How to Direct the Neuronal Growth Process in Peripheral Nerve Regeneration: Future Strategies for Nanosurfaces Scaffold and Magnetic Nanoparticles.

Currently, the gold standard to repair large nerve defects is the autologous nerve graft. These solutions offer a mechanical support, adhesion substrates, and, with Schwann cells (SC), a source of neurotropic factors for axonal growth. The technical limits are the donor side damage, multiple surgical accesses, and the unavailability of large amounts of grafts. In recent years, several researchers focused their attention on the interaction between cells (nervous and glial) and physic-chemical cues that arise from the extracellular milieu. Nanotechnologies produce surfaces that mimic the topographical signals (physical stimuli) that arise from enterprise content management (ECM) to modulate the forces acting during axonal elongation. The use of magnetic nanoparticles (MNPs) seems to be able to guide and to boost the nerve regeneration. Both research areas could be improved through surfaces functionalization by biological molecules (proteins/peptides, growth factors, etc.). In the future, the aim will be to help recovery after peripheral nerve lesion by producing a tridimensional structured conduit, then repeat the ECM architecture and take advantage of MNPs internalized by cells and guide them through tension forces by external magnetic fields to stimulate and direct axon growing. The aims of this review were to evaluate the findings of studies that used physical stimuli (nanoscaffold surfaces and MNPs) used for peripheral nerve regeneration support. The future trends in the field of peripheral nerve regeneration continue to produce a wide variety of new techniques to improve the opportunity for advances to treat peripheral nerve injuries.

Evaluation of the Effects of the Metha® Short Stem on Periprosthetic Bone Remodelling in Total Hip Arthroplasties: Results at 48 Months.

INTRODUCTION: Total hip arthroplasty is one of the most performed procedures in orthopaedic surgery. Implantation of a prosthesis determines changes in the distribution of loads on the host bone, and this phenomenon, known as stress shielding, is related to the biomechanical characteristics of the implant. Usually stress shielding involves the proximal portion of the femur by reducing the mechanical strength and ability to withstand the transmitted loads. The aim of our study is to demonstrate how the use of a short hip stem reduces the stress shielding phenomenon to the proximal femur. MATERIALS AND METHODS: The study analyzed 20 patients undergoing hip prosthesis surgery with a short stem (Metha<, B. Braun Medical, Inc., Bethlehem, Pennsylvania) at the Ist Orthopaedic Division of Pisa University (between December 2008 and January 2010). Each patient was subjected to analysis of periprosthetic bone mineral density by a bone densitometry (dual emission X-ray absorptiometry [DEXA] with the metal removal software) at 0, 6, 12, 18, 24, and 36 months, following a protocol based on the evaluation of the changes of bone density in the seven Gruen zones. RESULTS: We recorded minimal changes in bone mineral density (BMD) at the level of the greater trochanter (-1.44%) and at the level of the calcar (-3.7%). BMD increased significantly after four years at the level of the lateral distal regions (R2 +9.6% - R3 + 12.4%) and at the level of the distal medial regions (R5 + 8.2% - R6 + 13.1%). We compared the results obtained with the literature data at 12 and 24 months with the same stem (Metha<). At 12 months follow up, we did not see a significant difference between our data and the data published in the literature. However, after 48 months of follow-up, we recorded significant differences in the curves of periprosthetic bone reabsorption at the level of the greater trochanter (Zone 1) and at the level of the calcar (Zone 7). DISCUSSION: The data obtained from our study are in agreement with other studies in the literature, which demonstrates how the use of short stems preserves the metaphyseal bone stock at the level of the proximal femur, reducing the stress shielding phenomenon. From our data, obtained at 24 months and confirmed at 36, stress shielding seems to minimally occur at the level of the calcar. At the level of the great trochanter, we saw a good load distribution that maintained the baseline BMD; these data are in opposition to the literature data that showed a high increase of BMD at the level of the calcar (+12.9%) and a decrease at the level of the great trochanter. From the analysis of the radiographic images of our cases, and of the cases published with the same stem, these differences in load transfer encountered between the great trochanter and the calcar seems to be related to the level of the femoral neck osteotomy and the consequent stem position (varus/valgus). CONCLUSION: We conclude that the amount of periprostetic bone reabsorption around the Metha< stem seems to be strictly related to the surgical technique and the final implant position.

