Incidence and risk factors for anxiety disorders in young adults: A population-based prospective cohort study

Anxiety disorders are among the most common psychiatric disorders in the general population. Our objective was to describe the cumulative incidence and risk factors of anxiety disorders, including obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), in a follow-up of young adults over a five-year period. This is a prospective cohort conducted in two waves. The first took place from 2007 to 2009, in which 1,560 young adults aged between 18 and 24 years were evaluated using the Mini-International Neuropsychiatric Interview (MINI). Subjects were invited to participate in the second wave, which wave took place from 2012 to 2014, where 1,244 young adults were evaluated using the MINI-Plus. Our findings showed a cumulative incidence of 10.9% for any anxiety disorder, 6.5% for generalized anxiety disorder, 6.0% for agoraphobia, 2.0% for OCD, 1.6% for panic disorder, 1.1% for social anxiety and 0.7% for PTSD. Being female and having had a depressive episode were risk factors to develop any anxiety disorder. We observed a high cumulative incidence of anxiety disorders in a population-based sample of young adults. Our data highlights the importance of the early identification of these disorders as this could lead to early illness detection, early illness management and a reduced burden of disease.

Temporal Structures in Positron Spectra and Charge-Sign Effects in Galactic Cosmic Rays

We present the precision measurements of 11 years of daily cosmic positron fluxes in the rigidity range from 1.00 to 41.9 GV based on 3.4×10^{6} positrons collected with the Alpha Magnetic Spectrometer (AMS) aboard the International Space Station. The positron fluxes show distinctly different time variations from the electron fluxes at short and long timescales. A hysteresis between the electron fluxes and the positron fluxes is observed with a significance greater than 5σ at rigidities below 8.5 GV. On the contrary, the positron fluxes and the proton fluxes show similar time variation. Remarkably, we found that positron fluxes are modulated more than proton fluxes with a significance greater than 5σ for rigidities below 7 GV. These continuous daily positron fluxes, together with AMS daily electron, proton, and helium fluxes over an 11-year solar cycle, provide unique input to the understanding of both the charge-sign and mass dependencies of cosmic rays in the heliosphere.

Do prior intra-articular injections impact on the risk of periprosthetic joint infection in patients undergoing total hip arthroplasty? A meta-analysis of the current evidences with a focus on the timing of injection before surgery

Purpose

Intra-articular injection is a well-established and increasingly used treatment for the patient with mild-to-moderate hip osteoarthritis. The objectives of this literature review and meta-analysis are to evaluate the effect of prior intra-articular injections on the risk of periprosthetic joint infection (PJI) in patients undergoing total hip arthroplasty (THA) and to try to identify which is the minimum waiting time between hip injection and replacement in order to reduce the risk of infection.

Methods

The database of PubMed, Embase, Google Scholar and Cochrane Library was systematically and independently searched, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To assess the potential risk of bias and the applicability of the evidence found in the primary studies to the review, the Newcastle-Ottawa scale (NOS) was used. The statistical analysis was performed by using the software 'R' version 4.2.2.

Results

The pooling of data revealed an increased risk of PJI in the injection group that was statistically significative (P = 0.0427). In the attempt to identify a 'safe time interval' between the injection and the elective surgery, we conducted a further subgroup analysis: in the subgroup 0-3 months, we noted an increased risk of PJI after injection.

Conclusions

Intra-articular injection is a procedure that may increase the risk of developing periprosthetic infection. This risk is higher if the injection is performed less than 3 months before hip replacement.

Pulmonary Artery Pseudoaneurysms Embolization: Bicentric Experience and Review of the Literature

The purpose of this bicentric case series was to report the safety, efficacy, and clinical outcome of transcatheter embolization in pulmonary artery pseudoaneurysms (PAPAs). Between January 2016 and June 2021, eight patients with PAPA were subjected to transcatheter embolization. The total number of patients was eight, of which five were female, with a mean age of 62 ± 14 years (average ± standard deviation). Etiology was traumatic in 2/8 cases and iatrogenic in 6/8 cases (after positioning a Swan-Ganz catheter in 5/6 cases and a temporary pacemaker in the latter case). In a single case, the PAPA was incidentally discovered during a routine X-ray, in the remaining 7 cases, the procedure was performed in emergency settings. PAPA embolization was performed using detachable coils alone in 3 cases; coils and glue in 1 case; coils, glue, and vascular plug in 1 case; coils and non-adhesive liquid embolic agents (Onyx and Squid respectively) in 2 cases; and non-adhesive liquid embolic agent alone (Onyx) in 1 case. No peri-procedural or post-procedural complications were recorded. Both the technical and clinical success rates were 100.0%. In conclusion, endovascular embolization is a technically feasible and safe therapeutic option for patients with PAPAs.

Five-hub General Conceptual Framework to improve the vaccination coverage for newly arrived migrants

Background

Within the Project “Increased Access for Newly Arrived Migrants-AcToVax4NAM” (Grant n 101018349, 3rd EU Health Programme), a General Conceptual Framework (GCF) was developed for understanding how to improve vaccination coverage for Newly Arrived Migrants (NAM), by characterizing and critically analysing system barriers and possible solutions to increase vaccination

Methods

A logical pathway was hypothesized based on conceptual hubs in the immunization process. The identification of barriers and solutions was carried on by: a) non-systematic revision of scientific and grey literature, institutions and relevant websites, and documents suggested by Consortium Partners; b) qualitative research conducted in each Consortium Country. The GCF was used as a guide for the above mentioned activities and organize results into the GCF itself to enrich it with content

Results

5 conceptual hubs were identified: ENTITLEMENT to vaccination, REACHABILITY of people to be vaccinated, ADHERENCE to vaccination, ACHIEVEMENT of vaccination, EVALUATION of the intervention. All hubs are linked sequentially, starting with Entitlement without which the process cannot take place. Hubs are connected: if vaccination does not take place, it’s important to go back to the previous hubs to understand the barriers. Reachability-Adherence-Achievement are closely related because some approaches are cross-cutting, such as proximity interventions which, in addition to allowing the system to approach NAM, promote adherence and thus possibility of completing the process. Other strategies may be implemented with different purposes: training aims to foster a culturally competent approach to facilitate adherence and avoid vaccination hesitancy, but also to improve competence in the entire process and lead to vaccination completion

Conclusions

The proposed GCF facilitates identification of barriers and possible solutions to the effective achievement of immunization, at all stages of the process

Key messages

• The GCF can be the basis for the creation of country-specific flow-charts through which to test strategies aimed at increasing immunization coverage in NAM.

