Andrea Piazzolla

Vertebral body recollapse without trauma after kyphoplasty with calcium phosphate cement

Traditionally, immobilization and external bracing has been recommended for patients with type A traumatic and non-osteoporotic fractures that do not present neurological deficits or significant instability. Nevertheless, several authors have recently suggested the possibility to treat thoraco-lumbar and lumbar vertebral compression post-traumatic fractures using standalone balloon kyphoplasty with osteoconductive filler materials, such as calcium phosphate (CPC). Maestretti and Huang have demonstrated the advantages of this technique showing an almost immediate return to daily activities without the inconvenience of wearing a brace, pain reduction, minimal operative risks and maintenance of stability, therefore proposing this as a first-choice technique in young patient needing rapid spine stability. The authors present a case of vertebral body recollapse after kyphoplasty with calcium phosphate cement (CPC) in a 47-year-old man with an A1.2 post-traumatic L1 compression fracture.

Alumina-on-alumina total hip replacement for femoral neck fracture in healthy patients

BackgroundTotal hip replacement is considered the best option for treatment of displaced intracapsular fractures of the femoral neck (FFN). The size of the femoral head is an important factor that influences the outcome of a total hip arthroplasty (THA): implants with a 28 mm femoral head are more prone to dislocate than implants with a 32 mm head. Obviously, a large head coupled to a polyethylene inlay can lead to more wear, osteolysis and failure of the implant. Ceramic induces less friction and minimal wear even with larger heads.MethodsA total of 35 THAs were performed for displaced intracapsular FFN, using a 32 mm alumina-alumina coupling.ResultsAt a mean follow-up of 80 months, 33 have been clinically and radiologically reviewed. None of the implants needed revision for any reason, none of the cups were considered to have failed, no dislocations nor breakage of the ceramic components were recorded. One anatomic cementless stem was radiologically loose.ConclusionsOn the basis of our experience, we suggest that ceramic-on-ceramic coupling offers minimal friction and wear even with large heads.

Vertebral Bone Marrow Edema (vbme) in Conservatively Treated Acute Vertebral Compression Fractures (vcfs): Evolution and Clinical Correlations

Study Design. Prospective observational study. Objective. To assess (1) the evolution of vertebral bone marrow edema (VBME) in patients with A1 vertebral compression fractures (VCFs) conservatively treated and (2) the relationship between VBME and clinical symptoms, evaluated as Visual Analogue Scale (VAS) back pain and Oswestry Disability Index (ODI). Summary of Background Data. VBME is a marker of acute–subacute vertebral fractures. Little is known about the evolution of VBME in conservatively managed VCFs, as well as its clinical meaning. Methods. 82 thoracic or lumbar VCFs (21 post-traumatic; 61 osteoporotic VCFs), type A1 according to the AOSpine thoracolumbar spine injury classification system, in 80 patients were treated with C35 hyperextension brace for 3 months, bed rest for the first 25 days. Patients with osteoporotic fractures also received antiresorptive therapy and vitamin D supplementation. At 0 (T0), 30 (T1), 60 (T2), and 90 (T3) days, patients underwent magnetic resonance imaging evaluation and clinical evaluation, using VAS for pain and ODI. The paired t test was used to compare changes within groups at each follow-up versus baseline. The unpaired t test after ANOVA (analysis of variance) was used to compare the 2 groups at each follow-up. The association between VBME area, VAS score, and ODI score was analyzed by the Pearson correlation test. The tests were 2-tailed with a confidence level of 5%. Results. A significant VBME mean area, VAS, and ODI scores reduction was recorded at 60 and 90-days follow-ups versus baseline. A positive correlation between VBME reduction and clinical symptoms improvement (VAS and ODI scores improvement) was found in both traumatic and osteoporotic VCFs. Conclusion. In benign A1 VCFs conservatively managed, VBME slowly decreases in the first 3 months of magnetic resonance imaging follow-up. This VBME reduction is related to clinical symptoms improvement. Level of Evidence: 4

Reducing periprosthetic joint infection: what really counts?