Early post-surgical rehabilitation and functional outcomes of a traumatic ulnar nerve injury: a pediatric case report.

Background: Peripheral nerve injuries (PNIs) of the upper limb are very common events within the pediatric population, especially following soft tissue trauma and bone fractures. Symptoms of brachial plexus nerve injuries can differ considerably depending on the site and severity of injury. Compared to median and radial nerves, the ulnar nerve (UN) is the most frequently and severely injured nerve of the upper extremity. Indeed, due to its peculiar anatomical path, the UN is known to be particularly vulnerable to traumatic injuries, which result in pain and substantial motor and sensory disabilities of the forearm and hand. Therefore, timely and appropriate postoperative management of UN lesions is crucial to avoid permanent sensorymotor deficits and claw hand deformities leading to lifelong impairments. Nevertheless, the literature regarding the rehabilitation following PNIs is limited and lacks clear evidence regarding a solid treatment algorithm for the management of UN lesions that ensures full functional recovery. Case presentation: The patient is a 11-year-old child who experienced left-hand pain, stiffness, and disability secondary to a domestic accident. The traumatic UN lesion occurred about 8 cm proximal to Guyon's canal and it was surgically treated with termino-terminal (end-to-end) neurorrhaphy. One month after surgery, the patient underwent multimodal rehabilitative protocol and both subjective and functional measurements were recorded at baseline (T0) and at 3- (T1) and 5-month (T2) follow-up. At the end of the rehabilitation protocol, the patient achieved substantial reduction in pain and improvement in quality of life. Of considerable interest, the patient regained a complete functional recovery with satisfactory handgrip and pinch functions in addition with a decrease of disability in activities of daily living. Conclusion: A timely and intensive rehabilitative intervention done by qualified hand therapist with previous training in the rehabilitation of upper limb neuromuscular disorders is pivotal to achieve a stable and optimal functional recovery of the hand, while preventing the onset of deformities, in patients with peripheral nerve injuries of the upper limb.

Biological Prosthesis (Hollow 3D-Printed Titanium Custom-Made Prosthesis and Bone Graft) for Humeral Reconstruction in Pediatric Oncologic Patients: Surgical Indications and Results.

This study presents the mid-term outcomes of a novel "biological prosthesis" for pediatric humerus reconstruction after major bone tumor removal. This approach involves a hollow 3D-printed titanium custom-made prosthesis combined with bone grafting. The primary aim was to preserve and revitalize the unaffected autologous proximal or distal humeral stump. Between 2017 and 2021, we treated five pediatric patients (mean age 11.2 years; range 7-17) with humeral bone sarcomas. A one-stage surgical procedure involved tumor resection and implanting a hollow 3D-printed custom-made prosthesis. In two cases, we preserved the proximal humerus; in two, the distal part; and in one, both. Graft materials included homologous bone chips in three cases and free vascularized fibular grafts in two cases. All patients were clinically and radiographically assessed after a mean follow-up of 32.2 months (range of 14-68). No significant complications were observed, and no implant revisions were needed. Osseointegration was evident in all cases within eight months post-surgery; vascular support for the remaining autologous stump was demonstrated in all cases. Our hollow 3D-printed custom-made prosthesis and bone grafting offer the potential for partial or complete articular surface preservation. This approach encourages revascularization of the epiphysis, leading to satisfactory outcomes in humerus reconstruction within the pediatric population.

Custom-made 3D-printed prosthesis and free vascularised fibula for humeral reconstruction after osteosarcoma resection in a 13-year-old patient.

