Eugenio Vecchini

Three-Dimensional Matrix-Induced Autologous Chondrocytes Implantation for Osteochondral Lesions of the Talus: Midterm Results

Introduction. We evaluate the midterm results of thirty patients who underwent autologous chondrocytes implantation for talus osteochondral lesions treatment. Materials and Methods. From 2002 to 2009, 30 ankles with a mean lesion size of 2,36 cm2 were treated. We evaluated patients using American Orthopaedic Foot and Ankle Surgery and Coughlin score, Van Dijk scale, recovering time, and Musculoskeletal Outcomes Data Evaluation and Management System. Results. The mean AOFAS score varied from 36.9 to 83.9 at follow-up. Average of Van Dijk scale was 141.1. Coughlin score was excellent/good in 24 patients. MOCART score varied from 6.3 to 3.8. Discussion. This matrix is easy to handle conformable to the lesion and apply by arthroscopy. No correlation between MRI imaging and clinical results is found. Conclusions. Our results, compared with those reported in literature with other surgical procedures, show no superiority evidence for our technique compared to the others regarding the size of the lesions.

Clinical and radiologic outcomes of total knee arthroplasty using the Advance Medial Pivot prosthesis. A mean 7 years follow-up

BACKGROUND Medial Pivot total knee prosthesis has been designed according to studies on normal knee kinematics aiming to replicate physiological knee movement. The purpose of this study was to evaluate clinical and radiologic results of the Advance Medial Pivot Total Knee Arthroplasty, at a mean follow-up of seven years. METHODS One hundred seventy two Medial Pivot total knee arthroplasties in 160 consecutive patients have been evaluated using the American Knee Society Score and the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Statistical analysis was performed using the Students t-test and the Wilcoxon matched-pairs signed-rank (Mann-Whitney) test in order to evaluate the significance of differences within the groups of patients. Patients compliance was 93.75% thus only six patients (3.75%) lost to follow-up and four patients (2.5%) died for reasons unrelated to the surgery. RESULTS The mean Knee Society score and range of motion was improved from 77.6 points and 97.7° to 152.8 points and 112.5° respectively (p<.001). In total 85.8% and 82.4% of the knees had an excellent (≥ 80) or good (70-79) functional and knee scores respectively. Relief of pain was satisfactory in 88.9% of the patients, while 96% of the patients return to age-related daily life activities. Stability and comfort during walking was subjectively judged by the patients as satisfactory in about 90%. Anterior knee pain was observed in eight patients (5.4%). The Kaplan-Meier survivorship analysis showed a cumulative success rate of 98.6%. CONCLUSIONS The results are encouraging but longer follow-up of this cohort is necessary in the study of this specific design. Level of evidence IV.

Autologous chondrocyte implantation: Prospective MRI evaluation with clinical correlation

PurposeThis study was done to assess the progression of cartilage repair after autologous chondrocyte implantation (ACI) with magnetic resonance imaging (MRI) and to correlate the findings with the clinical outcome.Materials and methodsForty-one patients (mean age 30 years) affected by chondral defects of the knee (27 patients) and ankle joint (14 patients) who underwent arthroscopic autologous osteochondral grafting were studied 6 months and 1 year postoperatively with MRI. Cartilage repair after chondrocyte implantation was studied by assessing the degree of defect filling, graft integration, graft signal intensity, integrity of the subchondral lamina and trabecular oedema underneath the graft. MR findings were correlated with clinical data.ResultsPostoperative MRI evaluation at 6 months demonstrated complete filling of the osteochondral defect in 12/41 cases, complete integration in 18/41, mild hyperintensity in 28/41, intact subchondral lamina in 38/41 and trabecular oedema in 11/41. Postoperative MRI evaluation at 1 year demonstrated complete filling of the osteochondral defect in 9/41 patients, complete integration in 22/41, mild hyperintensity in 23/41, intact subchondral lamina in 36/41 and trabecular oedema in 8/41. Filling of the osteochondral defect and incomplete integration, nonintact subchondral lamina, high signal intensity and absence of oedema were found to correlate with worse clinical-functional outcomes.ConclusionsMRI shows direct prognostic signs of the clinical outcome of ACI.RiassuntoObiettivoValutare con risonanza magnetica (RM) l’evoluzione dell’impianto di cartilagine autologa nelle lesioni condrali e correlare i dati con i risultati clinici.Materiali e metodiSono state esaminate con RM a sei mesi ed un anno dall’intervento, 41 lesioni cartilaginee del ginocchio (27) e tibio-tarsiche (14), trattate per via artroscopica con impianto di condrociti autologhi su supporto tridimensionale di acido ialuronico. L’evoluzione dell’impianto è stata studiata analizzando il grado di colmatura del difetto osteocondrale, il grado di integrazione, l’intensità di segnale della cartilagine trapiantata, l’integrità della lamina corticale subcondrale e l’edema trabecolare. Tutti i dati sono stati correlati con la clinica.RisultatiA sei mesi: completo grado di colmatura in 12/41 pazienti, integrazione completa dell’impianto in 18/41, modesta iperintensità del segnale in 28/41, lamina subcondrale intatta in 38/41, edema trabecolare in 11/41. Ad un anno: completo grado di colmatura in 9/41 pazienti, integrazione completa dell’impianto in 22/41, modesta iperintensità del segnale in 23/41, lamina subcondrale intatta in 36/41, edema trabecolare in 8/41. Il grado di colmatura e di integrazione incompleti, la lamina subcondrale non intatta, l’iperintensità del segnale e l’assenza di edema sono risultati correlare con i risultati clinico-funzionali peggiori.ConclusioniLa valutazione RM presenta elementi prognostici in termini di buon attecchimento dell’impianto.

