Clinical and radiographical outcome after surgical treatment of periprosthetic type B proximal femur fractures: a retrospective study

PURPOSE

Periprosthetic fractures after hip prosthesis represent a constantly increasing clinical problem and a challenging complication to treat surgically. Among these, type B proximal femur fractures should be diagnosed correctly to be treated surgically. The aim of this study was to re-evaluate the type of surgical treatment of periprosthetic fractures.

METHODS

We examined the cases treated between January 2012 and February 2018, classifying them according to the U.C.S. AO/OTA. We evaluated the radiographic outcome according to the Beals and Tower criteria. Patients still alive were also re-evaluated according to the H.H.S. and the WOMAC score.

RESULTS

We treated 48 patients (12 men, 35 women, average age 81 years), divided into 24 type B1, 14 type B2 and 10 type B3 fractures. The overall consolidation rate was 95.4%, while the major complication (implant dislocation, pseudoarthrosis and deep infection) rate was 12.5%. Clinically, it was possible to reassess 34 patients with a mean follow-up of 38.4 months, an average HHS of 75.89 and a mean WOMAC score of 79.93.

CONCLUSIONS

Periprosthetic type B fractures are difficult to manage and require careful preoperative planning and appropriate intraoperative management. However, the overall clinical and radiographic result was satisfactory, although patients should still be aware of the risk of complications associated with this type of fracture.

Single-use, patient-specific instrumentation technology in knee arthroplasty: a comparative study between standard instrumentation and PSI efficiency system

Patient-specific instrumentation is a surgical technique that was created to improve the accuracy of implantation, surgical time and workflow in total knee arthroplasty. This study is a single-center, single-surgeon randomized clinical trial. The aim of this work was to evaluate clinical efficacy of PSI versus standard surgical instrumentation in malalignment risk and blood loss reduction. From April 2015 to September 2016, 40 patients for a total of 40 knees were included in the randomization process. Each patient underwent CT scan of the lower limb including hip, knee and ankle joint with the realization of the PSI system and the TKA with Medacta GMK Primary^®. Patients were evaluated 1 month after surgery with X-ray and after 2 months with clinical examination and assessment by Knee Society Score (KSS). Blood loss was detected by adding the values calculated in the operative room and the blood loss in the vacuum systems. In the study group, mean value of KSS was 85.2 (IC 95% 81.2-88.5), mean blood loss was 657 ml (IC 95% 580.6-735.4), and mean value of femorotibial angle was 178.8° (IC 95% 178.5-179.3). In the control group, mean value of KSS was 87.2 (IC 95% 85.3-89.4), mean blood loss was 866.5 ml (IC 95% 763.3-972.5), and mean value of femorotibial angle was 178.9°(IC 95% 177.6-180.3). The Student t test detected a significant difference in blood loss between groups (p < 0.05), and no differences were found between KSS. The single-use instrumentation should improve precision, operative time, turnover time, sterilization and maintenance costs and could help to reduce infection risks. Our results confirm only the improvement on reducing blood loss. In our opinion, this technique should be used in selected patients when the surgeon could have some difficulties to perform femoral cuts on coronal plane or when patients need to have a very little blood loss due to other conditions.

Biological Intercalary Reconstruction with Bone Grafts After Joint-Sparing Resection of the Lower Limb: Is this an Effective and Durable Solution for Joint Preservation?

