Static and dynamic baropodometry to evaluate patients treated by total knee replacement with a mobile meniscus.

It was the purpose of this study to use static and dynamic baropodometry pre- and postsurgery in patients submitted to knee replacement with a mobile bearing. Baropodometric analysis was accompanied by clinical and subjective evaluation. Data obtained from the baropodometer revealed considerable oscillations occurring between pre- and postsurgery. Static examination showed a significant increase in the percentage of loading on the side treated that was not observed in the dynamic evaluation. An analysis of the Knee Society score showed a considerable increase in values between pre- and postsurgery similar to how the interpretation of correlations presurgery revealed statistically significant values between function and length of step, between pre- and postsurgery data for scores for function and length of step and Knee Score. The short-term results obtained are encouraging but only a long-term follow-up will be able to confirm the use of evaluating total knee replacement.

Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery.

BACKGROUND: As continuous wound instillation with local anaesthetic has not been evaluated after hip/knee arthroplasties, our study was designed to determine whether this technique could enhance analgesia and improve patient outcome after joint replacement surgery. METHODS: Thirty-seven patients undergoing elective hip/knee arthroplasties under spinal block were randomly assigned to two analgesia groups. Group M received continuous i.v. infusion of morphine plus ketorolac for 24 h. Then, a multi-hole 16 G catheter was placed subcutaneously and infusion of saline was maintained for 55 h. Group R received i.v. saline. Thereafter the wound was infiltrated with a solution of ropivacaine 0.5% 40 ml, then a multi-hole 16 G catheter was placed subcutaneously and an infusion of ropivacaine 0.2% 5 ml h(-1) was maintained for 55 h. Visual analogue scale scores were assessed at rest and on passive mobilization by nurses blinded to analgesic treatment. Total plasma ropivacaine concentration was measured. RESULTS: Group R showed a significant reduction in postoperative pain at rest and on mobilization, while rescue medication requirements were greater in Group M. Total ropivacaine plasma concentration remained below toxic concentrations and no adverse effects occurred. Length of hospital stay was shorter in Group R. CONCLUSION: Infiltration and wound instillation with ropivacaine 0.2% is more effective in controlling postoperative pain than systemic analgesia after major joint replacement surgery.

Total hip arthroplasty using femoral head shelf autografts in dysplastic hips. Our experience.

The present work deals with a series of 28 patients (a total of 31 hips) suffering from coxarthrosis in dysplasia of the hip. All patients had undergone arthroplasty where an autograft of cortico-cancellous bone was taken from the head of the patientís femur. In 21 of these hips the prosthetic components were not cemented while the other 10 cases were. The patients (average age 57 years 5 months) underwent radiography and were clinically evaluated using the Harris Hip Score. The average follow-up was 6 years and 7 months. In the 10 hips which had been cemented, the average pre-operative Harris Hip Score was 46.9 points (range 24-85) while it was 80.5 upon check-up (range 50-98). In the 21 hips which were not cemented the average pre-operative Harris Hip Score was 44.3 points (range 21-62) while, at the time of check-up it was 90.8 (range 60-100). Only in 3 cases (9.67%) did the cotyloid portion require reoperation because of mobilization. In all cases (100%) the graft integrated perfectly with the host bone. The present study provides encouraging data regarding the use of autografts of cortico-cancellous bone taken from the head of the femur during hip replacement in patients with coxarthrosis in dysplasia of the hip. No differences were seen between the cemented and non cemented prostheses.

Modulation of gene expression in human osteoblasts by targeting a distal promoter region of human estrogen receptor-alpha gene.

Estrogen receptor (ER) alpha is expressed during osteoblast differentiation; however, both its functional role in bone metabolism and its involvement in osteoporotic pathogenesis caused by estrogen deficiency are not well understood. Loss of ER alpha gene expression could be one of the mechanisms leading to osteoporosis. Therefore, we investigated a possible modulation of ER alpha gene expression in a human osteoblastic cell line and in four primary osteoblast cultures by using a decoy strategy. Double stranded DNA molecules, mimicking a regulatory region of the ER alpha gene promoter (DNA-102) and acting as a 'silencer' in breast cancer cells, were introduced into osteoblasts as 'decoy' cis-elements to bind and functionally inactivate a putative negative transcription factor, and thus to induce ER alpha gene expression. We found that the DNA-102 molecule was able to specifically bind osteoblast nuclear proteins. Before decoy treatment, absence or variable low levels of ER alpha RNAs in the different cultures were detected. When the cells were transfected with the DNA-102 decoy, an increase in expression of ER alpha and osteoblastic markers, such as osteopontin, was observed, indicating a more differentiated osteoblastic phenotype both in the cell line and in primary cultures. These results showed that the DNA-102 sequence competes with endogenous specific negative transcription factors that may be critical for a decrease in or lack of ER alpha gene transcription. Therefore, osteoblastic transfection with the DNA-102 decoy molecule may be considered a tempting model in a putative therapeutic approach for those pathologies, such as osteoporosis, in which the decrease or loss of ER alpha expression plays a critical role in bone function.

Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings.

Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.

Effects of pulsed electromagnetic fields on human articular chondrocyte proliferation.

Low-energy, low-frequency pulsed electromagnetic fields (PEMFs) can induce cell proliferation in several cell culture models. In this work we analysed the proliferative response of human articular chondrocytes, cultured in medium containing 10% FBS, following prolonged exposure to PEMFs (75 Hz, 2.3 mT), currently used in the treatment of some orthopaedic pathologies. In particular, we investigated the dependence of the proliferative effects on the cell density, the availability of growth factors and the exposure lengths. We observed that PEMFs can induce cell proliferation of low density chondrocyte cultures for a long time (6 days), when fresh serum is added again in the culture medium. In the same conditions, in high density cultures, the PEMF-induced increase in cell proliferation was observed only in the first three days of exposure. The data presented in this study show that the availability of growth factors and the environmental constrictions strongly condition the cellular proliferative response to PEMFs.

The protective efficacy of surgical latex gloves against the risk of skin contamination: how well are the operators protected?

Latex gloves are used by surgical staff to avoid exposure to patient body fluids, thus reducing the risk of contracting bloodborne viral diseases, such as hepatitis C and HIV. We studied the efficacy of the surgical barrier provided by latex gloves, before and after use in the operating theater. The electrical conductivity, insulation and mechanical resistance of glove latex were investigated, using routine supplies of surgical gloves. Latex structure was assessed by scanning electron microscopy and by mercury intrusion porosimetry. Latex is subject to hydration, a phenomenon associated in the laboratory with the loss of its electrical insulation properties. Such glove latex properties were found to be highly variable, with latex hydration times varying between 2 and more than 30 min. Rapidly hydrating gloves showed increased permeability to methylene blue, associated with higher levels of porosity. Thirty min of surgical use was associated with measurable hydration of glove latex and a statistically significant loss of electrical and mechanical resistance, with rupture load decreasing by 24%. Electronic control of the insulation properties of gloves during surgery permits early detection of hydration, and allows prompt correction by glove change, before the gloves lose their electrical and mechanical competence.

Effects of pulsed electromagnetic fields on human chondrocytes: an in vitro study.

(3)H-thymidine incorporation was studied in cultured human nasal and articular chondrocytes exposed to low-energy, low-frequency pulsed electromagnetic fields (PEMFs) (75 Hz, 2.3 mT). The reverse transcriptase polymerase chain reaction (RT-PCR) analysis shows that human secondary chondrocytes derived from both nasal and articular cartilage express collagen type II mRNA, which is a specific marker of the chondrocyte phenotype. In a preliminary series of experiments, cells were exposed to PEMF for different time periods ranging from 6 to 30 hours (time-course), in medium supplemented with 10% or 0.5% fetal calf serum (FCS) and in serum-free medium. The ratios between the (3)H-thymidine incorporation in PEMFs and control cultures show an increase of the cell proliferation in cultures exposed to PEMFs when serum is present in the culture medium, whereas no effect was observed in serum-free conditions. The increase in DNA synthesis, induced by PEMFs, was then evaluated only at the times of maximum induction and the results were analyzed by the three-factor analysis of variance (ANOVA). The data presented in this study show that even if (3)H-thymidine incorporation is higher in nasal than in articular chondrocytes, PEMF induce an increase in the proliferation of both cell types. Moreover, the concentration of FCS in the culture medium greatly influences the proliferative response of human chondrocytes to the PEMF exposure. Though normal human osteoblast cells increase their proliferation when exposed to PEMFs if only 10% FCS is present in the medium, human chondrocytes are able to increase their cell proliferation when exposed to PEMFs in the presence of both 0.5% and 10% of FCS in the medium. The results obtained may help to explain the basic mechanisms of PEMF stimulation of fracture healing.

Correlation between pulsed electromagnetic fields exposure time and cell proliferation increase in human osteosarcoma cell lines and human normal osteoblast cells in vitro.

We have exposed cultured bone cells to a pulsed electromagnetic field (PEMF) for different times to find the minimal exposure time necessary to stimulate an increase of DNA synthesis. We used two different human osteosarcoma cell lines, TE-85 and MG-63, and human normal osteoblast cell (NHOC) obtained from surgical bone specimens. The cells were placed in multiwell plates and set in a tissue culture incubator between a pair of Helmoltz coils powered by a pulse generator (1.3-ms pulse, repeated at 75 Hz) for different periods of time. [3H]Thymidine incorporation was used to evaluate cell proliferation. The two osteosarcoma cell lines increase their thymidine incorporation when exposed to a PEMF for at least 30 min, both in a medium containing 10% fetal calf serum and in a serum-free medium. NHOC are known to increase their cell proliferation when exposed to PEMF but only if cultured in the presence of 10% fetal calf serum. In this experimental condition, three of the four cell lineages studied required at least 9 h of PEMF exposure to increase their DNA synthesis, whereas one cell lineage increased its cell proliferation after 6 h of PEMF exposure. Our observations confirm the hypothesis that the proliferative responses of NHOC and human osteosarcoma cell lines to PEMF exposure are quite different. Moreover, NHOC required minimal exposure times to PEMF to increase their cell proliferation, similar to that needed to stimulate bone formation in vivo.