Temporary bridging external fixation in distal tibial fracture

Fractures that involve the distal area of the tibia are associated with a high percentage of complications. Soft tissue oedema, swelling, blisters, skin abrasions and open wounds could compromise the outcome of these lesions. The waiting time before surgery with ORIF is mostly due to soft tissue conditions. Early application of a simple joint-spanning external fixator would achieve the initial goal of stability and the respect of soft tissue, thereby decreasing the time necessary for definitive treatment. A total of 40 consecutive patients (22 male and 18 female) with a mean age of 52 years (range 17-82 years) with distal tibial fracture treated between January 2010 and January 2013 were evaluated. Early temporary external fixation was the first treatment step. Twenty patients had pilon fractures, characterised by the intra-articular involvement of the distal tibia with metaphyseal extension, and 20 patients had malleolar fracture-dislocation. Patients were divided into two groups, A and B. Group A comprised 10 patients with ankle fracture-dislocation and bone fragmentation, who were treated with a temporary bridging external fixation that was maintained after ORIF to exploit ligamentotaxis during the first phases of bone healing. In Group B (30 patients), the external fixation was removed after ORIF. The results of the study are in line with the recent literature: temporary external fixation in high-energy trauma and fracture-dislocation of the ankle enables soft tissue to be restored, which facilitates postoperative assessment of bone fragments by CT scan. The complication rate in this study was 5% in patients with malleolar fractures and 20% in patients with pilon fractures. The maintenance of temporary external fixation after ORIF synthesis during the entire first stage of bone healing seems to be a good method of treatment that has a low rate of soft tissue complications.

A clinical and radiological study of biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tears

Total knee replacement is a common treatment for advanced knee osteoarthritis. The most common and widespread method is cemented arthroplasty. As in the prosthetic hip a gradual transition from cemented to uncemented fixation techniques occurred over time, increasing interest is growing also around cementless knee fixation, with the theoretical advantages of preserving the bone stock and obtaining a biological fixation avoiding cement fragmentation. On the basis of the actual knowledge, the uncemented knee prosthesis represents an interesting alternative especially for the patient under 65 years of age, with viable bone quality, in which a biological bone-prosthesis fixation is desirable, while avoiding the drawbacks of cement fragmentation and of the possible future revision of a cemented implant. However the weak link remains the tibial fixation, so that technical tips are important to avoid micromovements with subsequent lack of osteointegration. In our experience, gap balancing, mobile bearings and no haemostatic tourniquet well combine with this kind of implant.Injuries of collateral ligaments of MCPs joints are often underdiagnosed but have to be considered serious traumas of the hand. In many cases they concern thumb and rarely long fingers. Closed rupture of the deep transverse metacarpal ligament (DTML) is an unusual parallel injury. Both lesions present similar symptoms included local pain, swelling, ecchymosis and deviation of the finger in flexion and can be misdiagnosed. We describe the treatment of a 34 years old woman who sustained a complex lesion of the soft tissues of third metacarpophalangeal joint with complete close tear of the radial collateral and deep transverse metacarpal ligament following a fall during a walk thus leading to a multiplanar instability. Surgery consisted in mini anchor repair or the collateral ligament tear, direct resorbable suture of DTML and a double k-wire stabilization. Follow up at 11 months has shown excellent functional outcomes.

Antibiotic-Loaded Spacer for Two-Stage Revision of Infected Total Knee Arthroplasty.

Abstract Infection of total knee arthroplasty (TKA) is a challenge in orthopedic surgery. In literature TKA infection is classified according to the time after surgery: acute postoperative; late chronic; acute hematogenous; positive intraoperative microbiological growth. The purpose of this study is to present the results of the use of a preformed antibiotic‐loaded spacer in TKA infections, treated by a two‐stage revision procedure. A series of 19 consecutive patients (20 knees) with a diagnosis of infected TKA were treated from January 2003 to February 2012. Two‐stage reimplantation protocols were completed only in 16 patients and these data were included in the study. We lost three patients at follow‐up. An antibiotic‐loaded preformed articulating polymethylmethacrylate spacer was applied. Patients were observed 1, 3, and 6 months postoperatively and then yearly for clinical and radiographic examination. The mean American Knee Society Score improved from 68.4 preoperatively (range, from 34 to 108) to 112.7 at final follow‐up (range, from 49 to 180). The pain was evaluated as part of clinical score. It improved from an average of 19.3 preoperatively (range, from 10 to 30) to 34.3 at final follow‐up (range, from 10 to 50). The average range of motion improved from 40.1 degrees (range, from 6 to 90 degrees) to 79.3 degrees (range, from 45 to 125 degrees). The use of the spacer allows obtaining a reduction of pain, an improvement of quality of life in the period of time between the two surgical stages and an easier reimplantation of TKA.

Evolution of TKA design

Background and aim of the work : The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. Methods : Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. Results: The percentage of knees that had a HKA within ±3° of the desired value was 92.2. Conclusion: the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.

An unusual case of osteochondritis dissecans of the medial tibial plateau

Abstract We report the case of a 17-year-old boy with osteochondrosis of the medial tibial plateau treated with reasorbable screw. This is an unusual location for osteochondritis dissecans, a pathologic process resulting from ischemic necrosis and characterized by the detachment of a fragment of the cartilage together with the subchondral bone of the articular surface. The lesion may be located in many joints, most frequently in the knee, close to lateral side of the articular surface of the medial femoral condyle.