Cesare Stagni

Enhanced tibial osteotomy healing with use of bone grafts supplemented with platelet gel or platelet gel and bone marrow stromal cells.

BACKGROUND There is great interest in the use of bone substitutes to improve bone repair. We compared the osteogenic potential of lyophilized bone chips combined with platelet gel, or with platelet gel and bone marrow stromal cells, with that of lyophilized bone chips alone in the healing of a high tibial osteotomy. METHODS A prospective, randomized, controlled study was performed, and a standardized clinical model was applied. Thirty-three patients undergoing high tibial osteotomy to treat genu varum were enrolled and assigned to three groups. During the osteotomy, lyophilized bone chips with platelet gel were implanted into eleven patients (Group A), lyophilized bone chips with platelet gel and bone marrow stromal cells were implanted in twelve patients (Group B), and lyophilized bone chips without gel were placed in ten patients as controls (Group C). Six weeks after surgery, computed tomography-guided biopsies of the grafted areas were performed and the specimens were analyzed by histomorphometry. Clinical and radiographic evaluation was performed at six weeks, twelve weeks, six months, and one year after surgery. RESULTS Histomorphometry at six weeks showed significantly increased osteoblasts and osteoid areas in both Group A (p = 0.006 and p = 0.03, respectively) and Group B (p = 0.009 and p = 0.001) in comparison with controls, as well as increased bone apposition on the chips (p = 0.007 and p = 0.001, respectively), which was greater in Group B than in Group A (p < 0.05). Group B showed significantly higher revascularization than the controls (p = 0.004). Radiographs revealed a significantly higher rate of osseointegration in Groups A and B than in the controls at six weeks (p < 0.005 and p < 0.0001, respectively). At the final evaluation at one year, the osseointegration was still better in Groups A and B than in Group C; however, all patients had complete clinical and functional evidence of healing. CONCLUSIONS Adding a platelet gel or a platelet gel combined with bone marrow stromal cells to lyophilized bone chips increases the osteogenetic potential of the lyophilized bone chips and may be a useful tool in the treatment of patients with massive bone loss.

Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid, Separately and in Combination, for Hip Osteoarthritis: A Randomized Controlled Study.

Background: The effectiveness of intra-articular platelet-rich plasma (PRP) injections has been evaluated in knee chondroplasty and osteoarthritis (OA); however, little evidence of its efficacy in hip OA exists. Purpose: To compare the therapeutic efficacy of autologous PRP, hyaluronic acid (HA), or a combination of both (PRP+HA) in hip OA. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients aged between 18 and 65 years who were treated with outpatient surgery and who had hip OA and pain intensity at baseline of >20 on a 100-mm visual analog scale (VAS) were recruited for this study. Exclusion criteria were extensive surgery; presence of excessive deformities; or rheumatic, infective, cardiovascular, or immune system disorders. The primary outcome measure was a change in pain intensity as assessed by the VAS at 2, 6, and 12 months after treatment. Secondary outcome measures were the Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and concentration of growth factors in PRP and their correlation with clinical outcomes. Clinical outcomes were evaluated by assessors and collectors blinded to the type of treatment administered. Results: A total of 111 patients were randomly assigned to 3 groups and received 3 weekly injections of either PRP (44 patients), PRP+HA (31 patients), or HA (36 patients). At all follow-ups, the PRP group had the lowest VAS scores. In particular, at 6-month follow-up, the mean VAS score was 21 (95% CI, 15-28) in the PRP group, 35 (95% CI, 26-45) in the PRP+HA group, and 44 (95% CI, 36-52) in the HA group (P < .0005 [PRP vs HA] and P = .007 [PRP vs PRP+HA]; F = 0.663). The WOMAC score of the PRP group was significantly better at 2-month follow-up (mean, 73; 95% CI, 68-78) and 6-month follow-up (mean, 72; 95% CI, 67-76) but not at 12-month follow-up. A significant, “moderate” correlation was found between interleukin-10 and variations of the VAS score (r = 0.392; P = .040). Significant improvements were achieved in reducing pain and ameliorating quality of life and functional recovery. Conclusion: Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip OA without relevant side effects. The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP+HA did not lead to a significant improvement in pain symptoms.

Two Stage Hip Revision in Periprosthetic Infection: Results of 41 Cases

Background: two-stage revision is considered the best treatment approach for the eradication of chronic joint infection. We report the outcome of 41 consecutive patients with infected hip prostheses, treated between 2000 and 2005, with two-stage revision using an antibiotic-loaded cement spacer. Methods: Patients underwent a treatment protocol which included clinical and radiographic evaluation, laboratory investigations, hip aspiration, 99mTc-MDP and 99mTc-leukocyte-labeled scintigraphy and intraoperative assessment. All patients were diagnosed with a late chronic infection and classified as B-host according to the Cierny-Mader classification system. 9 patients out of 41 (22%) required a second interim treatment period, with exchange of the spacer. The proportion of methicillin-resistant Staphylococcus was similar between the one-spacer group and two-spacer group (28% vs 33%), whereas the proportion of patients with three or more risk factors was significantly higher in the two-spacer group than in the one-spacer group (28% vs 55%, respectively). Results: Forty patients had final reimplantation, one patient had a resection arthroplasty. At an average follow-up of 5.3 years no recurrence of infection occurred. The average post-operative Harris hip score improved from 41 to 80. Conclusions: In the treatment of two-stage revision arthroplasty the adherence to the protocol proved to be effective for infection eradication and final reimplantation.