Periprosthetic joint infection (PJI) remains one of the most challenging complications after joint arthroplasty. Despite improvements in surgical techniques and in the use of antibiotic prophylaxis, it remains a major cause of implant failure and need for revision. PJI is associated with both human host-related and bacterial agent-related factors that can interact in all the phases of the procedure (preoperative, intraoperative and postoperative). Prevention is the first strategy to implement in order to minimize this catastrophic complication. The present review focuses on the preoperative period, and on what to do once risk factors are fully understood and have been identified.

Irreducible posterolateral dislocation of the knee: A case report

Irreducible posterolateral dislocations of the knee are rare lesions, generally caused by high-energy trauma inducing rotational stress and a posterior and lateral displacement of the tibia. In these conditions, the interposition of abundant soft tissue inside the enlarged medial joint space prevents spontaneous reduction or non-surgical treatment by manipulation of the dislocation. Surgical treatment is therefore compulsory. We report the clinical case of a woman who suffered a subluxation of the knee while jogging. The case we describe is of interest because it shows that even less severe knee dislocations, like this subluxation caused by a low-velocity sports trauma, may present in an irreducible form requiring open surgery. Clinical-instrumental monitoring did not reveal any signs of vascular or nerve injury. Owing to the irreducibility of the lesion we were obliged to perform open surgery in order to free the joint from the interposed muscle tissue and repair medial capsule-ligament lesions. Repair of the damaged cruciate ligaments was deferred to a second stage, but ultimately rendered necessary by the persistence of joint instability and the need to address the patients functional needs. In the literature, different one- and two-step surgical options, performed by arthroscopy or arthrotomy, are reported for such related problems. The Authors discuss these various options and examine and discuss their own decision taken during the surgical work-up of this case.

Vertebral body reconstruction system B-Twin® versus corset following non-osteoporotic Magerl A1.2 thoracic and lumbar fracture. Functional and radiological outcome at 12 month follow-up in a prospective randomized series of 50 patients

INTRODUCTION Kyphoplasty and percutaneous vertebroplasty are two effective procedures for osteoporotic vertebral compression fractures, but there have been few publications on their use in non-osteoporotic forms. B-Twin(®) vertebral body reconstruction is a new minimally invasive vertebral body reconstruction technique developed for non-osteoporotic vertebral compression fractures of the thoracolumbar junction and lumbar spine. OBJECTIVES The present study describes this novel technique and assessed efficacy compared to a conservative method. PATIENTS AND METHODS Inclusion criteria were: Magerl type A1.2 non-osteoporotic thoracolumbar or lumbar spinal compression fractures in patients aged over 18 years, free of neurologic compromise. Patients were randomized to management by corset (group 1) or by the B-Twin(®) spacer (group 2). Follow-up used a visual analog scale (VAS) to assess pain, the Oswestry Disability Index (ODI) and, on radiology, the vertebral (VK) and regional (RK) kyphosis angles and anterior and medial height indices at baseline, 3 months and 12 months. RESULTS Group 1 comprised 26 patients; group 2 comprised 24 patients, with 44 implants. In group 1, mean VK was 10.7° (± 1.73°) at baseline, 11.9° (± 1.56°) at 3 months and 12.3° (± 1.6°) at 12 months. Mean RK was respectively 9.7° (± 0.97°), 11.10° (± 1.07°) and 11.8° (± 1.27). Mean medial height (medial-to-posterior [MH/PH] height ratio was respectively 0.75 [±0.05], 0.70 [±0.06] and 0.65 [±0.04]). Mean anterior height (anterior-to-posterior [AH/PH] height ratio) was respectively 0.79 [± 0.06], 0.76 [± 0.05] and 0.73 [± 0.05]). Mean VAS score was respectively 8.6 (± 0.52), 3.8 (± 0.82) and 2.3 (± 0.83). In group 2, mean VK was 13.8° (± 0.47°) at baseline, 4.88° (± 0.65°) at 3 months and 4.88° (± 0.65°). Mean RK was respectively 9.82° (± 1.67°), 4.47° (± 0.86°) and 4.82° (± 0.98°). Mean MH/PH ratio was respectively 0.69 (± 0.05), 0.86 (± 0.03) and 0.86 (± 0.03). Mean AH/PH ratio was respectively 0.73 (± 0.04), 0.90 (± 0.03) and 0.90 (± 0.03). Mean VAS score was 8.88 (± 0.47) at baseline, 2 (± 1) at 1-day post-surgery, 1.71 (± 0.88) at 3 months and 1.12 (± 0.23) at 12 months. The increase in vertebral body height in patients managed by B-Twin(®) was maintained at 6 and 12 months (P<0.0001). The study showed better results with the vertebral spacer than on conservative treatment, with a 95% reduction in bed-rest: 4-6 weeks in the conservative group vs. 2-3 days in the surgical group. CONCLUSIONS The vertebral body reconstruction technique provided anatomic vertebral body reconstruction and quick return to household activity without resort to a corset. Deformity was durably reduced. At 12-month follow-up, pain reduction and stasis were achieved. The risk of injected cement leakage was slight.