• The GCF will be useful at EU level, to facilitate both the harmonisation of approaches and interventions and the evaluation of comparable approaches.

Synovial mast cells from knee and hip osteoarthritis: histological study and clinical correlations

PURPOSE

The aim of this study was to investigate the presence of synovial mast cells (MCs) in hip and knee tissue from osteoarthritis (OA) patients and to correlate them with clinical and radiological data.

METHODS

Synovial tissue was obtained during arthroplasty from 60 patients, 30 with knee OA and 30 with hip OA. Control synovial tissue was obtained from 30 patients without OA, 15 undergoing above-knee amputation and 15 receiving a hip replacement for fracture. Before surgery, the radiographic findings were graded according to the Kellgren-Lawrence system and clinical data including pain (VAS) and functional information (KOOS and HOOS) was collected. The tissue was stained with hematoxylin-eosin and toluidine blue for histochemistry and incubated with CD117 and CD31 antibodies for immunohistochemistry. MC and vessel number and synovitis score were determined in all samples.

RESULTS

Mean MC number, synovitis score and vessel number were significantly higher in the OA samples (p < 0.05) than in control tissue. MC number correlated with the synovitis score and disease severity in both patient groups.

CONCLUSIONS

The prevalence of MCs in synovium from OA patients and their association with synovial inflammation and pain suggest a role for them in OA pathophysiology.

Role of biomechanical assessment in rotator cuff tear repair: Arthroscopic vs mini-open approach

BACKGROUND

Rotator cuff (RC) tears are one of the most frequent pathologies within the shoulder girdle. Hand dominance and older age are associated with RC tears. Two different surgical procedures, the mini-open (MO) and all-arthroscopic (AA) approach, represented the standard of treatment.

AIM

To compare the clinical and biomechanical outcomes of two surgical techniques (AA vs MO procedure) performed to address the painful shoulder syndrome with partial or total supraspinatus tendon tear.

METHODS

Eighty-eight participants, 50 following RC repair with AA and 38 with MO approach, were recruited in the present cross-sectional case-control study (ORTHO-SHOULDER, Prot. 0054602). All patients underwent postoperative clinical evaluation for pain (Visual analogic scale), impairment, and disability (disability of the arm, shoulder, and hand) and limitation in daily activity (Constant-Murley score). Patients’ shoulder mobility was also assessed in our Laboratory of Functional Movement through a wearable inertial sensor and surface electromyography to monitor kinematics and muscle activity during the movement on the frontal (abduction/adduction) and sagittal (flexion-extension) planes.

RESULTS

No statistically significant differences between the two procedures were observed in either main clinical score or range of motion. A significant increase in velocity during the movement execution and a higher contribution of upper trapezius muscles were found in the AA group compared with MO patients.

CONCLUSION

In terms of clinical scores, our findings were in line with previous results. However, the use of technology-based assessment of shoulder mobility has revealed significant differences between the two techniques in terms of mean velocity and pattern of muscle activation.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study

BACKGROUND

Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy.

MATERIALS AND METHODS

Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included.

RESULTS

Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home.

CONCLUSIONS

The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future.

LEVEL OF EVIDENCE

IV.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study

BACKGROUND

Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment.

MATERIALS AND METHODS

For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month.

RESULTS

Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group.

CONCLUSIONS

Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended.

LEVEL OF EVIDENCE

Therapeutic study, level 4.

Active septic arthritis of the hip in adults: what's new in the treatment? A systematic review

Treatment of bacterial septic arthritis in the native adult hip joint can be challenging. Prompt diagnosis and treatment decisions can reduce the associated morbidity and mortality.

For this systematic review of the literature, we asked: (1) What are the treatment options? (2) What are the success rates and the outcomes after treatment? (3) Which antibiotic and duration of therapy are optimal?

We searched the electronic databases PubMed, Scopus, and Embase using the search terms “hip” or “native hip” and “septic arthritis” or “coxitis”. Studies were included if they reported on: (1) bacterial infection of the hip, (2) treatment, (3) success rate/outcomes, (4) follow-up. The final review included 19 studies. The quality of study reporting was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire.

Three treatment options are: arthroscopy, single open surgery, and two-stage total hip arthroplasty (THA). A high success rate in infection eradication was reported for all three. Intravenous antibiotic therapy should be promptly initiated to eradicate septic arthritis and minimize potential sequelae and complications.

Arthroscopy, single open or two-stage THA were reported to be effective in treating bacterial septic arthritis of the native hip. The key to optimal outcome is early diagnosis and timely treatment.

Cite this article: EFORT Open Rev 2021;6:164-172. DOI: 10.1302/2058-5241.6.200082

Retrospective multi-centre study on head adapters in partial revision hip arthroplasty

BACKGROUND

Instability and dislocation after total hip arthroplasty (THA) is a common reason for revision surgery. THA head-neck adapters promise the reconstruction of optimal femoral offset and leg length in revision THA (rTHA) while retaining stable implants. The aim of this retrospective multi-centre study is to report on the results achieved with the use of head adapters in partial rTHA, to avoid the instability of the implant.

METHODS

55 cases of partial rTHA performed between February 2015 and April 2017 in 3 different hospitals using the Bioball Head Adapter (BHA) (Bioball Merete, Medical GmbH, Berlin, Germany) were retrospectively recorded. All patients were evaluated from a radiological point of view at an average follow-up of 3.5 years. Failure was defined as re-revision surgery for any cause as well as a subjective feeling of instability of the joint.

RESULTS

One failure was registered in an extreme case and radiological findings show no suggestive signs of radiolucencies or loosening and therefore all implants have been considered stable.

CONCLUSIONS

Despite some limitations of this retrospective study and according to the relevant literature, our data confirms that BHA is a safe system that allows the flexibility to restore femoral offset and version, to adjust leg length, to minimise instability, to avoid unnecessary removal of otherwise well-fixed components thus improving tribology and reducing the risk of taper junction issues without major complications in partial rTHA.

