and radiological outcomes.

Adjacent Single-level Combined Fixation Using Kyphoplasty and Percutaneous Pedicle Screws in Type A3 Unstable Vertebral Fractures in Elderly Patients.

We present a series of cases of type A3.1.2 unstable fractures of the thoracolumbar hinge treated percutaneously with third-generation kyphoplasty and only one next level percutaneous screws. Four women aged 75 to 85 years with thoracolumbar vertebral fractures, classified as type A.3.1.2, were treated with Precept® monosegmental percutaneous fixation and the third-generation SpineJack® augmentation system. The traditional treatment of type A3 unstable vertebral wedging fractures is performed with transpedicular fixation of two or more levels adjacent to the fracture causing great rigidity. Recently, the concept of bridge fixation combining one segment intrapedicular fixation with kyphoplasty has emerged as a more stable and less invasive system that allows greater mobility in this type of fractures. The combination of third-generation kyphoplasty and monosegmental bridge fixation may improve results to other fixation systems in type A3 vertebral fractures.

Prenatal Diagnosis of Clubfoot: A Review of Current Available Methodology.

BACKGROUND: Clubfoot is one of the most common congenital limb deformities. Prenatal diagnosis of the condition is essential as it can help treat the malformation as early as possible. We reviewed the recent available literature concerning the current methods for prenatal diagnosis of clubfoot. METHODS: The following databases were searched from 1966 to 2015: PubMed, OVID, Cochrane, CINAHL, Google scholar and Embase. RESULTS: Out of a total number of 197 retrieved articles, after abstract or title page evaluation, 158 articles not matching the inclusion criteria were excluded. The full text versions of the remaining 39 articles were obtained, and their reference lists screened, with the addition of another 5 full-text articles. CONCLUSIONS: Currently, ultrasonography is considered the most reliable method of prenatal diagnosis of clubfoot. Ultrasonographic diagnosis of clubfoot appears more likely between the 18th and the 24th week of pregnancy. Alternative imaging is not indicated. There is no agreement whether to propose foetal karyotyping when isolated clubfoot is diagnosed by prenatal ultrasonography. Early detection of clubfoot should prompt a careful surveillance during pregnancy in order to detect any possible additional abnormalities and, if any of these are detected, invasive testing should be offered.

How do we estimate survival? External validation of a tool for survival estimation in patients with metastatic bone disease-decision analysis and comparison of three international patient populations.

BACKGROUND: We recently developed a clinical decision support tool, capable of estimating the likelihood of survival at 3 and 12 months following surgery for patients with operable skeletal metastases. After making it publicly available on www.PATHFx.org , we attempted to externally validate it using independent, international data. METHODS: We collected data from patients treated at 13 Italian orthopaedic oncology referral centers between 2010 and 2013, then applied to PATHFx, which generated a probability of survival at three and 12-months for each patient. We assessed accuracy using the area under the receiver-operating characteristic curve (AUC), clinical utility using Decision Curve Analysis (DCA), and compared the Italian patient data to the training set (United States) and first external validation set (Scandinavia). RESULTS: The Italian dataset contained 287 records with at least 12 months follow-up information. The AUCs for the three-month and 12-month estimates was 0.80 and 0.77, respectively. There were missing data, including the surgeon's estimate of survival that was missing in the majority of records. Physiologically, Italian patients were similar to patients in the training and first validation sets. However notable differences were observed in the proportion of those surviving three and 12-months, suggesting differences in referral patterns and perhaps indications for surgery. CONCLUSIONS: PATHFx was successfully validated in an Italian dataset containing missing data. This study demonstrates its broad applicability to European patients, even in centers with differing treatment philosophies from those previously studied.

Surgical Site Infection In Orthopaedic Surgery: Correlation Between Age, Diabetes, Smoke And Surgical Risk.

