Can porous tantalum acetabular cups and augments restore the hip centre of rotation in revision hip arthroplasty? Long-term results.

BACKGROUND AND AIM: Loss of bone stock is the main problem in revision hip arthroplasty. Porous tantalum cups and augment constructs are possible solutions. The aim of this study was to describe results at an average follow-up of 10 years using these cups. METHODS: 25 patients underwent to revision hip arthroplasty with porous tantalum cups. Acetabular bone defects were classified according to Paprosky's in type II and III. All patients were reviewed clinically and radiographically at an average follow-up of 10 years (range 8.5 to 13 years). Changes in inclination angle of the cup and position of the hip centre of rotation (COR - measured and calculated using Pierchon's method), and possible periacetabular radiolucency lines were assessed. RESULTS: A statistically significant improvement in Harris Hip Score and hip range of motion was observed. The hip COR had been lowered by 19.33 mm after revision and no changes in COR position had been measured at follow-up. Kaplan-Meier survivorship was 100% at an average follow-up of 10 years, considering acetabular revision for any reasons as primary endpoint. 88% of patients was satisfied. Complications were 3 dislocations, 4 asymptomatic heterotopic ossifications and 1 partial reabsorption of greater trochanter. CONCLUSIONS: Porous tantalum cups and augments can be considered a valid solution in acetabular revisions for addressing massive bone defects and restoring the hip COR.

Factors influencing results and complications in proximal periprosthetic femoral fractures: a retrospective study at 1- to 8-year follow-up.

BACKGROUND AND AIM: Proximal periprosthetic femoral fractures (PPFFs) are gradually increasing and surgical management is often associated to high risk of complications, due to elderly population and associated comorbidities. We retrospectively assessed 79 patients at 1- to 8-years follow-up, focusing on factors that may have affected results and complications. METHODS: Seventy-nine PPFFs were classified according to Vancouver classification in: 4 type B1, 22 type B2, 29 type B3, 24 type C. The average age of the patients was 81.5 year-old (61-95). 37 PPFFs (12 type B2 and 25 type B3) were treated with uncemented tapered fluted revision stems (Link MP Recostruction Stem, Waldermar Link GmbH) and 42 patients with open reduction and internal fixation (ORIF). Patients were clinically and radiographically assessed at a mean 5-year follow-up (1-8 years). Elixhauser Comorbidity index was analysed. RESULTS: All PPFFs, except two, healed within 10 months. Harris Hip score at follow-up was 65.6 in ORIF group and 79.8 in revision hip group (p<0.05). 35.7% and 32.4% had blood transfusions in ORIF and revision hip group respectively (p> 0.05). 5 patients in ORIF group and 2 patients in revision hip group died within 12 months from surgery (p<0.05). CONCLUSIONS: Both ORIF and hip revision arthroplasty with modular uncemented tapered fluted stems are valid procedures for Vancouver B2 and B3 PPFFs. Restricted weight-bearing, high number of comorbidities with elevated Elixhauser Comorbidity Index and ORIF are associated to high 12-month mortality.

Complex open elbow fracture-dislocation with severe proximal ulna bone loss: a case report of massive osteochondral allograft surgical treatment.

We report a case of a 69-year-old right-dominant man who had an open Monteggia-like lesion of the right elbow (Gustilo-Andersen IIIA) with severe proximal ulna bone loss associated with an ipsilateral ulnar shaft fracture due to a motorcycle accident. The patient underwent two-stage surgery. Wound debridement and bridging external fixation were performed at first. Three months later, a frozen massive osteochondral ulnar allograft was implanted and fixed with a locking compression plate. A superficial wound infection appeared 5 weeks after the second surgery. Superficial wound debridement, negative pressure therapy, and antibiotics were administered for 3 months, achieving infection healing. At 3 years post-surgery, the elbow range of motion was satisfactory with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 16.7. Radiographs and computed tomography scans showed good allograft-bone integration without allograft reabsorption or hardware loosening. Although not complication-free, massive ulna osteochondral allograft implantation can be considered a valid option in cases of open Monteggia-like lesions associated with ulnar shaft fracture and severe bone loss in active patients, whenever osteosynthesis or joint replacement is not a proper solution. This type of bone stock restoration allows for future surgery, if needed.