Effect of the versatile bifunctional chelator AAZTA5 on the radiometal labelling properties and the in vitro performance of a gastrin releasing peptide receptor antagonist

Background

Gastrin Releasing Peptide receptor (GRPr)-based radioligands have shown great promise for diagnostic imaging of GRPr-positive cancers, such as prostate and breast.

The present study aims at developing and evaluating a versatile GRPr-based probe for both PET/SPECT imaging as well as intraoperative and therapeutic applications. The influence of the versatile chelator AAZTA⁵ on the radiometal labelling properties and the in vitro performance of the generated radiotracers were thoroughly investigated.

The GRPr-based antagonist D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH₂ was functionalized with the chelator 6-[Bis (carboxymethyl)amino]-1,4-bis (carboyxmethyl)-6-methyl-1,4-diazepane (AAZTA⁵) through the spacer 4-amino-1-carboxymethyl-piperidine (Pip) to obtain AAZTA⁵-Pip-D-Phe-Gln-Trp-Ala-Val-Gly-His-Sta-Leu-NH₂ (LF1). LF1 was radiolabelled with gallium-68 (PET), indium-111 (SPECT, intraoperative applications) and lutetium-177 (therapy, SPECT). In vitro evaluation included stability studies, determination of lipophilicity, protein-binding studies, determination of K_d and B_max as well as internalization studies using the epithelial human prostate cancer cell line PC3. In vitro monotherapy as well as combination therapy studies were further performed to assess its applicability as a theranostic compound.

Results

LF1 was labelled with gallium-68, indium-111 and lutetium-177 within 5 min at room temperature (RT). The apparent molar activities (A_m) were ranging between 50 and 60 GBq/μmol for the ⁶⁸Ga-labelled LF1, 10–20 GBq/μmol for the ¹¹¹In- and ¹⁷⁷Lu-labelled LF1. The radiotracers were stable for a period of 4 h post labeling exhibiting a hydrophilic profile with an average of a LogD_octanol/PBS of − 3, while the bound activity to the human serum protein was approximately 10%. ^68/natGa-LF1, ^177/natLu-LF1 and ^111/natIn-LF1 exhibited high affinity for the PC3 cells, with K_d values of 16.3 ± 2.4 nM, 10.3 ± 2.73 nM and 5.2 ± 1.9 nM, respectively, and the required concentration of the radiotracers to saturate the receptors (B_max) was between 0.5 and 0.8 nM which corresponds to approximately 4 × 10⁵ receptors per cell. Low specific internalization rate was found in cell culture, while the total specific cell surface bound uptake always exceeded the internalized activity. In vitro therapy studies showed that inhibition of PC3 cells growth is somewhat more efficient when combination of ¹⁷⁷Lu-labelled LF1 with rapamycin is applied compared to ¹⁷⁷Lu-laballed LF1 alone.

Conclusion

Encouraged by these promising in vitro data, preclinical evaluation of the LF1 precursor are planned in tumour models in vivo.

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war

BACKGROUND

From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed.

METHODS

The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019).

RESULTS

Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe.

CONCLUSIONS

Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Adverse reaction to metal debris after small-head diameter metal-on-metal total hip arthroplasty: an increasing concern

INTRODUCTION:

Failures due to adverse reaction to metal debris (ARMD) have become an area of common focus among surgeons performing hip replacements. Several authors have reported data on the prevalence of these masses, in both symptomatic and asymptomatic patients after either large-diameter head metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing arthroplasty, with a large variability of rate. To our knowledge, few data are reported on the association of this lesion with the use of small-head diameter MoM.

METHODS:

15 hips that were revised for ARMD in small-head MoM THA were included in this study. We focused our attention on the difficulties of diagnosis and treatment and also on the histologic aspects of the harvested pathologic tissue.

RESULTS:

The histological examination of our cases showed a presence of lymphocytic infiltrate suggesting a delayed hypersensitivity reaction to the metal of type IV (ALVAL), but different from each other in term of the prevalence of the cellular component. Osteolysis and severe soft tissue damage were also observed. Revision resulted in remission of the lesion and successful implant.

CONCLUSIONS:

Our observation suggests that the evidence of ARMD should be considered even in case of small-head MoM arthroplasty and therefore these patients should be followed scrupulously with 2nd level diagnostic tools such as magnetic resonance imaging with metal artifact reduction sequence (MARS-MRI) and metal ion levels at least once. Further investigations are necessary to establish the real prevalence of this phenomenon in the whole population of small-head MoM THAs.

DNAJC17 is localized in nuclear speckles and interacts with splicing machinery components

DNAJC17 is a heat shock protein (HSP40) family member, identified in mouse as susceptibility gene for congenital hypothyroidism. DNAJC17 knockout mouse embryos die prior to implantation. In humans, germline homozygous mutations in DNAJC17 have been found in syndromic retinal dystrophy patients, while heterozygous mutations represent candidate pathogenic events for myeloproliferative disorders. Despite widespread expression and involvement in human diseases, DNAJC17 function is still poorly understood. Herein, we have investigated its function through high-throughput transcriptomic and proteomic approaches. DNAJC17-depleted cells transcriptome highlighted genes involved in general functional categories, mainly related to gene expression. Conversely, DNAJC17 interactome can be classified in very specific functional networks, with the most enriched one including proteins involved in splicing. Furthermore, several splicing-related interactors, were independently validated by co-immunoprecipitation and in vivo co-localization. Accordingly, co-localization of DNAJC17 with SC35, a marker of nuclear speckles, further supported its interaction with spliceosomal components. Lastly, DNAJC17 up-regulation enhanced splicing efficiency of minigene reporter in live cells, while its knockdown induced perturbations of splicing efficiency at whole genome level, as demonstrated by specific analysis of RNAseq data. In conclusion, our study strongly suggests a role of DNAJC17 in splicing-related processes and provides support to its recognized essential function in early development.

Intestinal perforation after surgical treatment for incisional hernia: iatrogenic or idiopathic?

