Hybrid Cementation Technique Using the New Modular System for Aseptic Knee Arthroplasty Revision Surgery.

Background: To evaluate the clinical and radiological outcomes of aseptic revision of total knee arthroplasty (TKA) using the Vanguard 360 Revision Knee System with the hybrid cementation technique. Methods: Between January 2014 and October 2016, nineteen aseptic revision TKAs were carried out with the Vanguard 360 Revision Knee System (Zimmer-Biomet, Warsaw, IN, USA) performed by two different surgeons. The patients were evaluated clinically and radiographically at one, six, and twelve months after surgery and yearly thereafter. Functional outcomes were assessed according to the range of motion (ROM), knee society knee score (KSKS) and knee society function score (KSFS). Radiological evaluations were performed using the hip-knee-ankle angle (HKA), weight-bearing anteroposterior view, latero-lateral view, Rosenberg x-rays of the knee and skyline patellar x-rays. A triple-phase technetium bone scan was performed on all the patients complaining of knee pain after one year from surgery. Results: Clinical and radiological results including KSKS, KSFS, ROM and HKA angle improved after revision of TKA with a statistically significant difference (p <0.05). There were seven revisions of the CCK prosthesis due to persistent pain. Conclusion: Patients who underwent revision of TKA using the Vanguard 360 with the hybrid cementation technique had a failure rate of 36.8% at a mean time of 29 months due to aseptic loosening. Further studies are required to analyse the role of cementation in detail to prevent this complication.

Early results with a bicruciate-retaining total knee arthroplasty: a match-paired study.

BACKGROUND: The aim of this study is to compare 2 groups of total knee arthroplasties (TKAs): the bicruciate-retaining (BCR-group) and cruciate-retaining total knee arthroplasty (CR-group), evaluating the functional results in the short-term follow-up. METHODS: 24 BCR were included in the study and were compared with a group of 24 TKAs performed with the same implant, but with sacrifice of the ACL and retention of the posterior cruciate ligament. For preoperative and postoperative clinical evaluation, the visual analogue score (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used. Radiological evaluation included weight-bearing long-leg view, a Rosemberg view, lateral view of the knee and tangential view of the patella. Hip-knee-ankle angle (HKA) was recorded pre and postoperatively. Radiolucent lines (RLLs) were evaluated according the Knee Society Roentgenographic Evaluation System (KSRES). RESULTS: At last follow-up the mean VAS score was 1.81 for BCR group and 1.43 for CR group (p = 0.61). The mean WOMAC score was 8.68 for BCR group and 12.81 for CR group (p = 0.33). As for the radiological evaluation, preoperative HKA angle was 0.53° varus for BCR group and 3.14° varus for CR group (p = 0.24); postoperative HKA was 0.72° valgus for BCR group and 0.38° valgus for CR group (p = 0.75). The percentage of RLLs was similar between the two groups (12% versus 15%). CONCLUSIONS: BCR-TKA has showed to give similar functional and radiographic outcomes compared to conventional CR-TKA in a similar cohort of patients. An higher operative times and higher number of complications respect were found in BCR group. These results can be explained by the early learning curve experiences. Future randomized controlled trials should be performed to support new implant designs such as BCR. LEVEL OF EVIDENCE: Level of evidence Case-control study, level III.

Humeral head necrosis associated to shaft non-union with massive bone loss: a case report.

Humeral non-union is a rare complication in shaft fractures, as well as humeral head necrosis is a possible complication in fracture involving the proximal third especially in four-part fractures. The presence of head osteonecrosis and diaphyseal non-union in the same arm represents a formidable challenge for an orthopaedic surgeon. We could not find any similar report in the literature dealing with this issue thus far. We present a case of a 65 years old woman referred to our hospital being affected by an atrophic humeral diaphyseal non-union with a massive bone loss (>10cm) associated to a humeral head osteonecrosis following a previous surgical procedures with a clear loosening of the hardware. At our institution,she was treated with hardware removal and insertion of a diaphyseal antibiotic spacer with Gentamycin for 2 months suspecting an active septic process at the union site despite negative cultural exams. Finally, she was treated with a cemented modular humeral megaprosthesis. At 20 months follow up, the patient, despite a reduced shoulder range of motion, referred to a pain-free recovery to an almost normal lifestyle, including car driving with no major disturbances. This case suggests that, in extreme selected cases following several failed treatments, megaprosthesis can represent a viable solution, especially in huge bone loss associated to joint degeneration, to ensure an acceptable return to a normal lifestyle.

Autologous adipose stem cell therapy for knee osteoarthritis: where are we now?

