Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study.

PURPOSE: The aim of this study was to evaluate the relationship between the Löwenstein Lateral view and the True Lateral view for the positioning of the cephalic hip screw, through a cadaveric study. MATERIALS AND METHODS: We placed two Kirschner wires in eight femur specimens using an Antero-Posterior view, Löwenstein Lateral view and True Lateral view. The distances between the Kirschner wires and the anterior, posterior, superior and inferior cortex were measured in all projections. The head of the femur was then sectioned, and the same macroscopic distances were measured. Finally, we could calculate the accuracy of the two radiographic lateral projections. RESULTS: When the Kirschner wire was placed in the center of the head using the Antero-Posterior and the True Lateral view, the accuracy of Antero-Posterior view was 0.9705 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1479 and 1.1584, respectively. When the Kirschner wire was placed superior on the Antero-Posterior and centrally on the True Lateral view, the accuracy of Antero-Posterior view was 0.9930 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1159 and 0.7224, respectively. CONCLUSION: When the Kirschner wire was positioned proximal in Antero-Posterior view and central in True Lateral view, only the True Lateral view showed high accuracy.

Fast-Track for Total Ankle Replacement: A Novel Enhanced Recovery Protocol for Select Patients.

BACKGROUND: Enhanced recovery after surgery programs, also called fast-track protocols, were developed and successfully applied in the last decade for hip and knee reconstruction. Specific fast-track protocols have not yet been applied to ankle prostheses. The aim of the study was to develop and validate an enhanced recovery protocol for total ankle replacement (TAR) evaluating the clinical and radiographic results. We hypothesize that on the basis of well-defined pre- and postoperative characteristics, the current knowledge on ankle replacement, and referring to hip and knee reconstruction, it is possible to identify a "patient type" to be safely eligible to a Fast-Track Protocol with at least comparable results and without increasing the complications risk. METHODS: We identified 8 predictive variables that might affect the outcome of TAR. Those variables were the body mass index, the state of anxiety or depression, the functional preoperative status, ankle equinus, the coronal malalignment, the surgical time, the surgical accessory procedures, and the bone quality. These characteristics were evaluated for each patient with almost validated outcome tools attributing a specific score. Based on the score obtained, the patients were divided into 2 groups: the Standard Protocol group (Control Group) and the Fast-Track Protocol group (Study Group). The main difference between treatment of the 2 groups relates to the use of postoperative plaster casts: in the Fast-Track group the cast was removed the first day after surgery and walking was allowed in sports shoes assisted with crutches, whereas in the Standard Protocol group, the cast was removed after 3 weeks. Clinical and radiographic evaluation was performed for all patients preoperatively and postoperatively every 6 months. RESULTS: A total of 163 patients received a score between 1 and 5 and were included in the control group (Standard Protocol); 47 patients received a score of 0 and were allocated to the study group (Fast-Track Protocol). Clinically, except for the preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score, no statistically significant differences were recorded in the multiple comparisons between the 2 groups. No significant differences were found regarding complications. CONCLUSION: In selected patients, it is possible to apply an enhanced recovery protocol of rehabilitation, focused on immediate weightbearing and mobilization without any plaster or boot. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Transfibular total ankle arthroplasty : a new reliable procedure at five-year follow-up.

AIMS: This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years. METHODS: We prospectively evaluated 89 patients who underwent transfibular TAA for end-stage osteoarthritis. Patients' clinical and radiological examinations were collected pre- and postoperatively at six months and then annually for up to five years of follow-up. Three patients were lost at the final follow-up with a total of 86 patients at the final follow-up. RESULTS: A total of 86 patients were evaluated at a mean follow-up of 65.4 months (60 to 90). At five-year follow-up, statistically significant improvements (p < 0.001) were found in the mean American Orthopaedic Foot & Ankle Society Ankle Hindfoot Score (from 33.8 (SD 14.3) to 86.1 (SD 8.8)), visual analogue scale for pain (from 8.5 (SD 1.7) to 1.5 (SD 1.2)), Short Form-12 Physical and Mental Component Scores (from 29.9 (SD 6.7) and 43.3 (SD 8.6) to 47.3 (SD 7.5) and 52.2 (SD 8.0), respectively), and mean ankle dorsiflexion and plantarflexion (from 6.2° (SD 5.5°) and 9.6° (SD 5.8°) to 23.9° (SD 7.7°) and 16.9° (SD 7.2°), respectively). Radiologically, the implants maintained neutral alignment without subsidence. Tibial or talar radiolucency was found in eight patients, but none of these patients was symptomatic. At five-year follow up, 97.7% of implants (95% confidence interval 91.2 to 99.4) were free from revision or removal with 84 implants at risk. We recorded two cases (2.3%) of failure for septic loosening. CONCLUSION: Transfibular TAA is safe and effective with a high survival rate at mid-term follow-up and satisfactory clinical and radiological results. Further studies are required to determine the long-term performance of these implants. Cite this article: Bone Joint J 2022;104-B(4):472-478.

