Giuseppe Massazza

Arthroscopic Treatment of Hip Chondral Defects: Autologous Chondrocyte Transplantation Versus Simple Debridement—A Pilot Study

PURPOSE To compare the effectiveness of simple arthroscopic debridement versus arthroscopic autologous chondrocyte transplantation (ACT) for the treatment of hip chondral lesions. METHODS We carried out a controlled retrospective study of 30 patients affected by a post-traumatic hip chondropathy of the third or fourth degree, according to the Outerbridge classification, measuring 2 cm² in area or more. Of these patients, 15 underwent arthroscopic ACT, whereas the other 15 underwent arthroscopic debridement. The 2 groups were similar in age, sex, degree, and location of the pathology. All the patients were assessed before and after the procedure with the Harris Hip Score (HHS). RESULTS In both groups the mean follow-up was approximately 74 months (range, 72 to 76 months). The mean size of the defect was 2.6 cm². The patients who underwent ACT (group A) improved after the procedure compared with the group that underwent debridement alone (group B). The mean HHS preoperatively was 48.3 (95% confidence interval [CI], 45.4 to 51.2) in group A and 46 (95% CI, 42.7 to 49.3) in group B (P = .428 [no significant difference]). The final HHS was 87.4 (95% CI, 84.3 to 90.5) in group A and 56.3 (95% CI, 54.4 to 58.7) in group B (P < .001 [significant difference]). CONCLUSIONS This study indicates that an ACT procedure can be used in the hip for acetabular chondral defects. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Antibiotic-Loaded Cement in Orthopedic Surgery: A Review

Infections in orthopaedic surgery are a serious issue. Antibiotic-loaded bone cement was developed for the treatment of infected joint arthroplasties and for prophylaxes in total joint replacement in selected cases. Despite the widespread use of the antibiotic-loaded bone cement in orthopedics, many issues are still unclear or controversial: bacterial adhesion and antibiotic resistance, modification of mechanical properties which follows the addition of the antibiotic, factors influencing the release of the antibiotic from the cement and the role of the surface, the method for mixing the cement and the antibiotic, the choice and the effectiveness of the antibiotic, the combination of two or more antibiotics, and the toxicity. This review discusses all these topics, focusing on properties, merits, and defects of the antibiotic loaded cement. The final objective is to provide the orthopaedic surgeons clear and concise information for the correct choice of cement in their clinical practice.

Take-off analysis of the Olympic ski jumping competition (HS-106m).

The take-off phase (approximately 6m) of the jumps of all athletes participating in the individual HS-106m hill ski jumping competition at the Torino Olympics was filmed with two high-speed cameras. The high altitude of the Pragelato ski jumping venue (1600m) and slight tail wind in the final jumping round were expected to affect the results of this competition. The most significant correlation with the length of the jump was found in the in-run velocity (r=0.628, p<0.001, n=50). This was a surprise in Olympic level ski jumping, and suggests that good jumpers simply had smaller friction between their skis and the in-run tracks and/or the aerodynamic quality of their in-run position was better. Angular velocity of the hip joint of the best jumpers was also correlated with jumping distance (r=0.651, p<0.05, n=10). The best jumpers in this competition exhibited very different take-off techniques, but still they jumped approximately the same distance. This certainly improves the interests in ski jumping among athletes and spectators. The comparison between the take-off techniques of the best jumpers showed that even though the more marked upper body movement creates higher air resistance, it does not necessarily result in shorter jumping distance if the exposure time to high air resistance is not too long. A comparison between the first and second round jumps of the same jumpers showed that the final results in this competition were at least partly affected by the wind conditions.

Dislocation rate after hip arthroplasty within the first postoperative year: 36 mm versus 28 mm femoral heads.

Dislocation is a common and important complication of total hip arthroplasty (THA). Larger femoral heads may reduce the risk of dislocation and improve the range of movement. The aim of this study was to compare the relative risk (RR) of dislocation during the first year after THA between implants with 28mm and 36mm femoral heads. 198 consecutive hips with 28mm femoral head (Group-28) and 259 hips with 36mm femoral head (Group-36) were studied. The patients were assessed preoperatively and periodically using the Harris hip score (HHS) and radiographic analysis. The relative risk (RR) of dislocation was calculated. The average HHS significantly improved from a preoperative baseline to the last follow-up at 82.1 months (28mm) and 44.3 months (36mm). No statistically significant differences were revealed between the two groups for HHS results and complications (p>0.05), but the difference in RR of dislocation within the first year between the two groups was 7.85 (95%CI: 1.34–46.03), p=0.046. Although dislocation is multifactorial in etiology, the two groups were homogenous for all principal contributing factors except the diameter of the femoral head. Therefore, the use of 36-mm heads can reduce the risk of dislocation following THA by a factor of 8 compared to conventional 28mm heads.