INTRODUCTION: Surgical site infection is a common complication after orthopaedic surgery. It can be associated with increased morbidity rate and social cost. The accurate identification of risk factors is essential so that strategies to prevent these potentially devastating infections can be developed. We have conducted this study to determine the possible risk factors for the surgical site infections. OBJECTIVES: We aimed at finding exhaustive evidence concerning the potential risk factors for infections in orthopaedic surgery. PATIENTS AND METHODS: Between October 2009 and December 2011, we identified 84 patients with a superficial and/or deep surgical site infection and compared them with 203 uninfected patients (control group), taken out from a series of 486 patients. We considered the following risk factors: diabetes, BMI >30, ASA Score of 3 or 4, smoking and age. RESULTS: The most frequently performed operations of the 287 examined patients were the knee and hip arthroplasties (n = 32, 11.14%) and open fracture reductions (n = 178, 62.02%). Staphylococcus Aureus was the most common identified pathogen (n = 63, 75%). The analyses (preoperative and postoperative) of the infected patients showed them to have significantly high serum glucose levels in comparison with the control group (odds ratio = 8.7). We found a significant high rate of infection in patients smoking for more than 20 years (67 patients, 79.7%). The remaining variables (BMI, OR = 2.21; ASA score, OR = 1.3) showed no significant differences between the study group and controls. We also found a correlation between > 65-year-old patients and infections at the surgical site (61 patients, 72.6%). CONCLUSION: We found that there was correlation between diabetes, smoking and age as risk factors with the development of infection at the surgical site; other variables such as the ASA score and BMI are not relevant here (contrary to what is reported in literature). We believe that postoperative results can be improved considerably with a properly conducted antibiotic treatment, stringent glycemic control (achievable only with careful multidisciplinary management) and good compliance of patients.

Clear Cell Sarcoma Of Metatarsus.

We report a case of clear cell sarcoma in the third metatarsus of the right foot. This type of tumor is very rare and scantily reported in literature. A 42-year-old Caucasian male presented with a nodular ulcerated mass on the dorsal side of the left foot. X-rays demonstrated a nodular solid lesion which dislodged the third metatarsus. A biopsy revealed a neoplastic proliferation with a sarcoma clear cell profile; because of the aggressive nature of this type of neoplasm, we performed a trans-tibial amputation according to Bugess to achieve a better functionality for the patient. The present study underlines clinical, morphological, as well as imaging and therapeutic aspects of a rare neoplasm such as clear cell sarcoma. The location site is also quite unusual - the metatarsus of the foot. The histological and immunohistochemical data were suggestive of the diagnosis of clear cell sarcoma of metatarsus. After MRI and a bone scan, the surgical treatment suggested the extension over the forefoot and the ankle and therefore a trans-tibial amputation was made.

Immunolocalization of lactoferrin in cartilage-forming neoplasms.

BACKGROUND: Lactoferrin (Lf) is an 80-kDa basic glycoprotein, a member of the transferrin family of iron-binding proteins. Lf immunoreactivity has been extensively investigated in many neoplastic tissues. Recently, Lf expression was documented in the osteoblastic lineage of bone-forming tumors as well as in osteoblasts of fetal bone. METHODS: Lactoferrin (Lf) immunoexpression was investigated in 30 human cartilage-forming tumors [15 enchondromas, 6 osteochondromas, 3 chondroblastomas (CBL), 3 chondrosarcomas, and 3 chondromyxoid fibromas (CMF)] as well as in human normal bone specimens and cartilaginous tissues obtained at autopsy from 5 adults and 3 fetuses.In addition, the immunohistochemical expression of Ki-67 antigen was analyzed on parallel sections from the same specimens. Quantification of Lf immunoreactivity was performed by using an intensity distribution (ID) score. RESULTS: Lf immunoexpression with a variable ID score was encountered exclusively in 3 of 3 chondroblastomas and in 3 of 3 chondromyxoid fibromas. Lf immunoreactivity in these tumors, in clear contrast with the Lf absence in enchondromas, osteochondromas, and chondrosarcomas, may suggest a different histogenesis of the former. In agreement with this histogenetic origin, we detected Lf in the chondroblasts and osteoblasts within the fetal tissue, whereas no immunoreactivity was found in the corresponding adult cells. No significant associations were found between the Lf immunoexpression and the Ki 67 LI of the tumors of our series. CONCLUSIONS: The presence of Lf in neoplastic cells of CBL and CMF, as well as in fetal cartilaginous tissue, may reflect a less mature phenotype of these tumors.

A Large Extraskeletal Chondroma: An Unusual Location in the Lower Extremity, Huge Extraskeletal Chondroma: An Unusual Localization in the Leg.

