Orthobiologics in delayed union and non-union of adult long bones fractures: A systematic review

Background

Fracture healing poses a significant challenge in orthopedics. Successful regeneration of bone is provided by mechanical stability and a favorable biological microenvironment. This systematic review aims to explore the clinical application of orthobiologics in treating aseptic delayed union and non-union of long bones in adults.

Methods

A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Three databases were explored, with no date restrictions, using keywords related to orthobiologics and delayed union and non-union. Eligible studies included human clinical studies in English, with available full texts, examining orthobiologics such as platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), and bone morphogenetic protein (BMPs) for treating aseptic delayed unions and non-unions in adults. Animal studies, in vitro research, and studies on non-unions due to congenital defects, tumors or infections were excluded.

Results

The initial search identified 9417 studies, with 20 ultimately included in the review. These studies involved 493 patients affected by non-union and 256 patients affected by delayed union, with an average age respectively of 40.62 years and 41.7 years. The mean follow-up period was 15.55 months for non-unions and 8.07 months for delayed unions. PRP was the most used orthobiologic, and outcomes were evaluated through time to union, functional scores, and clinical examinations. The results indicated that orthobiologics, especially PRP, tended to yield better outcomes compared to surgical procedures without biological factors.

Conclusion

This systematic review suggests that orthobiologics, such as PRP, BMPs, and MSCs, can be effective and safe in the management of delayed union and non-union fractures. These biological treatments have the potential to improve union rates, reduce healing times, and enhance functional outcomes in patients with non-union fractures. Further research is essential to refine treatment protocols and determine the most suitable orthobiologic for specific patient populations and fracture types.

Age and anatomical region-related differences in vascularization of the porcine meniscus using microcomputed tomography imaging

Meniscal lesions in vascularized regions are known to regenerate while lack of vascular supply leads to poor healing. Here, we developed and validated a novel methodology for three-dimensional structural analysis of meniscal vascular structures with high-resolution microcomputed tomography (µCT). We collected porcine medial menisci from 10 neonatal (not-developed meniscus, n-) and 10 adults (fully developed meniscus, a-). The menisci were cut into anatomical regions (anterior horn (n-AH and a-AH), central body (n-CB and a-CB), and posterior horn (n-PH and a-PH). Specimens were cut in half, fixed, and one specimen underwent critical point drying and µCT imaging, while other specimen underwent immunohistochemistry and vascularity biomarker CD31 staining for validation of µCT. Parameters describing vascular structures were calculated from µCT. The vascular network in neonatal spread throughout meniscus, while in adult was limited to a few vessels in outer region, mostly on femoral side. n-AH, n-CB, and n-PH had 20, 17, and 11 times greater vascular volume fraction than adult, respectively. Moreover, thickness of blood vessels, in three regions, was six times higher in adults than in neonatal. a-PH appeared to have higher vascular fraction, longer and thicker blood vessels than both a-AH and a-CB. Overall, neonatal regions had a higher number of blood vessels, more branching, and higher tortuosity compared to adult regions. For the first time, critical point drying-based µCT imaging allowed detailed three-dimensional visualization and quantitative analysis of vascularized meniscal structures. We showed more vascularity in neonatal menisci, while adult menisci had fewer and thicker vascularity especially limited to the femoral surface.

Men and women undergoing total hip arthroplasty have different clinical presentations before surgery and different outcomes at 1-year follow-up

PURPOSE

The purpose of this study was to investigate the influence of sex on patients undergoing total hip arthroplasty (THA) for hip osteoarthritis (HOA), aiming to assess the clinical and functional outcomes using patient-reported outcome measures (PROMs).

METHODS

A retrospective analysis of patients undergoing THA at Ospedale Galeazzi-Sant'Ambrogio between 2016 and 2022 was conducted. Inclusion criteria encompassed Kellgren-Lawrence grade III or IV HOA, with preoperative and 12-month postoperative PROMs. Enroled patients have been selected from a larger cohort without matching design for confounders. The analyses were performed using R software v4.0.3 (R Core Team) and data distributions were assessed using the Shapiro-Wilk normality test.

RESULTS

One hundred ninety patients (72 male and 118 female) who had both preoperative and postoperative PROMs have been analysed from our institutional prosthesis registry (Datareg). Baseline and 12-month post-THA PROMs showed significant improvements overall. VAS score dropped notably from baseline to 3 months postsurgery (7.1 ± 2.1 vs. 0.9 ± 1.7). Functional and mental PROMs, including Harris Hip Score-functional (HHS-F), Harris Hip Score-total (HHS-t), SF-12PS and SF-12MS, exhibited substantial improvements post-THA. Stratifying by sex, males had lower baseline VAS, higher HHS-F, SF-12MS and hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS). At 12 months, males displayed significantly better VAS, HHS-F, SF-12PS and HOOS-PS scores. Complication rates were minimal (1.5%), with stable rates across genders, mostly involving dislocation and periprosthetic fractures. Implant survival at 12 months reached an impressive 99%.

CONCLUSION

THA remains an effective treatment for severe HOA. However, females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. This difference could be attributed to physiological and psychosocial factors associated with sex, including hormonal changes, muscle mass decline and perception of pain. Longer follow-ups and prospective studies are necessary to validate these findings and facilitate personalised approaches in HOA treatment, emphasising the need for careful consideration of sex-related variables in clinical decision-making for THA patients.

LEVEL OF EVIDENCE

Level III.

Limb asymmetries persist 6 months after anterior cruciate ligament reconstruction according to the results of a jump test battery

Objectives

Test batteries used to assess a patient's return-to-sports (RTS) following anterior cruciate ligament reconstruction (ACLR) are currently undergoing continual development, although no consensus exist on tests to be administered to athletes before allowing return to play. A simple standardized jump test battery was developed to objectively evaluate knee function following ACLR, thereby aiding in RTS decision-making.

Methods

Thirty-three patients who underwent ACLR were prospectively assessed pre-operatively, 6, and 12 months after surgery. Knee function was assessed using a device for optical detection using a test battery consisting of three jump tests: monopodalic countermovement jump (CMJ), drop jump, and monopodalic side-hop. Limb symmetry index (LSI) was reported for all tests at all time points. LSI ≥90% was defined as RTS criteria.

Results

At 12-month evaluation, mean LSI significantly improved compared to 6-month follow up (p < 0.01), and also compared to baseline (p < 0.01), reporting a mean value of 92.6% for CMJ, 90.6 for drop jump and 96.9% for side hop test. Most patients fulfilled the RTS criteria 12 months after surgery (LSI ≥90%). The percentages of patients demonstrating LSI ≥90% at 6 months was 7/33 (21.2%) for CMJ, 12/33 (36.4%) for drop jump, and 11/33 (33.3%) for side-hop test. One year after surgery, percentages grew up to 66.6% (22/33), 63.6% (21/33), and 81.8% (27/33) respectively.