Due to advances in neoadjuvant therapies and preoperative imaging modalities, joint-sparing resections have become appealing in bone tumor surgery. However, the intercalary reconstruction of metadiaphyseal bone defects of the femur and the tibia after juxta-articular tumor resection remains challenging. Both biological and prosthetic reconstructions have been used for joint-sparing resections, but little is known about the long-term outcome of these procedures. The authors reviewed a consecutive series of 64 patients treated with joint-sparing intercalary resection and reconstruction with bone grafts. Inclusion criteria were an osteotomy line within 5 cm from the knee and ankle joint surface and an osteotomy line proximal to 1 cm below the lesser trochanter at the hip level. Intra-epiphyseal resection was performed in 25 patients (39%)and intercalary resection was performed in 39 (61%). Reconstruction included 49 allograft + vascularized fibular graft (VFG), 10 allografts, and 5 VFG + structural allogenic grafts. At a mean follow-up of 117 months (range 12-305), 51 patients (80%) were continuously disease-free, and 6 showed no evidence of disease after treatment of local recurrence or metastatic lesion. One patient was alive with lung metastases at 26 months of follow-up and six patients died of disease. In the entire series of 64 patients, 26 had a non-oncological complication that required surgical revision (40.6%). Overall survival (OS) of reconstruction was 92% at 5 years and 90% at 10 and 15 years. Limb salvage survival (LSS) was 94% at 5, 10 and 15 years. Twenty-two fractures occurred in 17 patients (26.5%). There were a total of nine non-unions (14%). Six patients (9.3%) presented early wound dehiscence (average 1.8 months, range 0-6). A deep infection occurred in 3 cases (4.7 %). In 12 patients treated with VGF reconstruction (12/54:22%), a donor-site complication was observed. The overall Musculoskeletal Tumor Society (MSTS) functional score in 54 evaluable patients, who were alive with reconstruction in situ, was 27 points (range 18-30). Biologic intercalary reconstructions with bone grafts resulted in effective joint-sparing resections of the lower limb, allowing joint preservation in all but one case who required a total knee replacement for varus osteoarthritis. Despite the high rate of complications requiring surgical revision, at 15 years, overall survival of the reconstruction was 90% and limb salvage survival was 94%. In our experience, revision-free survival was better with VFG reconstruction than with allograft alone and the combination of VFG and allogenic graft seems to favor spontaneous fracture-healing and to decrease the non-union rate.

Percutaneous Hallux Valgus Correction: Modified Reverdin-Isham Osteotomy, Preliminary Results

BACKGROUND

Hallux valgus (HV) is a metatarsophalangeal joint deformity that can be classified as mild, moderate, or severe. Treatment is recommended for pain or severe deformities. Recently, operative percutaneous correction techniques have been performed to treat mild deformities.

MATERIALS AND METHODS

A retrospective, single-surgeon, single-center study of 49 HV percutaneous correction using a modified Reverdin-Isham osteotomy was conducted. HV, intermetatarsal angle (IM), proximal articular set angles (PASA), and American foot and ankle functional score (AOFAS) were assessed pre- and postoperatively by a single operator. Statistical analysis was performed using a Wilcoxon rank test. Medium time of follow-up was 34 months.

RESULTS

HV mean value decreased from a preoperative medium value of 35.18° to 14.3° postoperatively, IM mean value decreased from 15.5° to 8.7°, and PASA from 7.2° to 5.25°(p<0.001 for HV and IM, p<0.125 for PASA reduction). Postoperatively AOFAS medium score was 95.

DISCUSSION

In our series, functional and clinical results of percutaneous osteotomy without osteosynthesis were comparable to other percutaneous and conventional techniques, both in clinical and radiological findings. High level of patient's satisfaction and improvement on pain-related symptoms are even better referred to traditional techniques. Modified Reverdin-Isham osteotomy technique differs from the others for translation of metatarsal head after osteotomy; we do not correct PASA angles, but we can obtain more HV and IM correction and include some severe HV. Our results suggest that translation of metatarsal head could give higher HV angle correction.

Chronic Achilles Tendon Rupture Treated with Allograft: A Case Report

In clinical practice, chronic Achilles tendon ruptures are uncommon. Usually, these lesions are discovered four to six weeks after injuries. More frequently, Achilles tendon ruptures are acute and treated with tendon sutures.1 Many surgical techniques are available to treat chronic lesions such as sutures or V-Y elongation with or without augments.2-3 Our case is about a chronic Achilles tendon rupture discovered two years after injury. Our patient came to our attention with a 6 cm tendon gap. We performed tendon repair with cadaver allograft. After four years of follow-up, our patient has a complete functional recovery and he can normally perform daily and working tasks without pain.

Peroneal Tubercle Hypertrophy: A Case Report

The peroneal tubercle is an osseous prominence present on the calcaneus bone at the junction between the middle and the anterior third of its lateral surface. It is a bony septum which divides the tendons of the peroneus brevis and the peroneus longus and offers insertion to the inferior peroneal retinaculum. A hypertrophy of this prominence causes pain in the lateral and the posterior part of the foot while wearing shoes, rarely peroneal tenosynovitis can even cause it to break. In the following pages, we will describe a case of peroneal tubercle hypertrophy, visible even at clinical examination, in a 26-year-old male patient without apparent causes nor previous trauma.