Intestinal perforation (IP) is a life-threatening gastroenterological condition requiring urgent surgical care, which may present itself as an uncommon complication following incisional hernia repair surgery, most often because of iatrogenic traumatism occurring during the procedure. However, we report a case where a spontaneous onset can be hypothesised. A 60-years-old patient underwent repair of an abdominal laparocele, through rectus abdominis muscle plasty, 5 years after development of an incisional hernia due to exploratory laparotomy for the treatment of acute appendicitis. Xipho-pubic scar was excised and umbilicus and supra-umbilical hernia sac dissected, a linear median incision was performed along the sub-umbilical linea alba, reaching preperitoneal plane to assess any intestinal loop adherence to the abdominal wall. After limited viscerolysis, abdominal wall defect was corrected by ‘rectus abdominis muscle plasty’ and umbilicus reconstruction by Santanelli technique. Postoperative course was uneventful until Day 29, with sudden onset of epigastric pain, fever and bulge. Sixty cubic centimeter pus was drained percutaneously and cavity was rinsed with a 50% H2O2 and H2O V-V solution until draining clear fluid. Symptoms recurred two days later, while during rinsing presented dyspnoea. X-Ray and CT scan diagnosed IP, and she underwent under emergency an exploratory laparotomy, leading to right hemicolectomy extended to last ileal loops and middle third of the transverse, right monolateral salpingo-ovariectomy and a temporary ileostomy by general surgeon. Twenty-three days later an ileostomy reversal surgery was performed and 8 days after she was discharged. At latest follow-up patient showed fair conditions, complaining abdominal pain and diarrhoea, attributable to the extensive intestinal resection. IP following incisional hernia repair, is reported as uncommon and early postoperative complication. In our case, the previous regular postoperative course with late onset lead us to hypothesise a possible idiopathic etiopathogenesis, because of a strangulation followed by gangrene and abscess formation, which might begin before the incisional hernia repair and unnoticed at the time surgery was performed.

Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis of Risk Factors at 7 to 10 Years Follow-up

BACKGROUND

Dislocation of primary THA (total hip arthroplasty) is one of the most undesirable complications with an incidence ranging from 2% to 5%. Several risk factors are described, related to the patient, surgery, or prosthetic design. The aim of the study was to assess risk factors and their potential influence on dislocation.

MATERIALS AND METHODS

387 primary THA were performed between September 2005 to December 2008 at our institute (Varese, Italy) through a modified posterior-lateral approach. Clinical evaluation was based on range of motion (ROM) and Harris Hip Score; femoral offset, acetabular inclination, and anteversion were measured on plain radiograms. Data were analyzed by SPSS software (SPSS, Inc., Chicago, Illinois).

RESULTS

Excellent ROM and Harris Hip Scores were achieved in more than 95% of patients (p<0.05). The offset was restored in all patients. Most of the cases had their cup positioned in the "safe zone" (both inclination and anteversion). Six dislocations (1.87%) occurred: significant correlation was found between dislocation and preoperative diagnosis of femoral neck fracture.

CONCLUSIONS

THA dislocation rate appears not to be related to patient biometric parameters and prosthesis design. Femoral neck fracture is reported as the major risk factor for this complication, probably caused by higher preoperative activity and lesser compliance of the patient.

Self-referenced ultra-broadband transient terahertz spectroscopy using air-photonics

Terahertz (THz) air-photonics employs nonlinear interactions of ultrashort laser pulses in air to generate and detect THz pulses. As air is virtually non-dispersive, the optical-THz phase matching condition is automatically met, thus permitting the generation and detection of ultra-broadband THz pulses covering the entire THz spectral range without any gaps. Air-photonics naturally offers unique opportunities for ultra-broadband transient THz spectroscopy, yet many critical challenges inherent to this technique must first be resolved. Here, we present explicit guidelines for ultra-broadband transient THz spectroscopy with air-photonics, including a novel method for self-referenced signal acquisition minimizing the phase error, and the numerically-accurate approach to the transient reflectance data analysis.

HISTOLOGICAL FEATURES OF PSEUDOTUMOR AFTER SMALL HEAD DIAMETER METAL-ON-METAL TOTAL HIP ARTHROPLASTY

The pathologic aspects of periprosthetic tissues in failed second-generation metal-on-metal (MoM) resurfacing hip arthroplasties have been widely described in terms of necrosis and inflammation. To our knowledge little data are reported on the association of this lesion with the use of small head diameter (less than 32 mm). In this study we present a small series of pseudo-tumor in small head metal-on-metal total hip arthroplasty focusing our attention on the histologic aspects of the harvested pathologic tissue. The histological examination of our cases showed a presence of lymphocytic infiltrate suggesting a delayed hypersensitivity reaction to metal of type IV (ALVAL) but different to each other in terms of the prevalence of the cellular component. If macrophages are predominant, the pathogenetic mechanism seems to be the reaction against metallic particle. On the other hand, if granulocytes are predominant, it is possible to consider a hypersensitivity reaction. Our observation suggests that the evidence of Pseudotumor in case of small-head metal-on-metal arthroplasty should be considered with the same properties of big-head and therefore these patients should be followed scrupulously.

Computational modelling of mobile bearing TKA anterior-posterior dislocation

Anterior-posterior stability in an unconstrained mobile-bearing total knee arthroplasty (TKA) and one with rotational constraints is compared in a computational model based on an ASTM test. Both TKA designs dislocate at loads greater than reported maximum in vivo forces. The posterior drawer forces (mean: 3027 N vs. 1817 N) needed to induce subluxation increase with a greater anterior jump distance (12 mm vs. 7 mm; refers to the vertical height of the anterior or posterior border of the tibial insert's articulating surface). The posterior jump distance for both tested TKA differed by 1.5 mm and had minimal effect on the magnitude of the anterior drawer forces at dislocation in mid-flexion (unconstrained vs. constrained: 445 N vs. 412 N). The unconstrained insert dislocated by means of spin-out whereas in the constrained TKA the femur dislocated from the bearing during posterior drawer and the bearing from the baseplate during anterior drawer. MCL function is an important consideration during ligament balancing since a ± 10% variation in MCL tension affects dislocation forces by ± 20%. The simulation platform provided the means to investigate TKA designs in terms of anterior-posterior stability as a function of knee flexion, collateral ligament function and mechanical morphology.