Surgical reconstruction after humeral resection represents a challenging issue in orthopaedic oncology. Particularly in paediatric patients, the main concerns are maintaining limb function and reconstruction longevity. We describe a novel strategy of humeral reconstruction based on the use of a three-dimensional-printed custom-made prosthesis in a 13-year-old patient diagnosed with osteosarcoma. The implant was specifically designed to sustain the native head, which was spared, as it was not involved by the neoplastic tissue. The mechanical support the prosthesis provided was associated with the biological stimulus of a free vascularised fibular graft to obtain an anatomic, functional and stable construct. This solution has had good longevity, and after 3 years of follow-up, the patient still shows excellent limb function and personal satisfaction.

Corrective Procedure for Flexion Contracture of the Elbow in Neonatal Palsy Sequelae: Long-term Follow-up.

BACKGROUND: Aim of this paper is to validate a procedure for correcting elbow flexion contracture in patients suffering from brachial plexus neonatal palsy sequelae during their teens. Elbow flexion contracture represents an unsolved problem in the natural history of obstetric brachial plexus palsy (OBPP) because of the consistent deformity recurrence. Following a previous paper, in which an original technique was proposed in a small sample of patients, the authors show the possible correction of the deformity in a larger group of patients. METHODS: The procedure includes a combination of a posterior approach to the elbow with olecranon tip section and an anterior one with capsulotomy and soft tissue release to improve elbow range of motion. A series of 26 patients, who underwent the procedure, were checked out in medium and long term. Collected data were age, type of brachial plexus palsy, length of hospitalization, duration of surgery, preoperative and postoperative elbow range of motion, preoperative and postoperative DASH scores and satisfaction scores. Explaining further details about the procedure, the Authors report their results, including a statistical analysis. RESULTS: At the final follow-up, the mean increase of elbow extension was about 22°. Functional outcomes were successful as well, with a mean increase of 10 points of DASH score. Over 75% of patients were fully satisfied with their outcome. CONCLUSIONS: The outcome has confirmed the good efficacy of the procedure in increasing elbow extension but also in improving cosmetic appearance in adolescents suffering from flexed elbow in OBPP sequelae.

Bibliometric trend analysis in a decade of European Orthopaedic literature.

Purpose The purpose of this bibliometric study was to summarize European orthopedic literature produced by EFORT memberships between 2009 and 2019 and to identify the 100 most cited articles, analyzing the characteristics that made them so interesting for the orthopedic scientific world. Method A search of the literature was conducted using Clarivate Analytics Web of Science in the subject category "orthopaedics"; then the results were summarized using Web of Science tools. Results A total of 160.375 articles were found: most of these were produced by England. In particular the most prolific institution was the University of London. Analyzing in detail the 100 most cited publications emerged that most of them were review published in journal with high impact factor (Q1). The University of Oxford was the institution with the greatest number of contributions (13%). The most cited topics were osteoarthritis (24%), followed by orthopedic basic science (22%). Biomaterials was the most common topic by ordering the 100 analyzed articles according to "usage count", a recent indicator of the level of interest in a specific item. Conclusion This bibliometric study can be useful to identify topics of interest for future scientific research and to outline the features that make some publications more interesting than others.

How hand and wrist trauma has changed during covid-19 emergency in Italy: Incidence and distribution of acute injuries. What to learn?

