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Robotic-assisted medial unicompartmental knee arthroplasty (mUKA) has been introduced to improve accuracy in implant positioning and limb alignment, overcoming the reported high failure rates of conventional UKA. Indeed, mUKA is a technically challenging procedure strongly related to surgeons' skills and expertise. The purpose of this study was to evaluate the likelihood of robotic-assisted surgery in reducing the variability of coronal and sagittal component positioning between high- and low-volume surgeons. We evaluated a prospective cohort of 161 robotic mUKA implanted between May 2018 and December 2019 at two high-volume robotic centers. Patients were divided into two groups: patients operated by “high-volume” (group A) or “low-volume” (group B) surgeons. We recorded intraoperative lower-limb alignment, component positioning, and surgical timing. Postoperatively, every patient underwent a radiographical protocol to assess coronal and sagittal femoral/tibial component alignment. Range of motion and other clinical outcomes were assessed pre- and 12 months postoperatively by using oxford knee score, forgotten joint score, and visual analog scale. Of 161 recruited knees, 149 (A: 101; B: 48) were available for radiographic analysis at 1 month, and clinical evaluation at 12 months. No clinical difference neither difference in mechanical alignment nor coronal/sagittal component positioning were found (p > 0.05). A significant difference was recorded in surgical timing (A: 57 minutes; B: 86 minutes; p

Number of hip prosthesis implants in arthritis, number of patients treated with bisphosphonates to prevent fragility fractures and, together, number of atypical femoral fracture's cases are increasing.This article describes two cases of hip arthritis, treated with hip replacement, in patients using bisphosphonates for a long time; in both cases an incomplete atypical femoral fracture was misdiagnosed before the surgery. Authors describe the importance to carry out a complete osteometabolic and radiographic pre-operative examination of patients in treatment with bisphosphonates going to hip replacement, to check the possible presence of incomplete atypical femoral fracture and to optimize surgical and pharmacological treatment.In hip prosthesis surgery, prior diagnosis of incomplete atypical femoral fractures can indicate the choice of a different kind of prosthesis stem to optimize surgical results. This can also positively impact to rehabilitation in term of duration and daily activities recovery.

Mesangiogenic progenitor cells (MPCs) have been isolated from human bone marrow (BM) mononuclear cells. They attracted particular attention for the ability to differentiate into exponentially growing mesenchymal stromal cells while retaining endothelial differentiative potential. MPC power to couple mesengenesis and angiogenesis highlights their tissue regenerative potential and clinical value, with particular reference to musculoskeletal tissues regeneration. BM and adipose tissue represent the most promising adult multipotent cell sources for bone and cartilage repair, although discussion is still open on their respective profitability. Culture determinants, as well as tissues of origin, appeared to strongly affect the regenerative potential of cell preparations, making reliable methods for cell isolation and growth a prerequisite to obtain cell-based medicinal products. Our group had established a definite consistent protocol for MPC culture, and here, we present data showing MPCs to be tissue specific.

Purpose: The purpose of this bibliometric study was to summarize European orthopedic literature produced by EFORT memberships between 2009 and 2019 and to identify the 100 most cited articles, analyzing the characteristics that made them so interesting for the orthopedic scientific world. Method: A search of the literature was conducted using Clarivate Analytics Web of Science in the subject category “orthopaedics”; then the results were summarized using Web of Science tools. Results: A total of 160.375 articles were found: most of these were produced by England. In particular the most prolific institution was the University of London. Analyzing in detail the 100 most cited publications emerged that most of them were review published in journal with high impact factor (Q1). The University of Oxford was the institution with the greatest number of contributions (13%). The most cited topics were osteoarthritis (24%), followed by orthopedic basic science (22%). Bio-materials was the most common topic by ordering the 100 analyzed articles according to “usage count”, a recent indicator of the level of interest in a specific item. Conclusion: This bibliometric study can be useful to identify topics of interest for future scientific research and to outline the features that make some publications more interesting than others. (www.actabiomedica.it)

