Pilot study of home phototherapy for neonatal jaundice monitored in maternity ward during the enforced Italy-wide COVID-19 national lockdown.

In Italy, where neonatal jaundice treatment is required, it is largely carried out in hospitals. However, it is possible to safely administer home phototherapy (HPT). We report our pilot center's experience of HPT and its potential benefits during the COVID-19-enforced national lockdown. This is an observational study performed at the Policlinic Abano Terme, a suburban hospital that covers a large catchment area near the Euganean Hills in Northeast Italy with around 1000 deliveries per year. HPT was started after regular nursery discharge, and the mothers brought the neonates back to the hospital maternity ward each day to check infants' bilirubin levels, weight, and general state of health, until it was deemed safe to stop. The efficacy of HPT in bilirubin reduction, hospital readmission rates, and parental satisfaction were evaluated. Thirty infants received HPT. In 4 of these infants, HPT was associated with total serum bilirubin (TSB) between 75 and 95th percentile (high-intermediate-risk zone) and in 26 infants HPT was associated with TSB > 95th percentile (high-risk zone) of the Bhutani nomogram. Among these 30 infants, 27 (90%) completed the HPT with a progressive decrease of TSB levels with 4 neonates requiring a second course and 3 infants requiring a third course of 24-h HPT. Three (10%) neonates failed HPT and were readmitted after one 24-h phototherapy course. No abnormalities of breastfeeding, body weight (defined as > 10% decrease), temperature, nor COVID infections were detected following HPT consultation in the neonatal ward. Home treatment efficacy with varying degrees of parental satisfaction occurred in all but 3 cases that involved difficulties with the equipment and inconsistent lamp manipulation practices. CONCLUSION: Our pilot study suggests that HPT for neonatal jaundice can be carried out effectively and with parental satisfaction as supported by daily back bilirubin monitoring in the maternity ward during the enforced COVID-19 national lockdown in Italy. WHAT IS KNOWN: • No high-quality evidence is currently available to support or refute the practice of phototherapy in patients' own homes. WHAT IS NEW: • Phototherapy can be delivered at home in a select group of infants and could be an ideal option if parents are able to return with their infants to the hospital maternity ward for daily follow-up. • It can be as effective as inpatient phototherapy and potentially helps in delivering family-centered care.

Release of gentamicin and vancomycin from preformed spacers in infected total hip arthroplasties: measurement of concentrations and inhibitory activity in patients' drainage fluids and serum.

Gentamicin (G) and vancomycin (V) concentrations in drainage fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision of infected total hip arthroplasty were studied. The inhibitory activity of drainage fluids against different multiresistant clinical isolates was investigated as well. Seven hips were treated by implantation of industrial G-loaded spacers. Vancomycin was added by manually mixing with PMMA bone cement. Serum and drainage fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and drains bactericidal titer of combination were determined against multiresistant staphylococcal strains. The release of G and V from PMMA cement at the site of infection was prompt and effective. Serum levels were below the limit of detection. The local release kinetics of G and V from PMMA cement was similar, exerting a pronounced, combined inhibitory effect in the implant site. The inhibitory activity of drainage fluids showed substantial intersubject variability related to antibiotic concentrations and differed according to the pathogens tested. Gentamicin and vancomycin were released from temporary hip spacers at bactericidal concentrations, and their use in combination exerted strong inhibition against methicillin-resistant S. aureus and Coagulase Negative Staphylococci strains.

Long-term results of femoral revision with the Wagner Self-Locking stem.

