Fabrizio Perna

Current Concepts in the Biopsy of Musculoskeletal Tumors

In the management of bone and soft tissue tumors, accurate diagnosis, using a combination of clinical, radiographic, and histological data, is critical to optimize outcome. On occasion, diagnosis can be made by careful history, physical examination, and images alone. However, the ultimate diagnosis usually depends on histologic analysis by an experienced pathologist. Biopsy is a very important and complex surgery in the staging process. It must be done carefully, so as not to adversely affect the outcome. Technical considerations include proper location and orientation of the biopsy incision and meticulous hemostasis. It is necessary to obtain tissue for a histological diagnosis without spreading the tumor and so compromise the treatment. Furthermore, the surgeon does not open compartmental barriers, anatomic planes, joint space, and tissue area around neurovascular bundles. Nevertheless, avoid producing a hematoma. Biopsy should be carefully planned according to the site and definitive surgery and should be performed by an orthopedic surgeon with an experience in musculoskeletal oncology who will perform the definitive surgery. Improperly done, it can complicate patient care and sometimes even eliminate treatment options. Different biopsy techniques are suitable: fine-needle aspiration, core-needle biopsy, and incisional biopsy. The choice of biopsy depends on the size, the location of the lesion, and the experience of the pathologist.

Current classification systems for adult degenerative scoliosis

At present, a big effort of the scientific community has been directed toward a more proper and standardized approach to the patients affected by degenerative scoliosis, and recent attention has turned toward the development of classification schemes. A literature analysis highlighted several classification schemes developed for degenerative scoliosis patients: the Simmons classification system, the Aebi system, the Faldini working classification system, the Schwab system, and the Scoliosis Research Society system. Aim of the current manuscript is to scrutinize the available literature in order to provide a comprehensive overview of these current classification schemes for adult scoliosis, by describing and commenting clinical development, limits and potential of their application together with their implications for surgical planning.

Pedicle screw insertion techniques: an update and review of the literature.

Pedicle screw construct have become one of the most practiced procedure in spinal surgery. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the thoracic spine. Hence, various procedures have been described in order to improve pedicle screw insertion accuracy. Aim of this study is to evaluate current concepts on pedicle screws placement techniques to better understand recent attitude and clarify some doubts when selecting the most proper method.

Preservation of hamstring tibial insertion in anterior cruciate ligament reconstruction: a review of the current literature

Abstract Hamstring graft (HG) used in anterior cruciate ligament (ACL) reconstruction undergoes a biological modification process called “ligamentization” in the early postoperative period that proceeds through three different phases: an early graft-healing phase with central graft necrosis, a phase of proliferation, and finally, a ligamentization phase toward the properties of the intact ACL. The fastening of this process could result in more aggressive rehabilitation protocols as well as faster sport resumption. A recent literature supports the preservation of HG tibial attachment in order to enhance “ligamentization” process. Aim of this literature review is to describe all the techniques described that spare HG tibial insertion and the obtained results in order to evaluate evidence that would substantiate the maintenance of HG tibial insertion in ACL reconstruction. A search was performed using the following keywords “ACL reconstruction” in combination with “hamstrings,” “hamstrings insertion,” “tibial insertion,” “ligamentization,” and “over the top”; 18 articles were found to be relevant. Among these, eight randomized clinical trials (RCTs) were found. The RCT analyzed presented a high number of biases regarding the analyzed topic, thus making impossible to draw definitive evidences to validate HG tibial insertion sparing in ACL reconstruction. Despite the satisfactory results in many clinical series and the promising results in anatomic and animal studies, well-designed prospective clinical trials with large cohort of patients associated with MRI evaluation are mandatory to assess the beneficial effects of HG attachment preservation in ACL reconstruction.

Surgical tricks for open lumbar discectomy.

Herniated disc syndrome in the lumbar spine is the consequence of the conflict between a spinal root or cauda equina and a fragment of nucleus pulposus migrated through the annulus fibrosus. Patients usually complain of pain or paraesthesia travelling down to the lower extremity in the corresponding dermatome. In the majority of cases symptoms and radiographic signs regress with conservative measures [1]. However, many patients experience persistent symptoms or severe rapid pain progression with sensitive and motor deficits due to the rapid compression of one or more spinal roots. Lumbar discectomy is usually indicated after 6–12 weeks of conservative treatment if pain remains intractable or in case of severe sensitive or motor deficits [2, 3].