Introduction Periprosthetic femoral fractures (PFF) actually represent a serious public health problem. They are reported to occur in 0,1-4.5% of all patients undergoing total hip replacement (THR). PFF are commonly distinguished using the Vancouver classification. This study principal aim is to evaluate results obtained using the Intrauma Iron Lady® Conical Coupling locking plate for the treatment of Vancouver type B1 periprosthetic femoral fractures. Materials and Methods We enrolled 32 patients affected by Vancouver B1 PFF and treated with the same device. Metal cerclages were additionally used in 12 (38%) patients. A clinical and radiographical post-operative follow-up was then planned at 1, 3 and 6 months after surgery; than the follow-up was annually fixed. Results Mean age at the moment of trauma was 76,7 years. All involved femoral stem were uncemented and the they were all radiographically and intraoperativelly judged to be stable. Mean post-operative follow-up period was 5,8 years. 29 patients (91%) presented healed fracture at 6 months follow-up. 9% patients developed a superficial surgical site infection. Discussion and Conclusions Literature highlights that Vancouver B1 PFF should be treated with open reduction and internal fixation (ORIF) using polyaxial locking plates. However, no single technique has gained universal acceptance to be superior that the other. The current reported healing rate ranges from 40 to 100%. Using the Intrauma Iron Lady® Conical Coupling locking plate, we obtained a healing rate of 91%; this data is consistent with recent literature. Moreover, the role of cerclages in addition to femoral plating is actually controversial because they potentially damage the soft callus vascularization. Our results showed no difference in term of healing rate between patients with and without cerclages, according with some of most recent articles. A prospective study with a higher number of patients should be carried out in order to better evaluate the role of cerclages on healing rate but also the complications frequency after PFF surgical treatment.

The bio-engineering technologies of medical devices through nano-structuring and coating was recently proposed to improve biocompatibility and to reduce microbial adhesion in the prevention of implantable device-related infections. Our aim was to evaluate the ability of new nano-structured and coated materials to prevent the adhesion and biofilm formation, according to the American Standard Test Method ASTM-E2647-13. The materials composition was determined by X-ray Fluorescence and Laser Induced Breakdown Spectroscopy. Silver release was evaluated by Inductively Coupled Plasma Mass Spectrometry analysis. The gene expression levels of the Quorum Sensing Las and Rhl system were evaluated by the &Delta, &Delta, Ct method. The Log bacterial density (Log CFU/cm2) on TiAl6V4 was 4.41 &plusmn, 0.76 and 4.63 &plusmn, 1.01 on TiAl6V4-AgNPs compared to 2.57 &plusmn, 0.70 on CoCr and 2.73 &plusmn, 0.61 on CoCr-AgNPs (P &lt, 0.0001, A.N.O.V.A.- one way test). The silver release was found to be equal to 17.8 &plusmn, 0.2 &micro, g/L after the batch phase and 1.3 &plusmn, 0.1 &micro, g/L during continuous flow. The rhlR gene resulted in a 2.70-fold increased expression in biofilm growth on the silver nanoparticles (AgNPs) coating. In conclusion, CoCr showed a greater ability to reduce microbial adhesion, independently of the AgNPs coating. The silver release resulted in promoting the up-regulation of the Rhl system. Further investigation should be conducted to optimize the effectiveness of the coating.

Restoring bone loss is one of the major challenges when facing hip revision surgery. To eliminate the risk of disease transmission and antigenicity of allografts and donor-morbidity of autografts, the use of synthetic bioceramics has become popular in the last decade. Our study investigated the effectiveness of impaction bone grafting (IBG) of contained acetabular defects (Paprosky 2 and 3a) using a porous ceramic-based hydroxyapatite bone substitute (Engipore, provided by Finceramica Faenza S.p.A., Faenza, Italy) mixed with a low percentage of autologous bone (obtained from reaming when available). We retrospectively assessed 36 patients who underwent acetabular revision using IBG using a porous ceramic-based hydroxyapatite bone substitute with cementless implants with a mean follow-up of 4.4 years. We evaluated, at regular intervals, patients clinically (using the Hip Harris Score and Oxford Score) and radiologically to evaluate the rate of incorporation of the graft, the presence of radiolucent lines or migrations of the cup. Clinical scores significantly improved (WOMAC improved from 49.7&ndash, 67.30, and the HSS from 56&ndash, 89). The rate of implants&rsquo, survival was 100% at our medium follow-up (4.4 years). We reported five cases of minor migration of the cup, and radiolucent lines were visible in seven patients at the last-follow up. The graft was well-incorporated in all patients. The results presented in this study suggest the HA bone substitute is an effective and safe bone graft when facing hip revision surgery, thus, longer follow-up studies are required.