An intravascular papillary endothelial hyperplasia of the hand radiologically mimicking a hemangiopericytoma: A case report and literature review:

Intravascular papillary endothelial hyperplasia is a rare benign vascular lesion of the skin and subcutaneous tissues, characterized by a reactive proliferation of endothelial cells that can present de novo in normal blood vessels (primary intravascular papillary endothelial hyperplasia), but it can also develop from a pre-existing vascular process (type II intravascular papillary endothelial hyperplasia), or it can arise in an extravascular location from a post-traumatic haematoma. The differential diagnosis between intravascular papillary endothelial hyperplasia and malignant vascular tumours can be challenging, due to the lacking of a specific radiologic description. We present a case of intravascular papillary endothelial hyperplasia of the hand radiologically mimicking a hemangiopericytoma.

Il trattamento definitivo delle fratture del terzo prossimale dell’omero con fissatore esterno

Proximal humeral fractures are common finding, comprising 5–7% of all fractures, and being more common in the elderly. The incident of the proximal humerus fractures has been on the rise during the past decade. Many treatment options are available, such as conservative treatment, open reduction internal fixation (ORIF), joint replacement, percutaneous fixation and external fixation. ORIF has shown to be associated with surgical trauma, higher infection rates, avascular necrosis of the humeral head, and neurovascular lesions. Therefore, the trend has changed in the past few years from massive internal fixation to closed reduction and minimal fixation. The advantages of closed reduction and external fixation consist in the possibility of preserving blood supply to bone fragments, the absence of blood loss and the possibility of performing surgery under brachial plexus block.

Letter to the Editor concerning "Normative values for the spine shape parameters using 3D standing analysis from a database of 268 asymptomatic Caucasian and Japanese subjects" by JC Le Huec et al. Eur Spine J (2016) 25:3630-3637

With interest I read the article by Le Huec and Hasegawa [1] describing a meticulous study in which they used EOS low-dose full spine X-rays (EOS Imaging, Paris, France) to provide 3D information about standing spinopelvic reference values in Caucasian and Japanese subjects without back pain. Such novel methods, employing 3D radiography (very low X-ray dose, real size of the images, standing position, 3D and 2D clinical parameters, which are automatically calculated from 3D models), allow overcoming some limitations of previous similar studies. The comparison of Le Huec’s regression models with previously published models showed that calculation of lumbar lordosis (LL) based on pelvic incidence (PI) from Schwab’s equation was similar for subjects with low PI; nevertheless when PI was medium or high, the model of Schwab overestimated the LL [2]. The regression model from Legaye showed an overestimated LL also in subjects with low PI [3]. These differences could be related to the heterogeneity of Le Huec’s study population. The sagittal spinopelvic alignment of patients with hip disorders has been reported in a few studies [4–8]. Everyone agrees that any pathological changes in the spine, pelvis or legs modified the normal alignment. For this reason spine–pelvic–leg pathologies must always be excluded if the aim of the study is to provide information about reference values. Patients with HOA (hip osteoarthritis) have more anteverted pelvis, forward inclined spine and flexed hip joints, and a significantly greater risk of severe unbalance of sagittal spinal–pelvic alignment [9]. When the osteoarthritis (OA) is present, its grading is another important factor to consider. Patients with pre/early stage OA showed comparable lumbar lordosis and sagittal pelvic alignment, with a trend of greater anterior pelvic inclination [10]; patients with severe OA also had significantly anterior inclined pelvis (larger sacral slope) and hyperlordotic lumbar spine (larger lumbar lordosis) [11, 12]. Le Huec and Hasegawa do not consider the above observations recruiting patients between 18 and 76 years old without back pain while exclusion criteria must be ‘‘spine, pelvic, hip or lower limb disorders’’. In similar studies, subjects with a history of pain in the low back or hip for a minimum of 3 consecutive months were always excluded. At same time, it is hard to hypothesis that 20 and 60-year-old persons have the same hip function. Also spinal parameters differ through the aging; lumbar lordosis tends to decrease with aging process, as pelvic incidence remains constant for a given human being [13]. According to these considerations, data must always be ageand gender-matched to determine the theoretical ideal parameters. As such, these points are highlighted in the interest of other readers or researchers who may be interested to replicate the study in the near future. & Andrea Piazzolla dott.piazzolla@gmail.com

