Federico Pilla

Sex differences in hip morphology: Is stem modularity effective for total hip replacement?

Total joint arthroplasty, one of the most successful orthopaedic procedures, predictably relieves pain and improves function for patients with a painful arthritic hip joint1. This high success rate has increased patient expectations, particularly those regarding hip function, after the surgery. To achieve better function and to reduce the implant dislocation rate, more attention has been given to the role of the restoration of femoral offset and soft-tissue balancing2,3. Surgeons today are committed to restoring the anatomy in each case independent of the patients age or sex or the pathological condition of the hip. Anatomic studies of hip anatomy, specifically on the femoral side, have shown sex-based anatomic differences4-8. Women tend to have a shorter femoral neck, a thinner femoral shaft, a lower cervicodiaphyseal (CCD) angle, a lower femoral offset, and greater anteversion of the femoral neck (Fig. 1). These differences should be addressed during revision hip surgery in order to restore hip anatomy. In particular, to achieve proper soft-tissue balancing, the femoral offset should be accurately restored. The femoral offset is represented by the perpendicular distance from the center of the femoral head to the long axis of the femur (Fig. 2). McGrory et al.9 found a correlation between a lack of restoration of femoral offset and abductor muscle weakness and limping. These results depend on hip mechanics, with a fulcrum between body weight and the hip abductors (Fig. 3). The length of the lever arm of the hip abductors is smaller than that of body weight. Therefore, the abductors must generate a force that is larger than body weight to maintain a level pelvis. In contrast, an increase in femoral offset increases the lever arm of the abductors, reducing the force required to balance body weight and thereby …

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.

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review

PurposeInfrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting.MethodsThe available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords “Saphenous” and “Infrapatellar branch” in combination with “Anterior cruciate ligament”, “arthroscopy” and “hamstrings”, supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles.ResultsFive articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance.ConclusionAlthough the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice.Level of evidence Systematic review, Level II.

Periprosthetic femoral fractures: treatments and outcomes. An analysis of 47 cases

We evaluated the treatment and outcome of 47 cases of periprosthetic femoral fracture presenting to our unit over a nine-year period. The average follow-up period was 48 months (range 24-114). Surgical treatment involved stem revision in 29 hips, open reduction and internal fixation in 11 hips and conservative treatment in seven hips. The mean HHS at the most recent follow-up was 74 (range 49-91). Twenty-five patients were pain-free (53%), 10 patients had occasional mild pain (21%), eight patients had a limp and pain (17%) and four patients had severe disability (9%). Postoperative radiographs showed complete fracture union in all 47 patients. There were 11 complications: three further periprosthetic fractures, two aseptic loosenings, two dislocations, two aseptic loosenings of the primary prostheses, one stem breakeage, and one intraoperative fracture. Our results suggest cementless revision with tapered fluted stems used without cortical strut grafts are a valid procedure for the treatment of Vancouver B2 and B3 periprosthetic fractures.

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

In-Vitro and In-Vivo Ceramic Debris with Ceramic Prosthesis

Ceramic prostheses have had some promising long term results [1], and modern metal-back alumina cups have shown very good clinical results [2,3,4]. Alumina has excellent tribological properties, a very high Young’s modulus that leads to very good compression strength, but it has poor bending strength: it has no way to deform [5]. This means that ceramic can break without warning. With modern ceramics, under normal physiologic conditions, the fatigue limit is never reached, therefore ceramic head fractures are seldom reported (0.004%10 in one study). On the contrary, ceramic liner fractures are not well recognized and their frequency could be underestimated. Besides, it is difficult to identify those patients at risk, because liner fractures can be related to multiple causes: dislocation, impingement, malpositioning, microseparation [6,7]. When a ceramic fracture involves the liner and is the consequence of repeated micro-trauma, the diagnosis is rarely made early, except when ceramic fragments are visible on X-ray. Moreover, revision surgery decision making after a failed ceramic-on-ceramic prosthesis is troublesome: the ceramic fragments which have spread into the periarticular space are abrasive, and they can lead to early failure of the revision procedure. In a multicenter study on 105 total hip revisions due to ceramic head fracture, Allain et al. reported a second revision rate of 31% (33 hips) at 5 years follow up. The main cause of the repeat revisions was aseptic loosening due to metal and polymethyl methacrylate wear [8].