INTRODUCTION: Extraskeletal chondroma (EC) is a rare benign neoplasm predominantly composed of mature hyaline cartilage; it develops in the soft tissues without any connection to bone cortex, intra-articular synovium, or periosteum. To date, only few cases have been reported in the leg, mainly in the knee, thigh, and popliteal region. CASE REPORT: We describe herein the case of a 42-year-old woman with a 4-year history of a slow-growing, painful swelling on the posteromedial region of her left leg. Magnetic resonance imaging showed the presence of a huge mass occupying soleus muscle, compressing, and displacing anteriorly gastrocnemius muscle. After an incisional diagnostic biopsy, a complete surgical excision of the tumor was performed. On the basis of clinicoradiological and morphological findings, a diagnosis of EC was made. CONCLUSION: This report represents a clinicoradiological and morphological analysis about a very rare huge EC arising in the posteromedial region of the leg.

Conservative Treatment of Spondylodiscitis: Possible Therapeutic Solution in Case of Failure of Standard Therapy.

INTRODUCTION: Spondylodiscitis (SD) is an uncommon disease but not rare, because it represents around 3-5% of all cases of osteomyelitis. Late diagnosis and/or inadequate treatment often cause irreversible damage to cause neurological deficit. Most require only conservative treatment, sometimes a surgical approach is required. AIM: The purpose of this study is to propose a conservative protocol to treat spondylodiscitis when the standard conservative treatment has failed. This alternative treatment has been for a long time at the Codivilla-Putti Institute. METHODS: We performed a prospective cohort study of 192 consecutive patients who underwent paravertebral intramuscular injections of antibiotic associated with standard treatment at our Center from January 2010 to December 2015 with SD. Of this 192 patients we selected 98 who had already undergone standard antibiotic therapy at another hospital without resolution of the disease. All patients have performed our protocol that provides a total of 3 cycles, each of 3 weeks, repeated at approximately 5 weeks apart. For each patient we evaluated Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), White Blood Cells (WBC) indexes, SF36 and VAS Score at the beginning and at the end of the treatment. RESULTS: At a mean follow up of 22 months (range 60-12), clinical healing was achieved in 87 patients (88,9%) of cases with significant reduction in back pain and functional limitation. The VAS Score and the SF36 were better at the end of treatment compared to previous "GOLD STANDARD" treatments in the previous hospitalization in another hospital. In most cases there were slightly reduced in inflammatory indexes. CONCLUSION: There are no studies in the literature demonstrating the effective efficacy of local infiltrative treatment with antibiotics, associated with standard treatment protocol. We believe that our protocol in treating SD, favors an early functional recovery, and be able to offer more chance of success than the standard treatment.

A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement.

BACKGROUND: Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA). METHODS: A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared. RESULTS: The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred. CONCLUSIONS: This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.

All-Arthroscopic Treatment of Intra- and Extra-Articular Localized Villonodular Synovitis of Knee.

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic condition affecting synovial-lined anatomic spaces. PVNS is characterized by hypertrophy of a synovial membrane by villous, nodular, and villonodular proliferation, with pigmentation secondary to hemosiderin deposition. The two forms of PVNS that have been described are diffuse (DPVNS) and localized (LPVNS). The knee is the most commonly involved anatomic location, followed by hip, ankle, shoulder, and elbow. Diagnosis of PVNS is not always obvious clinically. Various imaging modalities are often necessary to exclude other conditions and narrow the diagnosis. Magnetic resonance imaging has become the modality of choice for diagnosing PVNS. We present a case of intra-articular LPVNS with an extra-articular extension through the posterior capsule that has been successfully removed in an all-arthroscopic fashion.

Single-Bundle versus Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial with 6-Year Follow-up.

Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction is increasingly used in a large number of patients and it allows obtaining very good clinical and subjective results; however, functional tests show a persistent rotational instability. Biomechanical studies seem to indicate that double-bundle (DB) ACL reconstruction allows to obtain increased anterior and rotational stability compared with SB. The aim of this prospective randomized controlled study was to compare the clinical outcome and the possible osteoarthritic evolution of patients treated either with a SB (freehand transtibial femoral tunnel) or with a DB technique (outside-in for posterolateral femoral tunnel/inside-out for anteromedial femoral tunnel) at a final follow-up of 6 years. A total of 60 patients with complete ACL rupture (age, 16-40 years) were prospectively randomized to SB (n = 30) or DB (n = 30) groups. Patients were evaluated preoperatively and after surgery at 6 months, 1, 3, and 6 years with Lysholm score, International Knee Documentation Committee (IKDC) form, and KT-2000 (Medmetric Corp). The degree of osteoarthritis (OA) based on the Kellgren-Lawrence grade was also assessed. No significant differences in background factors between the two groups were observed. Homogeneity was also found in term of preoperative Lysholm score, IKDC, and KT-2000 between SB and DB groups. After 6 months from surgery, both groups showed significant improvements for Lysholm, IKDC, and KT-2000 score with respect to preoperative observations (p < 0.001); however, no significant differences have been observed in term of postoperative values between SB and DB groups at each time point (6-year evaluation: Lysholm score 98.14 ± 10.03 and 97.22 ± 12.82; IKDC normal + nearly normal 95 and 100%; KT-2000 1.68 ± 1.26 and 1.03 ± 1.92 for SB and DB, respectively; all p > 0.05). At the final follow-up, three patients (11.11%) in the DB group and two patients (7.69%) in the SB group presented signs of OA progression. Our study did not reveal any advantages in using DB ACL reconstruction in mid- to long-term follow-up in term of clinical outcome and knee stability, as well as in term of OA progression.

The Management of Extensor Mechanism Disruption After Total Knee Arthroplasty: A Systematic Review.

We performed a literature search on PubMed, Web of Science, Science Direct/Scopus, Google Scholar, and Google to evaluate results of several techniques to manage disruption of the extensor mechanism after total knee arthroplasty. Different methods to manage extensor mechanism disruption are available at present, with no level I studies informing surgeons in an evidence-based fashion. Primary repair is not indicated. Allograft reconstruction could be effective, providing that appropriate surgical technique and allograft tensioning are implemented.

Catastrophic metallosis after tumoral knee prosthesis failure: A case report.

INTRODUCTION: Metallosis is a condition characterized by an infiltration of periprosthetic soft tissues and bone by metallic debris resulting from wear or failure of joint arthroplasties. PRESENTATION OF CASE: Authors describe a case of a 45-year-old man treated for an osteosarcoma of the distal femur with a modular prosthesis when he was 18 years old, he developed massive metallosis with skin dyspigmentation after 17 years. His medical\surgical history was remarkable for a left tumoral knee prosthesis implanted 21 years ago. Two years before revision, the patient had a car accident with a two-points prosthesis breakage and despite the surgeon's advice, the patient refused surgery. In two years, prosthesis malfunction caused a progressive catastrophic soft tissues infiltration of metallic debris. DISCUSSION AND CONCLUSION: Authors suggest that if prosthesis fracture is detected, revision surgery should be attempted as earlier as possible.

Peri-Prosthetic Knee Infection Management: Spacers Loaded with Two or Three Antibiotic Agents.

BACKGROUND: The purpose of this work was to compare pre-made antibiotic-loaded spacers with two commercially available antibiotic agents and custom-made cements with three antibiotic agents added. We evaluated: (a) the validity of our procedures, (b) the control of the rate of infection in the long term, (c) complications, and (d) quality of life and patient satisfaction. METHODS: A retrospective cohort study was performed on 112 consecutively treated patients between January 2010 and December 2013; 56 patients were treated with a pre-formed cement spacer (clindamycin + gentamicin), and 56 patients were treated with a spacer loaded with three antibiotic agents (clindamycin + gentamicin + vancomycin). Demographic data were collected: Classification of infection according to criteria of Cierny-Mader; microbiologic results; number of previous operations; and years of disease. Infection control or relapse after at least 18 months of follow-up was evaluated. Complications were recorded. Every patient completed the SF-36 test and Oxford Knee Score. RESULTS: With a follow-up of 32.87 months (standard deviation 12.04), at the end of treatment, amputation occurred in three of 112 patients because of recurrence of infection, and one patient died from other causes not related to the infection. The study population presented a rate of recurrence of infection of 2.70%. CONCLUSIONS: Our results suggest that a two stage re-implant with three antibiotic agents added to the spacer should be considered to avoid rescue procedures, especially in patients with multi-resistant micro-organism infections.

Diagnostic relevance of the immunohistochemical detection of growth factors in benign and malignant cartilaginous tumors.