How to prevent dislocation after revision total hip arthroplasty: a systematic review of the risk factors and a focus on treatment options

BackgroundDislocation represents the most common complication after revision total hip arthroplasty (rTHA). Understanding risk factors for dislocation has a great clinical relevance for every hip surgeon in order to consider all surgical options for effective planning. The aim of this systematic review was to answer two main questions—(1) what are the risk factors for instability after rTHA? and (2) what are the best preoperative assessments and surgical options to avoid dislocation after rTHA?Materials and methodsScientific databases were accessed to identify papers dealing with prevention and treatment of dislocation after rTHA. We performed a search using the keywords ‘revision hip arthroplasty’ and ‘dislocation’, ‘instability’, ‘outcome’, ‘failure’, ‘treatment’. After removal of duplicates and exclusion of works published in different languages, 33 articles were reviewed completely.ResultsRisk factors were analysed in order to establish the most relevant and evidence-based treatments available in the current literature.ConclusionsThe risk of dislocation after rTHA can be reduced using some precautions inferred from the literature. The use of a larger femoral and acetabular component, elevated rim liner and dual mobility implants can significantly reduce the risk of dislocation after rTHA. However, care must be taken regarding patient-related risk factors since these cannot be addressed and modified. Hence, a complete evaluation of risk factors should be performed for each patient and procedure before starting rTHA.

Surgical correction of double major adolescent idiopathic scoliosis

• To explain basic principles of adolescent idiopathic scoliosis management. • To show how to place pedicle screws in the thoracic and lumbar spine in case of adolescent idiopathic scoliosis. • To show how to properly bend rods in case of double major scoliosis curve. • To explain how to perform correction maneuvers by rotation and translation simultaneously on two rods. • To explain how to perform en-bloc direct vertebral rotation.

Two-stage surgical treatment for septic non-union of the forearm

AIM To investigate the effectiveness of a two-stage surgical procedure for the treatment of septic forearm non-union. METHODS Septic non-unions are rare complications of forearm fractures. When they occur, they modify the relationship between forearm bones leading to a severe functional impairment. Treatment is challenging and surgery and antibiotic therapy are required to achieve infection resolution. It is even harder to obtain non-union healing with good functional results. The aim of this study is to present a two stages surgical treatment for septic forearm non-union with revision and temporary stabilization of the non-union until infection has cleared and subsequently perform a new synthesis with plate, opposite bone graft strut and intercalary graft. We retrospectively reviewed 18 patients with a mean age at the time of primary injury of 34.5 years (19-57 years) and a mean follow-up of 6 years (2-10 years). All patients presented an atrophic non-union with a mean length of the bone defect of 1.8 cm (1.2-4 cm). Complications and clinical results after surgical treatment were recorded. RESULTS Mean time to resolution of the infectious process was 8.2 wk (range 4-20 wk) after the first surgery and specific antibiotic therapy. All the non-union healed with an average time of 5 mo (range 2-10 mo) after the second step surgery. Cultures on intraoperative samples were positive in all cases. No major intraoperative complications occurred. Two patients developed minor complications and one needed a second surgical debridement for infection resolution. At the last follow-up functional results were excellent in 5 (27.8%) patients, satisfactory in 10 (55.5%) and unsatisfactory in 3 (16.7%) patients. No activities of daily living (ADLs) limitations were reported by 12 (66.6%) patients, slight by 3 (16.6%) and severe limitation by 3 (16.6%) patients. Mean visual analog scale at the last follow-up was 1 (0-3). CONCLUSION The two-step technique has proven to be effective to achieve resolution of the infectious process and union with good functional results and low rate of complications.

Transforaminal lumbar interbody fusion.

L2–L3–L4 posterolateral arthrodesis associated with asymmetric right transforaminal interbody fusion at L3–L4 intervertebral space was planned. The patient was placed on a suitable spine frame in prone position with the hips in neutral extension, in order to maintain lumbar lordosis. A proper positioning allows the abdomen to hang free to reduce abdominal pressure, which leads to diminished venous engorgement and intraoperative bleeding. A standard midline approach was performed from L1 to L5. The supraspinous and interspinous ligaments were carefully left intact. Once the posterior processes were carefully exposed, the articular processes of L2, L3 and L4 joints were detected. Joint capsule of L2–L3 preserved intact in order to avoid proximal junction kyphosis. In order to find the entry point for pedicle screw we usually place a forceps over the transverse process to identify the proximal and distal margins of the pedicle. The cortex on the entry point is opened with an awl where the articular joint reaches the transverse process. Pedicles were gently drilled with a 2.7 mm drill bit. This technique provides a very fine hole during the pedicle penetration, which can be corrected simply in case of incorrect trajectory creation. The integrity of the walls of the pedicles was checked. 2 mm K-wires were inserted in each pedicle. Fluoroscopy

Single level anterior cervical discectomy and interbody fusion

Degenerative disorder of cervical intervertebral disc is a common cause of neck and upper limb pain. There are several reported surgical techniques available for decompression and stabilization of the interested segment in order to treat the degenerative disorder of cervical disc [1]. Anterior cervical discectomy and interbody fusion (ACDIF) for a single level can be performed in different ways to provide good stability and restoring sagittal segmental alignment [2]; however, the rationale for the choice between different techniques remains unclear [1, 3]. The aim of this video case presentation is to show the surgical technique of ACDIF using stand-alone polyetheretherketone (PEEK) cage.