Background: Although cementless implants are increasing in popularity, the use of cementless femoral stems for total hip arthroplasty (THA) and hip hemiarthroplasty (HH) in elderly patients remains controversial. The aim of this study was to report the outcomes of a cementless stem used in a large multicentric cohort of elderly patients receiving elective THA and HH for displaced femoral neck fracture. Methods: A total of 293 patients (301 hips) aged 70 years or older (mean age, 78 years, range, 70–93) who received the same cementless plasma-sprayed porous titanium–hydroxyapatite stem were retrospectively evaluated after primary THA and HH to investigate stem survival, complications, and clinical and radiographic results. Results: Cumulative stem survival was 98.5% (95% CI, 96.4–99.4%, 91 hips at risks) with revision due to any reason as the end-point at 10-year follow-up (mean 8.6 years, range 4–12). No stem was revised due to aseptic loosening. The mean Forgotten Joint Score was 98.7. Radiographically, the implants showed complete osseointegration, with slight stress-shieling signs in less than 10% of the hips. Conclusion: The use of cementless stems was proven to be a reliable and versatile option even in elderly patients for elective THA and HH for femoral neck fracture.

The use of tranexamic acid (TXA) in total hip arthroplasty (THA) can significantly reduce blood losses with many clinical and economical advantages. However, no consensus has been reached regarding the optimal regimen for TXA administration. The aim of this study is to analyse and compare the haemostatic effect of two different intravenous (IV) regimens of TXA. We planned a single-centre, prospective, randomized study including 80 patients who underwent primary unilateral minimally invasive THA because of a hip osteoarthritic degeneration. We divided patients into two groups: the G10 group received two IV doses of 10 mg/kg of TXA, and the G20 group received two doses of 20 mg/kg. No significant differences in mean minimum levels of Hb and HcT stratified by days after surgery were uncovered between the two groups despite the use of two different dosages of TXA. Also the mean blood volume loss was statistically similar between two groups. No differences were also observed regarding the occurrence of adverse effects. In two IV bolus regimens of TXA administration, the use of a dose of 10 or 20 mg/kg provides statistically similar results in blood loss sparing. Therefore, the use of two 10 mg/kg doses could be considered more advisable in order to reduce the potential thromboembolic risks related to this drug.

During the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction. Records of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed. Of the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components. Results of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

Over the years, the number of total hip replacements has been steadily increasing. Despite the improvement in surgical results, the number of claims for malpractice is higher. The primary endpoint of this work is to provide an analysis of litigation after hip replacement, to outline what are the instigating causes and costs. The secondary endpoint is to propose a possible preventive strategy for an improved care and a reduction in legal proceedings. The data of this study were collected from medical and legal files and from professional liability insurance of our institution from January 2005 to December 2016. Out of a total of 4770 THA, 40 claims were received. Peripheral nerve injuries represent the first cause of litigation (37%), followed by infectious complications, leg length discrepancy, metallosis, dislocations of the implant and a case of deep vein thrombosis. From the analysis of the past trial judgment, complications such as nerve lesions and infections are almost always recognized, as a medical error, with a high percentage of claims settled. This study shows the necessity of preventive strategies to reduce the higher number of claims for malpractice in total hip arthroplasty. Some complications such as nerve injuries and infection are frequently considered directly dependent on physician’s errors. Litigations can be reduced providing evidence of a diligent execution of the surgical procedure and of a proper postoperative management: the correct compilation of a specific informed consent and adequate doctor–patient communication.