BACKGROUND: the purpose is to gather and analyze the statistical datas of wrist and hand injuries admitted to the Hand and Reconstructive Microsurgery and Replantation Hub center of Careggi Hospital, Florence during the first two months of COVID-19 epidemic in Italy. The Authors investigated how the drastic changes in daily activities modified the epidemiology of hand trauma lesions. METHODS: The Authors analyzed the characteristics of hand and wrist traumatic disorders during the months of February and March comparing 2019 to 2020. Collected data included age distribution, traumatic etiology, diagnosis and type of surgical procedures. RESULTS: The total number of orthopedic and trauma patients significantly decrease in 2020 compared to 2019 (3360 vs 1470). The number of hand and wrist injuries didn't show a significant difference between 2019 and 2020 instead (192 vs 131). The overall number of patients hospitalized and surgically treated at our Operative Unit (OU) was 168 in 2019 and 120 in 2020. Male patients resulted prevalent (60,7 M vs 39,3F/2019; 63,2 M vs 36,8F/2020). In terms of patient age, in 2020 we registered a significant reduction of cases in the 20-35-year-old age group and a significant increase in the 51-65 and 66-80-year-old age groups. Traffic-related, sport-related and fortuitous injuries significantly decreased in 2020, while the number of domestic accidents significantly increased. Analyzing the Hospital Discharge Records (HDR), we found a significant increase in the number of proximal and middle phalanx fractures; no significant differences were found for other kinds of discharge diagnosis. As for the choice of surgical treatment options, no differences were found between 2019 and 2020. CONCLUSION: Even during drastic movement restrictions and the prolonged suspension of work and leisure activities secondary to COVID-19 epidemic in 2020, hand and wrist traumas rate remained almost the same compared to the same period of the previous year. Nevertheless, a significant change in the etiology and patient age was registered. In fact, sport and traffic-related traumas decreased respect to domestic traumas, while the previous prevalent involvement of young adults was surpassed by accidental hand traumas in the elderly and active adults.

Custom-Made 3D-Printed Implants as Novel Approach to Reconstructive Surgery after Oncologic Resection in Pediatric Patients.

Recently, custom-made 3D-printed prostheses have been introduced for limb salvage surgery in adult patients, but their use has not been described in pediatric patients. A series of 11 pediatric patients (mean age 10.8 years; range 2-13) with skeletal tumors treated with custom-made implants for the reconstruction of bony defects is described. Patients were followed up every 3 months. Functional results were evaluated by the Musculoskeletal Tumor Society Score (MSTS) for upper and lower limbs. The mean follow-up was 25.7 months (range 14-44). Three patients died after a mean of 19.3 months postoperatively-two because of disease progression and the other from a previous malignancy. Three patients experienced complications related to soft tissues. One patient required device removal, debridement, and antibiotic pearls for postoperative infection. Partial osseointegration between grafts and host bone was observed within a mean of 4 months. At the final follow-up, mean MSTS score was 75%. 3D prostheses may yield biological advantages due to possible integration with the host bone and also through the use of vascularized flaps. Further research is warranted.

Jammed ulnar nerve after distal radius fracture: A case report.

BACKGROUND: Ulnar nerve lesions represent a rare complication of wrist fracture. The present manuscript describes the case of a particular traumatic mechanism in which the nerve resulted crushed between radial fracture fragments. CASE PRESENTATION: A 47-year-old man suffered a subtotal lesion of the ulnar nerve following an open displaced distal radius fracture. Symptoms of ulnar nerve deficiency worsened after reduction and temporary stabilization. Further surgery was performed to achieve definitive stabilization and ulnar nerve neurolysis. The ulnar nerve was found to be jammed inside the fracture side, and so was repaired with a direct suture. Progressive recovery was observed in the following months. CONCLUSIONS: Given the paucity of reports of ulnar nerve injury in the literature, clear recommendations for treatment of nerve lesions after wrist fractures have not yet been defined. Nevertheless, in our experience, peripheral nerve function should be assessed before and after fracture reduction, as a worsening of symptoms after surgical intervention could indicate nerve entrapment inside the fracture site.

Percutaneous Intramedullary Headless Screw Fixation and Wide-Awake Anesthesia to Treat Metacarpal Fractures: Early Results in 25 Patients.

