Luigi Molfetta

Computer navigation versus conventional implantation for varus knee total arthroplasty: A case-control study at 5 years follow-up

BACKGROUND There is no evidence in the current literature of any significant improvement in clinical outcome when comparing computer-assisted total knee arthroplasty (CATKA) with conventional implantation. Analyses of alignment and of component orientation have shown both significant and non-significant differences between the two methods. OBJECTIVES We compared computer-assisted and conventional surgery for TKA at 5.4 years follow-up for patients with varus osteoarthritic knees. Our goal was to assess clinical outcome and restoration of normal limb alignment. MATERIALS AND METHODS We performed a retrospective case-control study comparing 30 patients who underwent CATKA with 30 subjects who underwent TKA by conventional methods. Patients were matched individually by preoperative clinical conditions and alignment. We analysed intraoperative data (surgical time and intraoperative complications), postoperative complications, lower limb alignment, radiographic complication on X-ray imaging, and clinical outcome through knee and function score and range of motion. RESULTS AND DISCUSSION We found no significant clinical difference between the two groups at 5 years post-surgery. However there was a statistically significant improvement in the restoration of the mechanical axis of the lower limb in the coronal plane but not in the sagittal plane. Whether or not this leads to a higher survival rate in the longer term requires further investigation.

Preservation of the femoral neck in hip arthroplasty: results of a 13- to 17-year follow-up

Abstract In prosthetic surgery of the hip, it is important to remove only the pathological tissues, preserving as much as possible the osteo-articular architecture, in particular the femoral neck and the subchondral cencellous acetabulum. This allows the bone to easily adapt to the new biomechanical situation created by the prosthesis. Our long-term study of patients who underwent total hip replacement has confirmed such presuppositions. For this study, we used a biodynamic prosthesis, composed of a Lord hemispheric screwed cup with a biequatorial liner and an anatomical stem in Cr-Co-Md with a completely madreporic surface. This prosthesis is ideally configured to preserve the femoral neck. We followed 44 prostheses for 13–17 years. The clinical results were excellent or good in 82% of cases. Thigh pain, reported in only 14% of cases, spontaneously resolved. The mobility of the prosthetic hip and the consequent functional recovery were excellent, since conserving the neck re-stabilized the natural off-set, providing good equilibrium of the hip and the periarticular muscles. Radiographic analysis revealed survival of the femoral neck in approximately 80% of cases. The madreporic surface, when associated with correct positioning of an undersized stem, allowed for osteointegration with significant bone remodeling in the long term. Distal cortical hypertropy, found in 48% of cases, made it necessary to limit the madreporic surface finish to the stems proximal two-thirds, leaving the distal one-third smooth.

Bone invading NSCLC cells produce IL-7: mice model and human histologic data

BackgroundBone metastases are a common and dismal consequence of lung cancer that is a leading cause of death. The role of IL-7 in promoting bone metastases has been previously investigated in NSCLC, but many aspects remain to be disclosed. To further study IL-7 function in bone metastasis, we developed a human-in-mice model of bone aggression by NSCLC and analyzed human bone metastasis biopsies.MethodsWe used NOD/SCID mice implanted with human bone. After bone engraftment, two groups of mice were injected subcutaneously with A549, a human NSCLC cell line, either close or at the contralateral flank to the human bone implant, while a third control group did not receive cancer cells. Tumor and bone vitality and IL-7 expression were assessed in implanted bone, affected or not by A549. Serum IL-7 levels were evaluated by ELISA. IL-7 immunohistochemistry was performed on 10 human bone NSCLC metastasis biopsies for comparison.ResultsAt 12 weeks after bone implant, we observed osteogenic activity and neovascularization, confirming bone vitality. Tumor aggressive cells implanted close to human bone invaded the bone tissue. The bone-aggressive cancer cells were positive for IL-7 staining both in the mice model and in human biopsies. Higher IL-7 serum levels were found in mice injected with A549 cells close to the bone implant compared to mice injected with A549 cells in the flank opposite to the bone implant.ConclusionsWe demonstrated that bone-invading cells express and produce IL-7, which is known to promote osteoclast activation and osteolytic lesions. Tumor-bone interaction increases IL-7 production, with an increase in IL-7 serum levels. The presented mice model of bone invasion by contiguous tumor is suitable to study bone-tumor cell interaction. IL-7 plays a role in the first steps of metastatic process.

Nerves of the hand beyond the carpal tunnel.

Imaging studies including ultrasound (US) and magnetic resonance imaging may be required to evaluate the median nerve in patients with suspected carpal tunnel syndrome. However, the radial and ulnar nerves contribute to sensory and motor innervations to the hand as well. Compressive, traumatic, and iatrogenic events may damage the small terminal branches of these nerves. In the hand, US is able to identify injuries of the median, ulnar, radial nerve, and terminal branches. This article presents the role of imaging to evaluate the nerves of the hand with an emphasis on US. Due to its high-resolution capabilities, US is useful to determine the location, extent, and type of nerve lesion. Moreover, US is useful for a postsurgical assessment. The anterior interosseous nerve, Guyons tunnel syndrome, and Wartenbergs syndrome are also described.