Conclusion

Six months after ACLR, knee functional performance was unsatisfactory in most patients, whereas a significantly higher percentage of patients met RTS criteria 1 year after surgery. The results of the jump test battery proposed in this study support the idea that timing for resumption of cutting and pivoting sports should be delayed later than 6 months, as still limb asymmetries persist at this time point.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Septic arthritis in the pediatric hip joint: a systematic review of diagnosis, management, and outcomes

Septic arthritis of the pediatric hip joint (SAH) is a rare but serious orthopedic emergency requiring immediate diagnosis and management. Delayed recognition can lead to severe complications, emphasizing the need for timely intervention. This systematic review aims to provide a comprehensive analysis of SAH in the pediatric population, focusing on its diagnosis, management, and outcomes. The review included 11 studies involving 391 patients with SAH, aged between three months and 12 years. Staphylococcus aureus was identified as the most common causative pathogen, with increasing cases of methicillin-resistant strains. Diagnosis is challenging due to nonspecific clinical presentations, necessitating validated criteria and a multidisciplinary approach. Ultrasound emerged as a valuable tool for early detection, and MRI was used in challenging cases. Treatment options include hip aspiration, arthrotomy, and arthroscopy, often combined with appropriate antibiotic therapy. Success rates were comparable among different surgical procedures. Early intervention is vital for optimal outcomes. However, the review highlights the need for standardized protocols and further prospective studies to address limitations and improve understanding and management of SAH in the pediatric hip joint.

How Do Older Patients with End-Stage Osteoarthritis of the Hip Eat Prior to Hip Replacement? A Preliminary Snapshot That Highlights a Poor Diet

Diet quantity and quality in older adults is critical for the proper functioning of the musculoskeletal system. In view of hip surgery, old patients should consume 1.2-1.5 g of proteins and 27-30 kcal per kilo of body weight daily, and adhere to healthy eating habits. In this analytical study, we studied diet quantity and quality in relation to the clinical chemistry and functional status of 57 older adults undergoing elective hip replacement. Nine in ten patients did not meet suggested protein and energy intakes and only one in ten patients exhibited high adherence to the Mediterranean diet. Legume consumption adjusted for sex, age, body mass index, and health status successfully forecasted haemoglobin levels (p < 0.05), and patients regularly consuming olive oil reported minor hip disability compared to those using it less frequently (p < 0.05). Patients who reported daily ingestion of <1 serving of meat versus those consuming >1.5 servings had greater cumulative comorbidity (p < 0.05), with meat consumption independently predicting walking ability, mobility, and balance in the fully adjusted model (p < 0.01). In conclusion, our patients seem to eat poorly. There is room for improvement in pre-operative pathways to make older adults eat better, but there is a need to plan an interventional study to fully understand the cause-effect of a dietary pattern or specific food in enhancing recovery after surgery.

ChatGPT in orthopedics: a narrative review exploring the potential of artificial intelligence in orthopedic practice

The field of orthopedics faces complex challenges requiring quick and intricate decisions, with patient education and compliance playing crucial roles in treatment outcomes. Technological advancements in artificial intelligence (AI) can potentially enhance orthopedic care. ChatGPT, a natural language processing technology developed by OpenAI, has shown promise in various sectors, including healthcare. ChatGPT can facilitate patient information exchange in orthopedics, provide clinical decision support, and improve patient communication and education. It can assist in differential diagnosis, suggest appropriate imaging modalities, and optimize treatment plans based on evidence-based guidelines. However, ChatGPT has limitations, such as insufficient expertise in specialized domains and a lack of contextual understanding. The application of ChatGPT in orthopedics is still evolving, with studies exploring its potential in clinical decision-making, patient education, workflow optimization, and scientific literature. The results indicate both the benefits and limitations of ChatGPT, emphasizing the need for caution, ethical considerations, and human oversight. Addressing training data quality, biases, data privacy, and accountability challenges is crucial for responsible implementation. While ChatGPT has the potential to transform orthopedic healthcare, further research and development are necessary to ensure its reliability, accuracy, and ethical use in patient care.

Bone Marrow Stem Cells with Tissue-Engineered Scaffolds for Large Bone Segmental Defects: A Systematic Review

Critical-sized bone defects (CSBDs) represent a significant clinical challenge, stimulating researchers to seek new methods for successful bone reconstruction. The aim of this systematic review is to assess whether bone marrow stem cells (BMSCs) combined with tissue-engineered scaffolds have demonstrated improved bone regeneration in the treatment of CSBD in large preclinical animal models. A search of electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) focused on in vivo large animal studies identified 10 articles according to the following inclusion criteria: (1) in vivo large animal models with segmental bone defects; (2) treatment with tissue-engineered scaffolds combined with BMSCs; (3) the presence of a control group; and (4) a minimum of a histological analysis outcome. Animal research: reporting of in Vivo Experiments guidelines were used for quality assessment, and Systematic Review Center for Laboratory animal Experimentation's risk of bias tool was used to define internal validity. The results demonstrated that tissue-engineered scaffolds, either from autografts or allografts, when combined with BMSCs provide improved bone mineralization and bone formation, including a critical role in the remodeling phase of bone healing. BMSC-seeded scaffolds showed improved biomechanical properties and microarchitecture properties of the regenerated bone when compared with untreated and scaffold-alone groups. This review highlights the efficacy of tissue engineering strategies for the repair of extensive bone defects in preclinical large-animal models. In particular, the use of mesenchymal stem cells, combined with bioscaffolds, seems to be a successful method in comparison to cell-free scaffolds.

Analysis of Short-Term Clinical and Functional Outcomes in Patients Undergoing Total Knee Arthroplasty with Kinematic Alignment Technique

BACKGROUND

Surgery remains the best option for more advanced stages of knee osteoarthritis (OA). Kinematic alignment (KA) is an innovative surgical technique that aims to co-align the rotational axes of the femoral, tibial, and patella components with the three kinematic axes of the knee. This study aims to evaluate and analyze short-term clinical, psychological, and functional outcomes in patients undergoing total knee replacement with the KA technique.

METHODS

Twelve patients who underwent total knee replacement surgery with kinematic alignment from May 2022 until July 2022 were prospectively followed and interviewed. Before surgery, the day after surgery, and postoperative day 14, the following tests were evaluated: VAS, SF-12 PS, SF-12 MS, KSS, KSS-F, PHQ-9, and KOOS-PS.

RESULTS

The mean BMI value of 30.4 (±3.4) Kg/m², mean age of 71.8 (±7.2) years. All the scores on the various tests administered consistently showed statistically significant improvement, not only immediately after surgery but also comparing the first to the fourteenth postoperative day.

CONCLUSION

Kinematic alignment technique as a surgical treatment for KO allows the patient a fast postoperative recovery and good clinical, psychological, and functional results in a short time. Further studies are needed with a larger sample size, and prospective randomized studies are essential to compare these results with mechanical alignment.

Knee Osteoarthritis: Epidemiology, Pathogenesis, and Mesenchymal Stem Cells: What Else Is New? An Update

Osteoarthritis (OA) is a chronic disease and the most common orthopedic disorder. A vast majority of the social OA burden is related to hips and knees. The prevalence of knee OA varied across studies and such differences are reflected by the heterogeneity of data reported by studies conducted worldwide. A complete understanding of the pathogenetic mechanisms underlying this pathology is essential. The OA inflammatory process starts in the synovial membrane with the activation of the immune system, involving both humoral and cellular mediators. A crucial role in this process is played by the so-called “damage-associated molecular patterns” (DAMPs). Mesenchymal stem cells (MSCs) may be a promising option among all possible therapeutic options. However, many issues are still debated, such as the best cell source, their nature, and the right amount. Further studies are needed to clarify the remaining doubts. This review provides an overview of the most recent and relevant data on the molecular mechanism of cartilage damage in knee OA, including current therapeutic approaches in regenerative medicine.

