Lorenzo Nistri

Growth factors in the treatment of early osteoarthritis.

Regenerative medicine is the science that studies the regeneration of biological tissues obtained through use of cells, with the aid of support structures and with biomolecules such as growth factors. As regards the growth factors the PRP, or the platelet-rich plasma, obtained from a withdrawal of autologous blood, concentrating the platelets, represents a safe, economical, easy to prepare and easy to apply source of growth factors. Numerous growth factors are in fact within the platelets and in particular a large number of them have a specific activity on neo-proliferation, on cartilage regeneration and in particular also an antiapoptotic effect on chondroblasts: - The PDGF which regulates the secretion and synthesis of collagen;- The EGF that causes cellular proliferation, endothelial chemotaxis and angiogenesis;- The VEGF that increases angiogenesis and vascular permeability;- The TGF-beta that stimulates the proliferation of undifferentiated MSC, stimulates chemotaxis of endothelial cells and angiogenesis;- The bFGF that promotes the growth and differentiation of chondrocytes and osteoblasts stimulates mitogenesis of mesenchymal cells, chondrocytes and osteoblasts. These properties have led to the development of studies that evaluated the efficacy of treatment of infiltrations in the knee and hip with platelet-derived growth factors. Regarding the knee it was demonstrated that in patients with moderate degree of gonarthrosis, the PRP is able to significantly reduce the pain and improve joint function, both on placebo and towards infiltrations with hyaluronic acid. The success of the treatment was proportional to the age of and inversely proportional to the severity of osteoarthritis according to Kellgren and Lawrence classification. The possibility of infiltrations guided with ultrasound into the hip led us to extend the indications also to hip arthrosis, as already showed by Sanchez. Even in coxarthrosis preliminary results at 6 and 12 months show that a cycle of 3 infiltrations of PRP has significantly decreased the pain and increased range of motion and joint function.

Oxidized zirconium femoral component for TKA: a follow-up note of a previous report at a minimum of 10 years.

BACKGROUND New bearing surfaces for total knee replacement have been described in an attempt to reduce polyethylene wear and secondary osteolysis and improve longevity of implants. Oxidized zirconium is a new material that combines the strength of a metal with the wear properties of a ceramic. However, there are no reports as to who documents the long term results. We report a 10 year follow-up note of a selected series of TKAs with an oxidized zirconium femoral component. METHODS We prospectively follow 98 TKAs performed in 94 patients with an oxidized zirconium femoral component. Five patients (5 knees) had died and 6 (6 knees) were lost to follow-up at a minimum of 2 years (mean, 6.3 years; range, 2-9 years) after the operation. For the remaining 83 patients (87 knees), the minimum follow-up was 10 years (mean, 11.3 years; range, 10.0-12.6 years). In 51 cases (58.6%), a cruciate-retaining implant with a deep-dished, more conforming PE was used, and in 36 cases (41.4%), a posterior-stabilized design was used. The patellae were resurfaced in 32 cases (36.7%) and in 55 cases (63.3%) were left unresurfaced. RESULTS Survivorship was 97.8% at 10 years postoperatively. Two knees were revised for aseptic loosening of the femoral component. No major complication was observed clinically or radiologically. Mean Knee Society score improved from 36 to 84 and functional score from 37 to 83. CONCLUSIONS Oxidized zirconium femoral component in TKA performs well over the first 10 years following implantation, with excellent survival rates and good clinical and radiological outcomes. LEVEL OF EVIDENCE Level IV, therapeutic study.

Hip arthrosis and surgical intervention: what and when?

Osteoarthritis of the hip is a common pathology and involves forms of disability and need for treatments that affect the quality of life of patients and their families, and in general of the whole society. It should be considered as such degenerative joint disease is increasing as the increase in life expectancy and musculoskeletal trauma, the latter responsible for secondary forms of osteoarthritis. The treatment of osteoarthritis of the hip has changed a lot over the years, since the earlier diagnosis and, before, with prevention through proper lifestyle. More in-depth knowledge of the biology of the tissues involved, first of all hyaline cartilage, has lead to non-surgical treatments such as infiltration with hyaluronic acid (viscosupplementation) and autologous growth factors derived from platelets (platelet rich plasma). Surgical therapy with prosthetic replacement is finally a choice to share with the patient based on pain and functional limitation, bearing in mind always the best technology and tribology and the possibility of less invasive surgical access, while recognizing that there are not still eternal prosthesis. Of particular importance then is the age of the patient. There are also other types of surgery (hip arthroscopy, forage) for other pathologies of the hip which can be resolutive, or, in a sense, can delay the arrival to the prosthetic replacement. We will discuss below the decision-making process that leads the surgeon with the patient to the surgery option.