Orthopaedic simulators are popular in innovative surgical training programs, where trainees gain procedural experience in a safe and controlled environment. Recent studies suggest that an ideal simulator should combine haptic, visual, and audio technology to create an immersive training environment. This article explores the potentialities of mixed-reality using the HoloLens to develop a hybrid training system for orthopaedic open surgery. Hip arthroplasty, one of the most common orthopaedic procedures, was chosen as a benchmark to evaluate the proposed system. Patient-specific anatomical 3D models were extracted from a patient computed tomography to implement the virtual content and to fabricate the physical components of the simulator. Rapid prototyping was used to create synthetic bones. The Vuforia SDK was utilized to register virtual and physical contents. The Unity3D game engine was employed to develop the software allowing interactions with the virtual content using head movements, gestures, and voice commands. Quantitative tests were performed to estimate the accuracy of the system by evaluating the perceived position of augmented reality targets. Mean and maximum errors matched the requirements of the target application. Qualitative tests were carried out to evaluate workload and usability of the HoloLens for our orthopaedic simulator, considering visual and audio perception and interaction and ergonomics issues. The perceived overall workload was low, and the self-assessed performance was considered satisfactory. Visual and audio perception and gesture and voice interactions obtained a positive feedback. Postural discomfort and visual fatigue obtained a nonnegative evaluation for a simulation session of 40 minutes. These results encourage using mixed-reality to implement a hybrid simulator for orthopaedic open surgery. An optimal design of the simulation tasks and equipment setup is required to minimize the user discomfort. Future works will include Face Validity, Content Validity, and Construct Validity to complete the assessment of the hip arthroplasty simulator.

Introduction Septic arthritis of the hip is a rare condition in adults and its treatment depends on symptoms duration: early onset of infection can be treated with open or arthroscopic debridement, while more aggressive surgery is required when articular damage takes place such as articular resection or total hip replacement (THA). Presentation of case We report a case of a 30 year old man affect by septic arthritis of the hip after an intramuscular injection of diclofenac successfully treated with a two-steps THA. Discussion In literature there aren’t many cases of septic arthritis of the hip developed after intramuscular injections. Early onset of infection can be treated with an accurate articular debridement, while chronic conditions are traditionally treated by resection arthroplasty. However resection arhtroplasty gives to the patients a significant leg length discrepancy and, especially in young adults, a two-steps surgery with the implant of THA can lead to good results, as reported in recent case series published. Conclusion In our experience two-stage total hip arthroplasty proved to be a reliable solution for septic arthritis of the hip and may be used in patient with severe joint damage. Furthermore we want underline importance of correct anamnesis to make quickly the right diagnosis and provide the right treatment of septic arthritis of the hip also in difficult clinical cases.

Surgical simulation can offer novice surgeons an opportunity to practice skills outside the operating theatre in a safe controlled environment. According to literature evidence, nowadays there are very few training simulators available for Hip Arthroplasty (HA).

A new philosophy of science and medicine had spread throughout the 17th-century Italy: the “Scientific Revolution.” Giovanni Alfonso Borelli (1608–1679) was one of the most charismatic and brilliant scientists of his generation in Europe. He extended to biology the rigorous analytic methods developed by his indirect mentor Galileo in the field of mechanics. In his masterpiece “De Motu Animalium,” Borelli analyzed structure, motion, balance, and forces concerning almost all the principal joints of the human body, in static and dynamic situations. In particular, he accurately studied the anatomy and biomechanics of the knee joint. He sustained that femoral condyles shift backward during flexion, allowing a wider range of movement. Furthermore, he observed that, when the knee flexes, the lateral condyle moves backward more than the medial condyle: this concept is nowadays known as medial pivoting. The aim of this article is to describe the life and work of this important Italian scientist and to present his unrecognized contribution to modern knee biomechanics.