Drop Jump Performance Improves One Year Following Anterior Cruciate Ligament Reconstruction in Sportsmen Irrespectively of Psychological Patient Reported Outcomes

Our study aims to prospectively report the functional outcomes of 31 sportsmen following anterior cruciate ligament (ACL) reconstruction, up to 12 months after surgery, with regards to subjective tests and drop jump performance, and to investigate the correlations between these variables, to be used for determining the return to sports after ACL reconstruction. Lysholm score, Tegner activity level, and the ACL-Return to Sport after Injury (ACL-RSI) scale were evaluated preoperatively, at 6 months, and at 12 months after surgery. Drop vertical jump was recorded using an infrared optical acquisition system. Lysholm and ACL-RSI scores significantly improved at the 12-month follow-up compared to the baseline and 6-month evaluations (p < 0.001). Concerning Tegner activity level, no statistically significant differences were reported between pre- and post-operative status (p = 0.179). Drop jump limb symmetry index significantly improved at 12 months, with the mean value improving from 76.6% (SD: 32,4) pre-operatively to 90.2% (SD: 14.7; p < 0.001) at follow-up. Scarce positive correlation was reported between the ability to perform drop jumps and activity level in athletes one year after ACL reconstruction. In addition, subjective knee score and psychological readiness were not related to jumping performance.

One-stage vs two-stage bilateral THA in Lombardy: a cost-effectiveness analysis

BACKGROUND

Total hip arthroplasty (THA) is the most common treatment for primary and secondary end-stage hip osteoarthritis (OA). Almost 20% of all patients undergoing primary THA suffer from bilateral hip OA and, consequently, will need a contralateral procedure to be performed in the following years. The aim of this study is to evaluate the cost-effectiveness and the reliability of one-stage bilateral THA (1-BTHA) compared to two-stage bilateral THA (2-BTHA), in low-risk patients, performed with anterior minimally invasive surgery (AMIS).

METHODS

Single patient's costs were obtained by dividing the annual costs report by the number of hospitalizations, considering the diagnosis related group (DRG) of the two procedures. Then, 16 patients undergoing 1-BTHA and 8 undergoing 2-BTHA were examined. Hemoglobin (Hb) values before surgery and before discharge, transfusion rate and the occurrence of post-operative complications were observed.

RESULTS

Procedural costs were divided in different subgroups: pre-hospitalization, operating room, hospital stay, post-operative follow-up and other costs. 1-BTHA total costs amount to 5.754,82€, while performing 2-BTHA costs 7.624,32€. However, considering DRG reimbursement, the hospital's profit margin following 1-BTHA is lower than that following 2-BTHA (6.346,18€ versus 9.261,68€). Surgical time was found not to be significantly different between 1-BTHA and 2-BTHA (141,13 ± 26,1 min vs 164,8 ± 44,3 min; p = 0,111). The two groups showed a statistically significant difference in Hb decrease (4,8 ± 1,3 g/dl vs 3,3 ± 0,9; p = 0,001), despite no variances in transfusion rate. No further complications were observed in either group.

CONCLUSIONS

This study demonstrates how, in carefully selected patients, 1-BTHA performed with AMIS is a cost-effective and safe technique compared to 2-BTHA, resulting in a shorter OR time, LOS and lower overall costs.

LEVEL OF EVIDENCE

III.

Relationships between Jumping Performance and Psychological Readiness to Return to Sport 6 Months Following Anterior Cruciate Ligament Reconstruction: A Cross-Sectional Study

Background: Investigating the relationship between functional capacity and psychological readiness is of paramount importance when planning sport resumption following knee surgery. The aim of this study was to prospectively assess clinical and functional outcomes in athletes 6 months after primary anterior cruciate ligament (ACL) reconstruction and to evaluate whether jumping ability is related to psychological readiness to return to sport following ACL surgery. Methods: Patients who underwent ACL reconstruction were prospectively enrolled and evaluated pre-operatively and 6 months after surgery. Assessment included Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level, and the ACL−Return to Sport after Injury (ACL-RSI) scale. Jumping ability was instrumentally assessed by an infrared optical acquisition system using a test battery including mono- and bipodalic vertical jump and a side hop test. Patients were dichotomized by ACL-RSI into two groups: group A (ACL-RSI > 60), and group B (ACL-RSI < 60). Results: Overall, 29 males and two females from the original study group of 37 patients (84%) were available for clinical evaluation. Mean age at surgery was 34.2 years (SD 11.3). Mean body mass index (BMI) was 25.4 (SD 3.7). Mean overall Lysholm, IKDC, and ACL-RSI scores increased from pre-operatively (p < 0.001). No differences in Tegner score were reported (p = 0.161). Similarly, improvement in most variables regarding jumping ability were observed at follow-up (p < 0.05). According to ACL-RSI, 20 subjects were allocated in group A (ACL-RSI > 60), while 11 were allocated in group B (ACL-RSI < 60). A statistically significant difference in favor of patients in group A was recorded for the post-operative Lysholm and Tegner score, as well as Side Hop test LSI level (p < 0.05), while a trend for IKDC was observed without statistical significance (p = 0.065). Conclusions: Patients with higher values of ACL-RSI scores showed better functional and clinical outcomes as well as improved performance 6 months after ACL reconstruction

Epidermal growth factor signalling pathway in endochondral ossification: an evidence-based narrative review

During endochondral bone development, a complex process that leads to the formation of the majority of skeletal elements, mesenchymal cells condense, differentiating into chondrocytes and producing the foetal growth plate. Chondrocytes progressively hypertrophy, induce angiogenesis and are then gradually replaced by bone. Epidermal Growth Factor (EGF), one of many growth factors, is the prototype of the EGF-ligand family, which comprises several proteins involved in cell proliferation, migration and survival. In bone, EGF pathway signalling finely tunes the first steps of chondrogenesis by maintaining mesenchymal cells in an undifferentiated stage, and by promoting hypertrophic cartilage replacement. Moreover, EGF signalling modulates bone homeostasis by stimulating osteoblast and osteoclast proliferation, and by regulating osteoblast differentiation under specific spatial and temporal conditions. This evidence-based narrative review describes the EGF pathway in bone metabolism and endochondral bone development. This comprehensive description may be useful in light of possible clinical applications in orthopaedic practice. A deeper knowledge of the role of EGF in bone may be useful in musculoskeletal conditions which may benefit from the modulation of this signalling pathway.Key messagesThe EGF pathway is involved in bone metabolism.EGF signalling is essential in the very early stages of limb development by maintaining cells in an undifferentiated stage.EGF pathway positively regulates chondrocyte proliferation, negatively modulates hypertrophy, and favours cartilage replacement by bone.EGF and EGF-like proteins finely tune the proliferation and differentiation of bone tissue cells, and they also regulate the initial phases of endochondral ossification.

Micro-fragmented adipose tissue (mFAT) associated with arthroscopic debridement provides functional improvement in knee osteoarthritis: a randomized controlled trial

PURPOSE

Current conservative treatments for knee OA provide limited benefits, with symptoms relief for a short amount of time. Regenerative medicine approaches such as the use of microfragmented adipose tissue (mFAT) showed promising results in terms of durable effects and the possibility to enhance tissue healing and counteract the progression of the pathology. Nevertheless, up to today, the large part of clinical data about mFAT use refers to uncontrolled studies, especially in the surgical setting. The purpose of this study was to evaluate the effectiveness of mFAT applied in association with arthroscopic debridement (AD) for the treatment of knee OA, in terms of symptoms relief and tissue healing.

METHODS

This study is a prospective, randomized controlled clinical trial. 78 patients affected by knee OA grade 3-4 according to KL classification were randomly assigned to AD or AD + mFAT treatment groups. Clinical, radiological and serological assessments were performed at 6 months after treatment. Additional clinical evaluation was performed at the end of the study with an average follow-up of 26.1 ± 9.5 months. VAS, KOOS, WOMAC and SF-12 were also collected at both timepoints, KSS only at 6 months.