Femoral revision total hip arthroplasty may be a complex procedure due to extensive periprosthetic bone loss. Fluted, tapered stems provide secure axial and rotational stability in the distal femur. We retrospectively evaluated the long-term outcome of the cementless Wagner Self-Locking prosthesis (Sulzer Orthopedics Ltd, Winterthur, Switzerland). From 1992 to 1998, 68 consecutive femoral revisions were performed in 66 patients using the Wagner tapered stem. Twenty-five patients deceased for unrelated causes without additional surgery. The studied group consisted of 41 hips in 41 patients, 12 males and 29 females, aged from 29 to 80 years (mean 61 years). Thirty-five hips (85.4%) included severe deficiency of bone stock. A transfemoral approach was carried out in 32 cases (78%). Bone grafting was never supplemented. Average follow-up was 13.9 years (range 10.4 to 15.8 years). Clinical evaluation was performed using Harris Hip Score (HHS). Osseointegration of the stem and progression of periprosthetic bone remodelling were assessed radiographically. Five stems required rerevision because of deep infection (2), progressive subsidence (2) complicated by hip instability and head-neck disassembly, and old dislocation following acetabular component failure (1). Four hips (9.7%) dislocated, and 8 stems (19.5%) subsided significantly. Average HHS improved from 33 points preoperatively to 75 points at the latest follow-up examination (p < 0.001). Thirty-three of the 36 unrevised stems (91.7%) had radiographic evidence of bone ingrowth. A constant or decreased resorption of the femoral bone was detected in 34/36 patients (94.4%). The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the end points were 92.0% and 96.6%, respectively. The current study documents the efficacy of distal fixation to the diaphysis in revision of bone-deficient femoral components, supporting the use of tapered, fluted stems. Higher-risk complications (dislocation, subsidence) should be minimized by the development of modular stems.

Diagnosis of periprosthetic hip infection: a clinical update.

Periprosthetic joint infection (PJI) is a serious complication following hip arthroplasty, which is associated with significant health cost, morbidity and mortality. There is currently no consensus in the optimal definition of PJI, and establishing diagnosis is challenging because of conflicting guidelines, numerous tests, and limited evidence, with no single test providing a sensitivity and specificity of 100%. Consequently, the diagnosis of PJI is based on a combination of clinical data, laboratory results from peripheral blood and synovial fluid, microbiological culture, histological evaluation of periprosthetic tissue, radiological investigations, and intraoperative findings. Usually, a sinus tract communicating with the prosthesis and two positive cultures for the same pathogen were regarded as major criteria for the diagnosis, but, in recent years, the availability of new serum and synovial biomarkers as well as molecular methods have shown encouraging results. Culture-negative PJI occurs in 5-12% of cases and is caused by low-grade infection as well as by previous or concomitant antibiotic therapy. Unfortunately, delay in diagnosis of PJI is associated with poorer outcomes. In this article, the current knowledge in epidemiology, pathogenesis, classification, and diagnosis of prosthetic hip infections is reviewed.

Cemented and uncemented stems for displaced femoral neck fracture in the elderly. Retrospective study with a minimum 1-year follow-up.

BACKGROUND AND AIM: Displaced femoral neck fracture (FNF) is a common and significant health issue especially in older population because of the high rates of mortality and complications. The standard surgical treatment is total or partial hip replacement, including a cemented or uncemented stem. The cemented prosthesis is considered the safer option because of a lower rate of periprosthetic fractures (PPFs) as well as an actually reduced risk of bone cement implantation syndrome (BCIS). This retrospective study aims to assess the efficacy and safety of cemented versus uncemented femoral stem for FNF in patients ≥70 years. METHODS: 139 patients affected by displaced FNF underwent hip replacement, receiving 89 cemented (64%) and 50 uncemented (36%) stems. Inclusion criteria were: ≥70 years of age, an ICD-9-CM diagnose code 820.00, 820.01, 820.02, 820.03, 820.10, 820.8, and a minimum 1-year follow-up. A p value <0.05 was considered statistically significant. RESULTS: Surgical time, overall perioperative complication rate with a particular focus on the thromboembolic events, and PPFs incidence were evaluated comparing cemented and uncemented group. No difference in duration of surgery was found. Intraoperative complications were not detected. Pulmonary embolism and deep vein thrombosis were observed each in 1 case of cemented prosthesis. Periprosthetic femoral fractures occurred only in the uncemented group postoperatively, with a statistically significant difference (p<0.05). CONCLUSIONS: The low incidence of BCIS and the higher risk of postoperative PPFs in cemented and uncemented stems, respectively, suggest that the use of cementation is a safer procedure.

Trajectory of serum bilirubin in offspring of women with gestational diabetes mellitus.

