Chemical variability of artificial stone powders in relation to their health effects

The occurrence of highly severe silica-related diseases among the resin- and silica-based artificial stone workers was claimed, associated to an extremely short latency. High levels of exposure and intrinsic properties of AS are thought to modulate the development of silicosis and auto-immune diseases. This study compares parent materials and processed dusts, to shed light on changes of AS occurring in the manufacturing process, through an XRF, EPR and XAS investigation. We point out the extremely wide variability of the materials, the occurrence of chemical signatures impressed by the processing techniques, and the unprecedented generation of stable radicals associated to the lysis of the Si-O chemical bond inside the resin coated respirable crystalline silica. These results suggest that the AS processing in industrial stone workshops can create respirable dusts with peculiar physical and chemical properties, to be correlated to the observed clinical evidences.

Total Knee Arthroplasty in Patients With Extra-Articular Deformity: Restoration of Mechanical Alignment Using Accelerometer-Based Navigation System

BACKGROUND

Total knee arthroplasty (TKA) in patients with post-traumatic extra-articular deformity (EAD) is difficult to manage using conventional instrumentation techniques. In this study, we evaluate whether accelerometer navigation system can be a valuable option to make accurate bone resections and restore the neutral mechanical axis in complex TKA patients with EAD.

METHODS

From May 2015 to June 2017, 18 consecutive TKA were performed in 18 patients with knee osteoarthritis with associated EAD. An accelerometer-based navigation system was used to guide tibial and femoral resection in the coronal and sagittal plane. Postoperative lower limb alignment in coronal plane and component position in coronal and sagittal plane was measured through full-leg weight-bearing X-ray. Clinical score were recorded using the Knee Society Score at the final follow-up.

RESULTS

The mean hip-knee-ankle angle was 0.9° ± 1.4° varus alignment. The coronal alignment of the femoral component was 89.2° ± 1.9°, and the coronal alignment of the tibial component was 89.4° ± 2.1°. The sagittal alignment of the femoral component was 93.2°± 1.9°, and the sagittal alignment of the tibial component was 84.4° ± 3.1°. At the final follow-up, the Knee Society Score was 89 points (range, 82-100), and the functional score was 86.7 points (range, 60-100). No intraoperative and postoperative surgical complications were reported using this technology.

CONCLUSION

Accelerometer-based navigation is accurate in achieving neutral mechanical alignment and optimal implant position after TKA in patients with EAD. This system should be considered a valuable option to the more complex technique of computer navigation or robotic surgery.

The biomolecular interactions between endothelium and bone cells: an overview

Bone turnover is a complex set of different molecules pathways and it is strictly connected with bone vasculature. It includes every bone process concerning bone modelling and remodelling such us skeletal growth and healing process. A fundamental component of this bone architecture is played by the endothelium, that acts in a paracrine fashion on other bone stromal cells via humoral factors, growth factors and chemokines/cytokines. The alteration of those biochemical interactions between endothelium, vasculature and bone tissue may cause various pathological manifestations. Understanding the bases of the interaction between those different pathways could provide novel therapeutic strate¬gies for bone disease. The Authors present an updated overview of the most common communication biomolecules between bone cells and endothelium and their interactions both in healthy and pathological conditions. Furthermore, focusing on gene and related therapies, possible future therapeutic strategies for bone vasculature/metabolic diseases are presented.

The anterior-based muscle-sparing approach to the hip: the "other" anterior approach to the hip

PURPOSE

The purpose of this study was to evaluate safety, efficacy, and learning curves of anterior-based muscle-sparing total hip arthroplasty (ABMS-THA) in the supine position. Furthermore, early functional outcome was evaluated and compared to direct anterior approach (DAA) by measuring surface electromyography (sEMG).

METHODS

We present a prospective cohort study of 343 hips. The safety and learning curve were assessed by recording operative time and peri-operative adverse events. For assessment of efficacy, functional and radiological outcomes were evaluated. A selected group of 32 patients have been studied by sEMG and compared to a matched group of 32 patients who received a THA using DAA approach.

RESULTS

There was one dislocation (0.3%); two (0.6%) patients had an intra-operative fractures of the greater trochanter; two patients (0.6%) experienced a self-limited femoral nerve palsy. Physical therapy milestones for hospital discharge were reached on an average of 1.7 days. sEMG showed that ABMS and DAA have a similar muscle recruitment pattern and functional recovery after THA. One patient was revised for infection, 16 were lost, and 326 hips were available with a median follow-up of 42 months (range 24-60). The mean Harris Hip Score (HSS) increased from 44.3 to 91.9. Ninety-six percent of the hips had a leg length discrepancy (LLD) < 5 mm. There were no radiological signs of mechanical loosening or osteolysis.