RESULTS

Treatment with AD + mFAT improved functional scores at both 6 months (KOOS-PS: + 11.7 ± 20.2 vs + 24.4 ± 22.5, in AD and AD + mFAT, respectively, p = 0.024; KSS: + 14.9 ± 15.9 vs + 24.8 ± 23.5, in AD and AD + mFAT, respectively, p = 0.046) and 24-month follow-ups (KOOS-PS Functional subscale: - 2.0 ± 3.5 vs - 4.7 ± 4.2, in AD and AD + mFAT, respectively, p = 0.012). Lower T2-mapping scores were obtained in AD + mFAT-treated group in medial and lateral condyle compartments (p < 0.001). Slight increase was observed in the levels of a serum biomarker of cartilage deposition (PIIINP) in both groups at 6-month follow-up (p = 0.037).

CONCLUSION

mFAT improves functional outcome and MRI appearance when used in association with AD, therefore supporting its use in the treatment of knee OA in an arthroscopic setting.

Human Osteochondral Explants as an Ex Vivo Model of Osteoarthritis for the Assessment of a Novel Class of Orthobiologics

Osteoarthritis (OA) is a highly prevalent joint disease still lacking effective treatments. Its multifactorial etiology hampers the development of relevant preclinical models to evaluate innovative therapeutic solutions. In the last decade, the potential of Mesenchymal Stem Cell (MSC) secretome, or conditioned medium (CM), has emerged as an alternative to cell therapy. Here, we investigated the effects of the CM from adipose MSCs (ASCs), accounting for both soluble factors and extracellular vesicles, on human osteochondral explants. Biopsies, isolated from total knee replacement surgery, were cultured without additional treatment or with the CM from 10⁶ ASCs, both in the absence and in the presence of 10 ng/mL TNFα. Tissue viability and several OA-related hallmarks were monitored at 1, 3 and 6 days. Specimen viability was maintained over culture. After 3 days, TNFα induced the enhancement of matrix metalloproteinase activity and glycosaminoglycan release, both efficiently counteracted by CM. The screening of inflammatory lipids, proteases and cytokines outlined interesting modulations, driving the attention to new players in the OA process. Here, we confirmed the promising beneficial action of ASC secretome in the OA context and profiled several bioactive factors involved in its progression, in the perspective of accelerating an answer to its unmet clinical needs.

Italian Translation, Adaptation, and Validation of the Novel Satisfaction Measure Assessment after Primary Total Joint Arthroplasty: The Goodman Score Questionnaire

Patient satisfaction after total joint arthroplasties (TJA) represents a key element for the evaluation of surgery success in relation to subjects' needs and expectations. The assessment tools are applied inconsistently throughout the literature, and thus, it is difficult to compare results among different studies. Goodman et al. proposed a standardized questionnaire with strong psychometric properties for the assessment of satisfaction. The present study aims to translate, adapt, and validate the Goodman questionnaire for the Italian population. After translation and back translation, the questionnaire was administrated to 50 patients. Internal consistency, test-retest reliability, floor and ceiling effects, and construct validity were evaluated (correlation with KOOS/HOOS, SF-12 PCS/MCS, EQ-5D). Responsiveness was evaluated with respect to SF-12 PCS improvements. The Italian version of the Goodman score questionnaire demonstrated psychometric properties similar to those of the original version. The translated questionnaire showed good internal consistency (Cronbach's alpha = 0.836) and test-retest reliability (ICC: 0.507). Moderate/strong correlations were observed between the Italian version of the Goodman score and other scores. The score significantly discriminated patients who improved from those who did not improve in SF-12 PCS after treatment. This study provides an adapted and validated Italian version of the Goodman score questionnaire, with psychometric properties similar to those of its original counterpart.

Role of the prophylactic fixation of contralateral unaffected hip in paediatric unilateral slipped capital femoral epiphysis: a systematic review

The aim of this systematic review is to assess the role of the prophylactic fixation of contralateral unaffected hip in unilateral slipped capital femoral epiphysis (SCFE) in children, focusing on the possible complications of this surgical procedure.

A systematic review of medical literature was conducted, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement, to analyse the complications of prophylactic contralateral hip fixation in unilateral paediatric SCFE. We registered the complications reported in the included studies, scoring their severity according to the orthopaedic adaptation of Clavien–Dindo classification.

From 1695 studies primarily identified, 14 studies were finally included: 1 prospective cohort study, 4 retrospective case-control studies and 9 retrospective case series, with a total of 811 children diagnosed with unilateral SCFE and treated on the unaffected contralateral hip. Grade IV complications were very rare (0.37%), while the rate of grade III events was 8%. No death was recorded. The most frequent complication was unplanned further surgery (6.29%) that was an epiphyseal refixation, owing to the physiologic growth of the proximal femur, in 42 cases. Cannulated screws fixation showed to have a lower major complication rate than pinning with K-wires, 5.37% vs 17.95%.

The prophylactic fixation of contralateral unaffected hip in paediatric unilateral SCFE is a safe procedure. Although a benefit-cost analysis on this topic has not been published yet, considering the low rate of complications, prophylactic hip fixation is a viable option for patients presenting with unilateral SCFE, to prevent the occurrence of severe hip deformity and avoid future invasive surgeries.

Scaffolds for Knee Chondral and Osteochondral Defects: Indications for Different Clinical Scenarios. A Consensus Statement

OBJECTIVE

To develop patient-focused consensus guidelines on the indications for the use of scaffolds to address chondral and osteochondral femoral condyle lesions.

DESIGN

The RAND/UCLA Appropriateness Method (RAM) was used to develop patient-specific recommendations by combining the best available scientific evidence with the collective judgement of a panel of experts guided by a core panel and multidisciplinary discussers. A list of specific clinical scenarios was produced regarding adult patients with symptomatic lesions without instability, malalignment, or meniscal deficiency. Each scenario underwent discussion and a 2-round vote on a 9-point Likert-type scale (range 1-3 "inappropriate," 4-6 "uncertain," 7-9 "appropriate"). Scores were pooled to generate expert recommendations.

RESULTS

Scaffold (chondral vs. osteochondral), patient characteristics (age and sport activity level), and lesion characteristics (etiology, size, and the presence of osteoarthritis [OA]) were considered to define 144 scenarios. The use of scaffold-based procedures was considered appropriate in all cases of chondral or osteochondral lesions when joints are not affected by OA, while OA joints presented more controversial results. The analysis of the evaluated factors showed a different weight in influencing treatment appropriateness: the presence of OA influenced 58.3% of the indications, while etiology, size, and age were discriminating factors in 54.2%, 29.2%, and 16.7% of recommendations, respectively.

CONCLUSIONS

The consensus identified indications still requiring investigation, but also the convergence of the experts in several scenarios defined appropriate or inappropriate, which could support decision making in the daily clinical practice, guiding the use of scaffold-based procedures for the treatment of chondral and osteochondral knee defects.