Growth hormone secretion and bone histomorphometric study in thalassaemic patients with acquired skeletal dysplasia secondary to desferrioxamine.

An auxological and endocrinological study was performed in 21 thalassaemic patients with growth retardation and skeletal dysplasia secondary to desferrioxamine. Bone metaphyseal proximal tibial or iliac crest biopsy was performed in six patients with severe genu valgum or non-traumatic vertebral compression. GH insufficiency/deficiency (GH deficiency: peak after stimulation test below 6 ng/ml) was found in 72% of our thalassaemic patients with skeletal dysplasia, but in only 41% of patients without skeletal dysplasia. Bone histology showed abnormal chondrocytes, alteration of staining pattern of cartilage, irregular columnar cartilage and lacunae in the cartilaginous tissue. The behaviour of bone tissue was unpredictable (presence of thick or thin osteoid layer). Bone microfractures were sometimes present. The bone microstructure showed scarce mineralization, which was evenly or irregularly distributed. The bone tissue apatitic phase was quantitatively reduced. The hardness of bone tissue was remarkably lower than that of normal bone in three out of six patients. In conclusion, iron chelation therapy in patients with acquired skeletal dysplasia seems to interfere with GH secretion. The early identification of clinical and radiological abnormalities of skeletal dysplasia is of paramount importance in preventing severe bone destruction.

Responses of human MG-63 osteosarcoma cell line and human osteoblast-like cells to pulsed electromagnetic fields.

We have studied the effects of low-energy, low-frequency pulsed electromagnetic fields (PEMF) on cell proliferation, in both human osteoblast-like cells obtained from bone specimens and in human MG-63 osteosarcoma cell line. Assessment of osteoblastic phenotype was performed both by immunolabeling with antiosteonectin antibody and by verifying the presence of parathyroid hormone receptors. The cells were placed in multiwell plates and set in a tissue culture incubator between a pair of Helmholtz coils powered by a pulse generator (1.3 ms, 75 Hz) for different periods of time. [3H]Thymidine incorporation was used to evaluate cell proliferation. Since it had previously been observed that the osteoblast proliferative response to PEMF exposure may also be conditioned by the presence of serum in the medium, experiments were carried out at different serum concentrations. [3H]Thymidine incorporation increases in osteoblast-like cells, when they are exposed to PEMF in the presence of 10% fetal calf serum (FCS). The greatest effect is observed after 24 hours of PEMF exposure. No effects on cell proliferation are observed when osteoblast-like cells are exposed to PEMF in the presence of 0.5% FCS or in a serum-free medium. On the other hand, PEMF-exposed MG-63 cells show increased cell proliferation either at 10% FCS, 0.5% FCS and in serum-free medium. Nevertheless, the maximum effect of PEMF exposure on MG-63 cell proliferation depends on the percentage of FCS in the medium. The higher the FCS concentration, the faster the proliferative response to PEMF exposure. Our results show that, although MG-63 cells display some similarity with human bone cells, their responses to PEMF's exposure are quite different from that observed in normal human bone cells.

[The echographic and clinical follow-up of patients operated on for subcutaneous rupture of the Achilles tendon]. / Follow-up ecografico e clinico di pazienti operati per rottura sottocutanea del tendine di Achille.

