Marco Basso

What is the preclinical evidence on platelet rich plasma and intervertebral disc degeneration

PurposeIntervertebral disc degeneration is a common disease that usually starts from the third decade of life and it represents a significant cause of socio-economic problems. The accepted surgical treatment for disc degeneration is disc removal and vertebral fusion or, in selected cases, intervertebral disc arthroplasty. Several studies have demonstrated the ability of platelet rich plasma (PRP) to stimulate cell proliferation and extracellular matrix regeneration. However, literature results are still limited and more studies are required to clarify the role of PRP in the prevention or in the treatment of degenerative disc disease. The aim of this review is to summarize and critically analyze the current preclinical evidence about the use of PRP in intervertebral disc degeneration.MethodsLiterature search was performed through various combinations of the following keywords: Intervertebral Disc Degeneration, Platelet Rich Plasma, PRP, Intervertebral disc regeneration. Papers included in our review cover the period between 2006 and 2014. The PRISMA 2009 checklist was followed.ResultsAt the end of the review process, 12 articles were included in our final manuscript, including 6 “in vitro” and 6 “in vivo” studies. All the included studies lead to positive preclinical results. No standardization of methodological analysis was observed.ConclusionIt is not possible to draw definitive evidence about the use of PRP in IVD regeneration. We advise a proper standardization of the methodological analysis in order to compare the available data and achieve definitive results. This should be the cornerstone for future clinical applications.

Kümmell disease: illustrative case for definition criteria

Kümmell disease (KD) is defined as a clinical condition in which patients develop a painful progressive angular kyphosis as a result of a delayed vertebral body collapse after a minor spinal trauma [1–3]. The most supported etiopathogenetic hypothesis is a posttraumatic avascular necrosis of the vertebral body [4]. The main cornerstones of KD are history of trauma with a negative x-ray investigation, an asymptomatic period, and a recurrence of symptoms that results in painful kyphosis deformity of the affected spine [5]. Intravertebral vacuum cleft is a widely reported radiological sign associated with KD [6,7]. Literature on this subject is limited and characterized by some inaccuracies and wrong diagnosis. Kümmell disease needs to be distinguished from other clinical situations, such as osteoporosis vertebral fractures or idiopathic

What is the fate of the neck after a collum femoris preserving prosthesis? a nineteen years single center experience

PurposeThe aim of our study is to evaluate long-term outcomes from a cohort of patients treated with collum femoris preserving (CFP) stem correlating neck resorption with comorbidities, clinical outcomes, and complications.MethodsOne hundred seventy-six patients (194 hips) were retrospectively reviewed with a minimum follow-up (f.u.) of tenxa0years. Demographic and surgical data were collected. Clinical and radiological evaluation was performed at the last follow up. We calculated a neck resorption ratio (NRR) for each patient. Main complications were recorded. A p-value of <0.05 was considered significant.ResultsThe mean Harris hip score (HHS) was 89.1u2009±u20095.7. The mean visual analogue scale (VAS) and Oxford hip score (OHS) values were 1.1u2009±u20091 and 41.3u2009±u20095.1, respectively. The mean leg length discrepancy was 1.5 mmu2009±u20091.9. The mean NRR was 0.35. We observed six cases of aseptic loosening, two cases of infection, one implant revision for recurrent dislocation, and one stem revision after periprosthetic femoral fracture. The overall survival rate of the stem was 94.8%. Statistically significant associations were found between NRR and steroid therapy/stem malposition. Correlation between aseptic loosening and NRR was also statistically significant. Correlations between NRR and HHS/OHS were −0.34 and −0.28 respectively. Odds ratio for aseptic loosening were: 4.6 if NRRu2009>u20090.25; 16.9 ifu2009>u20090.50 and 24.1 ifu2009>u20090.75.ConclusionCFP hip stem provided excellent long-term outcomes. NRR is correlated to steroid therapy and stem malposition. The risk of stem aseptic loosening rises according to NRR increase. Patients with an NRRu2009>u20090.5, especially if under steroid therapy or with stem malposition, should be strictly monitored.

