Giuseppe Tedesco

Atypical femoral fractures.

Bisphosphonates (BPs) represent the most widely used therapy for osteoporosis. Recently, a relationship between long-term treatment with BPs and a subset of atypical femoral fractures (AFFs) from below the lesser trochanter to the sovracondilar line has been described. Many etiopathogenetic theories have been invoked to explain AFFs: reduced bone turnover and increased osteoblast bone apposition with accumulation of microdamage and decreased bone toughness with subsequent increased risk of micro-cracks and duration fractures, collagen fiber cross-linking and vascularization impairment. Based on published studies, a task force of the American Society for Bone and Mineral Research has redacted the diagnostic criteria of AFFs by classifying them according to their major and minor criteria. The treatment for displaced AFFs is osteosynthesis, but there is a lack of evidence for undisplaced AFFs and the duration of fracture treatment. BPs have a proven efficacy in osteoporotic fracture reduction as well as in the treatment of other bone diseases caused by the downregulation of osteoclast activity. BPs have an excellent benefit-to-risk ratio; however, minor adverse events, such as AFFs, occur in a variable percentage of patients treated over a long period of time.

Autograft, allograft and bone substitutes in reconstructive orthopedic surgery

Reconstruction of bone defects is a challenge for all orthopedic surgeons worldwide; to overcome this problem there are different options: the use of autografts, allografts and bone substitutes (BSs) to enhance and accelerate bone repair. Autografts have excellent biological properties but are associated with morbidity of the donor site and are restricted in volume. Allografts are available in adequate quantity but concerns still remain about the risk of infections, moreover they do not have osteogenetic properties. Bone substitutes have different indications and are very attractive for orthopedic surgeons. The present paper briefly reviews the advantages and disadvantages of autografts, allografts and BSs for bone reconstruction.

Ankle fractures in elderly patients

The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner’s wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.

Bioabsorbable Calcaneo-Stop Implant for the Treatment of Flexible Flatfoot: A Retrospective Cohort Study at a Minimum Follow-Up of 4 Years

ABSTRACT Arthroereisis of the subtalar joint is a common surgical technique in Europe for the management of flexible flatfoot in the pediatric population. In most cases, it is performed using a calcaneo‐stop metallic screw. Despite the good clinical results, screw removal is always advised after 2 to 3 years. The use of a bioabsorbable screw might overcome the need for a second operation to remove a nonabsorbable device. We report the results of a biodegradable calcaneo‐stop screw at a minimum of 4 years of follow‐up. Eighty‐eight procedures were performed on 44 children. All patients were clinically and radiologically evaluated preoperatively and at a minimum 4‐year follow‐up period. Patient satisfaction and plantar collapse using Viladots classification were recorded. Mearys talus–first metatarsal angle and talocalcaneal angle were measured on radiographs preoperatively and at the last follow‐up visit. The presence of the device at the last follow‐up examination was assessed by magnetic resonance imaging. The mean follow‐up duration was 56 months. Of the 44 patients, 33 (75%) reported excellent clinical outcomes, 9 (20.5%) good outcomes, and 2 (4.5%) poor. Foot print improvement was registered for all patients. The mean Mearys talus–first metatarsal angle had improved from 160.6° ± 7.7° preoperatively to 170.6° ± 6.5° at the last follow‐up visit (p < .001). The talocalcaneal angle had decreased from 39.9° ± 5.2° preoperatively to 29.4° ± 4° at the last follow‐up examination (p < .001). At the 4‐year follow‐up point, the implant could be seen to have almost completely biodegraded on magnetic resonance imaging. Two screw breakages occurred. The bioabsorbable calcaneo‐stop screw seems to be an effective solution for flexible flatfoot in pediatric patients. Also, owing to its biodegradable composition, the need of a second operation for implant removal will not always be necessary. &NA; Level of Clinical Evidence: 4

Composite PEEK/Carbon fiber implants can increase the effectiveness of radiotherapy in the management of spine tumors

BACKGROUND Combination of surgery and radiotherapy in the treatment of primary spine tumour can be indicated in some cases where a satisfactory oncological margin cannot be achieved. The presence of metal hardware has always limited post-operative radiotherapy due to the scattering effects of ionizing radiation or particles. The use of a fixation system (including rods and screw) fully made in PEEK embedded Carbon fiber (CFR-PEEK) could make easier and more effective the post-operative radiotherapy as it is radiolucent and does not interfere with ionizing radiation and accelerated particles. METHODS An ambispective study was performed on the first 22 consecutive primary tumor patients, who underwent spinal surgery including a composite CFR-PEEK fixation system. Oncologic surgery was palliative decompression and fixation in 3 cases; tumor excision in 15; en bloc resection in 4. The incidence of complications (intra- and postoperative), local control (LC) and local recurrence (LR), and changes in neurological status were considered. RESULTS Only one intraoperative screw breakage occurred and one case of loosening of sacral screws were found at 12 months in one patient. No rod breakage, neither any screw/rod disconnection was found. Post-operative RT has been performed in 19 patients. The overall number of progression of the tumour or LR was 7. The actuarial rate of LR or progression of the tumour, calculated according to the Kaplan-Meier method, was 17.6% at 12 months. CONCLUSIONS The CFR-PEEK fixation system is comparable to standard titanium system in term of intraoperative complications, stability at weight bearing and at functional recovery. Thanks to radiolucency CFR-PEEK stabilization devices are more suitable in patients eligible for RT: the absence of image artifacts together with significantly less dose perturbation improve the treatment accuracy. Moreover the radiolucency is useful in the follow-up of patients thus allowing early detection of LR.