The Use of an Electronic System for Soft Tissue Balancing in Primary Total Knee Arthroplasties: Clinical and Radiological Evaluation

The eLibra® Dynamic Knee Balancing System (Synvasive Technology, Zimmer, Warsaw, IN) is an instrument designed to address the flexion stability during a TKA. It provides an objective measurement of the soft-tissue forces in the two compartments before the final cuts are made, allowing to obtain patient-specific rotational orientation of the femoral component. Between March 2010 and March 2012, the eLibra® system was used during the implantation of 75 TKAs in 75 patients at the author's institution. Preoperative and postoperative clinical assessment were evaluated using the Knee Society Score (KSS) and the Visual Analogical Scale (VAS). Radiographic evaluation was performed with weight-bearing radiographs in antero-posterior and lateral views in order to study the presence of radiolucencies. In a sample of 20 patients, representative of the population studied, the rotation of the femoral component was measured by two independent observers using the C-arm Cone Beam CT scan (XperCT/Allura FD20 angiography system; Philips, Best, Netherlands). At a mean follow-up of 42.3 months (29-54 months), three patients died from causes not related to the surgery. We had one case of aseptic loosening three years after surgery. None of the patients reported complications peri- or postoperatively. Clinical evaluation showed an improvement in KSS scoring, from preoperative means of 48.35 and 47.53 points for clinical and functional aspects, respectively, to postoperative means of 88.03 and 91.2 points, respectively (p<0.001 for both aspects). The current study demonstrates that the use of the eLibra® device is simple and reproducible. It could help surgeons objectively quantify ligament balance and perform soft tissue-guided resection in a reproducible way, resulting in better post-operative stability and reduced complications. The use of the postoperative cone beam computed tomography (CBCT), in a representative sample of patients, revealed a specific and optimal orientation of the femoral component with a mean of 2.18° of external rotation.

Macrophages promote epithelial repair through hepatocyte growth factor secretion

Macrophages play a critical role in intestinal wound repair. However, the mechanisms of macrophage-assisted wound repair remain poorly understood. We aimed to characterize more clearly the repair activities of murine and human macrophages. Murine macrophages were differentiated from bone marrow cells and human macrophages from monocytes isolated from peripheral blood mononuclear cells of healthy donors (HD) or Crohn's disease (CD) patients or isolated from the intestinal mucosa of HD. In-vitro models were used to study the repair activities of macrophages. We found that murine and human macrophages were both able to promote epithelial repair in vitro. This function was mainly cell contact-independent and relied upon the production of soluble factors such as the hepatocyte growth factor (HGF). Indeed, HGF-silenced macrophages were less capable of promoting epithelial repair than control macrophages. Remarkably, macrophages from CD patients produced less HGF than their HD counterparts (HGF level: 84 ± 27 pg/mg of protein and 45 ± 34 pg/mg of protein, respectively, for HD and CD macrophages, P < 0·009) and were deficient in promoting epithelial repair (repairing activity: 90·1 ± 4·6 and 75·8 ± 8·3, respectively, for HD and CD macrophages, P < 0·0005). In conclusion, we provide evidence that macrophages act on wounded epithelial cells to promote epithelial repair through the secretion of HGF. The deficiency of CD macrophages to secrete HGF and to promote epithelial repair might contribute to the impaired intestinal mucosal healing in CD patients.

Use of an electronic system for soft tissue balancing in primary total knee arthroplasty

Accurate soft tissue balancing during total knee arthroplasty has a direct effect on patellofemoral tracking and knee range of motion. Numerous instruments and methods are available to balance knee prostheses. The eLIBRA Dynamic Knee Balancing System (Synvasive Technology, Inc, Reno, Nevada) is an electronic device that establishes femoral component rotation using ligamentous tone. The eLIBRA is an articulating spacer that emulates implant trials before anteroposterior femoral cuts are made to obtain a dynamic gap symmetry.

Revision in cemented and cementless infected hip arthroplasty

Infection is a frequent cause of failure after joint replacement surgery. The infection rate after total hip arthroplasty (THA) has been reduced to 1-2% in the last years. However, it still represents a challenging problem for the orthopedic surgeon.

Difficulty of therapeutic approach, and poor functional outcomes together with length of treatment and overall cost are the main burden of this issue. Even the diagnosis of an infected hip could be challenging although it is the first step of an accurate treatment. At the end, many cases require removing the implants. Afterwards, the treatment strategy varies according to authors with three different procedures: no re-implantation, immediate placement of new implants or a two-stage surgery re-implantation.

Based on the most recently systematic review there is no suggestion that one- or two-stage revision methods have different re-infection outcomes.

The two-stage implant-exchange protocol remains the gold standard. It is considered as the most efficacious clinical approach for the treatment of periprosthetic infection, especially in patients with sinus tracts, swelling, extended abscess formation in depth and infection of Methicillin Resistant Staphylococcus Aureus (MRSA), and other multidrug-resistant bacteria as reported in recent consensus documents.

The use of a preformed spacer in two-stage revision of infected hip arthroplasties

Two-stage revision with the use of an antibiotic-loaded cement spacer has spread widely as a successful treatment for THA infection. Between 1999 and 2008, 28 patients with infected THA were treated with two-stage implant revision using a preformed spacer. The spacer was left in situ for 5.5 months (range 1-13 months), and the patients were allowed to walk with partial weight bearing. At a mean follow-up of 53 months (range 18-106 months), recurrence of infection was observed in only one patient. Complications were observed in five patients: three spacer dislocations, one distal femoral fracture occurred during stem removal, and one femoral artery pseudo-aneurysm. The mean HHS increased from 43 points (range 13-77) to 82 points (range 35-96). Though small prospective studies are reported in literature, good eradication rate and good functional outcomes encourage for the use of an antibiotic-loaded cement spacer. The industrial production ensures procedure standardization, well-defined physical and chemical properties to the device and eliminates time necessary to intraoperatory manufacturing.

[Pancreatic carcinoma presenting with invasion of the vena porta or the superior mesenteric vein: our experience and review of the literature]

AIM

Adenocarcinoma of the pancreas can present with invasion of the vena porta or the superior mesenteric vein (SMV). Pancreatectomy with resection of the vena porta and/or the SMV remains controversial although the procedure is potentially curative. The aim of this study was to validate the indication for resection on the basis of our experience and evidence from recently published studies.

METHODS

Studies published in the last 10 years on pancreatectomy (duodenocephalopancreatectomy, total and distal pancreatectomy) with resection of the vena porta and/or the SMV were retrieved from the Medline database and reviewed. A total of 18 studies meeting the inclusion criteria were analyzed for information about indications, type of intervention, use of adjuvant therapies, histopathology, perioperative results and survival in 620 patients with adenocarcinoma of the pancreas undergoing pancreatectomy with resection of the vena porta and the SMV. This data set was then compared with our experience with this procedure from the last 3 years.