Direct superior approach versus posterolateral approach in total hip arthroplasty: a randomized controlled trial on early outcomes on gait, risk of fall, clinical and self-reported measurements

Background and purpose - Several surgical approaches are used in primary total hip arthroplasty (THA). In this randomized controlled trial we compared gait, risk of fall, self-reported and clinical measurements between subjects after direct superior approach (DSA) versus posterolateral approach (PL) for THA.Patients and methods - Participants with DSA (n = 22; age 74 [SD 8.9]) and PL (n = 23; age 72 [7.7]) underwent gait analysis, risk of fall assessment and Timed Up and Go Test (TUG) before (PRE), 1 month (T1) and 3 months after (T3) surgery. Data on bleeding and surgical time was collected.Results - DSA resulted in longer surgical times (90 [14] vs. 77 [20] min) but lower blood loss (149 [66] vs. 225 [125] mL) than PL. DSA had lower risk of fall at T3 compared with T1 and higher TUG scores at T3 compared with T1 and PRE. PL improved balance at T3 compared with T1 and PRE. Spatiotemporal gait parameters improved over time for both DSA and PL with no inter-group differences, whereas DSA, regarding hip rotation range of motion, showed lower values at T3 and T1 compared with PRE and, furthermore, this group had lower values at T1 and T3 compared with PL. All foregoing comparisons are statistically signficant (p < 0.05)Interpretation - DSA showed longer surgical time and lower blood loss compared with PL and early improvements in TUG, spatiotemporal, and kinematic gait parameters, highlighting rapid muscle strength recovery.

The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery

BACKGROUND

Recent years have seen a resurgence of interest about lateral extra-articular procedures performed in association with anterior cruciate ligament (ACL) surgery, as they can reduce the positivity to pivot shift test by acting on rotational instability. The purpose of the present study is to compare the postoperative functional outcomes of ACL revision surgery using contralateral hamstring tendon autografts with or without extra-articular tenodesis.

HYPOTHESIS

The hypothesis is that combined extra-articular tenodesis gives better rotational stability following revision ACL surgery.

PATIENTS AND METHODS

Twenty-four patients who underwent ACL revision surgery were retrospectively reviewed at an average follow-up of 4.5 years; 12 underwent contralateral hamstring tendon autografts reconstruction (group A) while in 12 extra-articular tenodesis was associated (group B). Assessment included Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level and objective evaluation (range of motion, Lachman test, pivot-shift test and KT-1000 instrumented laxity testing).

RESULTS

Follow-up examination showed that there were no statistically significant differences in Lysholm, IKDC and Tegner scores between the groups (p=n.s.). Similarly, no differences concerning anterior tibial translation as measured with KT-1000 arthrometer were reported between the groups (p=n.s.); the percentage of positivity to pivot shift test was significantly higher in patients in group A (p<0.05).

CONCLUSIONS

The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL revision surgery alone.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament reconstruction combined to partial knee replacement in active patients with ACL deficiency and knee osteoarthritis

OBJECTIVES

To report, through a systematic review of the literature, the clinical and radiographic outcomes of unicompartmental knee replacement (UKR) combined to anterior cruciate ligament (ACL) reconstruction. It was hypothesized that this combined technique is a safe and effective procedure providing satisfactory post-operative functional outcomes.

METHODS

A systematic review was performed by searching Pubmed/MEDLINE, CINAHL, SCOPUS, Embase, and Ovid. Only studies in English pertaining all levels of evidence reporting on subjects with medial osteoarthritis and ACL deficiency undergoing UKR combined to ACL reconstruction were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications, clinical assessment including activity level, associated procedures, rate of complications such as revision surgery.

RESULTS

Overall, nine studies met all the inclusion criteria for this review. All were published between 2006 and 2019. The search resulted in one comparative case series (Level III), four prospective cohort studies (Level III) and four case series (Level IV). From these studies, 249 patients were identified.

CONCLUSIONS

The combination of UKR and ACL reconstruction appears a safe and effective procedure providing satisfying outcomes and limited complications in selected patients with medial OA and ACL insufficiency. Further comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are lacking.

Medium-term outcomes of total hip arthroplasty in juvenile patients

BACKGROUND

Juvenile hip osteoarthritis is often the end result of congenital conditions or acquired hip ailments occurred during the paediatric age. This study evaluated the middle term results of total hip arthroplasty for end-stage juvenile hip osteoarthritis.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data on a cohort of 10 consecutive patients (12 hips), aged between 14 and 20 at operation, who underwent cementless total hip arthroplasty for end-stage juvenile secondary hip osteoarthritis in two orthopaedic tertiary referral centres between 2009 and 2018.

RESULTS

Juvenile hip osteoarthritis occurred as a consequence of developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis. All patients showed a significant improvement in Harris Hip Score (p < 0.01) at 3.3 years average follow-up (range 0.7-10.1 years).

CONCLUSION

The management of juvenile hip osteoarthritis following developmental dysplasia of the hip, Legg-Calvé-Perthes disease, femoral head necrosis or slipped capital femoral epiphysis is still challenging. Careful preoperative planning is essential to achieve good outcomes and improve the Harris Hip Score in these young patients. Total hip arthroplasty is a suitable option for end-stage secondary juvenile hip osteoarthritis, when proximal femoral osteotomies and conservative treatments fail to improve patients' symptoms and quality of life.

LEVEL OF EVIDENCE

IV.

From Standard to Escalated Anticoagulant Prophylaxis in Fractured Older Adults With SARS-CoV-2 Undergoing Accelerated Orthopedic Surgery

Proximal femoral fractures in older adults are not uncommon and represent a great challenge for orthopedic surgeons because of the high risks of complications. In the COVID-19 panorama, fractures occurring in infected older adults become an even more intricate task because of concomitant metabolic derangements due to SARS-CoV-2. Multidisciplinary protocols are mandatory and pharmacological treatment in infected patients should be tailored. Regrettably, the spread of the virus in northern Italy, has been faster than scientific progress in characterizing the disease and many hospitals have had to manage the symptoms on a daily clinical bases. Our Italian hospital in the region of Lombardy, which has been the epicenter of the Italian pandemic, has admitted sixteen patients with fractured femurs in March and April 2020. The first seven patients were treated with the antithrombotic prophylaxis of a single daily dose of low-molecular-weight heparin, but we observed the highest prevalence of deaths from cardiovascular complications (four deaths). By doubling the daily dose of anticoagulants in the subsequent patients, we observed a reduction in the incidence of death (one death out of nine). Controversies exist about the surgical treatment of fractures in older adults during this pandemic. However, we have observed an increased survival after fall trauma in infected older adults if treated with high doses of anticoagulant. Although not being statistically significant, our results are in line with the current knowledge of the pathophysiology of SARS-CoV-2 infection, but more studies should be shared about the efficacy and dosage of anticoagulants in traumatic injuries of the elderly.

Orthotopic Bone Formation by Streamlined Engineering and Devitalization of Human Hypertrophic Cartilage

Most bones of the human body form and heal through endochondral ossification, whereby hypertrophic cartilage (HyC) is formed and subsequently remodeled into bone. We previously demonstrated that HyC can be engineered from human mesenchymal stromal cells (hMSC), and subsequently devitalized by apoptosis induction. The resulting extracellular matrix (ECM) tissue retained osteoinductive properties, leading to ectopic bone formation. In this study, we aimed at engineering and devitalizing upscaled quantities of HyC ECM within a perfusion bioreactor, followed by in vivo assessment in an orthotopic bone repair model. We hypothesized that the devitalized HyC ECM would outperform a clinical product currently used for bone reconstructive surgery. Human MSC were genetically engineered with a gene cassette enabling apoptosis induction upon addition of an adjuvant. Engineered hMSC were seeded, differentiated, and devitalized within a perfusion bioreactor. The resulting HyC ECM was subsequently implanted in a 10-mm rabbit calvarial defect model, with processed human bone (Maxgraft^®) as control. Human MSC cultured in the perfusion bioreactor generated a homogenous HyC ECM and were efficiently induced towards apoptosis. Following six weeks of in vivo implantation, microcomputed tomography and histological analyses of the defects revealed an increased bone formation in the defects filled with HyC ECM as compared to Maxgraft^®. This work demonstrates the suitability of engineered devitalized HyC ECM as a bone substitute material, with a performance superior to a state-of-the-art commercial graft. Streamlined generation of the devitalized tissue transplant within a perfusion bioreactor is relevant towards standardized and automated manufacturing of a clinical product.

