Alberto Tesconi Croci

Prospective study of the treatment of infected hip arthroplasties with or without the use of an antibiotic-loaded cement spacer

PURPOSE Our purpose was to compare 2 methods of treatment of chronic infection in hip arthroplasties--with or without an antibiotic-loaded cement spacer. METHODS In a prospective study, we treated 68 infected hip arthroplasties with discharging sinuses and bone loss, comparing 30 patients treated in 2 stages without the use of a spacer (control group) and 38 patients treated with a vancomycin-loaded spacer (study group). The average follow-up was 4 years (2-8.5 years). One patient died of unrelated causes 4 months after first-stage surgery and was excluded from the study. RESULTS The 2-stage surgery without spacer controlled the infection in 66.7% of patients, and the 2-stage surgery using the spacer controlled it in 89.1% (P < 0.05). At last follow-up, the average Harris Hip Score increased from 19.3 to 69.0 in the control group versus 19.7 to 75.2 in the study group (P > 0.05). The average leg length discrepancy was 2.6 cm in the control group and 1.5 cm in the study group (P < 0.05). The patients treated with a spacer had better clinical results (81.5% of patients with good results against 60.0% for the control group). CONCLUSION The use of an antibiotic-loaded spacer in the 2-stage treatment of infected hip arthroplasties provides better infection control with good functional results and is superior to treatment in 2 stages without a spacer. LEVEL OF EVIDENCE Therapeutic study, Level I-1.

Relationship between surgical procedure and outcome for patients with grade I chondrosarcomas.

PURPOSE To evaluate the oncological outcome of patients with grade I chondrosarcomas according to the type of surgical treatment performed, since there is still controversy regarding the need for aggressive resections to reach a successful outcome. MATERIALS AND METHODS The records of 23 patients with grade I chondrosarcomas were reviewed. The mean age was 38.4 years, ranging from 11 to 70 years; 52% were men and 48% were women. The femur was the site of 13 tumors. The tumors were staged as IA (17, 74%) and IB (6, 26%). Regarding tumor location, 74% (17) were medullary, 22% (5) were peripheral, and 4% (1) was indeterminate. Tumor size ranged from 2 to 25 cm, mean 7.9 cm. Regarding the surgical procedure, 11 patients underwent intralesional resection, 9 patients underwent wide resection, and 3 underwent radical resection. The follow-up period ranged from 24 to 192 months. RESULTS None of the patients developed local recurrence or metastases; 7 patients had other general complications. CONCLUSIONS This data supports the use of less aggressive procedures for treatment of low-grade chondrosarcomas.

Primary bone lymphoma in 24 patients treated between 1955 and 1999.

The authors present their experience in the treatment of 24 patients with primary bone lymphoma. Eighty-one patients treated between 1955 and 1999 were evaluated, and 57 were excluded because of misdiagnosis. The male to female ratio was 7:5 and the median age was 38.5 years (range, 18–69 years). Two patients had human immunodeficiency virus. Seventeen patients had intermediate-grade lymphomas (Working Formulation), nine patients had centroblastic subtype (Kiel), and 22 patients had B immunophenotype. Nine patients had combined treatment with chemotherapy and radiation therapy, and nine patients had chemotherapy alone. The mean followup was 13.2 years (range, 1.5–37.3 years). Three patients had surgery, two because of subtrochanteric fractures (one patient had closed reduction and internal fixation and the other patient had resection and endoprosthesis reconstruction). The third patient presented with myelocompression at the thoracic level, and he had decompression surgery. Only one patient had radiation therapy and two patients had no treatment. There have been no local recurrences in 17 patients (70.8%). Seven patients (29.2%) died with evidence of disease within a followup of 11 months. The results of the current study showed that patients with primary bone lymphoma have a good prognosis when they are treated with chemotherapy, regardless of whether radiation therapy was given. Surgery usually is appropriate for patients with fractures.