Instrumented Gait Analysis for an Objective Pre-/Postassessment of Tap Test in Normal Pressure Hydrocephalus

OBJECTIVE To present an objective method to evaluate gait improvements after a tap test in idiopathic normal pressure hydrocephalus (INPH). DESIGN Retrospective analysis of gait data. SETTING Public tertiary care center, day hospital. The gait analysis was performed before and 2 to 4 hours after the tap test. PARTICIPANTS Participants included patients with INPH (n=60) and age- and sex-matched controls (n=50; used to obtain reference intervals). From an initial referred sample of 79 patients (N=79), we excluded those unable to walk without walking aids (n=9) and those with incomplete (pre-/posttap test) gait data (n=10). Thirteen out of 60 patients were shunted and then reappraised after 6 months. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mahalanobis distance from controls, before and after the tap test. Eleven gait parameters were combined in a single quantitative score. Walking velocity was also evaluated because it is frequently used in tap test assessment. RESULTS Patients were classified into 2 groups: tap test responders (n=22, 9 of them were shunted) and not suitable for shunt (n=38, 4 of them were shunted). In the tap test responders group, 9 out of 9 patients improved after shunt. In the not suitable for shunt group, 3 out of 4 patients did not improve. Gait velocity increased after the tap test in 53% of responders and in 37% of patients not suitable for shunt. CONCLUSIONS The new method is applicable to clinical practice and allows for selecting tap test responders in an objective way, quantifying the improvements. Our results suggest that gait velocity alone is not sufficient to reliably assess tap test effects.

Post-operative rehabilitation after surgical repair of the rotator cuff

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient’s work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist’s choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and “core” stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

Comparison of Fixed and Mobile-Bearing Total Knee Arthroplasty at a Mean Follow-up of 116 Months

BACKGROUND The superiority of mobile-bearing total knee arthroplasty implants over fixed-bearing implants, or vice versa, is still debated. METHODS A series of patients with similar clinical and radiographic characteristics were treated consecutively with 100 fixed-bearing followed by 100 rotating-platform implants. Patients underwent prospective clinical and radiographic evaluation. RESULTS The mean duration of follow-up was 116 months (range, sixty-one to 144 months). Clinical, radiographic, and implant survival outcomes were compared. No significant differences between the mobile-bearing and fixed-bearing groups were found with respect to the clinical outcome or cumulative implant survival at the time of the latest follow-up. Three of the fixed-bearing implants and one of the rotating-platform implants had required revision surgery. CONCLUSIONS No differences between mobile-bearing and fixed-bearing designs were demonstrated at a mean of 116 months of follow-up.

A new technique to improve tissue grip and contact force in arthroscopic capsulolabral repair: the MIBA stitch

The success of anatomic repair of Bankart lesion diminishes in the presence of a capsule stretching and/or attenuation is reported in a variable percentage of patients with a chronic gleno-humeral instability. We introduce a new arthroscopic stitch, the MIBA stitch, designed with a twofold aim: to improve tissue grip to reduce the risk of soft tissue tear, particularly cutting through capsular–labral tissue, to and address capsule-labral detachment and capsular attenuation using a double loaded suture anchor. This stitch is a combination of horizontal mattress stitch passing through the capsular–labral complex in a “south-to-north” direction and an overlapping single vertical suture passing through the capsule and labrum in a “east-to-west” direction. The mattress stitch is tied before the vertical stitch in order to reinforce the simple vertical stitch, improving grip and contact force between capsular–labral tissue and glenoid bone.

Rotating-hinge total knee for revision total knee arthroplasty.

Rotating-hinge knee implants are used for revision total knee arthroplasty in patients with severe ligament instability and bone loss. This study evaluated the outcomes of a series of rotating-hinge knees. Thirty-one NexGen Rotating Hinge Knees (Zimmer, Warsaw, Indiana) were implanted in 29 patients (2 bilateral), with an average age of 72.8 years. Indications for surgery were aseptic loosening (n=23), septic loosenings (n=4), tibiofemoral instability (n=3), and wear (n=1). The Hospital for Special Surgery Knee Score and the Knee Society Roentgenographic Evaluation System were used. Statistical and cumulative survival rate analyses were performed. Average follow-up was 60.3 months (range, 32-100 months). The Hospital for Special Surgery Knee Score results indicated statistically significant improvement; the total score increased from 65.5 preoperatively to 88.4 postoperatively. Average range of motion increased from 90.9° preoperatively to 114.4° postoperatively. Radiographs showed no periprosthetic bone fractures or implant ruptures. Radiolucent lines were found in 20 of 26 patients and were progressive in 2 (both revised). Complications occurred in 10 patients. The rigidity of the hinge may be associated with a risk of aseptic loosening due to the increased stress transfer to the bone from the prosthesis through the locked hinge. Rotating-hinge knee implants provided acceptable mid-term outcomes for revision knee surgery with ligamentous instability. They are not at higher risk for early loosening unless short tibial stems are used. The high percentage of failures is more related to the complex surgery and to the status of the patients than to the hinged mechanism.

Multimodal Analgesia in Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Trial on Additional Efficacy of Periarticular Anesthesia

Pain management is a main determinant of functional recovery after total knee arthroplasty (TKA). We performed a randomized, controlled, double blind study to evaluate additive efficacy of periarticular anesthesia in patients undergoing TKA in reducing post-operative pain, operated limb edema and improving post-operative mobility. Patients were randomly assigned to study or control group; all subjects received the same analgesic protocol; before wound closure, the study group received also a periarticular anesthesia (ropivacaine 1% 20 mL). The results show no statistical differences in any of the variable evaluated. Our data suggest that additive periarticular anesthetic protocol with ropivacaine 1% 20 mL is not superior to oral and intravenous analgesia alone in patients undergoing TKA, regarding post-operative pain control, operated limb edema reduction and post-operative mobility improvement.