Functional and radiological outcome of anterior retroperitoneal versus posterior transforaminal interbody fusion in the management of single-level lumbar degenerative disease

OBJECTIVE

In this study the authors compared the anterior lumbar interbody fusion (ALIF) and posterior transforaminal lumbar interbody fusion (TLIF) techniques in a homogeneous group of patients affected by single-level L5–S1 degenerative disc disease (DDD) and postdiscectomy syndrome (PDS). The purpose of the study was to analyze perioperative, functional, and radiological data between the two techniques.

METHODS

A retrospective analysis of patient data was performed between 2015 and 2018. Patients were clustered into two homogeneous groups (group 1 = ALIF, group 2 = TLIF) according to surgical procedure. A statistical analysis of clinical perioperative and radiological findings was performed to compare the two groups. A senior musculoskeletal radiologist retrospectively revised all radiological images.

RESULTS

Seventy-two patients were comparable in terms of demographic features and surgical diagnosis and included in the study, involving 32 (44.4%) male and 40 (55.6%) female patients with an average age of 47.7 years. The mean follow-up duration was 49.7 months. Thirty-six patients (50%) were clustered in group 1, including 31 (86%) with DDD and 5 (14%) with PDS. Thirty-six patients (50%) were clustered in group 2, including 28 (78%) with DDD and 8 (22%) with PDS. A significant reduction in surgical time (107.4 vs 181.1 minutes) and blood loss (188.9 vs 387.1 ml) in group 1 (p < 0.0001) was observed. No significant differences in complications and reoperation rates between the two groups (p = 0.561) was observed. A significant improvement in functional outcome was observed in both groups (p < 0.001), but no significant difference between the two groups was found at the last follow-up. In group 1, a faster median time of return to work (2.4 vs 3.2 months) was recorded. A significant improvement in L5–S1 postoperative lordosis restoration was registered in the ALIF group (9.0 vs 5.0, p = 0.023).

CONCLUSIONS

According to these results, interbody fusion is effective in the surgical management of discogenic pain. Even if clinical benefits were achieved earlier in the ALIF group (better scores and faster return to work), both procedures improved functional outcomes at last follow-up. The ALIF group showed significant reduction of blood loss, shorter surgical time, and better segmental lordosis restoration when compared to the TLIF group. No significant differences in postoperative complications were observed between the groups. Based on these results, the ALIF technique enhances radiological outcome improvement in spinopelvic parameters when compared to TLIF in the management of adult patients with L5–S1 DDD.

Tips and tricks for writing a scientific manuscript

An original scientific manuscript is the target for any researchers whose aim is to show the innovative results arising from the original intuitions that drove all their experiments. Time and patience are essential to decide how to present the data, how to conceive the tables and figures representing the main outcomes of the research, and how to read and mention the necessary references. Few basic rules may help in this difficult task. The first basic rule is: "do not follow the sequence of the paper". On the opposite, i) start writing the "Materials and Methods (or Patients and Methods when dealing with a clinical study)", ii) then write the "Results" section, iii) then, write the "Discussion" paragraph, in which the principal investigator explains the results and the innovations proposed, iv) then, write the "Introduction", which should be clear and concise. The last element to be written should be the "Abstract", which is the "interface" between the authors and the readers. The second basic rule is that any of the central chapters of the manuscript, i.e. "Materials and Methods" (MM), "Results" (R) and "Discussion" (D), should follow a methodical and sequential description of the topics in a "corresponding sequence of paragraphs". In other words, in the R and the D chapter sequence of the paragraphs should be linked to the sequence of the concepts described and discussed in the paragraphs of the MM chapter. Thus, a sequential description of concepts will be easily followed by the writers, facilitating both the authors in the organization of the data and the reader in finding a reasonable "answer" to all the aspects of the study mentioned in the MM chapter. In this article, these two rules are extensively described and several tips and tricks for each chapter are suggested to ease the composition of a scientific paper. Indeed, it may be possible to solve the complex problem of "writing a scientific paper" by means of separating it in main sections (chapters) and subsections (paragraphs) and dealing with them one by one. Naturally, this takes time and passion, but, as affirmed by Steve Jobs, "the only way to do great work is to love what you do".

Inter-rater reliability of classification systems of scapular dyskinesis

Prevalence of scapular dyskinesis varies across records, with overhead athletes being more frequently affected than non-overhead athletes A number of methods have been described to evaluate scapular kinematics and scapular dyskinesis. The "yes/no" and the "4-type" classification systems are widely accepted and diffusely used among orthopaedics and physical therapists. The inter-rater reliability for both the "yes/no" and the "4-type" classification systems may be different. Moreover, differences between physical therapists and orthopaedic surgeons may exist. Seven examiners (2 orthopaedic surgeons and 5 physical therapists) were asked to evaluate a mixed sequence of video recordings of healthy subjects and patients affected by shoulder, scapular or clavicular disorders and to assess scapular dyskinesis using the "yes/no" and the "4-type" classification systems. Cohen's kappa coefficient (κ) and weighted kappa were used to measure inter-rater reliability. Twenty-four subjects were enrolled. In general, the "4- type" system has higher κ values than ''yes/no'' classification system and orthopaedic surgeons achieve higher reliability than physical therapists for both systems. The clinical evaluation of active shoulder movements permits reproducible assessment and classification of scapular dyskinesis, in particular for the "4-type" classification system. The "4-type" classification system can be used to assess and classify scapular dyskinesis, especially among orthopaedic surgeons.

Periprosthetic osteolysis: a narrative review

Periprosthetic osteolysis is still one of the major limitations of prosthetic joints longevity. The process of this "silent" iatrogenic disease involves both mechanical and biological factors that initiate a local immune response in the periprosthetic tissue that eventually lead to implant loosening and failure. There are many causes of the primary aseptic loosening inside the periprosthetic microenvironment, but the most important elements are the wear debris and the cell-particle interactions. Together with implant position, micromotion, bearings, joint fluid pressure, and increased load on the joints drive the pathogenesis of the disease. This narrative review aims to summarise recent studies describing the biological and mechanical factors in the pathogenesis of osteolysis and some of the current pharmacological attempts to "rescue" a failing implant.

Kinematic versus mechanical alignment in total knee arthroplasty: a preliminary study

Despite the great advances of the technology in the joint prosthesis and the high execution rate of total knee arthroplasty (TKA), there are still about 15% of clinical unsatisfactory rate in this surgery. TKAs are currently performed using a mechanical alignment of the knee, correcting varus/valgus deformities with the purpose to achieve a longer implant survivorship, but this surgical technique results in an alteration of the normal knee kinematics. Nowadays, the idea to restore the pre-arthritic alignment of the knee with the goal to obtain a normal kinematics and better functional results becomes more and more consistent and the kinematic alignment (KA) was developed as alternative to the mechanical one. The aim of this preliminary study is to analyse the functional outcomes in patients who underwent KA-TKA in the short-term follow-up and to compare them with those obtained in patients treated by the mechanical alignment (MA) TKA. Therefore, skeletally mature patients, with no history of previous knee surgical procedures, who underwent isolated TKA for knee osteoarthritis, were included in this study. The patients were prospectively divided into two homogeneous groups according to the different surgical techniques performed (KA-TKA and MA-TKA groups). Clinical and functional scores (VAS, KOOS-PS, MCS-12, Final KSS, and Functional KSS) were collected pre- and postoperatively at a mean follow-up of 3 three months. As a result, 26 patients were included in the study, with a mean age of 69.3±7.61 years old (range: 55 - 84 years old). There were 38.5% male and 61.5% female. There were 13 patients in KA-TKA and 13 patients in MA-TKA. Three months after surgery each of the scores tested demonstrated statistically significant better outcomes in KA-TKA, compared to the MA-TKA group. MCS-12 resulted comparable in the two study groups. This preliminary study compares the short-term clinical and functional outcomes between KA and MA in total knee replacement. Further studies are required to confirm these results and to extend the sample size to obtain reliable clinical evidences.

