Targeting the safe zones for cup position without fluoroscopic guidance in total hip arthroplasty: does the surgical approach affect the outcomes?

BACKGROUND: Proper acetabular cup positioning is crucial for achieving implant longevity and stability in total hip arthroplasty (THA). One of the elements that may affect the accuracy and precision of the positioning of the cup is the type of surgical approach used. This study compares the accuracy and the precision of conventional free-hand acetabular cup positioning relative to different "safe zones" in two groups of patients operated with THA using two different surgical approach. METHODS: Retrospective radiological comparative matched-pair controlled study of two groups of patients operated with primary THA: the first group was operated in supine decubitus with a mini-invasive direct anterior approach (DA group), the second group was operated in lateral decubitus with a conventional posterolateral approach (PL group). Cup inclination and anteversion were assessed using the digital planning software TraumaCad. Cup position in the two groups were compared in terms of accuracy and precision. RESULTS: Forty four patients were enrolled for each group. The DA group showed a less inclined and less anteverted cup compared to the PL group (respectively 38.5 ± 5.2 vs. 49.6 ± 5.6 and 16.2 ± 3.6 vs. 22.9 ± 6.4; p < 0.01). The DA group showed a significantly higher percentage of cups within the "safe zone" in 4 out of 6 reference zones and a significantly lower variance in anteversion (12.96 vs. 40.96, p < .01). There was no difference in the variance for inclination. CONCLUSIONS: Our study found greater accuracy and precision in the positioning of the cup when surgery was performed through a direct anterior approach compared to the posterolateral approach due to the supine position of the patient which allows greater stability of the pelvis during surgery and makes it easier to target the desired angular references for cup positioning.

Correction to: Biomechanical reconstruction parameters obtained after direct anterior approach total hip arthroplasty do not compromise clinical outcome.

The original version of this article unfortunately contained a mistake. Figures 3 and 4 captions were interchanged.

Biomechanical reconstruction parameters obtained after direct anterior approach total hip arthroplasty do not compromise clinical outcome.

INTRODUCTION: Accurate reconstruction of biomechanical parameters following total hip arthroplasty (THA) is crucial for good joint function. We investigated how reconstruction parameters achieved by minimally invasive anterior (MIS) THA may influence function and patient-related outcomes. METHODS: A consecutive series of 95 patients treated by MIS THA for primary osteoarthritis were retrospectively reviewed. Primary outcome measures were Harris Hip Score (HHS), hip disability and osteoarthritis outcome score (HOOS) and EQ-5D. Femoral offset (FO), abductor lever arm (ALA), centre of rotation (CoR), leg length discrepancy (LLD), cup version and stem alignment were measured pre- and post-operatively. Obtained reconstruction parameters compared to the contralateral hip were used as independent variables in a multivariate regression with each primary outcome measure as dependent variable. RESULTS: Mean age at surgery was 69 years. HHS rated 94.7% of patients as good/excellent and mean EQ-5D was 0.82. Post-operative HOOS subscales showed no statistical difference compared to the Italian benchmark population. Stem alignment averaged 0.2° valgus, mean cup inclination was 37.8° and mean anteversion was 12.8°. When compared to the contralateral side, CoR was post-operatively elevated by 2.6 mm and medialized by 2.4 mm averagely. An average FO reduction of -0.5 mm was observed while FO ratio increased by 1.9% averagely. ALA decreased by -3.3 mm while LLD was 2.3 mm averagely. Multivariate regression analysis revealed a significant contribution of ALA to HHS only. CONCLUSIONS: Biomechanical parameters achieved by MIS THA are satisfactory with negligible impact on functional results and no impact on patient-related outcomes certifying the high quality achieved in THA.

Year to year comparison of 2000-2015 in hip fracture management: same survival rate despite older and more fragile patients.