Long term results of percutaneous fixation of proximal humerus fractures

Background: Proximal humerus fracture in elderly osteoporotic patients usually leads to severe displaced and multifragmentary fractures. Associated comorbidities may limit surgical options and conservative treatment is commonly indicated, however, with variable results. In most cases, surgery is the treatment of choice in order to restore anatomical integrity, and allow early functional recovery. Several techniques were used over the years, each with specific indication. Percutaneous pinning after closed reduction, a mini-invasive technique and fixation by use of K-wires is not preferred commonly. We present our experience with this approach, focusing on its indications and advantages. Patients and Methods: A study group of 41 consecutive patients with a mean age of 65.5 years were evaluated clinically (VAS, Constant-Murley score, range of motion), and with radiological analysis: 35 patients finally completed a minimum followup of 24 months. Results: K-wires were removed after a mean interval of 4 weeks. Clinical and radiographic healing occurred in a mean time of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score of 87.6 points, mean VAS of 2.3. In 33 patients, the reduction was considered satisfactory. In two cases, reduction was poor, but the patients however presented acceptable functional outcome. Conclusions: Percutaneous pinning may represent a suitable option of treatment for 2-or 3-part proximal humerus fractures in selected subjects.

A steroid-induced bilateral avascular necrosis of the femoral head in an underage patient affected by multiple sclerosis

Patients affected by Multiple Sclerosis are often treated by pulsed intravenous corticosteroids to manage acute relapses with positive outcomes. The intravenous administration is frequently associated to avascular necrosis of several bones, particularly the femur. The present report regards a case of an underage MS patient with a bilateral ANFH secondary to pulsed administrations of steroids, managed by a conservative approach on a hip, and by a novel surgical technique on the contralateral side.

The kinetics of remodeling of a calcium sulfate/calcium phosphate bioceramic

In the last years considerable research and development activity have been expended to find new ceramic bone substitutes for the treatment of bone defects. However in many cases the drawback of synthethic bone substitutes are the slow graft incorporation and remodelling into the host bone. The purpose of this study was to analyze the kinetics of resorption and new bone formation of new calcium sulfate (CaSO4)/calcium phosphate (CaPO4) bioceramic engineered to enhance its bone forming properties. We prospectively evaluated the results of a series of 15 hips with osteonecrosis of the femoral head (ONFH) treated at with core decompression and injection of the CaSO4/CaPO4 composite. In all hips, a quantitative computed tomography (QTC) scan was taken within one week after the surgery, at 12 months, 2 years and finally with a minimum of 4 years follow-up. The mean HU in the immediate post-operative period was 1445 (Range 1388–1602); At one year the mean HU strongly decrease at 556.6 HU (P < 0.01); The mean HU at 2 years follow-up further decreased to 475.1. The mean HU at 4 years was unchanged. The quantitative and qualitative CT scan data of this series indicates that the CaSO4-CaPO4 ceramic composite resorbs over a narrow timeframe and the gradual resorption of the graft within the defect provides an ideal environment for the direct new bone growth that propagates across the defect.Graphical Abstract

Open Traumatic Osteochondral Fracture of the Femoral Medial Condyle and Trochlea Treated by Mosaicplasty: a Case Report at 11-Year Follow-Up

The management of articular cartilage defects continues to be one of the most challenging clinical problems for orthopaedic surgeons. Many surgical procedures have been described in literature with different outcomes, but it remains difficult to compare the efficacy of these techniques because of a paucity of well-designed randomized controlled trials [2]. Bone marrow stimulation, autologous chondrocyte transplantation and autologous-plus-scaffold transplantation are common solutions for superficial articular defects but are not recommended in deep articular lesions involving the subchondral bone. On the other hand, autologous osteochondral mosaicplasty is effective in repairing deep osteochondral defects of the knee. This technique consists of the transposition of multiple cylindrical autogenous osteochondral plugs, harvested from either the low-weight-bearing periphery of the articular surface of the femoral trochlea or the edges of the intercondylar notch, in order to resurface the defect in a congruent fashion [9, 12]. This paper reports the 11-year follow-up result of a large open osteochondral defect in the trochlea and medial condyle of the femur, sustained by a young female patient after a motorcycle accident and treated by an “emergency mosaicplasty”.