INTRODUCTION Metal-on-metal hip resurfacing (MOMHR) has recently been reintroduced as a viable treatment option for young active patients. A short femoral neck and insufficient head are common deformities following CDH, Perthes disease and SFCE. Therefore, severity of these deformities is a contraindication for MOMHR, as contact between the femoral resurfacing component and the femoral head would be inadequate and off-set insufficient. METHODS 32 patients with severe deformity of the hip were treated with Birmingham hip resurfacing and head lengthening. We used a standard acetabular component in 18 patients and a CDH acetabular component and supplementary screw fixation in 14. Bone chips produced while reaming the acetabulum were impacted on the femoral head to achieve the desired length, as evaluated on pre-op x-rays. Rehabilitation included no weight-bearing for 1 month and partial weight-bearing for another month. RESULTS Median patient age was 44 years. Median head lengthening was 1.2 cm. Minimum follow-up was 3.1 years, maximum 5.2. Mean Harris Hip Score was 98. At follow-up 82% of the patients were involved in heavy or moderately heavy work. 34% of the patients practiced sports. Co and Cr serum concentrations at 25 months were respectively ng/ml 1.76, and 0.75. DXA analysis of the proximal femur showed complete recovery of BMD in Gruen zone 1 and increased in zone 7 (p= 0.05). There were no major complications. DISCUSSION AND CONCLUSIONS The absence of major complications and the quality of our results support this technique in young active patients with severe deformity of the hip.
Purpose: Four external fixation pin types differing in coating, design and implantation technique were tested in an animal study. Methods: Forty tapered pins were divided into 4 Groups according to pin design type: Group A consisted of 10 standard self-tapping pins (o5–6mm, pitch 1.75mm), Group B 10 hydroxyapatite (HA)-coated self-tapping (o5–6mm, pitch 1.75mm), Group C 10 standard, self-drilling, self-tapping (o5–6mm, pitch 1.25mm) and Group D 10 HA-coated, self-drilling, self-tapping (o5–6mm, pitch 1.25mm). Four pins were randomly implanted into the femoral diaphysis of 10 sheep. The pins were implanted at 2-cm intervals apart. Pre-drilling was used for Groups A and B but not for Groups C and D. Sheep were euthanized 6 weeks after surgery. Results: There were no major complications. Mean pin insertion torque was 3100 ± 915 Nmm in Group A, 2808 ± 852 Nmm in Group B, 2589 ± 852 Nmm in Group C and 2180 ± 652 Nmm in Group D. Mean pin extraction torque was 1570 ± 504 Nmm in Group A, 2128 ± 1159 Nmm in Group B, 1599 ± 809 Nmm in Group C and 2200 ± 914 Nmm in Group D. Insertion torque of the coated groups was lower than insertion torque of the standard groups (p Conclusion/Significance: This study demonstrated that coating pins with hydroxyapatite is effective regardless of the pin design and the implantation technique.
Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB).
Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB.
Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years.
Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p<0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p<0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up.
Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained.
INTRODUCTION: Post-traumatic arthritis of the ankle in the young active patient represents a reconstructive challenge. Fresh total shell osteochondral allografts are an increasingly popular option in the reconstruction of various amounts of cartilage defects, although concerns for bipolar allografting are reported. The purpose of this study is to describe the preliminary results of a series of 18 bipolar shell ankle allografts performed by using a specifically designed instrumentation. METHODS: 18 patients, 13 males and 5 females (mean age 31±10 years) affected by post traumatic arthritis of the unilateral ankle joint grade III received bipolar shell allograft of the ankle. The mean follow-up was 12 months (range 24–8). The ideal patient to allograft match was permitted through CT scan and x-rays. Two steps surgery, one for allograft preparing and one for the recipient site, were performed by using specifically designed jigs. Patients evaluation was carried out clinically by AOFAS and radiographically by X-Rays, CT scans, MRI. RESULTS: No intraoperative, complications occurred. All the patients demonstrated good consolidation rates of the allograft at X-Rays, CT scan and MRI controls performed at 4, 6, 8, and 12 months. At 8 months follow-up, all the patients were allowed complete weight bearing. Normal ROM of the ankle and regular gait with no pain and no need of support was resumed in 13 patients. In 2 patients a fracture of the fibula was reported. In one case, cause of the fracture was patient non compliance to the weight-bearing restriction. In the other case the fracture occurred distal to the osteotomy site, possibly due to a trauma. Both the cases required revision of the graft which appeared damaged in the lateral site. In the first case an ankle arthrodesis was performed. A bioptic harvest of the transplanted cartilage in 5 patients at 1 year follow up demonstrated chondrocytes vitality > 90%. DISCUSSION: Accurate preoperative planning, sizing, and the use of specifically designed jigs makes viable and reproducible the bipolar shell allograft in the ankle joint in selected cases. Although preliminary results are encouraging, longer follow-up is required in order to confirm longer term cartilage viability and the validity of the technique.
