Federico Dettoni

Medial Opening Wedge High Tibial Osteotomy for Medial Compartment Overload/Arthritis in the Varus Knee Prognostic Factors

Background: Medial opening wedge high tibial osteotomy (OWHTO) is a widely accepted procedure for the treatment of medial compartment arthritis of the knee. Compared with closing wedge HTO, however, the outcomes of OWHTO reported in the literature are incomplete. Purpose: To identify the positive and negative prognostic factors related to the outcomes of OWHTO through an evaluation of midterm study results and survivorship analysis. Study Design: Case series; Level of evidence, 4. Methods: From January 2001 to December 2009, a total of 141 consecutive OWHTOs were performed in 123 patients. Only patients with symptomatic medial knee overload/arthritis were included. The patients were evaluated preoperatively and at every follow-up visit with (1) the Knee Society score, (2) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, (3) another self-evaluation scale, (4) long-leg radiographs, and (5) plain radiographs. Preoperative, intraoperative, and postoperative variables were investigated to find an association with the outcomes. Results: Of the 123 patients, 15 were lost to follow-up, and 24 were excluded from the study, leaving 84 patients (99 OWHTOs) for the present study. The mean age of the patients at the time of surgery was 54.5 ± 9.2 years. The mean follow-up was 51.5 ± 23.8 months. The Knee Society and WOMAC scores significantly improved after surgery (P < .001). The variables significantly related to a poor outcome were (1) age >56 years (P = .008) and (2) postoperative knee flexion <120° (P < .001); the variables significantly related to a good outcome were (1) Ahlbäck grade 0 arthritis of the medial compartment (P < .001) and (2) excellent preoperative Knee Society score (P < .001). The Kaplan-Meier analysis showed a survival rate of 98.7% at 5 years and 75.9% at 7.5 years. Conclusion: With correct indications, OWHTO is a reliable procedure for medial knee arthritis/overload. The outcomes reported are similar to those from other studies, although the variables related to outcomes are slightly different.

Treatment of medial and posteromedial knee instability: indications, techniques, and review of the results.

Until recently, the posterolateral corner of the knee was noted both for its complex anatomy and diagnostic challenges. To improve the understanding of the posterolateral knee, we completed a comprehensive and stepwise research program with a focus on five primary areas: (1) surgical approach and relevant anatomy; (2) diagnosis; (3) clinically relevant biomechanics; (4) natural history; and (5) surgical treatment. Based on this comprehensive research program, the diagnosis and outcomes following treatment of posterolateral knee injuries have been significantly improved comparing the preoperative state to the state of the knee at a minimum 2 year follow‐up in the cases series presented here.

Bone marrow derived stem cells in joint and bone diseases: a concise review

Stem cells have huge applications in the field of tissue engineering and regenerative medicine. Their use is currently not restricted to the life-threatening diseases but also extended to disorders involving the structural tissues, which may not jeopardize the patients’ life, but certainly influence their quality of life. In fact, a particularly popular line of research is represented by the regeneration of bone and cartilage tissues to treat various orthopaedic disorders. Most of these pioneering research lines that aim to create new treatments for diseases that currently have limited therapies are still in the bench of the researchers. However, in recent years, several clinical trials have been started with satisfactory and encouraging results. This article aims to review the concept of stem cells and their characterization in terms of site of residence, differentiation potential and therapeutic prospective. In fact, while only the bone marrow was initially considered as a “reservoir” of this cell population, later, adipose tissue and muscle tissue have provided a considerable amount of cells available for multiple differentiation. In reality, recently, the so-called “stem cell niche” was identified as the perivascular space, recognizing these cells as almost ubiquitous. In the field of bone and joint diseases, their potential to differentiate into multiple cell lines makes their application ideally immediate through three main modalities: (1) cells selected by withdrawal from bone marrow, subsequent culture in the laboratory, and ultimately transplant at the site of injury; (2) bone marrow aspirate, concentrated and directly implanted into the injury site; (3) systemic mobilization of stem cells and other bone marrow precursors by the use of growth factors. The use of this cell population in joint and bone disease will be addressed and discussed, analysing both the clinical outcomes but also the basic research background, which has justified their use for the treatment of bone, cartilage and meniscus tissues.

Bone Mineral Density and Singh Index Predict Bone Mechanical Properties of Human Femur

The aim of our study was to assess the predictive value of the Singh index (SI), which estimates bone architecture, and bone density (BMD) when dealing with the mechanical competence of bone and to analze possible differences in bone properties between gender in humans. The relationship between SI, BMD, and mechanical competence was analyzed in 106 bone cylinders from 37 human femoral heads obtained during hip-joint replacement surgery for low energy fracture or for osteoarthritis. Bones from osteoporotic patients are less dense and more brittle compared with bones from osteoarthritic patients, as expected. Among osteoporotic patients female bones were more brittle than those from males, although BMD was similar. In osteoarthritic patients there were no significant differences among sexes. Bone mechanical competence varies according to BMD and to SI categories. Thus, our study suggests that bone strength is predicted by both BMD and bone architecture.

Clinical examination of the knee: know your tools for diagnosis of knee injuries

The clinical evaluation of the knee is a fundamental tool to correctly address diagnosis and treatment, and should never be replaced by the findings retrieved by the imaging studies carried on the patient.Every surgeon has his own series of exams with whom he is more confident and on whom he relies on for diagnosis. Usually, three sets of series are used: one for patello-femoral/extensor mechanism pathologies; one for meniscal and chondral (articular) lesions; and one for instability evaluation.This review analyses the most commonly used tests and signs for knee examination, outlining the correct way to perform the test, the correct interpretation of a positive test and the best management for evaluating an injured knee both in the acute and delayed timing.