PURPOSE: The aim of this study was to compare clinical data, comorbidities and survival rates at 30 days and 1 year in two groups with femoral fractures, the first including patients admitted in 2000, and the other including patients admitted in 2015. The hypothesis of the study is that patients admitted in 2015 have more comorbidities and will therefore have a lower survival rate at 30 days and 1 year from trauma. METHODS: Patients admitted to the hospital with proximal femoral fractures in 2000 (90 patients) and 2015 (167 patients) were retrospectively reviewed. The following data were collected: age, gender, source of admission, ASA score, comorbidities, time from admission to surgery and length of hospital stay. The Charlson Comorbidity Index (CCI) score, a measure of comorbidity, and the Nottingham Hip Fracture Score (NHFS), a predictor of 30-day and 1-year mortality after hip fracture, were both calculated. RESULTS: Patients in the 2015 group were older and more institutionalized before fracture (p < 0.05), with a significant increase in Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure and renal impairment. The length of stay was significantly lower in 2015. The NHFS and CCI were significantly higher in 2000. Mortality at 30 days and 1 year did not differ significantly in 2000 when compared to 2015. The CCI had the best predictive ability for mortality in both groups at 30 days and 1 year. CONCLUSIONS: The increase of comorbidities was not found to be correlated to increased mortality. This could be explained by enhanced patient management permitting earlier mobilization and weight bearing.

An algorithm for predicting blood loss and transfusion risk after total hip arthroplasty.

INTRODUCTION: Patients receiving blood transfusions after total hip arthroplasty have increased morbidity and longer lengths of stay compared to non-transfused patients. The aim of this study is to create an algorithm in order to identify patients at risk for transfusion after total hip replacement and define a safe point in hemoglobin levels after which the need for blood, transfusion can be excluded. METHODS: This retrospective study analyzed hemoglobin (Hb) levels for 5 days in patients undergoing total hip replacement. An algorithm was implemented to identify the critical trends of Hb levels in the first two postoperative days, trying to identify the patients at high risk of transfusion. Specificity, sensibility and efficiency were calculated in relation to the capability of the algorithm to correctly identify transfused patients. RESULTS: The algorithm found a pre-operative Hb ≥ 13 g/dl as a cut off between patients at low-risk or high-risk for transfusion. When parameters were calculated considering the best efficiency with the least number of false negatives, the algorithm showed a specificity of 84% and a sensitivity of 70% with an efficiency of 80.6%. Hb values >10 g/dl in the first operative day for low-risk patients and Hb level > 11 g/dl the second post-operative day for high-risk patients led to exclusion of the need for transfusion. CONCLUSIONS: The algorithm suggested critical Hb levels to predict transfusion. In association with clinical data, the suggested critical values of Hb may be useful to schedule lab tests and a safe early discharge.

Long-term results of the M2A-38-mm metal-on-metal articulation.

BACKGROUND: Large-diameter head metal-on-metal (MoM) bearings in total hip arthroplasty (THA) are associated with increased whole blood levels of chromium (Cr) and cobalt (Co), adverse reactions to metal debris (ARMD) and poor survival rates. The prevalence of high metals concentrations, ARMD and the risk of revision surgery may vary significantly among different prostheses and long-term studies are few. This single-center study reports the long-term results of the 38-mm MoM bearing system. MATERIALS AND METHODS: Between 2003 and 2009, 80 patients received primary cementless THA using the large head metal-on-metal articulating surface M2A-38 cup (Biomet, Inc., Warsaw, IN, USA) at a single institution. Forty-five patients (53 hips) were retrospectively reviewed for a mean follow-up of 127 months. RESULTS: Two cups were revised. The cumulative implant survival rate was 98% at 10 years and 74% at 13 years. In the whole sample, the median Co and Cr concentrations were 4.8 µg/L (IQR 1.2-4.9 µg/L) and 2.5 µg/L (IQR 0.6-3.0 µg/L), respectively. The incidence of Co or Cr levels > 7 µg/L was 15.5% and the incidence of ARMD was 3.8%. Co and Cr levels showed no correlation with cup inclination, Harris Hip Score, or total Hip Disability and Osteoarthritis Outcome score. CONCLUSIONS: Our results confirm that the problems of release of metal ions with the possible increase of metal circulating levels and of adverse reactions may also occur in the long term with this brand of MoM large head, and that a structured follow-up program is mandatory. LEVELS OF EVIDENCE: Level 4.

Large-scale population analysis challenges the current criteria for the molecular diagnosis of fascioscapulohumeral muscular dystrophy.