Chronic Kidney Disease (CKD) provokes biochemical and systemic alterations, causing bone fragility with an increase in bone fracture risk, extraskeletal calcifications, increased morbidity, and cardiovascular mortality. The complex pathophysiological mechanism causes a syndrome called CKD-MBD (Chronic Kidney Disease - Mineral and Bone Disorders), which includes mineral and bone alterations leading to renal osteodystrophy (ROD). An early diagnosis is therefore essential to prevent the onset of more severe complications. A precise diagnosis of bone disorders and the subsequent administration of the best therapy is difficult without performing a bone biopsy. However, lately, the diagnostic focus is shifting to a series of molecules, the bone turnover markers (BTM), generated by the same bone tissue during the remodeling process, which is proving to be a useful diagnostic tool in the definition of ROD. BTMs are divided into bone formation molecules (amino-terminal propeptide of type 1 procollagen, P1NP; osteocalcin, OC; bone alkaline phosphatase, bALP) and bone resorption molecules (carboxy-terminal cross-linked telopeptide of type 1 collagen, CTX; isoform 5b tartrate-resistant acid phosphatase, TRAP-5b). There are also biomarkers of bone metabolism such as parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23), and sclerostin. Although PTH is one of the most used molecules, P1NP, bALP, CTX, and TRAP-5b have proven to be superior in the discrimination of low turnover pathologies. The diagnostic capability of these molecules and their potential still require further studies, but clinicians must include BTMs in the diagnostic process of CKD-MBD.
Osteochondral lesions of the dome of the talus whether medial or lateral are rare. Surgical treatment is required when there is a loose body, or when the lesion is symptomatic and resistant to nonsurgical treatment. Usually, the degenerated fragment is removed, followed by curettage and multiple perforations of the subchondral bed, but different methods may be used to reinsert the osteocartilaginous fragment. Having been satisfied with our first studies conducted both on animals and man, we began to reinsert the osteochondral fragment by using resorbable means of synthesis. The purpose of this study is to report our experiences with 3 such cases at a minimum follow-up of one year.
Introduction: Facioscapulohumeral muscular dystrophy (FSHD) is the third most common hereditary disease of the muscle after Duchenne and myotonic dystrophy. FSHD consists in an atrophic myopathy with predominant involvement of the face, upper arms, and shoulder muscles. FSHD compromises the muscles of the scapu-lothoracic joint, and usually spares muscles of the scapu-lohumeral joint. Consequently, when the patient tries to abduct or foreword flex the shoulder, the contraction of the relatively preserved scapulo-humeral muscles produces an abnormal rotation of the scapula, that is not hold to the chest wall because of the insufficiency of the scapulo-thoracic muscles, resulting in a winged scapula and in a limited arm motion. The aim of this study is to describe an original scapulopexy and report the long term results obtained in 9 patients affected by FSHD.