CONCLUSIONS

The ABMS approach in the supine position is clinically effective and safe; special advantages include a very low dislocation rate and a great control of LLD.

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.

Diagnostic Accuracy of Magnetic Resonance Arthrography in Detecting Intra-articular Pathology Associated with Femoroacetabular Impingement

Purpose  The aim of this study was to assess the diagnostic accuracy of magnetic resonance arthrography (MRA) in the detection of intra-articular lesions of the hip in patients affected by femoroacetabular impingement (FAI) by using arthroscopy as reference standard.

Methods  Twenty-nine consecutive hip arthroscopies performed in 24 patients were considered for the study. Patients had a mean age of 38.3 years. Ultrasound-guided 1.5-T MRA was performed with precontrast short tau inversion recovery, T1-weighted and PD coronal, T1-weighted, and T2-weighted axial with 3-mm-thick slice sequences, and postcontrast T1-weighted fat saturation MRA (Fat-SAT) axial, coronal and oblique sagittal, and T1-weighted Vibe 3D coronal sequences with MPR sagittal, axial, and radial reconstructions with 2-mm-thick slice and coronal density protonil (DP) Fat-SAT. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRA were evaluated by comparison arthroscopy for the following intra-articular findings: acetabular and femoral chondral lesions, labral degeneration, labral tears, synovitis, ligamentum teres (LT) tears, CAM lesions, pincer lesions, loose bodies, and osteophytes.

Results  An absolute per cent agreement (100%) was observed for all the variables in the assessment of CAM lesions. Sensitivity, specificity, PPV, and NPV of MRA were 100, 68.4, 72.7, and 100%, respectively, for acetabular chondral lesions; 100, 50, 47.3, and 100%, respectively, for femoral chondral lesions; 33, 85, 20, and 91.6%, respectively, for labral tears; 95, 71, 91.3, and 83.3%, respectively, for labral degeneration; 100, 88, 57.1, and 100%, respectively, for LT tears; 33.3, 85, 50, and 73.9%, respectively, for pincer lesions; 50, 96, 66.6, and 92.3%, respectively, for intra-articular loose bodies; and 100, 73.9, 50, and 100%, respectively, for osteophytes.

Conclusion  MRA may play an important role in detecting intra-articular lesions associated with FAI. This might be helpful for the preoperative planning before hip arthroscopy.

Level of Evidence  This is a Level 2, diagnostic accuracy study compared with gold standard.

Postoperative Complications and Reoperation Rates Following Open Reduction and Internal Fixation of Ankle Fracture

Purpose  The purpose of this study was to determinate the overall postoperative complication and reoperation rates related to open reduction and internal fixation (ORIF) of ankle fractures.

Methods  All patients who had undergone an ankle fracture operation at our institution from January 2005 through December 2013 were identified by querying the hospital surgical procedure database for diagnoses codes. Medical records, surgical procedure, and outpatient control reports were reviewed to collect pre-, intra-, and postoperative details. All data obtained were retrospectively analyzed by the authors to evaluate the postoperative complications and the type of further surgical treatment required to treat them.

Results  A total of 378 consecutive patients were included in the study. Overall complications rate was 36.0%. Minor complications (4.5%) were represented by superficial infection (1.3%) and impaired wound healing (3.2%). All these patients required advanced wound care and prolonged oral antibiotics. Major complications (31.5%) included: residual pain (17.2%), deep infection (3.4%), malunion (2.4%), posttraumatic ankle osteoarthritis (5.0%), implant breakage (0.3%), complex regional pain syndrome (1.3%), and arthrofibrosis (1.9%). Note that 21.7% of major complications required further surgical procedure. Reoperations included arthroscopic debridement (15.1%), hardware removal and debridement of all necrotic tissue (4.5%), and ankle fusion (2.1%). Surgery was necessary mainly for pain removal and function recovery.

Conclusion  Ankle fracture ORIF represents a satisfying surgical treatment. Nevertheless, postoperative complications are not uncommon. Minor complications can be easily managed with medications and repeated outpatient controls. Reoperation is occasionally required to treat major complications. Revision surgery is mandatory to ensure pain relief and function improvement.

Level of Evidence  Level II, retrospective cohort study.

Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution?

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

Patients and Methods

A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26).

Results

At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years.

Discussion

There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.