Facioscapulohumeral muscular dystrophy (FSHD) is a common hereditary myopathy causally linked to reduced numbers (≤8) of 3.3 kilobase D4Z4 tandem repeats at 4q35. However, because individuals carrying D4Z4-reduced alleles and no FSHD and patients with FSHD and no short allele have been observed, additional markers have been proposed to support an FSHD molecular diagnosis. In particular a reduction in the number of D4Z4 elements combined with the 4A(159/161/168)PAS haplotype (which provides the possibility of expressing DUX4) is currently used as the genetic signature uniquely associated with FSHD. Here, we analyzed these DNA elements in more than 800 Italian and Brazilian samples of normal individuals unrelated to any FSHD patients. We find that 3% of healthy subjects carry alleles with a reduced number (4-8) of D4Z4 repeats on chromosome 4q and that one-third of these alleles, 1.3%, occur in combination with the 4A161PAS haplotype. We also systematically characterized the 4q35 haplotype in 253 unrelated FSHD patients. We find that only 127 of them (50.1%) carry alleles with 1-8 D4Z4 repeats associated with 4A161PAS, whereas the remaining FSHD probands carry different haplotypes or alleles with a greater number of D4Z4 repeats. The present study shows that the current genetic signature of FSHD is a common polymorphism and that only half of FSHD probands carry this molecular signature. Our results suggest that the genetic basis of FSHD, which is remarkably heterogeneous, should be revisited, because this has important implications for genetic counseling and prenatal diagnosis of at-risk families.

Aseptic osteonecrosis of the hip in the adult: current evidence on conservative treatment.

Treatment of Avascular Osteonecrosis (AVN) of the femoral head to prevent progression to an arthritic hip is a challenging subject. Many conservative treatment options have been proposed in the literature. Weight bearing restriction as a stand-alone therapy is insufficient in preventing disease progression but it may be useful when combined with pharmacological agents or surgery. Bisphosphonate treatment in AVN might be efficient in early stages of disease, however there are no clear recommendations on length of treatment and therapeutic dosage and, considered the limited evidence and potential side effects of treatment, it could be considered in a pre-collapse stage in selected cases. Current literature suggests that low molecular weight heparin could lower disease progression in idiopathic AVN with quality of evidence being very low. Also the evidence to support the use of statins or vasodilators in the treatment of osteonecrosis is very low and their use cannot be recommended. Extracorporeal shock wave therapy may improve pain and function in early stages of disease with a low evidence, but there doesn't seem to be a significant change in time to the occurrence of femoral head collapse. Only one study has been conducted with pulsed electromagnetic fields therefore no recommendation can be given on clinical use of PEF in AVN. Evidence on hyperbaric oxygen therapy in the treatment of AVN is very limited and the high cost of treatment and the limited availability of structures that can provide the service poses other concerns about its feasibility. Based on current evidence, conservative treatment may be considered in early stages of asymptomatic AVN instead of observation only.

Undiagnosed myopathy before surgery and safe anaesthesia table.

Patients with muscle pathology are a challenge for anaesthesiologists because of possible life-threatening general anaesthesia complications. A review of the current medical literature on the issue clearly indicates that increasing awareness by anaesthesiologists in recent years has led to a reduction in the occurrence of adverse events in patients with diagnostically well-defined muscle disease. On the other hand, the current emerging aspect is that the great majority of complications concern subjects with clinically non-overt (silent to mildly symptomatic) and thus undiagnosed myopathy. With a view to improving prevention of possible critical anaesthesia complications in such patients, we present a "Safe Anaesthesia Table", listing both the anaesthetic drugs to be avoided and those considered harmless for myopathic patients, irrespective of age and type of pathology. In addition, a brief outline about the clinical aspects suggestive of a possible muscle pathology is also provided. Using "safe drugs" during routine surgical procedures in subjects with suspected undiagnosed myopathy will enable the anaesthesiologist to avoid delaying surgery, while protecting them from anaesthesia complications. By following this approach the presumed myopathy can be properly investigated after surgery.

Considerations on evolution and healing of vertebral fractures.

Only little is known when talking about the evolution of a vertebral fracture. From the few studies available in the literature, we can deduce that the risk a vertebral compression fracture has to worsen its deformity is consistent. It is important to try to make a prognosis on how the fracture is going to heal based on the type of fracture encountered. A chapter of its own is the occurrence of a vertebral fracture non-union that is difficult to diagnose and treat, but comes along with a poor prognosis.

