Locking Attachment Plate for the Surgical Treatment of Periprosthetic and Periimplant Fractures: Long-Term Follow-Up.

Objectives: The surgical management of periprosthetic fractures (PPF) and periimplant fractures (PIF) can be challenging. The locking attachment plate (LAP) was proposed in recent years for the osteosynthesis of such fractures. The aim of this study was to assess the experience of a third-level hospital with LAP for the treatment of PPF and PIF, and analyse the clinical outcomes. Methods: Data were prospectively collected and analysed from all patients whose PPF/PIF was treated surgically with LAP in a third-level hospital from June 2018 to June 2022. All fractures were postoperative low-energy femur fractures. The minimum follow-up period was six months. Results: Thirty-eight patients (31 women) met the eligibility criteria. The mean age was 86.3 years. The median time until surgery was 4 days. A mean of 3.61 screws were used for each LAP. The mean femur plate length was 14 holes, and the mean working length 7.1 holes. The median hospital stay was nine days. The mean follow-up was 19.56 months. At one month, 12 patients tolerated partial weight-bearing. Five patients walked independently indoors. One patient had died and seven patients were readmitted. At six months, six more patients had died. Fifteen patients tolerated full weight-bearing (FWB). Nine patients walked independently indoors, six outdoors. Twenty-five patients reached fracture consolidation without malalignment. Nine patients were readmitted. At 12 months, another patient had died. Seventeen patients tolerated FWB. Eleven patients walked independently indoors, six outdoors. Twenty-five patients achieved fracture consolidation without malalignment. Five patients were readmitted. Fourteen patients crossed the two-year postoperative threshold. All achieved fracture consolidation. Two patients passed the 4-year postoperative milestone. Conclusion: The clinical results of patients whose PPF or PIF was treated with the LAP are promising. This fixation method is a viable option to be considered when planning surgery for such fractures.

What factors are associated with a better restoration of pelvic version after adult spinal deformity surgery?

INTRODUCTION: Poor restoration of pelvic version after adult spinal deformity (ASD) surgery is associated with an increased risk of mechanical complications and worse quality of life. We studied the factors linked to the improvement of postoperative pelvic version. MATERIALS AND METHODS: This is a retrospective analysis of a prospective multicenter ASD database. Selection criteria were: operated patients having preoperative severe pelvic retroversion as per GAP score (Relative Pelvic Version-RPV < - 15°); panlumbar fusions to the pelvis; 2-year follow-up. Group A comprised patients with any postoperative improvement of RPV score, and group B had no improvement. Groups were compared regarding baseline characteristics, surgical factors, and postoperative sagittal parameters. Parametric and non-parametric analyses were employed. RESULTS: 177 patients were studied, median age 67 years (61; 72.5), 83.6% female. Groups were homogeneous in baseline demographics, comorbidities, and preoperative sagittal parameters (p > 0.05). The difference in RPV improvement was 11.56º. Group A (137 patients) underwent a higher percentage of ALIF procedures (OR = 6.66; p = 0.049), and posterior osteotomies (OR = 4.96; p < 0.001) especially tricolumnar (OR = 2.31; p = 0.041). It also showed a lower percentage of TLIF procedures (OR = 0.45; p = 0.028), and posterior decompression (OR = 0.44; p = 0.024). Group A displayed better postoperative L4-S1 angle and relative lumbar lordosis (RLL), leading to improved sacral slope (and RPV), and global alignment (RSA). Group A patients had longer instrumentations (11.45 vs 10; p = 0.047) and hospitalization time (13 vs 11; p = 0.045). All postoperative sagittal parameters remained significantly better in group A through follow-up. However, differences between the groups narrowed over time. CONCLUSIONS: ALIF procedures and posterior column osteotomies improved pelvic version postoperatively, and associated better L4-S1 and lumbar lordosis restoration, indirectly improving all other sagittal parameters. However, these improvements seemed to fade during the 2-year follow-up.

Future Data Points to Implement in Adult Spinal Deformity Assessment for Artificial Intelligence Modeling Prediction: The Importance of the Biological Dimension.