Fibular autograft and silicone implant arthroplasty after resection of giant cell tumor of the metacarpal—a case report with 9-year follow-up

Copyright

Return to sports activity with short stems or standard stems in total hip arthroplasty in patients less than 50 years old

Background The aim of this study was to compare return to sport activity between a short femoral cementless stem and a conventional femoral cementless stem in total hip arthroplasty in patients 50 years old and younger. Methods We retrospectively reviewed 55 patients (61 hips) treated with a short femoral cementless stem and 28 patients (32 hips) treated with a conventional femoral cementless stem 50 years old and younger from December 2009 and December 2014. Their mean age was 39.86 (22-49) years and 38.68 (18-49) years, respectively. The mean follow-up was 54.1 (15-68) months and 52.7 (15-72) months, respectively. They were pre- and postoperatively evaluated by the clinical and radiological examination. Results No patients with the short stem had intraoperative fracture, but 1 patient with the conventional stem had intraoperative fracture. At final follow-up, there was no statistically significant difference in Harris Hip Score, and radiographic review level between 2 stems. No hip with the short stem had thigh pain, but 6 hips with the conventional stem had thigh pain at the final follow-up. No component was revised for aseptic loosening in either group. There were no differences observed in the return to sports activity between the 2 groups. Conclusions Our study demonstrated that both short cementless stem and conventional cementless stem provided stable fixation and achieved a satisfactory result in patients 50 years old and younger. There is no difference in return to sports activity level after the procedure.

Relationship between mortality and proximal femur fractures in the elderly

Four hundred ninety-three patients aged > 65 years with proximal femur fractures were examined to assess the mortality rate within 1 year postoperatively. The risk factors that are most often associated with death were identified. Within the inhomogeneous group of patients, mortality was significantly higher in patients with poor mental status, with > or = 2 pre-existing diseases, a 3 or 4 American Society of Anesthetists class rating, and a lateral fracture. Regarding treatment and rehabilitation, special attention needs to be paid to these patients postoperatively.

Infiltrative therapy as conservative treatment in hip osteoarthritis: a literature review

Osteoarthritis (OA) is a very common disease, its prevalence increases with age and is a frequent cause of disability. Osteoarthritis is characterised by joint pain, stiffness and loss of range of motion. Overall, as many as 40% of those aged over 65 years in the community may have symptomatic OA of the knee or hip (1). OA results from a complex interaction of biomechanical and biochemical factors and is characterised by cartilage disruption and hypertrophy of bone. Intraarticular proinflammatory cytokines and proteinases in OA interfere with the synthesis of hyaluronic acid (HA), a complex glycosaminoglycan composed of repeated disaccharide units to form a linear polymer, resulting in an HA with a significantly reduced molecular weight and a reduction in synovial fluid viscoelasticity (2-3). Loss of normal characteristics of HA leads to the degradation of the articular cartilage and the disruption of the mechanical and homeostasis of the joint. Several pharmaceutical approaches, such as analgesics, non steroidal antiinflammatory drugs, COX-2 inhibitors and steroids, have been proposed (4), with the aim of reducing pain and maintaining and/or improving joint function. However, none of these options has shown to delay the progression of osteoarthritis or reverse joint damage. Infiltrative hip therapy involves injecting into the joint the drugs or medicinal substances that are used primarily to control the symptoms of the disease, such as pain and functional limitation. The aim of this review is to analyse existing infiltrative alternatives for hip osteoarthritis, and describe our experience.

Utilizzo di un nanocomposto costituito da Mg-idrossiapatite e matrice ossea demineralizzata nelle osteotomie tibiali: studio prospettico randomizzato

The autologous bone substitutes are the gold standard of orthopedic surgery for the treatment of severe losses of substance. Nevertheless there are different issues, from co-morbidity of the donor site, the limited quantity and poor osteogenic properties. To overcome these limits the bank of the skeletal muscle tissue of the Rizzoli Institutes in cooperation with FIN-ceramic Faenza SpA have developed DBSint: a new synthetic bone composite, equipped with biomimetic and osteoinductive properties, consisting of demineralized bone matrix conveyed by nanostructured hydroxyapatite enriched with magnesium. The DBSint has recently been evaluated with a clinical preliminary study with the purpose to analyze the ability to form new bone tissue and the time necessary to determine bone repair. We enrolled 36 patients with indication to perform a valgus osteotomy of the tibia, divided into 3 groups, respectively, treated with nano hydroxyapatite structured in the form of paste (SINTlife) currently on the market, the cortico-cancellous bone chips provided by the BTM-IOR, and finally DBSint. There were no adverse effects, we performed biopsies and histological exam, and radiographic assessment, respectively, at 40 days and 6 months after treatment, showing that the DBSint is able to promote a fast bone regeneration, higher than in the two groups treated with Sintlife and homologous bone.