Bisphosphonate treatment for osteolysis in total hip arthroplasty. A report of four cases.

Aseptic loosening due to wear debris is the most frequent modality of failure in total hip arthroplasty. Bisphosphonates, a class of molecules which inhibit bone resorption showed an inhibitory effects on particles-induced osteolysis in vitro and in animal models. We report the clinical, radiographic and densitometric outcome of four postmenopausal women with total hip arthroplasty affected by peri-prosthetic osteolysis treated with neridronate due to their unwillingness to be operated. After neridronate treatment, there was general improvement in pain and function: VAS decrease 13 points (15%), the Harris Hip Score increase 9 points (15%). An average number of 3.3 x-ray per patients with an average follow-up of 23 months (range 12-34) were collected and evaluated. In all the patients except one, serial radiographs didn't show any progression of radioluciencies lines or periprosthetic osteolysis. Bone density was evaluated by Dual energy X-ray absorptiometry after an average follow-up of 21 months (range 6-46 mo): periprosthetic BMD around the whole stem and the cup increased respectively 2.4% and 7.1%. Treatment was well tolerated and no significant side effects were registered. This retrospective collection of a small group of patients suggest that bisphosphonates should be clinically useful in preventing periprosthetic wear debris mediated osteolysis and claim for dedicated clinical trials.

Treatment Satisfaction, Efficacy, and Tolerability of Low-Dose Diclofenac Epolamine Soft Capsules in Acute, Mild, or Moderate Musculoskeletal Pain: A Prospective Open-Label, Single-Arm Interventional Study.

INTRODUCTION: The use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) for acute musculoskeletal pain should be at the lowest effective dosage and for the shortest duration to minimize potential adverse effects. This study evaluated treatment satisfaction, effectiveness, and tolerability of a low-dose diclofenac epolamine 12.5-mg soft capsule formulation (DHEP 12.5-mg capsules) using patient-reported outcome measures in a real-life setting over a short period (3 days) in subjects with mild-to-moderate acute musculoskeletal pain. METHODS: A prospective, open-label, phase IV clinical study in adult outpatients at hospital clinic departments/general practitioner's clinics at eight sites in Italy. The primary efficacy variable was the degree of satisfaction with treatment at 72 ± 7 h after initiation of treatment, assessed using the Overall Satisfaction Question of the Pain Treatment Satisfaction Scale (PTSS) and described by classic descriptive statistics. Secondary objectives were to evaluate the analgesic effect after the first administration and over time; the time to and satisfaction with the onset of pain relief, amount of and duration of pain relief; pain intensity differences over time; and safety and tolerability. The investigator's satisfaction with the treatment was also assessed. Subjects initially took 1-2 capsules of the study treatment and then one or two soft capsules every 4-6 h according to their needs. Not more than six soft capsules were to be taken in any 24-h period. RESULTS: A total of 182 subjects (mean age, 56.2 years; 54.4% female) took ≥ 1 dose of DHEP capsule and were included in the full analysis set. The most common musculoskeletal conditions were arthralgia (39.0%) and low back pain (23.1%). All subjects completed the study, and 165/182 (90.7%, 95% CI 0.86, 0.95) were satisfied or very satisfied with the treatment at 72 ± 7 h after the first dose (primary efficacy variable). Similar percentages were recorded for treatment satisfaction concerning other efficacy parameters. The onset of the analgesic effect was rapid, with complete pain relief reached after a mean of 49.45 min. Investigators rated their overall treatment satisfaction as 92.9%. Treatment was well tolerated. CONCLUSIONS: The low-dose (12.5 or 25 mg) oral diclofenac epolamine soft capsules formulation exerted rapid, effective, and safe analgesic activity in patients with mild-to-moderate musculoskeletal pain, with subjects' overall satisfaction with treatment more than 90%. TRIAL REGISTRATION: EudraCT Number: 2018-004886-15 (Study 18I-Fsg08). Registered 04/09/2018.

Taper-wedge stem suitable for anterior approach total hip arthroplasty: Adequate biomechanical reconstruction parameters and excellent clinical outcome at mid-term follow-up.