Letter to the Editor concerning “The surgical algorithm for the AOSpine thoracolumbar spine injury classification system” by A. R. Vaccaro et al. Eur Spine J (2016);25(4):1087–1094

Vaccaro et al. describe a surgical algorithm to accompany the AOSpine thoracolumbar spine injury classification system, the thoracolumbar AOSpine Injury score (TL AOSIS), but, although it presents several advantages, patients with A3 fractures need much more attention. Although these fractures are initially classified as non-operative by the AOSpine Trauma Knowledge Forum according to the algorithm, often, the choice of the minimally invasive surgery is preferred mostly when there is a high likelihood of subsequent kyphotic deformity [1–5]. The same authors underline into the discussion that using the results of their survey and the available literature, it is impossible to firmly recommend specific treatment for all A3 fractures. In an effort to improve the understanding of these fractures, we suggest a future adjustment to the management algorithm, for example, introducing new modifiers. In relation to burst fractures, the previous studies have suggested that loss of vertebral body height (LOVBH \50%) and kyphotic angle ([20 ) may be indicative of instability [6]. Loss of vertebral body height must be calculated according to the formula LOVBH = [(A1 ? A2) 2A0/(A1 ? A2)] 9 100%, where A0 is the anterior wall of the fractured vertebra, A1 is the anterior wall of the first vertebra upper to the fractured vertebra, and A2 is the anterior wall of the first vertebra lower to the fractured vertebra [7]. Another interesting attempt to account for the loss of the capacity of resisting axial load after anterior column fractures was the development of the so-called load-sharing classification (LSC) of spine fractures by McCormack in 1994. This system attempts to predict poor outcome following conservative treatment of burst fractures by evaluating three key factors: the extent of damage to the vertebral body, the displacement of fragments at the fracture site, and the degree of kyphosis. According to this scheme, grading the lesion according to each one of these three factors would lead to attribution of points from 1 and 3 to each criterion, so that the final score ranges from a minimum of 3 to a maximum of 9. According to the loadsharing classification, a final score of 7 suggests the presence of a lesion with significant instability and a relatively high likelihood of failing conservative treatment [8, 9]. Despite these old knowledge, into the TL AOSIS, none of these factors were taken into consideration. According to these considerations, the A3 fractures should provide at least three new qualifiers, vertebral kyphosis in sagittal plane, angulation in coronal plane, and comminution, which give the category cumulative modifications in the point score. Nowadays, in our personal experience, we use the following qualifiers; in sagittal plane, if the A3 fracture is angulated more than 20 , it receives 1 additional point. If the A3 fracture is angulated more than 15 in the coronal plane, it receives an additional 1 point. An LSC score of 7 or more receives an additional 1 point. In our guideline, also patient-specific modifiers were perfected. The BMI is an important aspect to consider in the decision-making program between conservative and surgical treatment. We assign 1 additional point to any patient in whom BMI is more than 30 kg/m. Therefore, according to our scheme, an incomplete burst fracture (A3 = 3 points), with 15 of vertebral kyphosis (0 & Andrea Piazzolla dott.piazzolla@gmail.com