AIMS: To investigate the trajectory of bilirubin from birth to the first 48 h of life in neonates of women with gestational diabetes. METHODS: In a cohort of 69 neonates of women with gestational diabetes, delivered at Policlinic Abano, Abano Terme, Italy, from October 2021 to May 2022, we conducted a case-control study (1:2 ratio) on total serum bilirubin (TSB) trajectory over the first 48 h after birth. An ancillary analysis was conducted on arterial cord blood gas analysis at birth and on concurrent hemoglobin, hematocrit, lactate, glycemia, and bilirubin levels. RESULTS: The neonates of women with gestational diabetes showed a significantly higher mean percent variation of TSB from birth to the first 48 h of life (p = 0.01), a finding supported by a higher, although not significant, TSB levels at 48 h of life in comparison to controls (8.05 ± 4.8 vs 8.05 ± 4 mg%, p = 0.082), and by a significantly lower cord TSB levels (2.3 ± 0.9 vs 2.6 ± 0.9 mg%, p = 0.010). CONCLUSIONS: The findings suggest that future primary studies on hyperbilirubinemia risk in neonates of women with gestational diabetes should consider the trajectory of TSB beyond the first 48 h, adjusting for a more complete set of pre-pregnancy and gestational prognostic risk factors.

A minimum of 10-year follow-up of the Burch-Schneider cage and bulk allografts for the revision of pelvic discontinuity.

Eighteen consecutive hips with pelvic discontinuity and associated periprosthetic bone deficiency were treated with bulk allografts and Burch-Schneider antiprotrusio cage. Clinical and radiographic follow-up was performed at an average of 13.5 (range, 10.5-16.6) years. Three cages required re-revision because of infection (1) and aseptic loosening (2). Average Harris hip score improved from 31.9 to 77.0 points (P < .001). A severe resorption of the bone graft occurred in 2 hips. The stability of the cage was detected in 13 cases. The cumulative survival rate at 16.6 years with acetabular revision for any reason, radiographic loosening, or unhealing of the discontinuity as the end point was 72.2%. The use of Burch-Schneider cage and bulk allografts is an effective technique for the treatment of pelvic discontinuity.

Calcium and lactate in the fetal-to-neonatal transition.

OBJECTIVE: To explore the relationship between calcium and lactate in arterial cord blood of healthy term neonates in response to the stress of labor. METHODS: This was a prospective cohort study of consecutive, vaginal, term births in a community medical center (April 2029 to February 2020). Calcium and lactate were measured in cord blood gas analysis immediately after delivery. RESULTS: In the arterial cord blood of 480 neonates, calcium levels were 1.5 (1.4; 1.5) mmol/L and lactate levels were 3.8 (2.9; 4.9) mmol/L. Calcium and lactate showed a statistically significant positive correlation (Pearson's correlation, r = 0.15, p = .001). Calcium levels had a significant positive correlation with PaCO2 and a significant negative correlation with pH, PaO2, HCO3-, and ABE levels. Multivariable analysis models confirmed that calcium levels were associated with HCO3-, gestational age, and birth weight, all accounting for 7% of the variability. CONCLUSION: In healthy term vaginally delivered neonates, it was found that calcium and lactate were strongly correlated, together pointing to a neonatal response to the stress of labor and delivery. Cord blood calcium regulation may have an ancillary role in defining neonatal adaptation to extrauterine life.

Postpartum bonding: the impact of stressful life events during pregnancy.

OBJECTIVE: We aimed to determine if and to what extent a woman's exposure to stressful life events were associated with impaired maternal bonding by using a sample of high-income Italian women. METHODS: In the second day postpartum, 425 healthy puerperae responded to Life Experiences Survey (LES), Mother-to-Infant Bonding Scale (MBS), and to the Edinburgh Postnatal Depression Scale (EPDS). RESULTS: Analysis revealed that the stressful life events scored by LES were a significantly predictor of impaired bonding as measured by MIBS (ß = 0.04; t = 3.45; p < .001) and of postpartum depression symptoms as measured by EPDS total score (ß = 0.32; t = 4.86; p < .001) as well as its subscales Anhedonia (ß = 0.059; t = 4.99; p < .001), Anxiety (ß = 0.03; t = 5.72; p < .001), and Depression (ß = 0.05; t = 6.53; p < .001). Moreover, the partial correlation between EPDS total score and MIBS accounting for LES positive and negative scores was statistically significant (r = 0.208; n = 332; p < .001). CONCLUSION: The findings emphasize the importance of identifying mothers with negative experiences toward pregnancy and delivery to address possible interventions beyond hospital-based antenatal care to improve bonding and maternal mental outcomes.