Reconstruction of a missing or insufficient distal fibula in the setting of a total ankle replacement: The Milanese technique.

BACKGROUND: The presence of an intact distal fibula is reported as a prerequisite when considering total ankle replacement and its lack is usually considered a contraindication. The purpose of the study was to describe the results of a surgical technique to reconstruct the distal fibula (Milanese fibular reconstruction technique) in the setting of a total ankle replacement and insufficient fibula. METHODS: Retrospective analysis of 15 patients (15 ankles) who underwent rotational fibular reconstruction technique with minimum follow-up of 24 months. Patients were evaluated preoperatively and at the last follow-up with AOFAS Ankle and Hindfoot score, VAS pain scale, SF-12 and range of motion. Standard weightbearing radiographs were used for radiographic assessment. RESULTS: The average of all clinical scores significantly improved (P<.001). The average radiographic parameters showed a neutral alignment. No cases of reabsorption of the new lateral malleolus were observed even in cases with complications that accounted for 2 superficial wound infection and 2 deep infections. CONCLUSIONS: The Milanese fibular reconstruction technique can successfully reestablish a lateral strut and in the setting of an ankle prosthesis in patients with an insufficient fibula.

Functional outcomes and mortality in geriatric and fragility hip fractures-results of an integrated, multidisciplinary model experienced by the "Florence hip fracture unit".

PURPOSE: The aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs. METHODS: Six hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated. RESULTS: 88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture. CONCLUSIONS: An integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

A comparison of two fixation methods for femoral trochanteric fractures: a new generation intramedullary system vs sliding hip screw.

INTRODUCTION: Trochanteric fractures are frequent and generally associated with bone fragility. There is still debate on the best fixation device to treat stable or rather stable trochanteric fractures: we report our clinical and radiological results of fixation with Proximal Femoral Nail "antirotation" (PFNa) in a population of patients compared to a control group treated by Sliding Hip Screw (SHS). MATERIALS AND METHODS: A prospective study was conducted in 71 consecutive patients treated by PFNa (group A), and 69 by a SHS (group B), with a mean age of 81.6 and 83.4 years respectively. Short Form 12 was administered to check postoperative results, and the following parameters were evaluated: range of motion, evaluation of pain, gait ability, X-rays, and Tip Apex Distance Index. RESULTS: A minimum follow-up was conducted in 128 patients: 66 subjects belonging to the PFNa group and 62 to the DHS group. All patients in the group A were able to reach partial or full weight-bearing on the operated leg before leaving the hospital. Forty-four patients (63.8%) of the group B were able to walk with partial weight-bearing before discharge. We recorded 17 complications with a final overall percentage of 17.2% on the overall study population with one single case of failure in both the two groups. DISCUSSION: A statistical significance (p<0.01) of superiority for PFNa was demonstrated regarding surgical time, amplioscope time, intraoperative blood loss, hospital stay, recovery of weight-bearing before discharge. Less significant results (p<0.05) were found for walking ability at the three-months follow-up and patients' satisfaction 6 months after surgery. CONCLUSIONS: PFNa may be considered an useful choice for the treatment of stable or rather stable trochanteric fractures as well as DHS. The light superiority of PFNa may be principally related to its mechanical advantages.

Oxidized zirconium versus cobalt-chromium against the native patella in total knee arthroplasty: Patellofemoral outcomes.

BACKGROUND: Oxidized zirconium (OxZr) has demonstrated excellent mechanical properties in vitro when used against articular cartilage; less coefficient of friction and less chondral damage have been found when compared with cobalt-chromium (CoCr) implants. However, controversy exists as to whether implants with a zirconium femoral component articulate safely with a native patella in total knee arthroplasty (TKA). To answer this question, the clinical and radiographic results were analysed from a group of patients who underwent a TKA with patella retention; the OxZr versus CoCr femoral components were compared. METHODS: The present study prospectively evaluated 83 knees of 74 patients from 2009 to 2010. Each patient was evaluated clinically (visual analogue scale, Knee Society score, patellar score) and radiographically (long leg standing radiograph, anterior-posterior and latero-lateral projections, axial view of the patella) pre-operatively and postoperatively with a mean follow-up of 4.47years. The patellar tilt and shift, and progression of patellofemoral osteoarthritis were calculated with the axial view. RESULTS: There were no patient reported adverse reactions and none of the evaluated prostheses failed. Both the clinical and radiographic evaluations showed no statistically significant between-group differences. CONCLUSION: No adverse events were observed clinically or radiologically. These results justify pursuing the use of oxidized zirconium as an alternative bearing surface for a femoral component associated with patellar retention in TKA.