Introduction: The purpose of this study was to evaluate the efficacy and safety of adipose-derived stem cell (ADSC) or stromal vascular fraction (SVF) injections for knee osteoarthritis (OA) treatment by analyzing all randomized controlled trials dealing with this topic. Materials and methods: The following search terms were used in PUBMED, EMBASE, Scopus, and the Cochrane Library Database on 14 November 2019: 'adipose derived stem cell' OR 'stromal vascular fraction' OR 'SVF' OR 'multipotent mesenchymal stromal cells' OR 'stem cell' OR 'derived stem cell' OR 'autologous' AND 'knee' OR 'osteoarthritis' OR 'chondral defect' OR 'randomized' OR 'controlled trial.' No time limit was given to publication date. We included randomized controlled trials (RCTs) based on the following criteria: (1) English studies; (2) patient population diagnosed with knee OA and treated with ADSCs or SVF injections; (3) comparison group treated with placebo, surgery, or adjuvant injections, such as platelet rich-plasma or hyaluronic acid. Results: Intra-articular injections of adipose stem cell therapy in the form of ADSC or SVF is a safe procedure for the treatment of knee OA, with good clinical and radiological outcomes in the early follow-up period (12-24 months). In addition, treatment with fat-derived cells showed a very low complication rate (16.15%) of which all were considered to be minor. Conclusions: ADSCs and SVF seem to produce promising good to excellent clinical results for the treatment of knee OA. However, the length and modalities of follow-up in the different conditions are extremely variable. Nevertheless, it appears that the use of adipose-derived stem cells is associated with clinical and radiological improvements and minimal complication rates. To avoid bias deriving from the use of biological adjuvants or surgical procedures, randomized controlled trials comparing ADSCs or SVF and other treatments (for example, platelet rich-plasma or hyaluronic acid injections) should be performed.

Computer-assisted surgery in total knee replacement: advantages, surgical procedure and review of the literature.

INTRODUCTION: Total knee replacement (TKR) is one of the most frequent orthopaedic procedures performed every year. At the same time 20% of patients who underwent TKR are not satisfied with the outcome. The reasons are unknown; we think that a mechanical alignment beyond 3° of varus-valgus can represent the most important cause of failure of TKR and consequently patient dissatisfaction. MATERIALS AND METHODS: Neutral mechanical alignment is the main goal in every TKR: this can be achieved through different tools, such as extramedullary and intramedullary guides, patient-specific instrumentation (PSI) and computer-assisted surgery (CAS). The aim of this review is to compare the different alignment techniques in TKR, to describe CAS procedure and CAS results in recent literature. RESULTS: Regarding the intramedullary guide, there is an increased risk of fatty embolism; there are great limitations on its use, or even impossibility, in cases of bone deformity and sequelae of trauma. Regarding the extramedullary guide, it becomes more difficult to use in cases of great obesity or increased soft-tissue volume around the tibia. PSI for TKR has been introduced to improve alignment, reduce outliers, operation time and the risk of fatty embolism by avoidance of intramedullary canal violation. Recent randomized controlled trials and meta-analysis proved no advantage of PSI in improving mechanical axis and implant survivorship. DISCUSSION: CAS has provided to be a useful tool in assisting the surgeon to achieve more accurate post-operative mechanical axis through precise and reproducible bone cuts and ligament balancing. Two meta-analyses definitively proved that CAS technique improves mechanical axis and implant survivorship and one recent meta-analysis demonstrated that CAS provides better mechanical alignment and higher functional scores at short-term follow-up.

Non artheritic bilateral anterior ischaemic optic neuropathy (NAION) as devastating complication following Total Hip Arthroplasty: a case report.

INTRODUCTION: Postoperative vision loss (PVL) is an extremely rare complication following major surgical procedures. Patients with systemic hypertension, diabetes, coronary diseases and smokers are generally predisposed to this complication. More frequently, it is caused by ischemic optic neuropathy (ION), central retinal artery occlusion or retinal vein occlusion. Rare cases of unilateral PVL following total joint arthroplasty surgery have been recently described in literature. CASE REPORT: This case report describes the first reported bilateral non-arteritic anterior ischemic optic neuropathy (NAION), which occurred 3 days following a total hip arthroplasty with a consequent post-operative hypotension. CONCLUSIONS: Orthopedic surgeons should be aware that in hip joint replacement procedures, selected patients present an higher risk of ION following intra/postoperative hypotension and prolonged surgical times. (www.actabiomedica.it).

Scapular reconstructions after resection for bone tumors: a single-institution experience and review of the literature.