Minimally-invasive treatment of calcaneal fractures: A review of the literature and our experience.

The optimal treatment of calcaneal fractures (CF) is currently controversial and is still under debate. It is well established that conservative treatment of these fractures is associated with poor results. Several surgical techniques are described in the literature; however, there is no consensus on which of these is more effective. The main goals of surgery are to restore the subtalar joint congruence, and calcaneal width, height, shape and alignment, thus avoiding medial and lateral impingement and enabling the patient to resume a normal lifestyle. ORIF is the most popular technique for these fractures, but it is associated with high rates of wound complications, hardware failure and infections. Several minimally-invasive techniques have been developed recently for the treatment of CF, with the common aim to be as simple, effective and inexpensive as possible and to reduce surgical times, complications and length of hospital stay.

Anterior Approach in Total Hip Replacement

In total hip replacement, the anterior approach is intermuscular and internervous and allows the surgeon to reach the capsule without muscle detachment. Advantages include faster recovery and excellent functional outcome as well as reduced postoperative pain and hospital stay. Experienced surgeons currently performing total hip replacement should be aware of all of the difficulties associated with this procedure as well as all of the tricks to overcome the most challenging steps in order to reduce complications during the learning curve. The authors present the most crucial steps in total hip replacement through the anterior approach and describe the potential pitfalls and solutions. [Orthopedics. 2017; 40(3):e553-e556.].

Effect of acetabular cup design on metal ion release in two designs of metal-on-metal hip resurfacing

The purpose of this observational prospective cohort study was to evaluate the serum concentrations of cobalt (Co), chromium (Cr), and nickel (Ni) at a 2-year follow-up in patients operated on with a novel design of hip resurfacing: Romax resurfacing system (RRS). RRS is characterized by the presence of an acetabular notch which theoretically provides a wider range of motion and a reduced incidence of groin pain. The presence of radiolucencies and functional outcome, assessed using the Harris hip score (HHS) and the University of California Activity scale (UCLA), were secondary endpoints. Moreover, these results were compared with those obtained in our previous study from a similar cohort of patients implanted using the Birmingham Hip Resurfacing (BHR) system. At a 2-year follow-up, the serum levels of Co in patients operated on using the RRS were five times higher (p = 0.0002) than those found before surgery (Co, means: 1.04 and 0.20 ng/mL, respectively); similarly, Cr levels were 13 times higher (p < 0.0001) at a 2-year follow-up than before surgery (Cr, means: 1.69 and 0.13 ng/mL, respectively). Ni concentrations (0.42 and 0.78 ng/mL) were not significantly different (p = 0.16), even if they increased 86% after surgery. In the RRS patients, an inverse correlation was found between Co and Cr concentrations and length of follow-up (Co: r = -0.64, p = 0.0096; Cr: r= -0.45, p = 0.08). The serum levels of Co and Cr were not significantly different between RRS (Co: 1.04 ng/mL and Cr: 1.69 ng/mL) and BHR (Co: 1.39 ng/mL and Cr: 2.30 ng/mL) patients at 2 years (p = 0.95 and 0.26 for Co and Cr, respectively). Our results showed that RRS patients achieved an excellent clinical outcome with limited metal ion release.

Hip Resurfacing Implants: A Literature Review and Our Experience

Hip resurfacing offers a suitable solution for young patients with high function demands and good bone quality affected by hip diseases. The bone stock preservation along with the restoration of the normal proximal femur anatomy, the lack of stressshielding and the resumption of sporting activity are proven advantages of hip resurfacing. However there are some disadvantages such as fracture of the femoral neck, onset of neck-narrowing and possible complications due to the metal-on-metal bearing: pseudotumors, peri-implant osteolysis and chronic elevation of metal ions serum levels. Recent data suggest that the ideal candidate for hip resurfacing is an active male, younger than 65 years old, suffering from primary or post-traumatic osteoarthritis with a femoral head diameter larger than 50/54 mm. Based on these selection criteria literature reports an implant survival similar to total hip replacement. Our experience confirms the low failure rate and the excellent functional outcomes, with stable metal ions serum levels over time in well-functioning implants. Proper surgical technique, correct patient selection together with the right choice of a well established prosthetic model are essential elements for the long-term success of these implants.

Management of Metastases to the Spine and Sacrum

The incidence of bone metastatic deposit from carcinoma is second only to pulmonary and hepatic metastases. The most frequently affected segment of the skeleton is the vertebral column. Refinement of the protocols for treating tumour patients has led to a progressive improvement in the prognosis for many tumour histotypes in terms of increase of life expectancy. The choice of the most appropriate treatment is of crucial importance for the patient who may be severely disabled by the presence of untreated spinal metastases. It is commonly accepted that bone metastases are an expression of a systemic disease, and therefore require multi-disciplinary treatment, integrating radiotherapy (RT), chemotherapy (CHT) and surgery. The most appropriate treatment for patients with metastatic disease of the vertebral column is controversial. Appropriate surgical treatment of bone metastases and tumours in general has now become an integral part of the correct approach to the tumour patient. The evolution of anaesthetic techniques now allows more aggressive treatment of some patients with spinal and sacral metastases. These procedures can dramatically improve the patient’s quality of life and may prolong the patient’s life expectancy by preventing complications related to paralysis.