When math meets surgery: how to improve femoral interference screw alignment in ACL reconstruction. A cadaveric study

Transtibial femoral tunnel drilling is still an alternative technique in ACL reconstruction. Femoral interference screw divergence is a potential pitfall associated with transtibial tunnel technique, as angles greater than 15° jeopardize graft fixation. Our mathematical model theorizes the proper degrees of knee flexion during femoral screw insertion and the correct screwdriver position to obtain a minimal divergence of the screw in the femoral tunnel. The cadaveric study confirms our method. Mathematical model: using rototranslation matrices, a correlation is demonstrated between the ACLtibial- guide angle, the knee flexion, and the screwdriver position. A theoretical minimal divergence between femoral interference screw and the femoral tunnel is obtainable following these assumptions: 1) knee hyperflexion during femoral screw insertion is obtained adding a flexion corresponding to the ACL-tibial-guide angle to the flexion while drilling the femoral tunnel; 2) screwdriver position (through the AM portal) is kept parallel to tibial plateau at a rotation of 15° medial to tibial sagittal plane. Cadaveric study: 24 cadaver knees were used. The transtibial tunnel was drilled with an 8 mm drill bit with the help of an ACL tibial guide set at 55°. To simulate femoral tunnel direction, a 2.4 mm K. wire was drilled through the femur with a transtibial 7 mm offset femoral drill guide. To simulate the femoral screw direction, a second 2.4 mm K. wire was drilled from the femoral entry point of the first wire through the femur, with a cannulated screwdriver. Screwdriver direction and knee flexion during the simulation were obtained following two different methods: GROUP A (mathematical model group, 12 knees), screwdriver direction and knee flexion were calculated following the mathematical model; in GROUP B (control group, 12 knees), knee hyperflexion and screwdriver medialization were manually obtained by a senior surgeon. The divergence between the femoral interference screw and the femoral tunnel was identified as the angle formed by the two wires, measured on the plane formed by the direction of the wires. Mean divergence angles between the K. wires were significantly different (p< 0.05) between the groups: GROUP 1 (mathematical rule): 7.25° (SD 2.2); GROUP 2 (free-hand technique): 17.3° (SD 2.9). Our study shows that a minimal divergence between the femoral tunnel and the screwdriver can be achieved simply by following a mathematical rule for correct intraoperative knee flexion and screwdriver position without the need for any specialized instrumentation. Namely, during femoral interference screw insertion through the anteromedial portal: 1) the correct knee flexion is the sum between the knee flexion angle while drilling the transtibial femoral tunnel AND the ACL tibial guide angle used during tibial tunnel drilling; 2) Correct screwdriver position is parallel to the tibial plateau, engaging the femoral tunnel with a position of 15° medial to tibial sagittal plane. This simple concept has clinical relevance in helping the surgeons in obtaining an optimal alignment between the femoral tunnel and the femoral interference screw during transtibial ACL reconstruction. Furthermore, following the assumptions of this study, a starting knee flexion angle around 70° during femoral tunnel drilling seems preferable for ACL reconstruction when the transtibial tunnel technique is used. Indeed, because ACL-tibial-guide angles range commonly from 50° to 60° and in vivo, the maximal intraoperative knee flexion attainable is 130°, a starting knee flexion around 70° is optimal to allows for adding flexion angles up to 60° before reaching the physiological limit value of 130°.

Combined circular external fixation and flexible intramedullary nailing for pediatric bilateral open tibia fractures in blast injury

Management of blast injuries with open fractures and extensive soft tissue damage in pediatric patients is a challenging task even in experienced hands. This article reports the case of an 8-year-old boy with bilateral open tibia fractures and soft tissue loss due to the accidental explosion of a skyrocket. After the emergency procedures with lavage, debridement and temporary bone stabilization, we performed the definitive reconstruction surgery using a combined circular external fixation and flexible intramedullary nailing technique on both legs. This technique allowed easy access to the wounds for plastic surgery procedures and early bilateral weight bearing. All implants were removed within 6 months, the fractures healed with good axial alignment and the patient returned to his preinjury activities one year after the trauma. In this case, the combined use of circular external fixation and flexible intramedullary nailing ensured optimal fractures stabilization, minimizing the damage to the soft tissues and the obstruction for plastic surgeons. We believe that this technique should be considered in pediatric patients with open fractures of the lower limbs and extensive soft tissue injuries.

Management of gunshot wound to the lumbosacral spine in a 17-year-old girl without neurological impairment

We report the case of a young girl (17-year-old) wounded by an accidental gunshot. The bullet entered through the skin midline over the navel area, passed through the stomach perforating the vena cava and, by breaking the right pedicle of L4, moved inside the vertebral canal (bridging the cauda equina) stopping just in front of the body of S2. Because of the sudden onset of acute abdomen due to a massive retroperitoneal hematoma, the patient underwent emergency explorative laparotomy with the evacuation of the hematoma and the suture of the perforated cava vein, the peritoneum, and the stomach. No neurological deficits were observed after the gunshot. Two weeks later, the patient underwent spinal surgery to remove the bullet from the spinal canal, which was performed successfully without any instrumentation and with no onset of new neurological signs and symptoms or surgery-related complications. Patient was discharged on day 9 after surgery in good general conditions.

Clinical anatomy of the meniscus in animal models: pros and cons

Nowadays, despite the possibility to use in vitro or computer models in research, animal models are still essential. Different animal models are available for meniscal repair investigation. Although a unique perfect model for the structure of the human's knee does not exist, the choice of the proper animal model is crucial for a correct research. The principal animal models in the meniscal repair are sheep, goats, pigs and dogs. Each of these has pros and cons for their utilization. Analysing each pro and con is essential for optimizing the choice of the animal model, which depends on the experimental question, avoiding unnecessary waste of resources and minimizing the animal suffering, according to the Russell and Burch's three "Rs" principles (Reduce, Refine and Recycle). In this concise review, we resume the meniscus anatomical features of the main large animals, to help choose the most suitable animal model for subsequent studies on meniscal repair.

Bilateral osteochondritis dissecans of the patella in an adolescent skier with patellofemoral maltracking treated with pulsed electromagnetic field therapy

Juvenile osteochondritis dissecans of the knee typically occurs in young athletes, and usually localizes on the medial femoral condyle. Bilateral localization is uncommon. Patellofemoral involvement is rare, mainly found in basketball and soccer players, and never related to patellofemoral congenital problems such as trochlear dysplasia. We report here the first case, to our knowledge, of bilateral juvenile osteochondritis dissecans with patellar localization in a young skier with patellofemoral maltracking and trochlear dysplasia.

