Luca Vaienti

Prophylactic use of antibiotic-loaded bone cement in primary total knee replacement

Despite significant advances in intraoperative antimicrobial procedures, deep infection remains the most devastating complication following total joint arthroplasty. Clinical studies’ results and safety profile of antibiotic-loaded bone cement are discussed in this review. Antibiotic bone cement prophylaxis is a safe and effective strategy in reducing the risk of deep infection following primary total joint arthroplasty.

The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers.

Hyaluronidases, a family of enzymes that are able to degrade hyaluronic acid (HA), are employed in medicine to increase drug diffusion and reverse the effects of HA filler injections. Hyaluronidases are able to dissolve subcutaneous nodules or to correct excessive quantities of injected filler. Knowledge of the use, methods of application, and adverse effects of hyaluronidases is essential for the aesthetic practitioner. Therefore, we performed an extensive review of the available literature from 1928 to 2011 and compared the different enzymes available, recording each authors indications regarding usage and side effects.

Distal Interphalangeal Joint Arthrodesis for Degenerative Osteoarthritis With Compression Screw: Results in 102 Digits

PURPOSE To assess objective and subjective outcomes of distal interphalangeal joint arthrodesis with a headless compression screw for degenerative osteoarthritis. METHODS We retrospectively analyzed 102 cases of distal interphalangeal joint arthrodesis performed with headless compression screws on 59 patients. We included only primary cases of degenerative osteoarthritis with a minimum follow-up of 7 months. We identified appropriate bone coaptation and hardware positioning on postoperative radiographs in all digits. The mean follow-up period was 26 months (range, 7-67 mo). RESULTS In 89 of 102 cases, patients were fully satisfied; in 9 cases, they were satisfied. Four complications occurred: 2 cases of prominent hardware, 1 complex regional pain syndrome type 1, and 1 symptomatic bony callus on the fused joint. Secondary surgery was required in each of these 4 cases. No nonunion, malunion, nail dystrophy, pseudarthrosis, or infection occurred. All arthrodeses healed. CONCLUSIONS Distal interphalangeal joint arthrodesis with headless compression screws was shown to be safe and effective in cases of degenerative osteoarthritis, with a low complication rate.

Perineural fat grafting in the treatment of painful end-neuromas of the upper limb: a pilot study.

The purpose of this study was to evaluate the effectiveness and middle-term durability of the results achieved with perineural fat grafting of painful neuromas of the upper limb. We retrospectively analysed eight patients, affected by eight neuromas, treated by neuroma excision and fat grafting around the proximal nerve stump. Clinical parameters, the disabilities of the arm shoulder and hand score, and the visual analogue scale were recorded at 2, 6 and 12 months after surgery. A reduction of 23.2% was observed in the mean disabilities of the arm shoulder and hand scores at 12 months. The spontaneous baseline visual analogue scale score showed a mean improvement of 22% at 12 months, although not this was not statistically significant. Perineural fat grafting is a quick and useful procedure and could represent a useful primary operation in the treatment of pain syndromes of neuropatic origin.

Perineural fat grafting in the treatment of painful neuromas.

Treatment of painful neuromas of the upper limb has been largely debated. The current surgical treatments spare from simple neuroma excision to proximal nerve stump relocation (into muscles, veins, and bones). Perineural fat grafting consists of neuroma excision and the creation of an autologous adipose graft wrapped around the proximal nerve stump. This technique should be prescribed to those patients suffering from terminal neuromas or neuromas in which functional reconstruction is contraindicated. The effectiveness of this technique could be addressed both to the mechanical and biological properties of the fat graft. On one hand the graft creates a gliding layer and a protective barrier, thus allowing longitudinal excursion and protection against mechanical solicitations. On the other hand the autologous adipose tissue brings neoangiogenesis, modulates the inflammatory response, and avoids scar adherences. A retrospective analysis was performed on 7 neuromas in 7 patients, treated with perineural fat grafting from June 2009 to February 2010. Pain and limb functionality were measured, respectively, with a visual acuity scale and the “Disabilities of the Arm, Shoulder, and Hand score,” preoperatively and 1 year after surgery. A mean pain reduction of 23% was recorded, without relevant complications. Improvements in limb functionality were also observed through the measurement of the Disabilities of the Arm, Shoulder, and Hand score, which improved to 18%. We believe that this technique represents a valuable and versatile option in the treatment of painful neuromas of the upper limb that could be hereafter performed for pain syndromes of neuropatic origin.

Failure by congestion of pedicled and free flaps for reconstruction of lower limbs after trauma: the role of negative-pressure wound therapy

Lower limb reconstruction with pedicled or free flaps can be commonly compromised by venous insufficiency. This complication often leads to partial/complete flap necrosis and increases the risk of superinfection. Negative-pressure wound therapy (NPWT) is known to increase local blood flow, decrease edema, promote tissue granulation, and reduce the likelihood of soft tissue infection. This study aims to evaluate the effectiveness of NPWT in the treatment of congested pedicled and free flaps of the lower limb after reconstructions in lower limb traumas. A retrospective analysis was performed on four congested (pedicled and free) flaps on the lower limbs. NPWT was applied in all cases after partial flap debridement. NPWT was able to improve and resolve tissue edema and venous insufficiency, avoid further flap necrosis, and promote granulation. On NPWT removal, a split-thickness skin graft was applied on the wound, achieving complete and uneventful healing. NPWT is a useful instrument in managing flaps affected by venous insufficiency in lower limb reconstruction, although larger studies are necessary to better define the effectiveness and indications of NPWT in this setting.

Distally based sural fasciomusculocutaneous flap for treatment of wounds of the distal third of the leg and ankle with exposed internal hardware

Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.

First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

BackgroundFractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.Methods13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.ResultsWound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).ConclusionOur approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

The salvage of knee-exposed prosthesis using neurofasciocutaneous sural flap

Prosthetic exposure is a severe complication of total knee arthroplasty. Many factors are responsible for failed wound healing, and successful salvage of total knee arthroplasty requires early identification of infection, antecedent events related with wound healing failure, aggressive surgical debridement and early appropriate soft-tissue coverage with local skin, fasciocutaneous, muscle, neurocutaneous or perforator flaps. In this report, we present 15 cases of exposed knee prosthesis treated with island sural neurocutaneous flap. Follow-up showed favorable clinical outcomes: all flaps survived and only two cases of hematoma and one of aseptic phystula occurred. According to our results, the island neurofasciocutaneous sural flap represents a sensate reconstructive alternative for providing fine and dependable soft tissue for covering skin defects around the knee.

A sneaky surgical emergency: Acute compartment syndrome. Retrospective analysis of 66 closed claims, medico-legal pitfalls and damages evaluation

BACKGROUND Acute compartment syndrome (ACS) is a clinical condition with potentially dramatic consequences, therefore, it is important to recognise and treat it early. Good management of ACS minimises or avoids the sequelae associated with a late diagnosis, and may also reduce the risk of malpractice claims. The aim of this article was to evaluate different errors ascribed to the surgeon and to identify how the damage was evaluated. MATERIALS AND METHODS A total of 66 completed and closed ACS cases were selected. The following were analysed for each case: clinical management before and after diagnosis of ACS, imputed errors, professional fault, damage evaluation and quantification. Particular attention was paid to distinguishing between impairment because of primary injury and iatrogenic impairment. Statistical analyses were performed using Fishers exact test and Pearsons correlation. RESULTS The most common presenting symptom was pain. Delay in the diagnosis, and hence delay in decompression, was common in the study. A total of 48 out of 66 cases resolved with the verdict of iatrogenic damage, which varied from 12% to 75% of global capability of the person. A total of