Angular stable plates in proximal meta-epiphyseal tibial fractures: study of joint restoration and clinical and functional evaluation

BACKGROUND

The tibial plateau fractures involve one of the main weight bearing joints of the human body. The goals of surgical treatment are anatomical reduction, articular surface reconstruction and high primary stability. The aim of this study was to evaluate the clinical and functional outcomes after internal plate fixation of this kind of fractures.

MATERIALS AND METHODS

From January 2009 to December 2012, we treated 75 cases of tibial plateau fracture with angular stable plates. We used Rasmussen Score and the Knee Society Score for the clinical and functional evaluation. Twenty-five cases that underwent hardware removal had arthroscopic and CT evaluation of the joint.

RESULTS

No complications occurred. The clinical and functional evaluation, performed by the KSS and Rasmussen Score, highlighted the high percentage of good-to-excellent results (over 90 %). In every case, the range of motion was good with flexion >90°. Arthroscopy showed the presence of chondral damage in 100 % of patients. In all the cases, we found that X-ray images seem better than the CT images.

CONCLUSIONS

Angular stable plates allow to obtain a good primary stability, permitting an early joint recovery with an excellent range of motion. Avoiding to perform a knee arthrotomy at the time of fracture reduction could prove to be an advantage in terms of functional recovery. The meniscus on the injured bone should be preserved in order to maintain good function of the joint. X-ray images remain the gold standard in checking the progression of post-traumatic osteoarthritis.

Single-Use Instrumentation Technologies in Knee Arthroplasty: State of the Art

The surgical site contamination and the resulting periprosthetic infections are an important cause of morbidity and socio-economic impact. In total knee arthroplasty, the single-use instrumentation is developed to simplify the surgical procedure, reduce the chance of instrument contamination, improve the operating room efficiency, and reduce overall costs (low cost of instrument washing and sterilization as well as personnel management). Surgical single-use instrumentations on the market are complete with all you need for the surgical procedure-cutting guides, conventional or PSI (patient-specific instrumentation), femoral cutting block, re-cutting block, trials components, alignment rods, inserts, and impactors. In recent years, PSI (patient-specific instrumentation) was introduced. It decreases operative time and blood loss without violating the intramedullary canal. It also allows the surgeon to preoperatively plan the patient's component size, position, and alignment. We reported an average of 30 minutes saved for each surgical procedure, a saving of 60€ for each surgical tray. Moreover, we avoided surgery cancellation or delay due to un-sterile, missing, or dysfunctional instruments. We think that this technology is the first step in developing implants that are entirely customized for each patient, and we believe that it will have a more relevant role in knee surgery in the future.

Three-dimensional parametric mapping in quantitative micro-CT imaging of post-surgery femoral head-neck samples: preliminary results

Osteoporosis and pathological increased occurrence of fractures are an important public health problem. They may affect patients' quality of life and even increase mortality of osteoporotic patients, and consequently represent a heavy economic burden for national healthcare systems. The adoption of simple and inexpensive methods for mass screening of population at risk may be the key for an effective prevention. The current clinical standards of diagnosing osteoporosis and assessing the risk of an osteoporotic bone fracture include dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) for the measurement of bone mineral density (BMD). Micro-computed tomography (micro-CT) is a tomographic imaging technique with very high resolution allowing direct quantification of cancellous bone microarchitecture. The Authors performed micro-CT analysis of the femoral heads harvested from 8 patients who have undergone surgery for hip replacement for primary and secondary degenerative disease to identify possible new morphometric parameters based on the analysis of the distribution of intra-subject microarchitectural parameters through the creation of parametric images. Our results show that the micro-architectural metrics commonly used may not be sufficient for the realistic assessment of bone microarchitecture of the femoral head in patients with hip osteoarthritis. The innovative micro-CT approach considers the entire femoral head in its physiological shape with all its components like cartilage, cortical layer and trabecular region. The future use of these methods for a more detailed study of the reaction of trabecular bone for the internal fixation or prostheses would be desirable.