Which patients risk segmental kyphosis after short segment thoracolumbar fracture fixation with intermediate screws

INTRODUCTIONnThe use of intermediate screws in fractured vertebrae has been proposed to decrease the number of fused levels in thoracolumbar fractures and to enable short fixations. The aim of this study was to evaluate the results of this technique and to establish predictive factors involved in loss of segmental kyphosis correction (LKC).nnnMETHODSnForty-three patients who underwent short-segment spinal fixation with intermediate screws for a thoracolumbar spine fracture in a two-year time period were enrolled in the study. Patients had AO-type A3, A4 and B2 thoracolumbar fractures. Radiological parameters included segmental kyphosis (SK), vertebral wedge angle (VWA) and loss of anterior and posterior vertebral body height. Patients were evaluated up to one-year follow-up. The correlation between LKC and potential risk factors, such as smoking habit, sex, age, neurological status and BMI was evaluated.nnnRESULTSnMean preoperative SK was 16.5°±6.5°, and it decreased to 3.4°±3.5° postoperatively (P<0.01). At the one-year follow-up mean SK dropped to 5.5°±3.9° (P<0.01). Mean preoperative VWA was 20.0°±8.1°, and significantly improved to 6.3°±3.1° after surgery (P<0.01). There was a mean LKC of 1.8°±2.1°at one year. LKC mildly correlated with body mass index (BMI, r: +0.31), and obese patients (BMI>30) had an increased risk of LKC at the one-year follow-up (P=0.03; odds ratio [OR]=3.2).nnnDISCUSSIONnAnalysis of the radiological data at one-year follow-up showed that all the evaluated parameters were associated with a mild loss of correction, with no impact on the clinical outcomes or implant failure. These findings confirm the trends reported in the literature. The correlation between LKC and clinical features, such as BMI, age, sex, smoking habit and preoperative neurological status was investigated. Interestingly, a positive correlation was observed between BMI and LKC, and obese patients with BMI>30 had an increased risk of LKC at one-year follow-up (OR 3.2); to our knowledge this finding has never before been reported.nnnCONCLUSIONnShort-segment fixation with intermediate screws is a viable technique with positive clinical and radiological outcomes at one-year follow-up. However, surgeons should be aware that in obese patients (BMI>30) this technique is associated with an increased risk of LKC.nnnLEVEL OF EVIDENCEn3.

Conservative treatment of meniscal tears in anterior cruciate ligament reconstruction

BACKGROUNDnManagement of small and stable meniscal tears within the vascular zone at the time of anterior cruciate ligament (ACL) reconstruction is controversial. The purpose of this study was to evaluate the outcome of meniscal tear left in situ at the time of ACL reconstruction.nnnMETHODSnUsing the IKDC, KT-1000 and the Tegner Activity Score (TAS), we retrospectively analysed 175 cases of ACL reconstruction with meniscal tears performed from 2006 to 2012. Patients with residual laxity on clinical assessment were identified and considered as a subgroup. Clinical outcome and failure rate were evaluated.nnnRESULTSnIn 83 patients (47.4%), a meniscal tear was left in situ at the time of ACL reconstruction: 45 were medial and 38 were lateral. Patients were clinically reassessed with a minimum follow-up of 24 months. The overall failure rate of conservative meniscal treatment in patients with objective residual laxity was 87.5%, and 6.7% in patients with a stable knee (P<0.001). Those with stable knees had higher postoperative IKDC subjective scores (P=0.0022) and TAS (P<0.0001). Patients without residual laxity had higher failure rate for the medial meniscus compared with lateral meniscus - 10.5% versus 2.7% (P=0.36)-and the red-red zone had lower revision rate compared with the red-white zone (P=0.0322).nnnCONCLUSIONSnThe conservative treatment of small and stable peripheral tears of the medial and lateral menisci had low failure rate and no described complications. In our series residual laxity significantly increased the failure rate.nnnLEVEL OF EVIDENCEnlevel IV, therapeutic case series.

Is it possible to preserve lumbar lordosis after hybrid stabilization? Preliminary results of a novel rigid-dynamic stabilization system in degenerative lumbar pathologies

AbstractPurpose of the studyTo evaluate the results of a novel rigid–dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL).Materials and methodsnForty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively.ResultsAt 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level.ConclusionsWhen properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion.

Acetabular spacers in 2-stage hip revision: is it worth it? A single-centre retrospective study

Purpose The aim of this work is to evaluate an acetabular antibiotic loaded bone cement spacer in 2-stage revision surgery as a potential approach able to reduce complications during the inter-stage period (i.e. dislocation, acetabular wear), as well as simplify 2-stage hip revision surgery and improve hip biomechanics. Methods We performed a retrospective comparative study and evaluated clinical, radiological and surgical data of 71 patients affected by periprosthetic hip infection who were treated with 2-stage exchange. 31 patients were treated using an acetabular spacer in addition to the femoral (group A) while 40 underwent a standard revision surgery (femoral spacer only, group B). Results Mean time of surgery for the first stage was 148 ± 59 minutes and 142 ± 45 minutes for group A and B respectively; we noted a statistically significant reduction (26 min, p = 0.015) in the same parameter for the second stage (83 ± 35 minutes for group A and 109 ± 36 minutes for group B). We observed the following interstage complications: 5 femoral spacer dislocations (1 for group A and 4 for group B); 1 spacer fracture (group B), 1 spacer fracture (group A), 2 periprosthetic fractures (group B) and 2 patients with acetabular spacer instability (group B). Additionally, we observed a significant improvement in leg length restoration for group A (p = 0.03). Conclusions Our data show that the acetabular spacer technique is able to reduce the interstage complication rate and allow improved hip biomechanics restoration.