Thanks to its good long-term results, surgery is the method of choice to treat subcutaneous ruptures of the Achilles tendon. Reconstructed tendons present typical morphological and functional US patterns which depend partly on the kind of surgical reconstruction and partly on the time passed since surgery. The authors report the results of the clinical and US follow-up of a series of 62 surgical patients treated in 7 years for the subcutaneous rupture of the Achilles tendon. The patients were 55 men and 7 women, whose mean age was 36 years (range: 25-65 years). The left-hand side was affected in 38 patients and the right-hand side in 24 patients. All patients were operated on using an end-to-end suture and reinforcement plastic surgery pulling down a gastrocnemius tendon flap. To homogenize the results, all the US exams were performed by the same operator, in the presence of the orthopedic specialist and under the same conditions: both the involved and the contralateral Achilles tendons were studied, longitudinal and transverse scans were performed with the foot in max. plantar and dorsal flexion and, whenever possible, dynamic scans were also performed making the sural triceps contract against resistance. The following parameters were studied clinically: pain (which was absent in 39 patients, occasional in 11, after stress in 9 and on walking in 3 patients), skin scar trophism (which was eutrophic in 53.23% of patients, keloid in 27.42% and hypertrophic in 19.35% of patients), ankle joint excursion (plantar flexion was impaired in 32.3% and dorsal flexion in 36% of patients), walking on tiptoe (in all, 22.6% of patients complained of difficulties walking on tiptoe) and, finally, work activity resumption (which all patients achieved). US depicted the surgical tendons as much bigger than the contralateral ones (3-4 times on the average), which increase in volume lasted throughout the follow-up. In 75% of patients the echo structure of the surgical tendons was inhomogeneous, with scattered hypoechoic and hyperechoic areas. In the extant 25% of patients, nearly all of them followed-up for over 6 years, US depicted a clear-cut hyperechoic area whose size and echo structure were similar to the healthy tendons'. Our results strongly suggest that tenorrhaphy and flap plastic surgery be used to repair subcutaneous ruptures of the Achilles tendon. US proved to be the most reliable and feasible method also in the follow-up. The US images of the patients submitted to surgery more than 6 years earlier revealed fibrillate reorganization patterns and tendon restructuring. These processes involve both ends of the sutured tendon and not the reinforcement flap, which further confirms the exclusively mechanical, and not biological, function of the latter.

Periprosthetic bone density in uncemented femoral hip implants with proximal hydroxylapatite coating.

The short term results of a prospective dual energy x-ray absorptiometry (DEXA) study of periprosthetic bone remodeling around titanium femoral stems proximally coated with hydroxyapatite are presented. Thirty patients underwent DEXA scanning on the 15th and 45th postoperative days, 12th, 18th postoperative month. DEXA showed global femoral periprosthetic remodeling during the first 18 postoperative months. However, no significant variation in bone mineral density occurred around the lateral metaphyseal regions, where cancellous bone is greatest.

Clinical and ultrasound follow-up of 62 patients submitted to the surgical treatment of subcutaneous rupture of the Achilles tendon.

A total of 62 patients submitted to the surgical treatment of subcutaneous rupture of the Achilles tendon were followed up after a period of time ranging from 2 to 8 years. End-to-end suturing and reinforcement plastic surgery obtained excellent clinical results in more than 80% of the cases, with complications which were principally inherent to scarring. There were no cases of rupture. In cases with a longer follow-up, ultrasound examination revealed aspects of fibrillate restructuring of the tendon.

The electrical stimulation of tibial osteotomies. Double-blind study.

The effect of electromagnetic field stimulation was investigated in a group of 40 consecutive patients treated with valgus tibial osteotomy for degenerative arthrosis of the knee. All patients were operated on by the same author and followed the same postoperative program. After surgery, patients were randomly assigned to a control group (dummy stimulators) or to a stimulated one (active stimulators). Four orthopedic surgeons, unaware of the experimental conditions, were asked to evaluate the roentgenograms taken 60 days postoperatively and to rate the osteotomy healing according to four categories (the fourth category being the most advanced stage of healing). In the control group, 73.6% of the patients were included in the first and second category. In the stimulated group, 72.2% of the patients were included in the third and fourth category. On a homogeneous group of patients, electromagnetic field stimulation had positive effects on the healing of tibial osteotomies.

Recurrent posterior subluxation of the shoulder.

The rare posterior form of instability syndrome of the shoulder is taken into consideration. A diagnostic protocol aimed at revealing posterior slipping of the humeral head following spontaneous movement or with stress is suggested; this involves semiological maneuvers, and the help of radiographs in specific projections and CT scan. As for treatment, the importance of physiatric treatment is emphasized, and surgery advised in young patients who do not benefit from conservative treatment. The authors prefer posterior capsulomyoplasty associated with posterior glenoplasty in forms of the pathology characterized by excessive glenoid retroversion. Finally, 4 personal cases are presented.

Congenital dislocation of the hip. A protocol for early diagnosis.

On March 13, 1987 the Academy of Sciences and the Medico-Surgical Association of Ferrara organised a Meeting in Ferrara to commemorate Professor Marino Ortolani on the occasion of the 50th anniversary of his publication of the click sign which he proposed as an early means of diagnosis in congenital dislocation of the hip. It was thought that the 50th anniversary of the description of this sign would be a fitting occasion on which to compile a joint orthopaedic, radiological and paediatric document in which current views on the early diagnosis of congenital dislocation of the hip could be reported. The proposal was taken up and sponsored by the following Italian Associations: Orthopaedic Surgery, Paediatric Orthopaedics, Radiology and Nuclear Medicine, Paediatrics, Preventive and Social Paediatrics. A committee was formed representing the various Associations, to which was entrusted the task of compiling the proposed document.