Scapulectomy and limb-salvage surgery are indicated for low and high-grade tumors of the scapula and soft-tissue sarcomas that secondary invade the bone. After total or partial scapulectomy there are 3 options of reconstruction: humeral suspension (flail shoulder), total endoprosthesis and massive bone allograft. Nowadays prosthesis and allograft reconstructions are the most used and humeral suspension is reserved only as salvage technique when no other surgery is possible. Several studies reported dislocations and wound infections as the most frequent complications of scapular prosthesis, account for 10-20%. Recently, in the attempt to prevent these complications, some authors have used homologous allografts to replace shoulder girdle after scapulectomy for bone tumors, avoiding common complications of scapular prosthesis. Scapular reconstruction following tumor resection is a safe procedure and can be performed with good functional, oncological and cosmetic results but in reference centres and by skill surgeons. In this paper we present three cases of scapular reconstructions following resections for scapular tumors (chondrosarcoma in all cases) performed in our Institute and we analyse the different options of reconstruction described in the current literature. The final message is to send these rare tumors to reference centres where a multidisciplinary team is able to treat these rare entities and where a group of skill oncology surgeons are able to plan this complex surgery.

Periosteal osteoblastoma of the distal fibula with atypical radiological features: a case report.

We reported the case of a 22 year-old boy who suffered a periosteal osteoblastoma of the distal fibula. The radiographic features of our case did not correlate with the majority of periosteal osteoblastomas of the long bones reported in the literature and were identical to a periosteal aneurysmal bone cyst. Periosteal osteoblastoma is a very rare tumor with a wide range of clinical and radiological features, showing in 15% of cases association with secondary aneurysmal bone cyst. Radiologist and orthopaedic surgeon should be aware of the atypical behavior of this rare entity in order to avoid mistakes with other more common tumors arising on the surface of the long bones.

Intramuscular oxygen-ozone therapy in the treatment of low back pain.

BACKGROUND AND AIM OF THE WORK: Intramuscular paravertebral injections of ozone are minimally invasive, safe and efficacy in reducing pain and disability. The aim of this paper is to present the early results of paravertebral lumbar ozone injections in the treatment of low back pain. METHODS: Between February 2011 and December 2015, a total of 109 patients underwent intramuscular paravertebral lumbar injections of ozone due to low back pain. Of them, 42 interrupted the treatment at a medium of 5.4 injections and were lost to follow-up. Of the 67 remaining patients, only 24 answered to our questionnaire. Local and radiating pain was assessed using a 10-cm horizontal Visual Analogue Scale. Perceived functional status and disability were evaluated using the Oswestry Disability Index, administered before treatment and one month after the last injection. RESULTS: Visual Analogue Scale reduction was demonstrated in 23 out of 29 cycles (79%) of ozone therapy. Regarding disability evaluation, Oswestry Disability Index score reduction was assessed in all except one. No complications were recorded. Our results are similar to the other reports: 79% of patients had VAS reduction of 2.3 points and all except one patient reported ODI reduction (average reduction of 9%). CONCLUSIONS: Lumbar paravertebral oxygen-ozone injections are minimally invasive, safe, cheaper and effective in relieving pain as well as disability. This technique is easy to perform, it doesn't need computed-tomography or anesthesiologist support. We suggest its application in low back pain as first choice to replace intradiscal computed-tomography-guided infiltrations and to avoid or delay surgery.

Bi-unicompartmental versus total knee arthroplasty: long term results.

The purpose is to demonstrate that Bi-Unicom- partmental knee arthroplasty (Bi-Uni) can produce equivalent long-term outcomes to total knee arthroplasty (TKA) in patients with bicompartmental knee osteoarthritis involving both the medial and lateral tibio-femoral compartments. A total of 37 patients with bicompartmental tibio- femoral osteoarthritis of the knee treated between January 1999 and March 2005 underwent either Bi-Uni or TKA. Nineteen patients who underwent simultaneous implantation of 2 unicompartmental knee arthroplasties (UKA) were matched and compared with 18 patients who had undergone a computer assisted TKA. At latest follow-up no statistically significant differences were seen between the 2 patient groups for KSS, Function scores and WOMAC Arthritis Index (pain score). The patients undergoing Bi-Uni did showed a statistically significant superior outcome for function (P < 0.05) and stiffness (P < 0.01) WOMAC indexes compared with the TKA group. The results of this study suggest that Bi-Uni is a valid alternative to address medial and lateral tibio- femoral osteoarthritis of the knee in selected cases. Bi-Uni replacement produces results equivalent TKA in patients with bicompartmental knee osteoarthritis involving both the medial and lateral tibio-femoral compartments and could represent a new frontier in modern knee reconstructive surgery. Level of Evidence: Level IV, retrospective comparative study.