The goal of this study was to evaluate the diagnostic relevance of the expression of growth factors in cartilaginous tumors and to investigate on the possible correlation with grade, local recurrence, metastatic potential, and survival. Expression of VEGF, PDGF, FGF1, TFGbeta2, TNFalpha, Ki-67, and p53 was analyzed in 21 cases of benign and malignant cartilaginous tumors using immunohistochemistry. Immunohistochemical staining was performed on sections from paraffin-embedded tissue. The correlation of these markers' expression and grading or clinical outcome was also evaluated. Immunohistochemistry revealed a high correlation between grading and VEGF-positive staining (P=0.001). In addition, a correlation with local recurrence was found in cases with a positive expression of Ki-67 (P=0.035), TGFbeta (P=0.007), PDGF (P=0.007), and p53 (P=0.0455), with a time-related association. These data suggest a progressive modification in the biologic behavior of malignant cartilaginous tumors. VEGF could be used as a marker in the preoperative surgical assessment of chondrosarcoma. New therapeutic strategies could be considered for VEGF-positive cases. Positive expression of TGFbeta and PDGF seems to be a predictor of clinical outcome.

Central sensitization in chronic low back pain: A narrative review.

Low back pain is one of the four most common disorders in all regions, and the greatest contributor to disability worldwide, adding 10.7% of total years lost due to this health state. The etiology of chronic low back pain is, in most of the cases (up to 85%), unknown or nonspecific, while the specific causes (specific spinal pathology and neuropathic/radicular disorders) are uncommon. Central sensitization has been recently recognized as a potential pathophysiological mechanism underlying a group of chronic pain conditions, and may be a contributory factor for a sub-group of patients with chronic low back pain. The purposes of this narrative review are twofold. First, to describe central sensitization and its symptoms and signs in patients with chronic pain disorders in order to allow its recognition in patients with nonspecific low back pain. Second, to provide general treatment principles of chronic low back pain with particular emphasis on pharmacotherapy targeting central sensitization.

Medial collateral ligament reconstruction during TKA: a new approach and surgical technique.

Medial collateral ligament (MCL) injuries during total knee arthroplasty are rare but severe complications. They can be treated conservatively, by increasing prosthetic constraint, by using a thicker polyethylene insert, or by directly suturing the ligament. A prosthesis is successful to the extent that it ensures long-term knee stability. We describe our surgical approach to the restoration of knee joint stability in MCL deficiency: a reconstructive technique using the semitendinosus tendon.

Morpho-structural alterations of sub-chondral bone tissue in patients with osteoarthritis: a scanning electron microscopy study.

Osteoarthritis focuses principally on the degeneration of articular cartilage as a primary cause of the disease. The pathophysiological process of osteoarthritis is characterized by alteration of chondrocytes and the increased bone formation by sub-chondral osteoblasts. Infiltration of macrophages and perivascular T and B lymphocytes is observed, and these infiltrates have been demonstrated in both early and advanced disease. The morphological and phenotypic characteristics of osteocytic cells attached to the normal and the osteoarthritic matrix differ from each other, suggesting that specific signalling pathways arise or are altered between matrix and cells. On this basis, we have examined biopsies of bone obtained by normal femur and by femur of subjects affected by osteoarthritis using techniques of scanning electron microscopy in order to identify the morphostructural alterations that occur in the sub-chondral bone. Our results have shown that the bone tissue of subjects not affected by any disease of bone presents a well-organized structure, while the bone tissue obtained by patients affected by osteoarthritis shows a derangement of tissue itself possibly correlated with altered function of the osteoblasts, that during the pathological process produce a less mineralized extracellular matrix with consequent loss of the normal bone structure. In our opinion, during the osteoarthritic process there would be a defective signalling between bone cells leading to the production of an irregular, amorphous extracellular matrix by osteoblasts, characteristic of the pathological condition.

Corticosteroid Treatment Impact on Spinal Deformity in Duchenne Muscular Dystrophy.

Duchenne muscular dystrophy is a progressive disease with loss of ambulation at around 9-10 years of age, followed, if untreated, by development of scoliosis, respiratory insufficiency, and death in the second decade of life. This review highlights the natural history of the disease, in particular, with regard to the development of the spinal deformity and how this complication has been modified by surgical interventions and overall by corticosteroid treatment. The beneficial effect of corticosteroids may have also an impact on the clinical trial design of the new emerging causative therapies.