Metacarpal fractures constitute 7.8% of the upper extremity fractures. The common treatments remain nonsurgical procedure, but high-demanding patients or unstable fractures require fixation with Kirschner wire (K-wires), plate, and screws. However, these approaches may cause scarring and adhesion with poor functional results. From 2014 to 2015, the authors used an intramedullary headless screw to treat 25 patients (24 men, 1 woman) with metacarpal bones fractures (20 V, 3 IV, 1 III, and 1 II). The fractures patterns were 23 fractures of distal third of metacarpal bone (16 oblique, 5 comminute configurations, and 2 transverse), 1 fracture of the base of the II metacarpal bone. One case presented a multiple metacarpal and phalangeal facture associated. The authors used wide-awake anesthesia (bupivacaine-epinephrine 1:100,000) and intramedullary titanium headless screw fixation percutaneously inserted (CCS Medartis and HCS Synthes 3 mm of diameter). No open reduction was needed. Early active mobilization started with a buddy strapping soon after surgery (0-3 days). The authors followed all patients until satisfactory function was achieved (4-6 weeks) and recorded the time till return to work. All fracture healed with less than 5 degrees of rotational or axial deformities. All patients return to work within 2.38 weeks after surgery (0.5-6 weeks). No cases of complex regional pain syndrome (CRPS), tendon lesions, nerve injuries, infection, hardware protruding, or mobilization were reported. Intramedullary screw fixation with wide-awake anesthesia for transverse, oblique, and select comminuted fractures treatment metacarpal fractures represent a reliable option to early active mobilization recovery and a quick return to the work and ordinary activities.

Traumatic anterior dislocation of a prosthetic knee, from trauma to delayed onset of vascular injury.

Anterior dislocation of a prosthetic knee is a rare event. Only few episodes have been described in the past and have never been linked with neurovascular injury. This could lead orthopaedic surgeons to focus on the implant instability factors and underrate other complications. The authors report a case of a patient who experienced popliteal artery dissection 80 hours after traumatic anterior knee dislocation of a previously well-functioning total knee arthroplasty. Given that there is a lack of clinical cases that have established guidelines for management of this problem, the authors have focused on the importance of performing computed tomography angiography in the management of an anterior traumatic knee dislocation of a prosthetic knee.

The 50 most cited articles about wrist surgery.

The purpose was to establish a ranking of the 50 most cited articles about wrist surgery and analyse their features. Science Citation Index Expanded was used to identify the 50 most frequently cited orthopaedic journal articles written in English, searching for the topic "wrist surgery" in the subject category ''Orthopaedics''. Then, we analysed the number of citations, citation density, authorship, article institution, the year of publication, the country of origin of the article, name and impact factor of the journal, and publication type of the article. The 50 most cited articles were published in only 6 of the 74 journals included under the category "orthopaedics". Citation count ranged from 256 for the first one to 67 for the 50th article. Most of them were written by American authors. These articles were published between 1991 and 2011. "Distal Radius Fractures" was the most common issue. This type of bibliographic analysis could be particularly useful for other young Authors who would like to improve their research in wrist and hand surgery and make their publications more citable and appreciated by the scientific community.

Profunda Femoris Artery Pseudoaneurysm after Intramedullary Fixation for a Pertrochanteric Hip Fracture.

INTRODUCTION: Vascular complications after femoral fixation are rare and not only easy to recognize but also potentially life-threatening. The aim of this case report is to describe how a pseudoaneurysm of the deep femoral artery can complicate an intramedullary nailing after a pertrochanteric fracture and how it can be treated. CASE REPORT: We report the case of a 90-year-old female who developed a pseudoaneurysm of the profunda femoris artery 16 days after intramedullary femoral nailing for a pertrochanteric hip fracture. Stenting of the artery was urgently performed with a consequent resolution of the symptoms. CONCLUSION: Diagnosis of vascular complications after hip surgery may be very challenging because symptoms are often nonspecific. Despite their rarity, it is important to know this type of complications to address the diagnostic pathway in the right direction and to treat them promptly.