Mazabraud syndrome associated with McCune-Albright syndrome: a case report and review of the literature.

Mazabraud syndrome is a very rare benign disorder characterized by the association of monostotic or polyostotic fibrous dysplasia and one or multiple intramuscular myxomas. McCune -Albright syndrome is a rare benign disorder characterized by the association of polyostotic fibrous dysplasia, cafè-au-lait skin pigmentations and endocrine dysfunction, such as precocious puberty, diabetes mellitus, goiter and breast fibroadenomatosis. The association of Mazabraud syndrome and McCune-Albright in the same patient is an anecdotal event. We report the case of a 28-year-old girl with Mazabraud syndrome associated with McCune-Albright syndrome. Our literature review shows that in these patients there is a higher risk of malignant transformation of fibrous dysplasia into osteosarcoma, confirming previous reports. Conversely, no malignant transformation has been reported for myxomas in isolated Mazabraud syndrome or in the association with McCune-Albright syndrome. We conclude that these patients should be scheduled to a close and long-term follow-up.

Early results for treatment of two- and three-part fractures of the proximal humerus using Contours PHP (proximal humeral plate).

BACKGROUND AND AIM OF THE WORK: The management of displaced 2- and 3-part fractures of the proximal humerus is controversial, both in younger and in elderly patients. The purpose of this paper is to evaluate the functional results of the Contours Proximal Humerus Plate (OrthofixR, Bussolengo,Verona, Italy), for the treatment of displaced 2- and 3-part fractures of the proximal humerus. METHODS: We retrospectively reviewed 55 patients with proximal humerus fractures, who underwent osteosynthesis with Contours Proximal Humerus Plate from December 2011 to March 2015. We had 21 patients with 2-part fractures and with an average age of 67.1 years and 34 patients with 3-part fractures, with average age of 63.6 years. RESULTS: The average union time was 3 months. The mean Constant score was 67 for 2-part fracture group and 64.9 for 3-part fracture group. The difference was not statistically significant (p = 0.18). The overall complication rate was 14.5 %. Six patients underwent additional surgery (10.9%). CONCLUSIONS: The most frequent major complication was secondary loss of reduction following varus collapse of the fracture (2 cases). In these patients, there was loss of medial hinge integrity due to impaction and osteoporosis. The placement of the main locking screw in the calcar area to provide inferomedial support is the rational of the Contours Proximal Humerus Plate. Osteosynthesis with Contours Proximal Humerus Plate is a safe system for treating displaced 2- and 3-part fractures of the proximal humerus, with good functional results and complication rates comparable to those reported in the literature.

Navigated "small implants" in knee reconstruction.

PURPOSE: At the beginning of this century, unprecedented interest in the concept of using less invasive approaches for the treatment of knee degenerative diseases was ignited. Initial interest in this approach was about navigated and non-navigated knee reconstruction using small implants and conventional total knee arthroplasty. METHODS: To this end, a review of the published literature relating to less invasive compartmental arthroplasty of the knee using computer-based alignment techniques and on soft tissue-dedicated small implants is presented. The authors present and compare their personal results using these techniques with those reported in the current literature. These involved the use of a shorter incision and an emphasis sparing. However, nowadays most surgeons look at compartmental knee resurfacing with the use of small implants as the new customized approach for younger and higher-demand patients. The aim of this paper is to stimulate further debate. RESULTS: Since the beginning of 2000, computer-assisted surgery has been applied to total knee arthroplasty (TKA) and later to compartmental knee arthroplasty. Recent studies in the literature have reported better implant survivorship for younger patients using navigation in TKA at longer-term follow-up. Only one published report was identified showing superior clinical outcomes at short-term follow-up using computer-assisted technology compared with conventional alignment techniques in small implant surgery. No studies were found in the literature that demonstrated similar clinical advantages with navigated small implants at long-term follow-up. Two published meta-analyses were identified reporting better implant and limb alignment and no increase in complications using a navigated unicompartmental knee arthroplasty. However, neither meta-analysis showed superior clinical outcomes or survivorship with the navigated techniques. CONCLUSION: In conclusion, we can assert that replacing just the damaged compartment and preserving the normal biomechanics will require not only new implant designs but also new technologies allowing the surgeon to make extremely precise adjustments to implant alignment and providing continuous feedback during surgery. LEVEL OF EVIDENCE: IV.

Synovial chondrosarcoma.