COVID-19 pandemic: Impact on gestational diabetes mellitus prevalence.

AIM: Although an increased risk of gestational diabetes mellitus (GDM) has been noted in women exposed to stressful conditions and traumatic events, limited information is available about such risk in the context of the COVID-19 pandemic. METHODS: The study was designed as a non-concurrent case-control study on the prevalence of GDM, defined according to IADPSG 2010, in women giving birth during the COVID-19 pandemic in the hot spot of Northeast Italy from March 9th to May 18th, 2020, with an antecedent puerperae-matched group whose women had given birth in 2019. RESULTS: Analysis revealed that during the COVID-19 pandemic in 2020, GDM prevalence was significantly higher than in 2019 (GDM, 48/533, 9 vs 86/637, 13.5%, p = 0.01), as illustrated by a higher GDM prevalence in 5/6 months of the final semester of 2020. In addition, logistic regression analysisconfirmed a statistically significant temporal relationship between experiencing the lockdown during the first trimester of gestation and later GDM incidence (t = 2.765, P = 0.012), with an 34% increase in mean number of GDM diagnoses per month (antilog of the parameter = 1.34). CONCLUSION: The COVID-19 pandemic negatively impacted GDM prevalence in 2020 compared to 2019, especially for pregnant women in the 1st trimester of gestation.

Late intraprosthetic dislocation of a monoblock dual-mobility cup cemented into a well-fixed cementless acetabular shell. A case report.

Intraprosthetic dislocation (IPD) is a specific implant-related complication of dual mobility (DM) implants, which is defined as a dissociation of polyethylene (PE) liner from the femoral head. We report a unique case of  late IPD of a monoblock DM cup cemented into a well-fixed cementless acetabular shell for recurrent dislocation of total hip arthroplasty (THA). A 77-year-old woman was admitted to our department for acute right hip pain, functional impairment and inability to bear weight without any trauma. Three years earlier, she underwent revision THA for recurrent dislocation with a monoblock DM cup cemented into a well-fixed cementless acetabular shell according to the "double-socket" technique. Three months after that revision the patient experienced an anterior THA dislocation, which was managed by closed reduction under sedation in the emergency room. No additional episodes of prosthesis instability occurred. Upon admission, radiographic evaluation showed  right THA dislocation. X-rays performed  after closed reduction revealed eccentric positioning of the head inside the cup, and a direct contact between the metal head and the cup was revealed by subsequent CT scan, confirming the suspicion of IPD. The patient underwent revision surgery, during which the PE liner was found lodged within the cup in a subluxated position, disassembled from the inner head. Both the acetabular cup and modular femoral stem proved well-fixed and impossible to remove, therefore they were retained. The explanted DM components were replaced with new ones of the same size and, thanks to the femoral neck's modular nature, it was substituted with a longer one, which resulted in improved stability against intraoperative stress maneuvers. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a good functional recovery.

Six-year follow-up of a preformed spacer for the management of chronically infected total hip arthroplasty.

Antibiotic-loaded cement spacers are currently used in two-stage revision of septic total hip arthroplasty as temporary devices. Prolonged spacer implantation in infected shoulder has been described occasionally in poor candidates for reconstruction surgery (medically compromised and/or low-physical demand patients, deficient bone stock). Few papers previously reported the use of spacers in infected hip prosthesis as a permanent solution, but limited information is available on the medium-term behaviour. We detail medium-term clinical and radiographic follow-up of a preformed spacer in the management of a chronically infected hip arthroplasty in a 50-year-old female patient who did not undergo a second-stage surgery. Normalization of inflammatory markers was detected 3 weeks after surgery and persisted over time. Six years after surgery, the patient recovered a good range of motion and was able to walk pain free with assisted weightbearing. Remarkable radiological changes of the bone stock around the spacer stem have been assessed. New bone formation developed rapidly in the femur, leading to the consolidation of transfemoral osteotomy 6 months postoperatively. Two years after implantation, spontaneous and asymptomatic fatigue fracture in the mid-part of the stem occurred. Radiographs at 6 years showed a sufficient preservation of bone stock, though a slowly progressive resorption of the cortical femur around the stem was evident in the last year. In conclusion, prolonged spacer implantation seems to be not appropriate in septic hip arthroplasty as a permanent solution. In patients not undergoing a second-stage surgery, a careful and periodic monitoring is required to rule out possible and severe complications.