RESULTS

The mortality and postoperative complication rates varied between 0% and 7.7% and 12.5% and 54%, respectively. The median survival varied from 12 to 22 months; the 1 year survival rate was between 31% and 83%; the 5-year survival rate was between 9 and 18% according to the studies reviewed.

CONCLUSION

On the basis of evidence from the literature and our experience, en bloc resection of the vena porta and/or the SMV during pancreatectomy appears to be a safe procedure with acceptable outcomes, and should be considered in patients with pancreatic cancer presenting with venous invasion. Venous resection increases the surgical cure rate, prolonging survival in patients selected according to correct indications.

Micropatterned hydrogenated amorphous carbon guides mesenchymal stem cells towards neuronal differentiation

This study investigated how the design of surface topography may stimulate stem cell differentiation towards a neural lineage. To this end, hydrogenated amorphous carbon (a-C:H) groove topographies with width/spacing ridges ranging from 80/40μm, 40/30μm and 30/20μm and depth of 24 nm were used as a single mechanotransducer stimulus to generate neural cells from human bone marrow mesenchymal stem cells (hBM-MSCs) in vitro. As comparative experiments, soluble brain-derived neurotrophic factor (BDNF) was used as additional biochemical inducer agent. Despite simultaneous presence of a-C:H micropatterned nanoridges and soluble BDNF resulted in the highest percentage of neuronal-like differentiated cells our findings demonstrate that the surface topography with micropatterned nanoridge width/spacing of 40/30μm (single stimulus) induced hBM-MSCs to acquire neuronal characteristics in the absence of differentiating agents. On the other hand, the alternative a-C:H ridge dimensions tested failed to induce stem cell differentiation towards neuronal properties, thereby suggesting the occurrence of a mechanotransducer effect exerted by optimal nano/microstructure dimensions on the hBM-MSCs responses.

Femoral revision with taper stems: results at ten years follow-up

In the case of extensively damaged meta-diaphyseal femoral bone with cortices thinning and widened femoral canal, tapered stems allow a good primary fixation and early weight-bearing. A retrospective review was conducted to evaluate long-term results of modular revision taper stems implanted from March 1999 to December 2002. Sixty-five consecutive hip revision surgeries were performed, mostly for aseptic loosening (75% of the cases). Femoral bone stock defects were classified according to AAOS's criteria and consisted mainly in type II (cavitary defects, 44.6%) and type III (combined defects, 33.9%). A trochanteric osteotomy was performed in 25 cases (38%) to remove primary implants that were cemented in 35 cases (54%). The mean postoperative follow-up was 109 months (range, 76 to 131 months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 42 points preoperatively to 81 points postoperatively, while the x-ray examination did show a satisfactory distal integration of the stem in all cases and satisfactory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was less than one millimeter. According to data analysis, a leg-length discrepancy exceeding 15 millimeters caused significantly worse functional outcome and pain.

The use of cementless acetabular component in revision surgery without pelvic discontinuity

Reconstruction of the failed acetabular component in total hip arthroplasty (THA) can be challenging. Although there are multiple reconstructive options available, a cementless acetabular component inserted with screws has been shown to have good intermediate-term results and is the reconstructive method of choice for the majority of acetabular revisions This reconstruction is feasible provided at least 50% of the implant contacts host bone. When such contact is not possible, and there is adequate medial and peripheral bone, techniques using alternative uncemented implants can be used for acetabular reconstruction. An uncemented cup can be placed at a "high hip center." Alternatively, the acetabular cavity can be progressively reamed to accommodate extra-large cups. Oblong cups, which take advantage of the oval-shaped cavity resulting from many failed acetabular components, can also be used. The success of these cementless techniques depends on the degree and location of bone loss. The correct indication to revision and the choice of the correct implant is the keystone for the success of this type of surgery and follows an accurate preoperative planning in order to understand the specific pathologic scenario. The aim of this paper is to review some technical options for the revision of the acetabular component also taking into account our personal experiences and series.

Seven to twelve year results with Versys ET cementless stem. A retrospective study of 225 cases

A retrospective review was conducted to evaluate the mid-term results (8.5 years follow-up) of the Versys ET stem (Zimmer, Warsaw, Indiana, USA). From 1995 to 2000, 225 total hip arthroplasties (THA) were performed using this device. All patients were evaluated clinically by the Harris Hip Score, and radiographically. The Hip Score increased from 54 preoperatively to 97 points postoperatively. The stem displayed a varus alignment between 5 degrees and 10 degrees in 17 cases without any clinical consequences (HHS 96.8). We recorded one case of septic loosening and one case of aseptic loosening. The stability of the stem was radiographically evaluated according to Engh's criteria, confirming bone ongrowth in all other cases.

Italian cross-cultural adaptation and validation of the Oxford Shoulder Score

BACKGROUND

The Oxford Shoulder Score (OSS) is an English-language questionnaire specifically designed to evaluate patients affected by shoulder pain. Although this scoring system has been translated into other languages, an Italian version of it is still not available. The aim of the present study was to translate, culturally adapt, and validate the Italian version of the OSS.

MATERIALS AND METHODS

We recruited 140 patients with shoulder pain caused by degenerative or inflammatory state or disorder of the shoulder. Patients completed the following questionnaires: Italian OSS, University of California, Los Angeles (UCLA) Shoulder Rating Scale, Constant-Murley shoulder assessment, and the Medical Outcome Study Short-Form 36 Health Survey (MOS SF-36). Internal consistency was tested using Cronbach coefficient alpha. Reproducibility was assessed by asking 110 patients to complete another OSS 48 hours after the first. Correlation between the total results of both tests was determined by the Pearson correlation coefficient. Validity was assessed by calculating the Pearson correlation coefficient between the OSS and the UCLA, Constant-Murley, and SF-36 assessments.

RESULTS

Cronbach alpha was 0.95. The Pearson correlation coefficient was r=0.97. With respect to validity, there was a significant correlation between the Italian OSS and the individual scores of UCLA, Constant-Murley, and SF-36.