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) is a less invasive and muscle-sparing approach that seems to improve early function and patient satisfaction. Several studies, however, have reported high complication and revision rates due to the technical difficulties related to the femoral preparation. AIM: To evaluate the usefulness and safety of a new stem equipped with a morphometric design and a size-specific medial curvature in DAA for THA. METHODS: This retrospective study was based on 130 patients that underwent mini-invasive DAA procedures for THA using the Accolade II stem. A total of 144 procedures were included in the assessment, which was based on postoperative complications, survival rates, functional parameters, and patient related outcomes. RESULTS: Overall complications were recorded in 6 procedures (4.2%). There were no complications related to the stem implantation and no intraoperative fractures. Only one patient was revised for deep infection. On radiographs, biomechanical hip reconstruction was satisfactory and no stem showed any subsidence greater than 2 mm. Full osseointegration based on Engh scores was seen in all of the implanted stems. Median Harris hip score at final follow-up was 99 points (range 44-100 points), which resulted excellent in 91.3% of patients. The median values of the osteaorthritis outcome score ranged from 87.5 to 95. CONCLUSION: The mid-term positive outcomes and low complication rate in our consecutive series of patients support the safety and suitability of this new stem design in DAA for THA.

All-arthroscopic Knee Patellofemoral Ligament Repair.

Patellar dislocations are common injuries in the pediatric and adolescent population, with an estimated mean incidence of 42/100,000 person-years. The medial patellofemoral ligament is the most important structure preventing lateral patellar translation, whereas its patellar attachment is frequently damaged after patellar dislocations. This technical note presents an all-arthroscopic medial patellofemoral ligament repair technique suggested after a first episode of patellar dislocation.

Spinal cord herniation: a missing piece in the pathogenesis of amyotrophic lateral sclerosis and multiple sclerosis?

BACKGROUND: Idiopathic spinal cord herniation (SCH) is a rare and often misdiagnosed condition characterized by displacement of the spinal cord through an anterior defect of the dural sac. This condition determines continuous focal trauma of the spinal cord, causing slowly progressive myelopathy. The peculiar MR scan findings, particularly sagittal T(2)-weighted images, allow its recognition. OBJECTIVE: Herein, we report 3 cases of SCH and suggest a possible association with trauma-related neurodegenerative or chronic inflammatory diseases. METHODS: We reviewed the clinical files of all patients admitted to our hospital with a history and signs of progressive myelopathy (paraparesis and/or lower extremity hypoesthesia) who were diagnosed with SCH by MRI. RESULTS: We found 3 female patients (37, 69 and 68 years of age) with a diagnosis of SCH. Two of them presented with concomitant, relatively rare disabling neurological diseases, namely amyotrophic lateral sclerosis and multiple sclerosis. The third patient underwent surgery and gradually recovered over 6 months. CONCLUSIONS: Persistent central nervous system trauma due to idiopathic SCH might provide an unexpected hint about the pathogenesis of amyotrophic lateral sclerosis and multiple sclerosis.

Fifteen years change in acute management of hip fracture patients: 1-year mortality calls for improvements.

INTRODUCTION: Over the past two decades, the average age of hip fractured patients has increased, patients are increasingly fragile and their management is more complex. Most of the literature suggest that care improvement lowered short-term mortality but there is no clear evidence whether mid- and long-term mortality rates are improving. The aim of this study was to evaluate the variations in comorbidities in hip fractured patients over 15 years, the changes in mortality and identify the predictive factors for mortality for identifying the patients at higher risk. MATERIALS AND METHODS: Hip fractured patients admitted in hospital in 2000-2001 (192 patients) and 2015-2016 (323 patients) were retrospectively reviewed. Demographic, clinical and management data from the two cohorts were compared. Thirty-day and 1-year mortality were calculated and compare between the two cohorts. A multivariate logistic regression model were performed to identify the most significant predictors of mortality. RESULTS: After fifteen years, mean age of hip fracture patients increased by 2.6 years with a 31% increase in comorbidity. The most prevalent comorbidities were hypertension, COPD, diabetes, arrhythmia, renal impairment and dementia. In the 2015-2016 cohort, the age-adjusted mortality at 30 days significantly declined compared to the 2000-2001 cohort (respectively 6.9% vs. 12.5%) but the age-adjusted mortality at 1-year was equivalent. Older age, reduced mobility, higher comorbidity, lateral fractures and male sex were significant risk factors for reduced survival time CONCLUSIONS: After 15 years, there was a significant improvement in 30-days mortality in hip fractured patients despite their increase in comorbidities but this advantage was not observed in 1-year mortality. This suggests the need to implement targeted and longer-term care support for males, older patients and those with greater comorbidities which are at higher risk.