Fourth generation head fracture in ceramic-on-polyethylene bearing after hip revision surgery: a case report.

Fourth generation ceramic bearings (BIOLOX delta, CeramTec AG; Phlochingen, Germany) were developed to reduce wear debris and improve fracture resistance. A case of a fourth generation head fracture in ceramic-on-polyethylene (COP) coupling after hip revision surgery is reported. A 58-year-old man was admitted to our department for increasing hip pain following a direct trauma which occurred during skiing activity 4 months before. Six years earlier, he had undergone a right cementless revision surgery with a 36-mm BIOLOX delta femoral head on polyethylene liner for metallosis and foreign body reaction after primary total hip replacement for hip osteoarthritis. At admission, radiological evaluation revealed a fracture of ceramic femoral head requiring a new revision surgery. Extensive synovectomy, lavage and capsulectomy were performed. Both acetabular cup and femoral stem were well fixed with no damage of trunnion, and therefore they were retained. A 36-mm internal diameter polyethylene acetabular liner was inserted along a 36-mm BIOLOX delta head with a BioBall adapter XL. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a complete functional recovery. To our knowledge, BIOLOX delta ceramic femoral head fracture after COP hip revision surgery has not been previously reported.

Stem modularity alone is not effective in reducing dislocation rate in hip revision surgery.

BACKGROUND: Dislocation is a serious complication following total hip arthroplasty (THA). Femoral revision using monoblock components has been associated with high incidence of subsidence and dislocation. Advantages of modular stems in THA have long been debated. The aim of this retrospective study is to assess the capability of an uncemented modular stem in decreasing the incidence of early dislocation subsequent to revision THA. MATERIALS AND METHODS: We evaluated the dislocation rate during the first 2 years following revision surgery in two groups of patients who were treated by implantation of a cementless tapered femoral prosthesis; a standard-modularity stem (Wagner SL) and an increased-modularity stem (Profemur R) were used, respectively, in 66 hips (group I, 64 patients) and 102 hips (group II, 97 patients). Group I consisted of 47 females and 17 males with average age of 66 years (range 29-84 years). Group II included 60 females and 37 males with average age of 70 years (range 48-89 years). RESULTS: Dislocation occurred in six hips (9.1%) of group I and in seven hips (6.8%) of group II (P = 0.401). Dislocations were observed early in both groups, except one hip in group II that dislocated 434 days postoperatively and required surgical reduction. All other dislocations were treated by closed reduction. No recurrence was observed. CONCLUSIONS: The use of an increased-modularity revision stem alone did not prove to be effective in reducing the risk of postoperative dislocation.

Incomplete, stable-like, peri-prosthetic Vancouver B fracture around an ha-coated stem. Is there a case for strategic thoughtful neglect?

The Periprosthetic fracture of the proximal femur is usually treated by internal fixation of the fracture or revision of the femoral stem depending on the characteristics of the fracture and stability of the implant. This case report shows an early periprosthetic fracture around an uncemented straight stem which is treated conservatively with an excellent clinical radiographic result and explains the biomechanics related to this non-operative choice. A conservative treatment of periprosthetic fracture is possible but only after a careful analysis of the fracture pattern, the characteristics of the prosthetic stem and the time elapsed from implanting the prosthesis to the fracture.

Open patellar tendon avulsion from tibial tuberosity after ACL reconstruction successfully treated with suture anchors.

Patellar tendon rupture after anterior cruciate ligament (ACL) reconstruction is a rare complication which usually occurs in the early postoperative period during rehabilitation. The management of open avulsions from tibial tuberosity has not been clearly defined yet. We describe a previously unreported case of traumatic and open patellar tendon avulsion from tibial tuberosity one year following ACL reconstruction in an elite football player which was successfully treated with suture anchors.