Talonavicular Coalition as a Cause of Foot Pain

Tarsal coalitions have an incidence of 2% and are often underdiagnosed. These are considered to be one of the causes of chronic ankle and foot pain. Among all tarsal coalitions, the talonavicular type represents a rare and uncommon condition. The purpose of this article was to present the case of a 35-year-old male patient with a bilateral talonavicular coalition treated conservatively. A review of the literature was also performed to understand the management of this rare condition.

The Use of a High-Tech Knee Pad for Reduction of the Postoperative Effusion after Total Knee Arthroplasty

Purpose  After total knee arthroplasty (TKA), pain and swelling, especially in older and less cooperative patients, can limit the retrieval of a good range of motion and muscle tone and consequently the achievement of an optimal function outcome. A high-tech knee pad made of metal fibers emitting infrared energy was used in a group of patients undergoing TKA to assess its efficacy in the postoperative period with respect to a group with a placebo.

Methods  Twelve patients used knee pads after surgery for 3 weeks and were evaluated using visual analog scale (VAS), Knee Society Rating Score, Cincinnati Knee Rating Score, and painkillers at specific timings.

Results  At 3 weeks, all scores improved in a significant manner in the treated group compared with the placebo group. At 2 months after surgery, VAS was better in the study group than the control group, whereas other parameters were similar. However, the use of rescue drugs was less in the study group than in the placebo group.

Conclusion  A high-tech knee pad may contribute to a faster recovery within the first week after a knee replacement, limiting the use of painkillers and allowing a quick functional recovery by the control of pain and postoperative effusion.

Level of Evidence  Level II, randomized prospective study with small sample size.

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.

Reconstructive techniques for revision and limb salvage surgery in persons with haemophilia

Haemophilia is an inherited haemorrhagic disease characterized by the lack of coagulative factors associated nowadays mostly to musculoskeletal complications, particularly severe secondary arthritis in specific joints. Recurrent traumatic or spontaneous joint bleeding, induce severe arthropathy at a young age that can be treated only by joint replacement. Total knee or hip arthroplasty in young subjects may fail earlier due to wear or infections and in the haemophilic population, this means bone loss, pseudo tumours and the need of revision or even limb salvage surgery. Modern modular implants and the use of bone graft enriched by tissue engineering techniques such as a concentration of autologous mesenchymal cells or PRP may be helpful to compensate all bone loss and anatomic alterations due to failures of orthopaedic implants. The authors present their experience with this type of surgery and their biological approach to these challenging cases.

Cemented versus cementless fixation in total knee arthroplasty

The question of whether to use cemented or cementless fixation for a total knee arthroplasty (TKA) is still debated. Discouraging preliminary results of cementless TKAs have determined the worldwide use of cemented implants. However, with the development of biotechnologies and new biomaterials with high osteoconductive properties, biological fixation is now becoming an attractive option for improving the longevity of TKAs, especially in young patients.

There is no evidence in the current literature to support the use of one method of fixation. The extensive clinical experience with cemented implants gathered over the years justifies their widespread use. New randomized clinical trials are necessary to compare cementless fixation based on the new ingrowth surfaces with standard cemented implants.

The kinetics of remodeling of a calcium sulfate/calcium phosphate bioceramic

In the last years considerable research and development activity have been expended to find new ceramic bone substitutes for the treatment of bone defects. However in many cases the drawback of synthethic bone substitutes are the slow graft incorporation and remodelling into the host bone. The purpose of this study was to analyze the kinetics of resorption and new bone formation of new calcium sulfate (CaSO₄)/calcium phosphate (CaPO₄) bioceramic engineered to enhance its bone forming properties. We prospectively evaluated the results of a series of 15 hips with osteonecrosis of the femoral head (ONFH) treated at with core decompression and injection of the CaSO₄/CaPO₄ composite. In all hips, a quantitative computed tomography (QTC) scan was taken within one week after the surgery, at 12 months, 2 years and finally with a minimum of 4 years follow-up. The mean HU in the immediate post-operative period was 1445 (Range 1388-1602); At one year the mean HU strongly decrease at 556.6 HU (P < 0.01); The mean HU at 2 years follow-up further decreased to 475.1. The mean HU at 4 years was unchanged. The quantitative and qualitative CT scan data of this series indicates that the CaSO₄-CaPO₄ ceramic composite resorbs over a narrow timeframe and the gradual resorption of the graft within the defect provides an ideal environment for the direct new bone growth that propagates across the defect.

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. (www.actabiomedica.it)

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.