Metal hypersensitivity after knee arthroplasty: fact or fiction?

BACKGROUND AND AIM OF THE WORK: Hypersensitivity to metals in the general population has an incidence of about 15%, and in rising also for the higher number of joint replacements in the last decades. Total Knee Arthroplasty (TKA) represents the most performed orthopaedic procedure during last years, and it seems to be particularly associated with sensitization after surgery. On the other hand, there is a rising amount of patients with painful but well implanted and functioning TKAs: in certain cases, after the exclusion of the most frequent causes of failure, a condition of hypersensitivity may be found, and a revision with anallergic implants is mandatory. The present study is a review of the potential problems related to hypersensitivity in TKA, its possible diagnostic procedures, and the surgical options to date available. METHODS: Medical history, patch testing, and other specific laboratory assays are useful to assess a status of metals hypersensitivity before surgery in subjects undergoing a knee replacement, or even after TKA in patients complaining pain in otherwise well implanted and aligned prostheses. However, few groups worlwide deal with such condition, and all proposed diagnostic protocols may be considered still today conjectural. On the other hand, these represent the most updated knowledge of this condition, and may be useful for both the patient and the orthopaedic surgeon. Once assessed a possible or ascertained allergy to metals, several options are available for primary andr revision knee surgery, in order to avoid the risk of hypersensitivity. RESULTS: A review of the recent publications on this topic and an overview of the related aspects has been made to understand a condition to date considered negligible. CONCLUSIONS: Hypersensitivity to metals has not to be nowadays considered a "fiction", but rather a possible preoperative risk or a postoperative cause of failure of TKA. Crucial is the information of patients and the medical history, associated in suspect cases to laboratory testings. Today in the market several knee implants are available and safe for allergic patients undergoing TKA.

Play in adult bonobos (Pan paniscus): modality and potential meaning.

The aim of this study was to thoroughly investigate social play and its modalities among adult bonobos. We evaluated how play intensity varies according to the sex-class combination of the playmates and we also performed an analysis on social locomotor-rotational movements (L-R play) and contact interactions (C play). Rough and gentle play sessions were performed with comparable frequencies by male-female and female-female adult dyads, with play signals unlikely when the playmates strongly differed in age and in rank position. L-R play rates did not differ according to the sex-combination of the players; in contrast, C play sessions were particularly frequent among females. Play faces (play signals) were significantly higher during C play than L-R play sessions, thus suggesting that playmates assess reciprocally yet safely their relationships by using facial displays to avoid any kind of misunderstanding. Play was positively correlated with grooming and contact sitting interactions, suggesting that it may be used as a social enhancer. Finally, we found no correlation between both play contexts (L-R and C play) and age, size and rank differences of the players. In conclusion, we suggest that bonobos with their egalitarian society, peculiar social structure, and playful tendency represent an attractive testing subject to examine empirically many emerging hypotheses on adult play behavior.

Reconciliation and consolation in captive bonobos (Pan paniscus).

Although reconciliation in bonobos (Pan paniscus) has previously been described, it has not been analyzed heretofore by the postconflict (PC) match-control (MC) method. Furthermore, although reconciliation has been investigated before in this species, consolation has not. In this study we analyzed agonistic and affiliative contacts in all sex-class combinations to clarify and reevaluate the occurrence of reconciliation in bonobos via the PC-MC method. We also investigated the occurrence of consolation by analyzing the victims' triadic contact tendency (TCT), the influence of the sex of victims, and the relative occurrence of consolation and reconciliation. We collected 167 pairs of PC-MC observations in a captive group of bonobos (in Apeldoorn, The Netherlands). The conciliatory tendency (CCT) we obtained was tendentially lower than the mean value previously found for Yerkes captive chimpanzees. Close relationships, which were present in all female-female (FF) and some male-female (MF) dyads, positively affected reconciliation rates. When only adult PC-MC pairs (157) were considered, the mean TCTs and CCTs did not differ significantly. When we focused on types of PC affiliative contact, in the case of consolation we found a striking preference for sociosexual patterns. As to the relative occurrence of consolation and reconciliation, the highest level of the former was found in the absence of the latter. When reconciliation took place, consolation generally preceded it, suggesting that consolation may be a substitutive behavior. Our findings suggest that even if reconciliation remains the best option, consolation may be an alternative substitute for reconciliation that is used to buffer the tension originating from an unresolved conflict. Reconciliation and consolation are complex phenomena that are probably related to the life history of a group. Given that few studies have been conducted on this subject, we can not at this time make any generalizations regarding conflict resolution in certain species by comparing results among studies.