Trapezio-metacarpal arthritis: functional and radiographic results at an average 5-year follow-up using trapeziectomy associated to a modified Ceruso's suspensionplasty.

BACKGROUND AND AIM: Trapezial-metacarpal arthritis (TMA) is a common and highly disabling pathology. Trapeziectomy and Ceruso's suspensionplasty is described for moderate-severe stages. The aim of the present study was to assess functional and radiographic results at an average 5-year follow-up using a modified Ceruso's technique where the Abductor Pollicis Longus (APL) is passed twice around the Flexor Carpi Radialis (FCR) and a suture mini-anchor in the base of the first metacarpal is used to further stabilize the thumb. METHODS: 85 consecutive modified Ceruso's suspensionplasty were performed from 2012 and 2018. All the patients were evaluated at an average 5.1-year follow-up (21-96 months). Subjective patient satisfaction rate, NRS, DASH score, abduction angle, Kapandji score and pinch strength using functional tests were assessed. The scapho-metacarpal distance was measured at follow-up radiographs. RESULTS: 90.6% of the patients were satisfied by the treatment. The NRS and the DASH score improved (from 8.5 pre-operatively to 1.53 and from 87.5 to 24.6 respectively-p<0.001). The Kapandji test was rated from 7 to 10 in 65.9% of the patients. The pinch strength was good in 75.3% of the patients at follow-up. The abduction angle of the thumb was 38.2° (20°-55°). The mean scapho-trapezial distance decreased of 2.45 mm (from 9.87 mm to 7.42 mm - p<0.05). 8 patients had persistent pain and thumb disfunction, 1 patient had De Quervain's tenosynovitis. CONCLUSIONS: Suspensionplasty according to Ceruso's is a relatively simple and reproducible technique for moderate-severe TMA. It improves pain and thumb function, giving good stability without significant shortening.

Do tourniquet and drainage influence fast track in total knee arthroplasty? Our results on 151 cases.

BACKGROUND: Fast track in total knee replacement (TKR) is a widely used protocol. Tranexamic acid proved to be effective in reducing perioperative bleeding without increasing thromboembolic risk. The aim of this study was to assess if tourniquet and suction drainage might affect perioperative blood loss and postoperative functional recovery after TKR. METHODS: 151 patients, who underwent to TKR, were assessed and divided into three homogeneous groups: group A (51 patients) in which both tourniquet and suction drainage have been applied (tourniquet has been release before wound closure); group B (50 patients) in which neither tourniquet nor suction drainage have been used; group C (50 patients) in which only tourniquet has been used. Perioperative intravenous tranexamic acid and post-operative low-molecular-weight heparin have been administered. Trend of haemoglobin values, transfusion rate, pain, ability to obtain 90 degrees of flexion and length of stay were analysed. RESULTS: The average intra-operative blood loss was statistically higher in group B in comparison to other two groups. Haemoglobin values were lower in group A in comparison to group C in the third and fifth post-operative days. Patients in group A had higher transfusion rate, higher pain and had more difficulties in reaching a 90 degrees of knee flexion than the other two groups. There was one infection in group A. No differences in length of stay. CONCLUSION: Suction drain seems to be associated to lower haemoglobin values, higher transfusion rate, higher pain and slower functional recovery. Short-term tourniquet does not influence post-operative bleeding and rehabilitation program.

Dedifferentiated chondrosarcoma: prognostic factors and outcome from a European group.