Adult spinal deformity (ASD) surgery is still associated with high surgical risks. Machine learning algorithms applied to multicenter databases have been created to predict outcomes and complications, optimize patient selection, and improve overall results. However, the multiple data points currently used to create these models allow for 70% of accuracy in prediction. We need to find new variables that can capture the spectrum of probability that is escaping from our control. These proposed variables are based on patients' biological dimensions, such as frailty, sarcopenia, muscle and bone (tissue) sampling, serological assessment of cellular senescence, and circulating biomarkers that can measure epigenetics, inflammaging, and -omics. Many of these variables are proven to be modifiable and could be improved with proper nutrition, toxin avoidance, endurance exercise, and even surgery. The purpose of this manuscript is to describe the different future data points that can be implemented in ASD assessment to improve modeling prediction, allow monitoring their response to prerehabilitation programs, and improve patient counseling.

Sagittal realignment: surgical restoration of the global alignment and proportion score parameters: a subgroup analysis. What are the consequences of failing to realign?

INTRODUCTION: The Global Alignment and Proportion (GAP) score incorporates three domains directly modified with surgery (relative pelvic version-RPV, relative lumbar lordosis-RLL, lumbar distribution index-LDI) and one indirectly restored (relative spinopelvic alignment-RSA). We analyzed our surgical realignment performance and the consequences of domain-specific realignment failure on mechanical complications and PROMs. MATERIALS AND METHODS: From an adult spinal deformity prospective multicenter database, we selected patients: fused to pelvis, upper instrumented vertebra at or above L1, and 2 years of follow-up. Descriptive, univariate and multivariate analyses were employed. RESULTS: The sample included 333 patients. RLL-6w showed the highest success rate (58.3% aligned), but 16.5% of patients were classified in the "Severe hypolordosis" and "Hyperlordosis" subgroups. RPV-6w was the most challenging to realign, with 51.6% moderate or severe retroversion. Regarding RSA-6w, 21.9% had severe positive malalignment. Correct alignment of RPV-6w (p = 0.025) and RSA-6w (p = 0.002) proved to be protective factors against the development of mechanical complications. Severe pelvic retroversion (p = 0.026) and severe positive malalignment (p = 0.007) were risk factors for mechanical complications. RSA-6w "Severe positive malalignment" was associated with less improvement in PROMs: ∆ODI (8.83 vs 17.2; p = 0.011), ∆SRS-22 total (0.54 vs 0.87; p = 0.007), and ∆SF-36PCS (3.47 vs 7.76; p = 0.04); MCID for ODI (37.0 vs 55.5%; p = 0.023), and SRS-22 (40.8 vs 60.1%; p = 0.015); and PASS for ODI (17.6 vs 31.7%; p = 0.047). CONCLUSIONS: RPV was the most underperformed modifiable parameter. Severe pelvic retroversion and severe positive malalignment influenced the occurrence of mechanical complications. Severe positive malalignment affected PROMs improvement.

Influence of Coronoid fixation on the functional outcome and rate of complications in surgically treated acute complex elbow instability.