Imaging finger joint instability with ultrasound.

Closed injuries affecting the metacarpophalangeal and interphalangeal joints and their stabilizers in the thumb and fingers occur very commonly in athletes, possibly leading to finger joint instability and long-standing or permanent disability. This article reviews the spectrum of joint injuries of the thumb and fingers that are common in the athletic population with a main focus on the ultrasound features of collateral ligament tears, palmar plate injuries, and thumb sesamoid fractures. A thorough understanding of the complex anatomy, mechanism of injury, soft tissue abnormalities, and imaging findings is critical in the diagnostic work-up of closed finger joint trauma and may help improve outcomes.

GIR classivication of acetabular and femoral bone loss in revision hip arthroplasty surgery

Abstract Acetabular and femoral bone loss, the common feature of prosthetic failure, represents the most serious problem during revision surgery. The study of bone loss extent starts with pre-operative X-ray analysis, but the definitive evaluation is performed intra-operatively. The Italian Society for Revision Arthroplasty (GIR) has proposed a classification that correlates the various grades of bone loss with surgical strategies for reconstruction. The GIR classification does not distinguish bone loss into types. Instead, it recognizes different grades and emphasizes the possible evolution not only in time, but even during the surgical procedure. In this classification, we recognize four different grades of acetabular and femoral bone loss; for each of them we suggest different surgical strategies and resources.

False aneurysm of the superficial femoral artery after total hip arthroplasty: a case report

Vascular lesions in hip prosthetic replacement are rare events; it is mandatory to be aware of the risk, though, in order of the vascular bundles proximity to the surgical field. A 74-year-old patient was admitted to our department for primary hip arthroplasty for osteoarthritis. The patient was healthy but had mild hypertension. A cemented total hip prosthesis was implanted. The patient complained of growing groin pain and swelling from the third postoperative day. The suspicion of a vascular injury arose with worsening pain and low haemoglobin at blood tests. Then ultrasonography scans and digital angiography were performed, showing a superficial femoral artery pseudo-aneurysm. The patient had further surgery to repair the lesion. In the described case, the pseudo-aneurysm might have been caused by the pulling of a Hohmann retractor on arterial vessels possibly affected by atherosclerosis. The final output was favourable, but the authors point out that knowledge of neurovascular anatomy is necessary as well as postoperative surveillance of the clinical presentation of the patient if groin pain or swelling should arise. In the case of suspicion of vascular lesions, ultrasound and angiography will allow diagnosis and confirm the indication for surgical repair.

Temporary vena cava filters in the prevention of pulmonary embolism during total hip arthroplasty

Abstract Thromboembolism constitutes one of the most dangerous complications during the immediate postoperative period of prosthetic surgery. Pharmacological prophylaxis and mechanical vascular compression are not always sufficient to protect from this surgical complication. In patients at greatest risk for thromboembolism, often with a positive history for pulmonary embolism, temporary vena cava filters may be used to reduce the incidence of vascular and pulmonary complications. However useful, these filters cannot be routinely used in orthopedic surgery. We present our results with the use of Filcard RFO2 vena cava filters in an open, randomized study of 30 patients.

Evaluation of prognostic indices in elderly hospitalized patients

Prognosis informs the physicians decision‐making process, especially for frail older adults. So far, any non‐disease‐specific index has proven full evidence for routine use in clinical practice. Here, we aimed at assessing, prospectively, the calibration and discriminating accuracy of validated prognostic indices in a cohort of elderly hospitalized patients.

Analysis of clinical data in patients with Girdlestone arthroplasty: a new score

Girdlestones arthroplasty is an uncommon surgical procedure; it is performed in patiens with recurrent infection of the hip, polymicrobic sepsis or after multiple revisions. The number of hip replacements all over the world is always increasing, so the total number of prosthesis infections also continues to rise, although the relative incidence is lower than in the past. For this reason Girdlestones arthroplasty must be a well-known procedure to hip surgeons. Clinical assessment of such patients cannot be performed with common hip ratings (e.g. Harris Hip Score) since hip instability, low range of motion, limb shortening and severe muscle loss are common. The patients independence in daily living activity and freedom from pain should be the surgeons main goals. We propose a specific clinical score for the outcome of the procedure, which is not to be found in the current literature as far as the authors are aware. The score can be useful for comparative clinical trials, for legal medicine purposes, etc. To illustrate it, we present 20 cases of Girdlestones arthroplasty out of 265 hip revisions performed in our hospital. The outcome of the procedure in our patients was clinically good in eight cases, intermediate in ten cases, and bad in two cases. We believe the performing of such an intervention is justified when indicated by clinical signs, as we analyse them in our work. Our clinical score has been shown to be adequate to assess the clinical presentation of such patients.