Total hip arthroplasty is one of the most performed procedures in orthopaedic surgery. Implantation of a prosthesis determines changes in the distribution of loads on the host bone, and this phenomenon, known as stress shielding, is related to the biomechanical characteristics of the implant. Usually stress shielding involves the proximal portion of the femur by reducing the mechanical strength and ability to withstand the transmitted loads. The aim of our study is to demonstrate how the use of a short hip stem reduces the stress shielding phenomenon to the proximal femur.The study analyzed 20 patients undergoing hip prosthesis surgery with a short stem (Metha, B. Braun Medical, Inc., Bethlehem, Pennsylvania) at the Ist Orthopaedic Division of Pisa University (between December 2008 and January 2010). Each patient was subjected to analysis of periprosthetic bone mineral density by a bone densitometry (dual emission X-ray absorptiometry [DEXA] with the metal removal software) at 0, 6, 12, 18, 24, and 36 months, following a protocol based on the evaluation of the changes of bone density in the seven Gruen zones.We recorded minimal changes in bone mineral density (BMD) at the level of the greater trochanter (-1.44%) and at the level of the calcar (-3.7%). BMD increased significantly after four years at the level of the lateral distal regions (R2 +9.6% - R3 + 12.4%) and at the level of the distal medial regions (R5 + 8.2% - R6 + 13.1%). We compared the results obtained with the literature data at 12 and 24 months with the same stem (Metha). At 12 months follow up, we did not see a significant difference between our data and the data published in the literature. However, after 48 months of follow-up, we recorded significant differences in the curves of periprosthetic bone reabsorption at the level of the greater trochanter (Zone 1) and at the level of the calcar (Zone 7).The data obtained from our study are in agreement with other studies in the literature, which demonstrates how the use of short stems preserves the metaphyseal bone stock at the level of the proximal femur, reducing the stress shielding phenomenon. From our data, obtained at 24 months and confirmed at 36, stress shielding seems to minimally occur at the level of the calcar. At the level of the great trochanter, we saw a good load distribution that maintained the baseline BMD; these data are in opposition to the literature data that showed a high increase of BMD at the level of the calcar (+12.9%) and a decrease at the level of the great trochanter. From the analysis of the radiographic images of our cases, and of the cases published with the same stem, these differences in load transfer encountered between the great trochanter and the calcar seems to be related to the level of the femoral neck osteotomy and the consequent stem position (varus/valgus).We conclude that the amount of periprostetic bone reabsorption around the Methastem seems to be strictly related to the surgical technique and the final implant position.

We report our initial experience of total knee arthroplasty (TKA) using customized cutting block technology in 30 TKAs from December 2010 to September 2012. Customized blocks were generated for each of the knees using preoperative magnetic resonance imaging of knee and long-leg weight-bearing radiographs. At 30 days, long-leg radiographs were obtained to evaluate the coronal alignment. Twenty-six of the 30 knees had a mechanical axis restored to within 3° of neutral. We conclude that this technology can be safely used in most of the cases of osteoarthritis.

Purpose Total hip arthroplasty could fail due to many factors and one of the most common is the aseptic loosening. In order to achieve an effective osseointegration and reduce risk of lossening, the use of cemented implant, contact porous bearing surface and organic coating were developed. Aim of this study was to evaluate clinical and radiological mid-term outcomes of a porous titanium alloy/hydroxyapatite double coating manufactured cementless femoral stem applied with "plasma spray" technique and to demonstrate the possibility to use this stem in different types of femoral canals. Methods Between January 2008 and December 2012, 240 consecutive primary total hip arthroplasties (THAs) were performed using a porous titanium alloy/hydroxyapatite double coating manufactured cementless femoral stem. 182 patients were examined: 136 were females (74.7%) and 46 males (25.2%); average age was 72 years old (ranging from 26 to 92 years old). For each patient, Harris Hip Scores (HHS) and Womac Scores were collected. All X-ray images were analyzed in order to demonstrate stem survival rate and subsidence. Results Harris Hip Score was good or excellent in 85% of the cases (average 90%) and mean WOMAC score was 97.5 (ranging from 73.4 to 100). No cases of early/late infection or periprosthetic fracture were noticed, with an excellent implant survival rate (100%) in a mean period of 40 months (ranging from 24 and 84 months). 5 cases presented acute implant dislocation, 2 due to wrong cup positioning in a dysplastic acetabulum and 3 after ground level fall. Dorr classification of femoral geometry was uses and the results were: 51 type A bone, 53 type B bone and 78 type C bone. Stem subsidence over 2 mm was considered as a risk factor of future implant loosening and was evidenced in 3 female patients with type C of Dorr classification. No radiolucencies signs around the proximally coated portion of stem or proximal reabsorption were visible during the radiographic follow-up. Conclusions Concerning the use of porous titanium alloy/hydroxyapatite double coating, this study reported an excellent implant survival rate in a mid-term period with a rate of 1,64% of subsidence in patients with type C of femoral canal but with an optimal HHS and Womac Score results. Regarding this stem, primary stability is guaranteed by trapezoid shape of proximal region and tapering in frontal plane through press-fit technique. Radiological absence of pedestal has been accepted as sign of no excessive stress transmission to distal cortex due to its tapered diaphyseal region. Thanks to the reported data, Authors can consider this double coating a valid choice with an excellent medium-term survival and encouraging subsidence results. Further studies are needed to ensure these results can be replicated.