BACKGROUND: Synovial chondrosarcoma (SCH) is a very rare tumor arising in the intra-articular cavity. In the majority of literature reports it is described as a malignant transformation of a pre-existing synovial chondromatosis (SC). We reported a systematic review of primary and secondary SCH described in the literature with the aim to recollect data from different case-reports and case-series, trying to summarize general aspects of this very rare disease. METHODS: We collected 42 abstracts in the form of case series and case reports, which reported 67 cases of SCH. Studies were taken into account only if they proved a histological diagnosis of SCH, either primary or secondary, with or without evidence of pre-existing SC. RESULTS: The average age of SCH was 56.9 years, with prevalence for male sex. The average time of malignant transformation was 11.2 years. The most affected joint was the knee (47.7%), followed by hip (34.3%) and ankle (5.9%). SCH was described as de novo sarcoma only in 13 cases (19%). Surgery ended up with amputation in 59.7% of cases. Local recurrence rate was 28.3%. CONCLUSIONS: We concluded that prognosis of SCH is worse than conventional one and we speculated this is due to the difficult site of the tumor (intraarticular), diagnostic delay and inappropriate previous treatments. We consider that a rapid deterioration of a SC or rapid recurrence after synoviectomy should be considered suspicious of malignant transformation and should be treated in a reference center.

Osteosarcoma in identical twins: A case report.

Osteosarcoma (OS) is the most frequent primary malignant bone tumor, if we exclude myeloma, a hematologic systemic disease. OS is relatively uncommon, with an estimated incidence of 600 cases per year in the United States. Among siblings is an even rarer phenomenon, with scattered reports throughout the English literature(1). We report the incidence of OS in identical twins. The first case is a low-grade OS arisen in the proximal tibia of a 25-year-old man, treated with en-bloc resection and reconstruction with allograft. The second one is a high-grade OS of the distal tibia of the 33-year-old twin, developed in a previous non-ossifying fibroma (NOF) followed over the time. The patient was treated with neo-adjuvant chemotherapy, en-bloc resection and reconstruction with allograft. Our literature review did not find any case of OS in identical twins, while 26 reports of OS in siblings are described.

The use of iliac stem prosthesis for acetabular defects following resections for periacetabular tumors.

INTRODUCTION: The management of pelvic tumors is a challenge for orthopaedic oncologists due to the complex anatomy of the pelvis and the need to have extensive exposure. Various reconstructive techniques have been proposed with poor functional results and a high percentage of complications. Our purpose is to determine the functional results and the rate of complications of iliac stem prosthesis for acetabular defects following resections for periacetabular tumors. MATERIALS AND METHODS: Between 1999 and 2012, 45 patients underwent pelvic resections for periacetabular bone tumors followed by reconstruction with stem cup prosthesis. The most common diagnosis was CS (chondrosarcoma, 29 cases), followed by OS (osteosarcoma, 9 cases) and metastasis (3 cases). In 33 cases, this implant was associated with massive bone allografts. Minimum follow-up required to evaluate functional outcome was 2 years. We classified pelvic resections according to Enneking and Dunham's classification and we used MSTS (musculoskeletal tumor system) score to evaluate functional outcomes. RESULTS AND DISCUSSION: Sixteen patients died of their disease, three were lost to follow-up, four are alive with disease, and twenty-two are alive with no evidence of disease. Fifteen patients had local recurrence. Sixteen patients had bone or lung metastasis. We have had 6 infections, 2 aseptic loosening, and 2 cases of hip dislocation. Iliac sovracetabular osteotomy was fused in all cases at 10 months from surgery. Functional results were good or excellent in 25 of 31 patients with long-term follow-up (77%), with a percentage similar to that reported in the literature. CONCLUSION: The use of iliac stem prosthesis is a simple reconstructive technique that reduces operative times and risk of infection. It allows having good results and low rate of complications, but it should be performed in selected cases and centres of reference.

Palliative therapy for osteosarcoma.

Despite advances in diagnostic imaging, the evolution of neoadjuvant chemotherapy and the refinements in limb-salvage surgery, the progression-free survival rate remains poor for patients with metastatic, recurrent or unresectable osteosarcoma. Different therapeutic strategies for these subgroups of patients have been employed to control disease and prolong survival. Treatment options are limited and controversial, including systemic and localized therapies. Surgical resection, whenever feasible, is still the standard treatment in advanced osteosarcoma. The role of chemotherapy is unclear while the use of radiotherapy, embolization and thermal ablation is increasing. New therapeutic experimental approaches and novel target therapies are needed to improve the outcome of these subgroups of patients.