Validation and cross cultural adaptation of the Italian version of the Harris Hip Score

Introduction The Harris Hip Score (HHS) is one of the most widely used health related quality of life (HRQOL) measures for the assessment of hip pathology: in spite of this, a validation study, and an official Italian version have not been provided yet. The aim of this study was to create an Italian valid and reliable version of the HHS. Materials and methods The score was translated and modified in Italian; then 103 patients with different hip pathologies were evaluated using this HHS version and also with the WOMAC and the SF-12 questionnaires. Content, construct and criterion validities were tested, such as interobserver reliability, test-retest reliability and internal consistency. Results Cross-cultural adaptation was easy, and only minor adaptation was required in the translation process. Construct and criterion validity of the HHS Italian Version were confirmed by satisfactory values of Spearmans Rho for correlation between specific domains of HHS and Womac and SF12 scores. Interobserver and test-retest reliabilities obtained values of 0.996 and 0.975 respectively; Cronbachs alpha for internal consistency was 0.816. Discussion Statistical and clinical analysis showed that HHS is highly valid and reliable in this new Italian version.

Use of tranexamic acid in total knee arthroplasty

PURPOSE different strategies have been developed to reduce blood loss in total knee arthroplasty (TKA). The efficacy of both systemic and local tranexamic acid (TXA) administration is demonstrated in the literature. The aim of the present study was to compare the efficacy of systemic, local and combined (systemic + local) administration of TXA in reducing blood loss after TKA. METHODS we enrolled all patients submitted to a primary TKA in our department between November 2014 and August 2015. They were divided into three groups corresponding to the method of TXA administration used: intravenous (IV), intra-articular (IA), and a combination of the two. Demographic data, as well as preoperative hemoglobin and platelet levels, were collected. The primary outcome was the maximum hemoglobin loss, while the secondary outcomes were the amount of blood in the drain (cc/hour) and the rate of transfusions; postoperative pain was also assessed. Students t-test or a χ2 test was used to evaluate between-group differences, using p<0.05 as the cut-off for statistically significant differences. RESULTS the sample comprised 34 patients: IV, 10 cases; IA, 15 cases, and combined (IV + IA), 9 cases. The average age of the patients was 71.1±6.4 years. No significant differences in the outcome measures were found between the groups, with the exception of a significantly lower maximum hemoglobin loss in the combined versus the IV group (p=0.02). There were no differences between the groups in the amount of blood in the drain or the rate of transfusions. CONCLUSIONS the data from this preliminary study, as well as data from the literature, confirm that TXA administration is safe and effective in reducing total blood loss in TKA, and no administration protocol seems to be superior to the others. LEVEL OF EVIDENCE Level II, prospective comparative study.

Treatment of Bone Losses in Revision Total Hip and Knee Arthroplasty Using Trabecular Metal

Revision Total Knee or Hip Arthroplasty is challenging procedures for surgeons usually characterized by bone loss. There are different options available to treat those bone losses. However, there is still a concern on the stability of bone-implant interface, which is mandatory to achieve good long-term results in prosthetic implants. Recently, porous tantalum has been introduced, with the aim of improving the bone-implant interface fixation and implant primary stability. Different solutions for the treatment of bone defects in both revision Total Knee and Hip Arthroplasty have been proposed. In revision Total Hip Arthroplasty (THA) tantalum shells can be used to treat Paprosky type III defects also, because of their mechanical properties. Similarly, trabecular metal has been proposed in revision Total Knee Arthroplasty (TKA), being considered a viable option to treat severe type 2 or 3 defects. The aim of this paper is to review the mechanical properties and characteristics of tantalum. Furthermore, we will discuss its role in treating bone defects in both revision THA and TKA, as well as the outcome reported in literature.

Patellar tendon: From tendinopathy to rupture

Patellar tendinopathy is very common in patients complaining of anterior knee pain. Its aetiology is still unclear, but neovascularisation seems to play a role. Different treatments have been proposed overtime, from rehabilitation to platelet-rich-plasma injections, but there is no agreement on the best treatment protocol. The final stage of patellar tendinopathy is patellar tendon rupture. In these cases surgical treatment is often required. The aim of this literature review is to focus on the aetiology, diagnosis, and treatment of both patellar tendinopathy and rupture. We report the conservative treatments proposed for patellar tendinopathy and the surgical techniques described for its rupture.

High tibial osteotomy in varus knees: indications and limits.

Opening wedge high tibial osteotomy (OWHTO) is a surgical procedure that aims to correct the weight-bearing axis of the knee, moving the loads laterally from the medial compartment. Conventional indications for OWHTO are medial compartment osteoarthritis and varus malalignment of the knee; recently OWHTO has been used successfully in the treatment of double and triple varus. OWHTO, in contrast to closing wedge high tibial osteotomy, does not require fibular osteotomy or peroneal nerve dissection, or lead to disruption of the proximal tibiofibular joint and bone stock loss. For these reasons, interest in this procedure has grown in recent years. The aim of this study is to review the literature on OWHTO, considering indications and prognostic factors (body mass index, grade of osteoarthritis, instability, range of movement and age), outcomes at mid-term follow-up, and limits of the procedure (slope modifications, patellar height changes and difficulties in conversion to a total knee arthroplasty).