Revision of Total Hip Arthroplasty with Acetabular Bone Defects: Are Biological Grafts Really Better than Synthetic Bone Graft Substitutes?

Background: Acetabular aseptic loosening due to bone defect in total hip arthroplasty revisions is a great challenge and several solutions have been proposed, but a broadly accepted consensus in the literature has not been reached yet. The aim of this study is to compare the clinical and radiographic results of acetabular bone defects treatment with biological-only graft or with a mixture of bone graft substitute and biological graft. Methods: 33 patients had revision hip arthroplasty using impaction grafting with biological-only graft (21 patients, Group A) or a 1/3 mixture of allograft and tricalcium phosphate bone graft substitute (12 patients, Group B). Patients were reassessed at a minimum of one year after surgery with new x-rays and the Harris Hip Score (HHS). Results: Survivorship of bone graft was 86% in Group A and 100% in Group B at a mean follow-up of 35 months. No statistical difference between the two groups was found in terms of implants survivorship (P=0.28), clinical (P=0.08) or radiographic (P=0.27) outcomes. Conclusion: In our experience the use of tricalcium phosphate bone graft substitutes in combination with allo and autograft provides good outcomes, low risk of failure and great clinical and radiographic results. Further investigations on larger samples are needed to impact clinical practice.

Efficacy and Safety of Subacromial Corticosteroid Injection in Type 2 Diabetic Patients.

PURPOSE: In type 2 diabetic patients affected by chronic shoulder pain, subacromial injection with corticosteroid could be an effective treatment. The aim of this study was to measure the risk-benefit ratio of this treatment. METHODS: Twenty patients with well-controlled diabetes were included in a prospective study. In a first preinjection phase, patients were asked to measure glycemia for 7 days, before breakfast and dinner, and then 2 hours after lunch and dinner. Baseline data including Constant Score (CS), Subjective Shoulder Value (SSV), and Numerical Rating Scale (NRS) for pain were collected. Patients were treated with subacromial injection with 40 mg of Methylprednisolone Acetate and 2 ml of Lidocaine. At discharge, patients were asked to remeasure glycemia for the following week. RESULTS: The overall pain improved and patients graded their shoulder as "greatly improved". At 30-day follow-up, the SSV and the CS improved, considering pain but not ROM. The average daily glycemia was 136 mg/dl before injection, 161 mg/dl the day of the injection (p<0.001), and 170 mg/dl one day after injection (p<0.001). Glycemia was not statistically different 3 days after injection. CONCLUSION: Subacromial injection is an effective short-term treatment in type 2 diabetic patients affected by shoulder pain, but a closed follow-up is recommended in all these patients. This trial is registered with NCT03652480. The Protocol ID is SHOULDERDM2013.

Prognostic factors for mortality after hip fracture: Operation within 48 hours is mandatory.

The aim of this study was to assess whether surgery delay and other variables are associated with an increased mortality rate after surgical treatment of hip fractures in the elderly. Patients treated for a proximal femoral fracture at our Orthopaedic Department between 2005 and 2012 were included in this study. A logistic regression was performed to evaluate the relationship between mortality rate at different follow-up times (30 days, six months and one year) and different patient or treatment variables. A total of 1448 consecutive patients with 1558 proximal femoral fractures (55 bilateral) were enrolled in this study (mean age 80.3 years, 75.8% female). The postoperative mortality rate was 4% at 30 days, 14.1% at six months, and 18.8% at one year after surgery. Logistic regression revealed an increased mortality at all the endpoints in patients affected by more than two co-morbidities (respectively OR30-day=2.003, OR6-month=1.8654 and OR1-year=1.5965). Male sex was associated with an increased six-month (OR=1.7158) and one-year (OR=1.9362) mortality. Patients aged under 74 years had a decreased mortality at all endpoints (OR30-day=0.0703, OR6-month=0.2191 and OR1-year=0.2486). In this study, the surgery delay influenced mortality at one-year follow-up: operating within 48hours was associated with a decreased mortality rate (OR=0.7341; p=0.0392). Additionally, the patients who were operated on within 72hours were specifically analysed to understand if the option of 'operating within day 3' was acceptable. In the logistic regression, operating between 48 and 72hours was not reported as a risk factor for mortality, both compared to early surgery (within 48 hours) and to late surgery (after 72hours). This study showed that age, sex and number of co-morbidities influenced both early and late mortality in patients affected by proximal hip fractures. Early surgery influenced late mortality, with a decreased risk in patients operated on within 48hours. The option of operating within day 3 is not a valid alternative.

Patient specific instrumentation in total knee arthroplasty: a state of the art.