DISCUSSION

Psychometric properties of the Italian OSS compared well with those reported for the English OSS. As demonstrated by the high values of Cronbach alpha and Pearson correlation coefficients, in accordance with the English version of the OSS, the Italian version proved to be a reliable, valid, and reproducible measure of shoulder pain perception in Italian-speaking patients.

Two stage fracture of a polyethylene post in a 9-year-old posterior-stabilized knee prosthesis: a case report

Introduction

Several cases of tibial post breakage are reported in the literature. To the best of our knowledge, only three cases of NexGen knee prosthesis (Zimmer, Warsaw, Indiana, USA) tibial post failure have been reported.

Case presentation

In November 1999, a 63-year-old Caucasian woman from Italy with a history of symptomatic left knee osteoarthritis underwent a total knee arthroplasty. In March 2008, while rising from a chair, she felt a sudden pain and instability in her left knee. She reported a fracture of the polyethylene post of the tibial insert. No malposition or malalignment of either the femoral or tibial components were identified. The polyethylene tibial insert was studied under light microscopy and scanning electron microscopy. The fracture was also noted to have occurred without any notable polyethylene wear.

Conclusion

Scanning electron microscopy revealed two different damage patterns that could be explained with a two-stage rupture of our patient's polyethylene post. This could have been caused by a non-optimal ligamentous balancing during first implant surgery. Her knee probably developed a varus instability that weakened the post, and then a posterior anterior stress finally broke the polyethylene.

Failure of dual radius hydroxyapatite-coated acetabular cups

Introduction

Many kind of hydroxyapatite-coated cups were used, with favorable results in short term studies; it was supposed that its use could improve osteointegration of the cup, enhancing thus stability and survivorship. The purpose of this study is to analyze the long term behavior of the hemispheric HA coated, Dual Radius Osteonics cup and to discuss the way of failure through the exam of the revised components and of both periacetabular and osteolysis tissue.

Materials and Methods

Between 1994 and 1997, at the Department of Orthopedic Sciences of the Insubria University, using the posterolateral approach, were implanted 276 Dual Radius Osteonics^® in 256 patients, with mean age of 63 years.

Results

At a mean follow-up of 10 years (range 8–12 years), 183 cups in 165 patients, were available for clinical and radiographical evaluation. 22 Cups among the 183 were revised (11%). The cause of revision was aseptic loosening in 17 cases, septic loosening in one case, periprosthetic fracture in another case, osteolysis and polyethylene wear in two cases and, finally, recurrent dislocations in the last one. In the remaining patients, mean HHS increased from a preoperative value of 50,15 to a postoperative value of 92,69. The mean polyethylene wear was 1,25 mm (min. 0,08, max. 3,9 mm), with a mean annual wear of 0,17 mm. The mean acetabular migration on the two axis was 1,6 mm and 1,8 mm. Peri-acetabular osteolysis were recorded in 89% of the implants (163 cases). The cumulative survivorship (revision as endpoint) at the time was 88,9%.

Conclusion

Our study confirms the bad behavior of this type of cup probably related to the design, to the method of HA fixation. The observations carried out on the revised cup confirm these hypotheses but did not clarify if the third body wear could be a further problem. Another interesting aspect is the high incidence of osteolysis, which are often asymptomatic becoming a problem for the surgeon as the patient refuses the possibility of a revision.

[A rare presentation of Amyand's hernia. Case report and review of the literature]

Amyand's hernia is defined as an inguinal hernia within the hernial sac containing the appendix. It is a rare disease, reported in 1% of cases of inguinal hernia repair. The appendix can be complicated by acute appendicitis in 0.13% of cases. This disease is often very difficult to diagnose, and most of the time it can be confused with an incarcerated or strangulated inguinal hernia. Often, it requires an emergent surgical treatment. This article describes the case of a 82-year-old female who was admitted for an intestinal obstruction and a bulge in the right inguinal region. An abdominal computed tomography scan showed dilated small bowel loops with multiple air/liquid levels and one loop herniating into the right inguinal canal. The patient underwent a laparotomy that showed the presence of an acute appendicitis and a necrotized ileal loop protruding into the right inguinal canal. The patient underwent an appendectomy and small bowel resection and she was discharged on postoperative day 10. Amyand's hernia can be a challenge for the surgeon. Its treatment depends on the grade of inflammation of the appendix. In fact, it can range from the simple repair of the abdominal defect with a prosthetic mesh, to appendectomy, small bowel resection and repair of the abdominal wall defect without a mesh.

Combined treatment of ablative therapy with percutaneous radiofrequency and cementoplasty of a symptomatic metastatic lesion of the acetabulum

We report the case of a symptomatic metastatic lesion of the acetabulum from colon adenocarcinoma in an 82-year-old woman patient treated by a combined approach of thermal ablation with percutaneous radiofrequency and cementoplasty. We obtained an immediate technical success with a good control of pain without any complications at a 6-month clinical follow-up.

The unstable total hip replacement

BACKGROUND

Dislocation is one of the most common complications of total hip arthroplasty with a reported dislocation rate of 3.2%. Despite increased experience with hip replacement, the overall rate has not yet changed. The aim of this paper is to review the most recent literature published on this topic and indexed in Medline, in order to clarify the main risk factors, and to standardize a treatment protocol of such an important complication of prosthetic surgery.

MATERIALS AND METHODS

Medline database was searched using key words: "hip dislocation", "hip instability" from 1980-2007. Studies were eligible for review and included if they met the following criteria: (1) publication in English, (2) clinical trials (3) review papers.

RESULTS

The risk of first-time dislocation as a function of time after the surgery is not well understood. Most, but not all, series have demonstrated that the risk of dislocation is highest during the first few months after hip arthroplasty; however, first-time late dislocation can also occur many years after the procedure. Several risk factors were described, including the surgical approach, the diameter of the head, impingement, component malposition, insufficient abductor musculature. In addition, there are also many treatment options, such as long-term bracing after closed reduction, component reorientation, capsulorraphy, trochanteric advancement, increasing offset, exchange of the modular head and the polyethylene liner, insertion of constrained liner.

CONCLUSION

Preventing hip dislocation is obviously the best strategy. Surgeons must take into account patient and surgical risk factors. For patients at high risk for dislocation the surgeon should accurately restore leg length and femoral offset; the use of larger femoral heads, posterior transosseous repair of the capsulotendinous envelope if posterior approach is chosen or the use of a lateral approach should be considered. Proper patient education and postoperative care are very important.