Tradução e validação da escala Knee Society Score: KSS para a Língua Portuguesa

Objective: To translate, culturally adapt and validate the “Knee Society Score” (KSS) for the Portuguese language and determine its measurement properties, reproducibility and validity. Method: We analyzed 70 patients of both sexes, aged ages between 55 and 85 years, in a crosssectional clinical trial, with diagnosis of primary osteoarthritis, undergoing total knee arthroplasty surgery. We assessed the patients with the English version of the KSS questionnaire and after 30 minutes with the Portuguese version of the KSS questionnaire, done by a different evaluator. All the patients were assessed preoperatively, and again at three, and six months postoperatively. Results: There was no statistical difference, using Cronbach’s alpha index and the Bland-Altman graphical analysis, for the knee score during the preoperative period (p = 1), and at three months (p = 0.991) and six months postoperatively (p = 0.985). There was no statistical difference for knee function score for all three periods (p = 1.0). Conclusion: The Brazilian version of the Knee Society Score is easy to apply, as well providing as a valid and reliable instrument for measuring the knee score and function of Brazilian patients undergoing TKA. Level of Evidence: Level I - Diagnostic Studies— Investigating a Diagnostic Test - Testing of previously developed diagnostic criteria on consecutive patients (with universally applied ‘gold’ reference standard).

Histological study of fresh versus frozen semitendinous muscle tendon allografts

OBJECTIVE: The purpose of this study was to histologically analyze allografts from cadaveric semitendinous muscle after cryopreservation at −80°C in comparison to a control group kept at only −4°C to test the hypothesis that the histological characteristics of the tissue are maintained when the tendons are kept at lower temperatures. METHODS: In a tissue bank, 10 semitendinous tendons from 10 cadavers were frozen at −80ºC as a storage method for tissue preservation. They were kept frozen for 40 days, and then a histological study was carried out. Another 10 tendon samples were analyzed while still “fresh”. RESULTS: There was no histological difference between the fresh and frozen samples in relation to seven variables. CONCLUSIONS: Semitendinous muscle tendon allografts can be submitted to cryopreservation at −80ºC without suffering histological modifications.

Blood loss in the minimally invasive posterior approach to total hip arthroplasty: a comparative study

AIMS Our primary aim was to evaluate whether there is really less bleeding in patients for whom the minimally invasive posterior approach is used in comparison with the direct lateral approach for primary total hip arthroplasty. Our secondary aim was to evaluate the clinical functional results after six months as well as the postoperative radiographic result. METHODS In a comparative non-random prospective study, 76 adult patients underwent elective total hip arthroplasty using one of two approaches. The minimally invasive posterior approach (34 cases; mini-incision group) was compared with the standard direct lateral approach (42 cases; control group). RESULTS Lower total estimated bleeding (means of 1083.5 ml versus 1682.3 ml; p < 0.001) and lower intraoperative bleeding (means of 745.6 ml versus 1282.8 ml; p < 0.001) were found in the mini-incision group. There was, however, no difference in the volume of blood drained after the operation (means of 340 ml and 399 ml; p = 0.77). There was also a difference between the two groups regarding the need for allogenic transfusion (8.8% in the mini-incision group versus 28.6%, p = 0.02). We observed a better clinical result in the mini-incision group (p = 0.002) despite the lack of difference between the two groups in relation to the radiographic result. DISCUSSION Our results draw attention to the possibility that other authors may have underestimated blood losses when using minimally invasive approaches. CONCLUSION The minimally invasive approach gave rise to a positive final impression with regard to lower blood loss.

Estudo comparativo entre a aplicação de crioterapia, cinesioterapia e ondas curtas no tratamento da osteoartrite de joelho

Osteoarthritis is the most prevalent form of joint disease. Physical agents such as ice and heat can fight the pain process, when correctly indicated and used. The objective of this study was to compare physiotherapy protocols involving the use of exercise, cryotherapy and short waves in individuals with knee osteoarthritis. In a prospective randomized study, 25 individuals were treated (25 knees), with ages ranging from 58 to 78 years. GROUP A: exercise and short-waves (n=9). GROUP B: exercise and ice (n=6). GROUP C: exercise alone (control) (n=9). Analyzed variables were: subjective perception of pain (Borg), functional quality (Lequesne), range of motion, flexibility and muscular strength. Pain significantly improved only for group B, with positive functional quality and flexibility in all groups. The improvement in range of motion was similar for groups B and C. Flexion strength was maintained for groups A and B, and strength gain for individuals in group C. In the extensors muscles, strength gain was seen in groups B and C, while strength loss was reported for group A. The best protocol was that one involving cryotherapy and exercises for pain relief. All groups showed improved functional quality; no correlation was found for range of motion gain, flexibility and strength gain associated with thermotherapy.