Material and methods: Nine patients (4 male and 5 female) affected by winged scapula in FSHD were observed and selected. Average age at surgery was 25 years (range 13–39). Surgery consisted in scapulopexy of both sides in the same surgical time. Through a skin incision on its medial border the scapula was exposed and positioned over the chest. The 5th to the 8th ribs were exposed in the part below the scapula. The position of the scapula over the chest was fixed by 4 doubled metal wires to the 5th, 6th, 7th and 8th rib. Each wire was passed anteriorly to the rib, and into a hole performed 1.5 cm from the medial border of the scapula. By tightening the wires, the scapula was fixed firmly over the chest. A figure of eight dressing that holds the shoulders back was applied immediately after surgery and maintained for six weeks.
Results: The average surgical time was 65 minute for each single procedure. One patient experienced an unilateral pneumothorax the day after operation, which resolved spontaneously in 48 hours. Average follow up was 11 years (range 3–15). All patients experienced a complete resolution of the winged scapula and an improvement of range of motion of the shoulder compared to the pre operative conditions. Average pre-operative abduction was 68 and post-operative was 85. Average pre-operative flexion was 78 and post-operative 112.
Discussion: This technique is easy and quick to perform, does not require grafts, reduces post surgical complications such as pneumothorax or haemothorax, and ensures good results even at considerable follow-up.
The prevalence and the effects of hypercalciuria on bone in patients with primary osteoporosis are poorly defined. We therefore retrospectively analyzed the data of 241 otherwise healthy women. They were 45-88 years of age and had been referred for their first visit to our Unit for Metabolic Bone Diseases over a 2-year period because of primary osteoporosis (bone density T-score < -2.5).The main parameters of calcium and skeletal metabolism had been analyzed in all subjects. This population was then divided into two groups, according to the presence (HC+) or absence (HC-) of hypercalciuria.Elevated urinary calcium was present in 19% of the subjects. Due to the selection criteria, spinal and femoral bone loss was similar in the two groups. Urinary calcium, phosphate and fractional calcium excretion were higher in hypercalciuric patients. In a logistic regression model, the higher the Tm of phosphate, the lower the risk of hypercalciuria (odds ratio 0.33, confidence interval 0.18-0.62). On the contrary, hypercalciuria was the most important predictor of low bone mass in HC+ (accounting for more than 50% of the variance in spinal bone density).Hypercalciuria is a common feature in postmenopausal bone loss. Since increased urinary calcium excretion and low bone mass appear to be linked, hypercalciuria seems to be an important determinant of reduced bone density in this setting as well.
To estimate the proportion of patients with very severe osteoporosis (those covered by the reimbursement criteria of the Italian National Health Service) experiencing new vertebral and non-vertebral fragility fractures in the first 24 months of a new anti-osteoporosis treatment.Prospective observational study in men and post-menopausal women (aged > 21 years) initiating anti-osteoporosis treatment for very severe osteoporosis. Eligibility was based on teriparatide (TPD) reimbursement criteria in Italy: incident of vertebral or hip fracture during anti-resorptive treatment (minimum 1 year), or at least three prevalent severe vertebral fractures, or two prevalent severe vertebral fractures and a historical proximal hip fracture. Incidence of new clinical vertebral and non-vertebral fractures was documented by original x-rays and/or radiological reports, and a post-hoc analysis compared data from the TPD monotherapy population versus the total treated group.Overall, 767 patients (mean age 72.8 years, 90.7% women) were enrolled in the study, of whom 628, 538, 419 and 424 attended visits at 6, 12, 18 and 24 months, respectively. The most commonly prescribed therapy was TPD (single-agent; 64.5%), then bisphosphonates and other anti-resorptives (33.3%). A combination of different oral treatments was given to 22.5% of the patients. Overall treatment adherence at 24 months was 65.7%. In a post-hoc analysis, the overall incidence of new clinical vertebral and non-vertebral fractures in the total treated population was, respectively, 4.7% and 2.3% in the first 6 months; 1.8% and 1.6% in the 6-12 month period; 2.9% and 1.4% in the 12-18 month period; and 2.2% and 1.0% in the 18-24 month period.In patients with very severe osteoporosis, the risk of new vertebral and non-vertebral fractures declined after the first 6 months and remained low throughout the study.