Comparison of the Therapeutic Effect of Treatment with Antibiotics or Nutraceuticals on Clinical Activity and the Fecal Microbiome of Dogs with Acute Diarrhea.

Dogs with acute diarrhea are often presented to clinical practice and, although this generally represents a self-limiting condition, antibiotics are still frequently used as treatment. The aim of this study was to evaluate the effects in dogs with acute non-hemorrhagic diarrhea of the administration of an antibiotic combination in comparison to a nutraceutical product. Thirty dogs were enrolled and randomly assigned to two groups: 15 dogs (group A) received a nutraceutical commercial product while 15 dogs (group B) received an antimicrobial combination of metronidazole and spiramycin. For each dog, the Canine Acute Diarrhea Severity Index, the fecal microbiota and the Dysbiosis Index were assessed. Both stool consistency and frequency decreased on day 2 in the dogs of group A compared to baseline, while in group B, these parameters significantly decreased at days 3 and 4. The global concern for rising antibiotic resistance associated with indiscriminate use of antimicrobials, in both humans and animals, suggests the necessity of avoiding empirical and injudicious use of these molecules in diarrheic dogs. These results suggest that the nutraceutical treatment had a similar clinical effect compared to the antibiotic formulation, representing a valid antibiotic-sparing therapeutic approach in canine acute diarrhea.

Antero-inferior paralabral cyst of the shoulder: An atypical cause of rapidly evolving axillary and musculocutaneous nerve palsy.

Paralabral cysts of the shoulder are a rare cause of shoulder pain. Their association with neurological symptoms is uncommon. This case report presents an antero-inferior paralabral cyst in a painful atraumatic shoulder causing axillary and musculocutaneous nerve palsy. The patient in the present study showed a rapidly worsening active shoulder function with dull pain in the posterior shoulder and hypoesthesia over the deltoid. Magnetic resonance imaging revealed an antero-inferior paralabral cyst. Electromyography showed a profuse denervation of the deltoid, teres minor and biceps brachii muscles. The patient was diagnosed with a axillary and musculocutaneous nerve compression neuropathy caused by the cyst. Shoulder arthroscopy was performed with the goal of decompressing the cyst and explore the terminal branches of the brachial plexus. During surgery a partial labral tear was detected and anatomically repaired after cyst resection. Exploration of the terminal roots of the plexus brachialis showed the presence of dense fibrotic tissue that was released. Shoulder function recovered completely after surgery. Paralabral cysts are rare and surgical management consists of cyst removal and labral repair. In presence of neurological symptoms exploring the retrocoracoid plexus may be a useful option to check for fibrosis around the nerves that could limit or slow down nerve recovery.

Comparative transcriptional and biochemical studies in muscle of myotonic dystrophies (DM1 and DM2).

Myotonic dystrophy type 1 (DM1) and myotonic dystrophy type 2 (proximal muscular myopaty/DM2) are caused by similar dynamic mutations at two distinct genetic loci. The two diseases also lead to similar phenotypes but different clinical severity. Dysregulation of alternative splicing has been suggested as the common pathogenic mechanism. Here, we investigate the molecular differences between DM1 and DM2 using reverse transcriptase-polymerase chain reaction of troponin T (TnT) and the insulin receptor (IR), as well as immunoblotting of TnT in muscle biopsies from DM1 and DM2 patients. We found that: (a) slow TnT was encoded by two different transcripts in significantly different ratios in DM1 and DM2 muscles; (b) DM2 muscles exhibited a higher degree of alternative splicing dysregulation for fast TnT transcripts when compared to DM1 muscles; (c) the distribution of TnT proteins was significantly skewed towards higher molecular weight species in both diseases; (d) the RNA for the insulin-independent IR-A isoform was significantly increased and appeared related to the fibre-type composition in the majority of the cases examined. On the whole, these data should give a better insight on pathogenesis of DM1 and DM2.