It is widely known that in Orthopaedics, as in each specialty, the academic influence of an article is also determined by the number of times the article is cited. The aim of this study was to identify the 50 most frequently cited Italian orthopaedics journal articles and to analyse the characteristics that might have made them more citable. Science Citation Index Expanded was searched for the 50 most frequently cited Italian orthopaedics journal articles between 1988 and 2013 in the subject category “Orthopaedics”. The 50 most frequently cited articles were all published in English and were published in 12 of the 67 journals in the subject category “Orthopaedics” in the Institute for Scientific Information Web Science (Thomson Reuters, New York, New York, USA). One half of the articles were published before 2000 and the other half later. The number of citations ranged from 423 of the first article (mean citation/years 21.15) to 83 of the fiftieth (mean citation/years 16.60). The articles were all categorized under orthopaedic field, but each of them spanned from orthopaedics to a specific sub-specialty. The majority was clinical articles (n = 39), and the most common fields were sport orthopaedic surgery (including arthroscopy and cartilage) (n = 19) and biomechanics (n = 12). This list of 50 most frequently cited Italian articles is, to our knowledge, significantly important for the general orthopaedic scientific community, particularly for the Italian orthopaedic community. Researchers and doctors may use this work to make their future publications more influential and citable.

Microorganisms universally attach to surface and produce extracellular matrix of polysaccharidic nature termed slime. This phenomenon is now regularly referred to as biofilm formation. Biofilm-associated infections pose a serious problem for public health because bacteria growing in a biofilm are more recalcitrant to the action of antibiotics and host defenses than cells growing in a planktonic state. In orthopedic surgery, such proprieties of biofilm made prosthesis-associated infection a devastating complication. In such a “war,” the prevention with adequate pharmacological prophylaxis, pathogen-specific treatment, and the combination antimicrobial regimens are of paramount importance.

Acetabular cup loosening is associated with pain, reduced function, and instability of the implant. If such event happens while the femoral implant is in a satisfactory position and is well fixed to the bone, isolated acetabular revision surgery is indicated. The aim of this single-center retrospective study was to evaluate the clinical and radiological results over the medium term (12-month follow-up mean 36, max 60) of isolated acetabular revisions surgery using a porous hemispheric revision shell matched with a cemented all-poly cup and large diameter femoral head (>32). 33 patients were enrolled. We collect any relevant data from the clinical board. Routine clinical and radiographic examinations were performed preoperatively; the postoperative follow-up was made at 1, 3, and 6 months and yearly thereafter. At the last available follow-up, we report satisfactory improvement of functional scores in all the patients; 2 patients (6.1%) showed thigh pain and only 4 hips (12.11%) presented mild groin pain; all the femoral components are well fixed and there were no potential or pending rerevisions. With bias due to the follow-up and to the retrospective design of the study, we report clinical, functional, and radiological satisfactory results.