Lumbar Traction in the Management of Low Back Pain: A Survey of LatestResults

Introduction : Low back pain (LBP) is one of the most common complaints in the general population, affecting about 70-80% of the population at some point in life. LBP management comprises a wide range of different intervention strategies. One of the treatment options is traction therapy. The aim of our short review is to summarize and analyze the latest result reporting the use of lumbar traction in LBP treatment in order to evaluate the real effectiveness and indications of this specific physical therapy. nMaterials and methods: A comprehensive search of PubMed, Medline, Cochrane, Embase, and Google Scholar databases was performed, covering the period between 2006 and 2013. 54 citations were obtained. Relevant data from each included study were extracted and recorded. nResults: A total of 14 studies were included in the review. Among these 14 studies, 11 were randomized clinical trials, 1 was a retrospective cohort study and 2 were case series. The majority of included studies used traction on patients that suffered nerve rootxa0compression symptoms. The mean number of traction sessions was 19. At most, the duration of each session was 30 min (range 3-30 min). The mean period of traction treatment was 6 weeks(range 3-12 weeks). 11 studies coupled with traction other therapies. Only 3 studies used traction as a single treatment. The mean follow up period was 16,5 weeks from the end of treatment. nConclusion: Several biases can be introduced by limited quality evidence from the included studies. Lumbar traction seems to produce positive results in nerve root compression symptoms. Data in degenerative and discogenic pain are debatable. To date, the use of lumbar traction therapy alone in LBP management is not recommended by the best available evidence.

What is the clinical evidence on regenerative medicine in intervertebral disc degeneration

PurposeThis review aims to explore and summarize the current clinical evidence about the use of regenerative medicine such as mesenchymal stem cells or platelet-rich plasma in intervertebral disc regeneration, in order to clarify the state of art of these novel approaches.Materials and methodsWe performed a research of the available literature about regenerative medicine strategies aiming to prevent intervertebral disc degeneration. All preclinical trials and in vitro studies were excluded. Only clinical trials were critically analysed.ResultsThe manuscript selection produced a total of 7 articles concerning the use of regenerative therapies in intervertebral disc degeneration, covering the period between 2010 and 2016. Articles selected were 4 about the injection of mesenchymal stem cells-related results and 3 using platelet-rich plasma. The total population of patients treated with regenerative medicine strategies were 104 patients.ConclusionsRegenerative medicine, such as the use of mesenchymal stem cells or platelet-rich plasma, in intradiscal disc degeneration has shown preclinical and clinical positive results. Randomized clinical trials studying the potential of MSCs intradiscal injection have not been conducted, and PRP effect has been studied only preliminarily. Additional more powered high-quality studies are needed to really appreciate the long-term safety and efficacy of regenerative medicine approaches in IDD.

Vertebral body osteonecrosis: proposal of a treatment-oriented classification system

AbstractPurposeTo present a classification system for vertebral body osteonecrosis (VBON) based on imaging findings and sagittal alignment and consequently to propose treatment guidelines.MethodsChart review and classification of imaging and clinical findings. An analysis of literature about VBON has been evaluated to conceive the classification. The current data allows to correlate radiological findings with different stages of the pathophysiological process and consequently to propose a patient-tailored treatment plan.ResultsThe classification identifies 4 stages: stage 0 (theoretical phase), stage 1 (early phase), stage 2 (instability phase) and stage 3 (fixed deformity phase). Local (angular kyphosis expressed as anterior–posterior wall height ratio) and global (sagittal vertical axis and pelvic tilt) sagittal alignment are considered as complementary modifiers to tailor the most suitable treatment. Stage 1 is generally managed conservatively. Stage 2 and 3 often require different surgical approaches according to local and global sagittal alignment.ConclusionsThe classification allows a systematic staging of this disease and can help establish a proper and patient-oriented treatment plan. Further researches are advocated to fully validate the proposed classification system.Graphical abstractnThese slides can be retrieved under Electronic Supplementary Material.