Functional and radiographic evaluation of 214 aggressive benign bone lesions treated with curettage, cauterization, and cementation: 24 years of follow-up

PURPOSE Treatment with curettage, cauterization, and methylmethacrylate of aggressive benign bone lesions is a method now widely accepted in most orthopedic oncology centers. However, one of the controversies regarding this technique is the possible complications that may arise from the use of methylmethacrylate, which has caused some authors to remove it 2 years after the surgery and replace it with bone graft. The objective of this paper is to present a functional and radiographic evaluation of 214 patients presenting with aggressive benign bone lesions treated with curettage, cauterization, and methylmethacrylate from 1974 to 1998, with some of them having 24 years of follow-up. These patients were clinically and radiographically evaluated for the incidence of late osteoarthrosis, range of motion, and pain in the involved joint. METHOD This study comprised 214 patients, with an average follow-up duration of 10.6 years (range: 2 to 24 years. All cases involved aggressive benign lesions. The patients were evaluated according to the Musculoskeletal Tumor Society Score (MSTS) functional evaluation system, and the complications are described. RESULTS The MSTS functional evaluation was excellent in 166 cases (78%), good in 26 (12%), fair in 11 (5%), and poor in 11 (5%). The following complications were observed: late osteoarthrosis, 25 cases (12%); infection, 12 (6%); pathologic fracture, 11 (5%); and local recurrence, 19 (9%). CONCLUSION Based on clinical assessment, no significant deleterious effects directly related to the use of methylmethacrylate were observed. The functional evaluation performed in 1998 (up to 24 years of follow-up) did not show significant change when compared to the evaluation performed in 1985.

Synovial sarcoma of the extremities: prognostic factors for 20 nonmetastatic cases and a new histologic grading system with prognostic significance

PURPOSE To evaluate 20 cases of nonmetastatic synovial sarcoma of the extremities regarding prognostic factors, and to propose a histologic grading system with prognostic significance. METHODS The cases of 20 patients (14 females and 6 males) with nonmetastatic synovial sarcomas of the extremities treated between 1985 and 1998, were retrospectively evaluated regarding prognostic factors. A histologic grading system with prognostic significance is proposed. RESULTS The mean follow-up period was 48.4 months (range, 16-116 months). There was local recurrence in 3 cases (15%), microscopic surgical margin being the only prognostic factor identified. Seven patients (35%) died of the disease in a mean postoperative period of 31.7 months (range, 16-53 months), all with pulmonary or brain metastasis. The survival rate was 65% in 48.4 months of follow-up. CONCLUSION The unfavorable prognostic factors identified regarding survival were high histologic grade, tumors proximal to the knee or elbow, and spontaneous tumor necrosis over 25%. Local recurrence did not have influence on survival in this study. The presence of mast cells appears to have a positive influence on survival, although statistical significance was not reached (P = 0.07). The oncologic and functional result was good in 6 cases (30%), regular in 7 (35%), and poor in 7 cases (35%).

Acetabular Component Positioning in Total Hip Arthroplasty With and Without a Computer-Assisted System: A Prospective, Randomized and Controlled Study

In a study of the acetabular component in total hip arthroplasty, 20 hips were operated on using imageless navigation and 20 hips were operated on using the conventional method. The correct position of the acetabular component was evaluated with computed tomography, measuring the operative anteversion and the operative inclination and determining the cases inside Lewinneks safe zone. The results were similar in all the analyses: a mean anteversion of 17.4° in the navigated group and 14.5° in the control group (P=.215); a mean inclination of 41.7° and 42.2° (P=.633); a mean deviation from the desired anteversion (15°) of 5.5° and 6.6° (P=.429); a mean deviation from the desired inclination of 3° and 3.2° (P=.783); and location inside the safe zone of 90% and 80% (P=.661). The acetabular component positions tomography analyses were similar whether using the imageless navigation or performing it conventionally.