In this report, we describe the effect of vitamin D and calcium supplementation on fracture healing in a young boy with a hypovitaminosis D who had a radius refracture. The radiographic evaluation of the callus formation shows a clear effect of vitamin D on fracture healing in absence of additional variables. Fracture healing restores the tissue to its original physical and mechanical properties and it involves a complex multistep process that involves response to injury, intramembranous bone formation, chondrogenesis, endochondral bone formation, and bone remodeling. All this process is influenced by a variety of systemic and local factors. It is generally assumed that vitamin D plays an intimate role in healing fractures; however, very little data exists on how it does. In this report, the authors describe the effect of vitamin D and calcium supplementation on fracture healing in a young boy with a hypovitaminosis D who had a radius refracture. Our case report suggests that the hypovitaminosis D is a possible cause of inadequate fracture healing and refracture in children and it shows a clear effect of vitamin D supplementation on callus formation in the absence of additional variables.

A number of interspinous devices (ISD) have been introduced in the lumbar spine implant market. Unfortunately, the use of these devices often is not associated with real comprehension of their biomechanical role. The aim of this paper is to review the biomechanical studies about interspinous devices available in the literature to allow the reader a better comprehension of the effects of these devices on the treated segment and on the adjacent segments of the spine. For this reason, our analysis will be limited to the interspinous devices that have biomechanical studies published in the literature.

This is a retrospective study. All the patients gave their written consent to participate at this study. All data were obtained through the collection of the patients medical records and from our surgical and radiological digital databases. The inclusion criteria were first knee arthroplasty procedure and patient consent. We selected 100 patients, from April 2008 to September 2009 (group A) without the application of Fast-track protocol and they were compared to 100 patients, from January 2013 to December 2013 (group B) with the application of the new method. All the patient were operated in our Department (Orthopaedic and Traumatology I Department, University of Pisa, Italy) by 2 senior orthopaedic surgeon (M.L. and E.B.). For each patient the following factors were examined: age, gender, body mass index (BMI in kg/m2), diagnosis (osteoarthritis, rheumatoid arthritis, or others), co-morbid conditions (osteoporosis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease [COPD], history of cerebrovascular or cardiovascular disease etc), ASA score, pre and postoperative hemoglobin levels, blood transfusions number, post-operative analgesia, physiotherapeutic protocol; for the surgical details we examined any complication occurred during surgery, the standard or minimal invasive approach, the anesthesiological procedures and the tourniquet time.

The application of Dual-energy X-ray absorptiometry (DEXA) in orthopaedic surgery gradually has been extended from the study of osteoporosis to different areas of interest like the study of the relation between bone and prosthetic implants. Aim of this review is to analyze changes that occur in periprosthetic bone after the implantation of a total hip arthroplasty (THA) or a total knee arthroplasty (TKA). In THA the pattern of adaptive bone remodeling with different cementless femoral stems varies and it appears to be strictly related to the design and more specifically to where the femoral stem is fixed on bone. Short stems with metaphyseal fixation allow the maintenance of a more physiologic load transfer to the proximal femur decreasing the entity of bone loss. Femoral bone loss after TKA seems to be related to the stress shielding induced by the implants while tibial bone remodeling seems to be related to postoperative changes in knee alignment (varus/valgus) and consequently in tibial load transfer. After both THA and TKA stress shielding seems to be an inevitable phenomenon that occurs mainly in the first year after surgery.

Osteoid osteoma is a benign tumor especially affecting young males generally treated with radiofrequency ablation. This is a non-invasive and safe procedure, major complications are very rare, most of them consisting in local skin burns. The present case shows a late subtrochanteric fracture in a young boy after CT guided termoablation of osteoid osteoma of proximal femur and short review of the literature.

The osteointegration of the orthopaedic implants could improve the biocompatibility and the life span of the implants. The ideal implants should be made by materials easily colonized by bone-forming cells (osteoblasts), which can synthesize new bone matrix. Some implant materials are not often compatible with osteoblasts, but rather they promote the formation of soft connective tissue. There are a number of important reasons to explore the potential for the application of nanomaterials in orthopedic surgery. The use of nanotechnology has been tested on a wide range of materials (such as metals, ceramics, polymers, and composites), where either nanostructured surface features or constituent nanomaterials (including grains, fibers, or particles with at least one dimension from 1 to 100 nm) have been utilized. These nanomaterials have demonstrated superior properties compared with their conventional (or micron structured) counterparts, due to their distinctive nanoscale features and the novel physical properties that ensue. Aim of this paper is to explore how nanotechnology can really improve the future of orthopedic implants and scaffolds for bone and cartilage defects. Here we are showing the most relevant works about the use of nanotechnologies for the treatment of osteocondral defects.