Analysis of bone ingrowth on a tantalum cup

BACKGROUND

Trabecular Metal (TM) is a new highly porous material made of tantalum (Zimmer, Warsaw, Indiana, USA). Its three-dimensional structure is composed of a series of interconnected dodecahedron pores that are on average 550 microm in diameter. This size is considered optimal for bone ingrowth and is similar to trabecular bone. The elastic modulus of TM (3 GPa) is more similar to that of cancellous (0,1-1,5 GPa) or cortical (112-18 GPa) bone and is significantly less similar to that of Titanium (110 GPa) and Co-Cr alloys (220 GPa). These features enable bone apposition and remodeling. The purpose of the present study was to evaluate the histology of the bone-implant interface in a human specimen.

MATERIALS AND METHODS

A highly porous tantalum cup (Zimmer, Warsaw, Indiana, USA) was removed for recurrent dislocations three years after implantation. In order to obtain a slice of the cup, two cuts were made on the centre using an Exakt cutting machine. Then the slice was embedded in a Technovit resin and a Hematoxylin-eosin stain was used to study the bone tissue. Bone ingrowth was calculated using a method based on simple calculations of planar geometry.

RESULTS

The histological evaluation of the periprosthetic tissues revealed a typical chronic inflammation with few particles of polyethylene that were birefringent using polarized light. The quantitative evaluation of bone ingrowth revealed that more than 95% of voids were filled with bone.

DISCUSSION

In the literature, a lot of studies focused on tantalum were carried on animal model. Up to now little information is available about the histology of the bone-tantalum interface in a human artificial joint. We had an opportunity to remove a well integrated cup hence this study. The histology confirmed the strong relationship between the structure of this material and bone. The morphometric analysis revealed a high percentage of bone ingrowth.

Contrast enhanced ultrasound with second generation contrast agent for the follow-up of lower-extremity muscle-strain-repairing processes in professional athletes

PURPOSE

In literature, ultrasonographic potentials in traumatic muscle lesions have been codified, whereas the data about this method utility in follow-up are dissonant. The purpose of this work is to evaluate a second-generation ultrasound (US) contrast agent rule for the professional athletes' distractive lesions.

MATERIALS AND METHODS

Twenty professional athletes (18 men and two women, aged between 18 and 34 years) affected by different muscle lesions were examined. All the patients were evaluated within 48 h of the trauma by US device Esaote Technos MPX with a high-frequency linear probe. The examinations were carried out with and without contrast agent after 20, 40 and 60 days after the trauma; second-generation contrast agent was used (SonoVue).

RESULTS

In all athletes (nine first-grade lesions, 11 second-grade lesions), by using contrast agent intravenous injection done after 20 days, the appearance of contrast spots affecting part or all the lesioned area were observed. During the follow-up, after 40 days. the contrast spots widened to include the entire scar area, with haemorrhagic residual in three cases. After 60 days, in no case was a liquid haemorrhagic collection still present, and we found an important reduction of extension of vascular spots and US intensity and their total disappearance in seven cases.

CONCLUSIONS

US with a second-generation contrast agent, thanks to the neoangiogenesis identification, allows recognition, individuation and monitoring the repair processes in the muscle lesion and allows estimation of when athletes can return to competitive activity. This fact obviously reduces both relapses and complications.

Endovascular repair of a pseudo-aneurysm of the common femoral artery after revision total hip arthroplasty

Vascular injuries with acute arterial haemorrhage are rare but the infrequency of these complications may make their diagnosis and treatment challenging for surgeons unfamiliar with their management. In the past, surgery or coil embolisation has been used to treat these lesions; we describe the case of a pseudo-aneurysm of the common femoral artery developed during a total hip arthroplasty, promptly managed with an endovascular stent graft.

Popliteal artery pseudoaneurysm after a revision of total knee arthroplasty: endovascular treatment with a stent graft

Injury to the popliteal artery during total knee arthroplasty is a very rare but dangerous complication. Several mechanisms are capable of generating a direct trauma to the vessel, like posterior retractor and oscillating saw. We report a case of popliteal artery pseudoaneurysm in a 52-year-old woman that occurred during revision of total knee arthroplasty, requiring emergency repair by means of percutaneous endovascular covered stenting.

"Conus" uncemented stem in developmental hip dysplasia

The purpose of this study was to evaluate 115 "Conus" uncemented stems at an average follow-up of 6 years (2-9 years). Seventeen patients were lost at follow-up for a final number of 98 stems in 75 patients. The clinical outcome of 71 hips (72%) was graded excellent, 25 (25%) were good, one (2%) fair and one (2%) poor. The average Harris Hip Score increased from 49.35 before operation to 96.30 at the time of the last follow-up. None of the stems implanted required a revision for aseptic or septic loosening. Cortical hypertrophy or radiolucencies were never seen in any of the stems evaluated. Heterotopic ossification was seen in one hip (1%). Modification of the calcar was observed in 29 hips (30%) and they consisted in a slight rounding off of the proximal medial edge of the cut femoral neck. These results encourage the use of this versatile stem which showed a good primary and secondary stability, with a good load distribution along the femur.

Structural, mechanical and wear resistance assessment of UHMWPE orthopedic components

The long-term survival of total joint prostheses is influenced by many factors. Among these factors, the most critical one is the presence of wear debris, particularly from the joint articulating surfaces. While ultra high molecular weight polyethylene (UHMWPE) has shown to be extremely promising in vitro and short-term clinical results, shelf-aged, oxidized components have been extremely unsuccessful clinically. Although shelf-aged components have been frequently tested in the laboratory, few studies have compared the properties of clinical retrievals to shelf-aged UHMWPE components. In this study, a thorough analysis method was developed and applied to both UHMWPE components retrieved at the time of revision, and non-implanted, shelf-aged UHMWPE components with the aim to understand better the significance of the in vivo factors on the material properties of the retrievals. The UHMWPE components were analyzed and characterized by visual observation of the surfaces, mechanical properties were assessed by small punch tests, wear resistance was analyzed by a multidirectional pin-on-disk test, and the oxidation level was detected by the Fourier transformed infrared (FT-IR) technique. The results indicated a strong correlation between the UHMWPE oxidation level, mechanical properties and wear resistance.