Total hip arthroplasty for osteonecrosis of the femoral head in sickle cell disease: a case series from our African experience

Sickle cell disease causes osteonecrosis (20% to 50% of patients) and collapse of the femoral head that result in secondary osteoarthritis. Total hip arthroplasty (THA) is a valid alternative for these patients. We define the difficulties that can be encountered when undertaking THA in sickle cell disease patients and give advice on how to deal with these technically demanding procedures. We undertook total hip arthroplasty procedures on 12 patients (4 females and 8 males) with osteonecrosis of the femoral head. Two bilateral prostheses were performed. We had only one type of stem, only one type of acetabular cup and only 28 mm cobalt chrome heads. The procedures were performed through either an anterior or a direct lateral approach. The average size of the Cup was 46 (Versafit, Medacta), the average size of the femoral stem was 0 (Amistem, Medacta), the most used size of the modular head was a S. Standard stem that was used in nine patients, while three patients received a lateralizing stem. Three patients had periprosthetic fracture, treated by cerclage. Total hip replacement is an excellent alternative for patients with osteonecrosis from sickle cell disease. The preparation of the acetabulum and the femur is difficult and requires attention, time and appropriate equipment.

Posterior dynamic neutralization and hybrid stabilization in degenerative spine diseases: long-term clinical and radiological outcomes

Dynamic spinal stabilization aims to reduce some of the problems inherent with traditional fusion. The aim of our study is to analyse clinical and radiological outcomes and to identify the causes of clinical failure in patients who underwent posterior dynamic neutralization or posterior hybrid stabilization because of degenerative lumbar spine diseases. We retrospectively analysed 80 patients at 7.1 years mean follow-up (Range: 5.1 - 8.3 years): 50 were treated with Dynamic Stabilization System (Dynesys) (mean age 47 years old) and 30 with Dynamic Transition Option (mean age 48 years old). We performed clinical pre-and post-operative evaluation using Visual Analogue Scale (VAS), Oswestry Low Back Pain Scale (ODI) and X-rays study. Results: we reported an important reduction of VAS from 7 to 2 (p<.001) and minimal disability in 65% of the patients, moderate disability in 18.2%, severe disability in 12.5% and crippling back pain in 4.3%. X-ray analysis showed a significative decrease of 3.5° with respect to the preoperative values, exactly 2° in neutral position postop, 1.2° in flexion postop and 2.5° in extension postop. Data showed greater reduction of extension than flexion in postoperative period. Dynamic neutralization limits more the extension than flexion. The correct preoperative planning, the careful selection of patients and the meticulous surgical technique are mandatory to avoid clinical failures. It is very important to identify the correct screw positioning and to avoid excessive pre-tensioning of the implant. Posterior dynamic neutralization and hybrid stabilization are valid alternative to spinal fusion in degenerative spine disease.

Modifications of spinopelvic parameters and acetabular orientation after spinal surgery for adult deformity in patient who underwent bilateral total hip arthroplasty

The spine and the hip are two anatomical districts that have close biomechanical relationship. The management of their degenerative disorders involves an in-depth biomechanical analysis of the patient, in order to define the proper hip-spine relation, using different biomechanical classifications that have been proposed in recent years. The changes in the spino-pelvic and acetabular parameters induced by prosthetic hip surgery and spinal surgery must be carefully evaluated, calculated and foreseen in the pre-operative phase, as they play a crucial role in defining the clinical success or failure of the operations. In this paper we present a case of a patient who underwent spinal surgery after a bilateral THA analyzing both spino-pelvic parameters and acetabular orientation and highlighting the strict relations between spine and hip.

Two-stage total hip arthroplasty for septic arthritis through the minimally invasive direct anterior approach

The use of minimally invasive direct anterior approach to perform total hip arthroplasty is gaining increasing popularity for its short-term advantages, compared to other approaches. Nevertheless, its use in hip revision surgery has been criticized. We report here the first case of hip septic arthritis treated with two-stage THA through this tissue-sparing approach, with good implant positioning and functional results.

Hamstring grafts are tenogenic constructs for ACL reconstruction and Pulsed Electromagnetic Fields improve tendon specific markers expression. An in-vitro study

Hamstring tendons represent one of the commonest autologous graft used during ACL reconstruction. The harvest of the tendon and the time of tendon processing on the operating table, together with the pretensioning maneuvers and the permanence out of the joint during the time of surgery, might impair tendon derived cells (TCs) viability. The aim of the study was: i) to assess the effective viability of the TCs at the end of the surgical procedure; ii) to investigate if TCs viability and the expression of tendon specific markers may be improved through exposure to prolonged pulsed electromagnetic fields (PEMF) similar to that of clinical practice. Remnants of semitendinosus and gracilis tendons (discarded at the end of the ACL reconstruction) were collected from 13 healthy donors. To isolate TCs, the tendon tissue was minced and digested enzymatically with 0.3% type I collagenase in DMEM with continuous agitation for 15 h at 37°C. The isolated nucleated cells were then plated at 5x103 cells/cm2 in a complete medium composed of DMEM, 10% fetal bovine serum, 50 U/ml Penicillin, 50 mg/ml Streptomycin, 2 mM L-glutamine, and supplemented with 5 ng/ml basic fibroblast growth factor (b-FGF). They were maintained at 37 °C in a humidified atmosphere with 5% CO2, changing culture medium every 3 days. When they reached 80-90% of confluence, the cells were detached by incubation with trypsin/EDTA and then cultured at a density of 5x103 cells/cm2. TCs were cultured in complete medium for 7, 14, 21 days (in chamber slides, to optimize the final immunofluorescence analysis). The following cell cultures were set up: i) TCs cultured with differentiation medium + exposure to PEMF 8 h/day; ii) TCs cultured with differentiation medium without exposure to PEMF. The stimulation with PEMF was generated by a pair of electrical coils, connected with the generator of pulsed electromagnetic fields (PEMF generator system IGEA, Carpi, Italy, intensity of magnetic field = 1.5 mT, frequency = 75 Hz). At day 0, day 7, day 14 and day 21 immunofluorescence analysis was performed to evaluate the expression of tendon specific markers (collagen type I, collagen type VI, scleraxis) and proliferative markers (PCNA, beta-catenin). The TCs from the hamstring tendon fragments at the end of the ACL reconstruction were alive and they expressed markers of proliferation and tendon phenotype at the end of the culture period. The TCs in the presence of PEMF 8h/day showed a greater production of collagen type I, collagen type VI and scleraxis than TCs cultured without PEMF (p<0.05). The expression of these markers increased from 7 to 21 days of culture. The expression of proliferative markers in the presence of PEMF stimulus was significantly lower (p<0.05) than that of TCs cultured without PEMF. Hamstring tendons are not simple "tenoconductive" scaffolds but biologic alive tenogenic constructs rich in cells that can sustain tenogenic behavior and tendon matrix synthesis. Prolonged exposure to PEMF improves their phenotype. Thus, from a clinical perspective, the use of PEMF may represent a possible future strategy to positively influence the early phase of graft remodeling and, ultimately, improve the ligamentization process. Following these concepts, further studies might also exploit the anabolic role of PEMF as an adjunctive postoperative strategy in different tendon pathologies.

Periprosthetic joint infection from Mycobacterium Tuberculosis in Togo, Africa

Mycobacterium Tuberculosis infections are moderately frequent in developing countries. Because of migratory flows, these diseases will always have an increasing prevalence even in those countries that do not usually present these types of cases. Extra-pulmonary tuberculosis often affects the musculoskeletal system. The sites most involved are the spine (Pott's disease) and the large joints, especially hips and knees. We describe a patient with tuberculosis of the hip, who underwent total hip arthroplasty.