INTRODUCTION: Fractures of the coronoid commonly present in elbow fracture-dislocations. Despite the evidence that the coronoid plays an important role in elbow stability, there is still controversy on which fractures should be surgically fixed. The aim of this study is to compare the clinical outcomes and rate of complications of patients with elbow fracture-dislocations in which the coronoid was fixed or left untreated. MATERIALS AND METHODS: Thirty-nine patients with an elbow fracture-dislocation involving a coronoid fracture were prospectively followed for an average of 90 months (range 24-190). According to Morrey´s classification there were 22 type II and 8 type III. Nine patients had an anteromedial fracture of the coronoid. In 24 patients the coronoid was repaired (suture fixation in 9, screws fixation in 10 and plate fixation in 5) and in 15 patients the coronoid was not fixed. In 18 patients the radial head was replaced and in 8 patients it was fixed. All patients underwent repair of the lateral ligament complex. Clinical evaluation was performed with the MEPS. Radiographically, the rate of coronoid nonunion was specifically analyzed. Postoperative neurological complications were recorded. RESULTS: At the most recent follow up, the average arc of flexion-extension was 120° (range 70°-140°) with a mean MEPS of 90 (range 25-100). No statistically significant differences were found in the MEPS and flexion-extension arc between the patients in whom synthesis was performed (117° ROM, and 89 MEPS) and those in whom it was not (122° ROM, 94 MEPS) (p = 0.42; p = 0.34). Coronoid fracture healing could be assessed in 36 patients: in 19 patients the coronoid was radiographically healed, and in 17 a nonunion was present, with no difference in the final clinical outcome between both groups. Nine patients, 6 of whom had undergone coronoid fixation, had a neurological complication related to the ulnar nerve. CONCLUSIONS: Coronoid fractures affecting around 50% of its height can be treated without internal fixation as long as the rest of the osteo-ligamentous structures are adequately repaired. Osteosynthesis of the coronoid through a medial approach may carry a non-negligible risk of associated neurological injury.

Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer.

Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women's age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women's age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.

Counting deficits or diseases? The agreement between frailty and multimorbidity in subjects with cognitive disturbances.

In the present study, we explored the relationship between multimorbidity and frailty in a population of older individuals with cognitive disturbances attending a memory clinic. All subjects consecutively attending the Memory Clinic of the Department of Human Neuroscience, "Sapienza" University of Rome, between January 2017 and April 2018 for a first neurological evaluation were considered for the present analysis. Multimorbidity was defined as the simultaneous presence of two or more diseases in the same individual. A Frailty Index was computed by considering 44 age-related, multidimensional health deficits. Overall, 185 subjects were recruited in the study. A condition of multimorbidity was detected in 87.6% of the sample, whereas only the 44.6% of the study population was considered as frail. A poor agreement was observed between multimorbidity and frailty. The present findings confirm that counting diseases or health deficits may provide discordant information concerning the risk profile of older subjects.

Role of frailty in the assessment of cognitive functioning.

Neuropsychological tests, besides reflecting the cognitive reserves and deficits of the tested individual, might also be differently affected by his/her underlying biological asset. In this context, the construct of frailty may offer an opportunity for better weighting the results of traditional tests. We evaluated the relationships between a set neuropsychological measures and a 35-item Frailty Index (FI). The role played by the FI in the relationship between neuropsychological tests and global cognition was also explored. Data from the first neurological and neuropsychological assessments of 79 subjects attending our university memory clinic because complaining cognitive disturbances were considered for the present analysis. A statistically significant correlation between FI and Trail Making Test-B was observed (Spearman's rho 0.33; p = 0.02). The relationship between the performance at the Rey Complex Figure and global cognition (as measured by the Mini Mental State Examination) was influenced by the FI. In fact, participants with higher FI levels had a weakened association linking constructional/visual memory abilities and general cognitive functioning. The interpretation of the neuropsychological assessment can be biased by the frailty status of the tested individual. It can be hypothesized the need of developing new models of correction, that may better reflect the person's biology and complexity.

Race reporting and disparities in clinical trials on Alzheimer's disease: A systematic review.

INTRODUCTION: Race is an important health determinant and should adequately be considered in research and drug development protocols targeting Alzheimer's disease (AD). METHODS: A systematic review of available randomized controlled trials (RCTs) on the currently marketed treatments for AD was conducted with the aim of 1) documenting the reporting of race, and 2) exploring the impact of race on the efficacy and safety/tolerability of the considered medications. RESULTS: Overall, 59.2% of the 49 retained RCTs reported information concerning the race of participants. Only a striking minority of enrolled patients was constituted of blacks and Hispanics. None on the retained studies reported results on the efficacy and safety/tolerability of the tested treatment separately for racial groups nor performed sensitivity analyses accounting for the race of participants. DISCUSSION: Race has insufficiently been reported in previous interventional studies on AD. Its potential association with the effectiveness and safety/tolerability of the tested medications has completely been neglected.