Patient specific instrumentation (PSI) is a modern technique in total knee arthroplasty (TKA) aiming to facilitate the implant of the prosthesis. The customized cutting blocks of the PSI are generated from pre-operative three-dimensional model, using computed tomography (CT) or magnetic resonance imaging (MRI). A correct surgical plan is mandatory for a good surgical implant. The PSI guide takes into account any slight deformities or osteophytes and applies preoperative planning for bone resection, using the pre-determined implant size, position, and rotation. The apparent benefits of this technology are that neutral postoperative alignment is more reproducible, surgical time is decreased, and the entire procedure results more efficient and cost-effective. The use of PSI is indicated when advanced osteoarthritis, severe pain, and limited function/walking ability are present, such as in a standard instrumentation TKA. In addition to that, PSI finds its indication when intra-medullary guides cannot be used. For example, when there is a post-traumatic femoral deformity. Large debates have taken place about this topic during the last years and, at the moment, there is no consensus in literature regarding the accuracy and reliability of PSI as many studies have shown controversial and inconsistent results. Literature does not suggest PSI techniques as a gold standard in TKA, and therefore it cannot be recommended as a standard technique in standard, not complicated primary TKA. Moreover, literature does not underline any improvement in components alignment, surgical time, blood loss or functional outcomes. Nevertheless, many patients who underwent TKA suffered a previous trauma. In case of deformities, like femoral or tibial fractures healed with a malalignment, preoperative planning may result difficult, and some intra-operative technical difficulties can occur, such as the use of intra-medullar rod. In these selected cases, PSIs may be very useful to avoid errors in alignment and planning.

Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder.

HYPOTHESIS: The critical shoulder angle (CSA) could be responsible for cuff tears and concentric osteoarthritis. We aimed to assess this association when potential confounding factors were excluded and to test the hypothesis that more extreme CSAs are associated with larger tears and more severe osteoarthritis. METHODS: The study cohort was composed of 200 patients with primary concentric osteoarthritis (40 patients), isolated supraspinatus tears (40 patients), cuff tears involving at least the supraspinatus and infraspinatus (40 patients), and no history of shoulder problems (control group, 80 patients). Data pertaining to CSA, age, gender, dominant arm, smoking, hypertension, body mass index, and type of work were collected. RESULTS: The average CSA angle was 34° ± 3° in the control group, 36° ± 3° with supraspinatus tears, 40° ± 3.5° with supraspinatus and infraspinatus tears, and 28° ± 2° with concentric osteoarthritis. Patients with large cuff tears had a significantly greater CSA compared with those with isolated supraspinatus tears (P = .03). The CSA (odds, 1.7; confidence interval [CI], 1.4-2.0) was the most relevant risk factor for cuff tears. The Spearman coefficient between CSA and grade of eccentric osteoarthritis was 0.4 (P = .01). The 2 significant risk factors for concentric osteoarthritis were the CSA (odds, 0.5; CI 0.4-0.6) and age (odds, 1.1; CI, 1.0-1.2). CONCLUSION: Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.

Anatomic shoulder arthroplasty: an update on indications, technique, results and complication rates.

A shoulder replacement is indicated in patients affected by glenohumeral arthropathy with severely reduced range of motion, persistent pain, especially at night, and loss of strength. There is much discussion in the scientific community about the prosthetic options for these cases: hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse total shoulder arthroplasty. We analyzed the indications for, results of, and complications associated with this kind of surgery, focusing on anatomic arthroplasty and on the concept of modularity.

Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment.

Fibromyalgia syndrome is mainly characterized by pain, fatigue, and sleep disruption. The etiology of fibromyalgia is still unclear: if central sensitization is considered to be the main mechanism involved, then many other factors, genetic, immunological, and hormonal, may play an important role. The diagnosis is typically clinical (there are no laboratory abnormalities) and the physician must concentrate on pain and on its features. Additional symptoms (e.g., Raynaud's phenomenon, irritable bowel disease, and heat and cold intolerance) can be associated with this condition. A careful differential diagnosis is mandatory: fibromyalgia is not a diagnosis of exclusion. Since 1990, diagnosis has been principally based on the two major diagnostic criteria defined by the ACR. Recently, new criteria have been proposed. The main goals of the treatment are to alleviate pain, increase restorative sleep, and improve physical function. A multidisciplinary approach is optimal. While most nonsteroidal anti-inflammatory drugs and opioids have limited benefit, an important role is played by antidepressants and neuromodulating antiepileptics: currently duloxetine (NNT for a 30% pain reduction 7.2), milnacipran (NNT 19), and pregabalin (NNT 8.6) are the only drugs approved by the US Food and Drug Administration for the treatment of fibromyalgia. In addition, nonpharmacological treatments should be associated with drug therapy.