BACKGROUND: Dedifferentiated chondrosarcoma has a very poor prognosis. Because of its rarity, there are few large studies of outcome which might identify potential prognostic factors. In particular there remains uncertainty about the value of chemotherapy for this condition. METHOD: A retrospective study was done using data supplied by members of the European Musculo Skeletal Oncology Society (EMSOS). We obtained data on 337 patients from nine European centres with this rare condition, with details on patients, treatment and outcome which were then analysed in an attempt to identify prognostic features. RESULTS: The median age was 59 years and there was a slight predominance of males (53%). The most common sites were the femur and pelvis. Twenty-nine percent of patients with a long bone tumour had a pathological fracture. 71 patients (21%) had metastases at the time of diagnosis and these patients had a median survival of 5 months with a 10% chance of survival at 2 years. For the 266 patients without metastases at diagnosis, 254 underwent surgery with 79% having limb salvage. Thirty-one percent of these 266 patients had chemotherapy with 47% of those under 60 receiving it. In this group of 266 patients, overall survival was 28% at 10 years and poor prognostic factors were the presence of a pathological fracture at diagnosis, a pelvic location and increasing age. Local recurrence and overall survival were related to inadequate margins of excision. We did not find that the histological subtype, size of the tumour or the use of chemotherapy significantly affected outcome. For all patients the overall survival was 24% at 5 years. CONCLUSIONS: The prognosis for patients with dedifferentiated chondrosarcoma remains dismal. Surgery with clear margins remains the principal treatment for this condition. Further use of chemotherapy should be within a trial or treatment protocol.

Carbon-fiber reinforced intramedullary nailing in musculoskeletal tumor surgery: a national multicentric experience of the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group.

INTRODUCTION: Carbon fiber reinforced (CFR) implants have been proposed for the treatment of fractures or impending fractures of the long bones in the oncology patient. Aim of this study is to present the largest cohort of oncology patients operated by CFR nailing by the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group. METHODS: 53 adult oncology patients were operated on with a CFR-PEEK nail. All the data from adjuvants therapies were collected. Bone callus formation, response to radiotherapy, relapse or progression of the osteolysis were recorded. Hardware survival and failure, breakage and need for implant revision were also analysed. RESULTS: Anatomical implantation of nails include humerus (n = 35), femur (n =11) and tibia (n = 7). The most frequent tumors affecting the bone were myeloma (n = 13), breast (n = 11), lung (n = 8), and renal cell cancer (n = 7). Acrylic cement reinforcement was used in 2 patients. One patient was subjected to electrochemotherapy after nail insertion. Intraoperative and early postoperative complications occurred in 13.2% and 7.54% of patients respectively. Eight patients had local progression and one developed a stress fracture proximally to the distal static screw. Radiographic union occurred in 14 patients; one screw loosening was recorded. DISCUSSION: There is currently a lack of solid evidence on the clinical use of CFR nails in oncologic patients. This is the first and largest study of CFR nailing, with the longest available follow up. CONCLUSIONS: Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.

Adjuvant treatment of high-risk adult soft tissue sarcomas: a survey by the Italian Sarcoma Group.

AIMS AND BACKGROUND: After the first adjuvant study on adult soft tissue sarcomas was concluded, the participating institutions continued to select and treat patients according to that protocol. The aim of this study was to test the protocol reproducibility when applied as a standard practice. METHODS: A call for retrospective data was launched in June 1999 (self-referral of consecutive unregistered patients); thereafter, a prospective follow-up was performed. The treatment regimen consisted of epirubicin (60 mg/m2 days 1 and 2), ifosfamide (3 g/m2/die for 3 days) and equimolar doses of 6-mercapto-ethansulfonate (MESNA), with 300 microg G-CSF administered subcutaneously from day +8 until recovery, every 3 weeks for a total of 5 cycles. RESULTS: From November 1996 to June 1999, 55 high-risk, adult patients were treated. The average median dose intensity was 89% of the planned program. Grade 3-4 toxicities were leukopenia (49%), thrombocytopenia (14%), transfusion requiring anemia in 7 patients (16%), and alopecia in all patients (100%). After a median follow-up of 70 months, 23 patients (41.8%) relapsed and 19 died. Median disease-free, local disease-free and overall survival rates have not yet been reached. The disease-free survival rates at 2 and 4 years were 73% and 57%, respectively; the corresponding overall survival rates were 91% and 70%, respectively. CONCLUSIONS: The feasibility and reproducibility of the original protocol were confirmed, since disease-specific overall survival and disease-free survival rates at the same period of observation and with the same prolonged follow-up did not differ.