Each year approximately 1 million total hip replacements (THR) are performed worldwide. A percentage of failure due to surgical approach and imprecise implant placement still exists. These result in several serious complications. We propose an approach to plan, to simulate, and to assist prosthesis implantation for difficult cases of THR based on 3-D virtual models, generated by segmenting patients' CT images, 3-D solid models, obtained by rapid prototyping (RP), and virtual procedure simulation. We carried out 8 THR with the aid of 3-D reconstruction and RP. After each procedure a questionnaire was submitted to the surgeon to assess the perceived added value of the technology. In all cases, the surgeon evaluated the 3-D model as useful in order to perform the planning. The clinical results showed a mean increase in the Harris Hip Score of about 42.5 points. The mean time of prototyping was 7.3 hours, (min 3.5 hours, max 9.3 hours). The mean surgery time was 65 minutes (min 50 minutes, max 88 minutes). Our study suggests that meticulous preoperative planning is necessary in front of a great aberration of the joint and in absence of normal anatomical landmarks, CT scan is mandatory, and 3-D reconstruction with solid model is useful.

Acromio-clavicular joint (ACJ) injuries represent nearly half of all athletic shoulder injuries. Stability of this joint depends on the integrity of the acromio-clavicular and coracoclavicular ligaments. Although the traumatic acromioclavicular joint separation is a well-known topic, there are different classifications, diagnostic procedures, concepts of intervention, and a great variety of implants. In this paper, we present an overview of the recent literature about this issue and the results of a retrospective non-randomized study with 2 different techniques. At the first Orthopedic Department of University of Pisa, a retrospective study was performed starting from January 2007 to February 2011 in our electronic database. We selected patient treated with two different techniques (tight-rope(®) system and hook plate) by the same senior surgeon with experience in shoulder surgery. The mean Costant score was 90 for the tight-rope(®) system group and 75 for the hook plate group. At the final follow-up, most of the patients had returned to their preinjury level of activity. Two patients had a breakage of the fixating system. The above-mentioned techniques provided satisfactory results with no loss of reduction except in two cases. The use of the hook plate is useful in fracture-dislocation of ACJ, but this requires another surgery to remove it. On the contrary, the use of the tight-rope(®) system does not require a new surgery or use of expensive synthetic graft or a graft harvested from a distant donor site.

The ageing of the population in developed countries has led to an increased number of patients with hip fractures all over the world. POSSUM and P-POSSUM scores predict morbidity and mortality of patients who will be undergoing a surgical treatment. The aim of this study was to evaluate accuracy of these two scores in hip-fractured patients. Between January and December 2012, in our department 144 patients were hospitalised for femoral neck fractures according to the grade III or IV of Garden’s classification treated with total hip arthroplasty or endoprosthesis. POSSUM scores and P-POSSUM scores were calculated for each patient with complete clinical data. We then calculated the observed and the expected ratio. 134 patients were eligible: 110 females and 24 males. The mean age for women was 79 years, and the mean age for men was 84 years. We observed 13 deaths and 66 complications. The POSSUM scores predicted 16 deaths and 60 complications, while P-POSSUM scores predicted 6 deaths. The O/E ratio for POSSUM mortality was 0.81 and for P-POSSUM was 2.17, while POSSUM morbidity was 1.1. In our study, we have shown that on the one hand, the POSSUM score predicted accurately both the mortality and morbidity in patients undergoing surgery for the femoral neck fracture, while on the other hand, the P-POSSUM score underestimated them. For this reason, we believe that the POSSUM is indeed a good audit tool, which can accurately predict both mortality and morbidity in a cohort of patients.

Initial stability with press-fit cups can be achieved in a number of ways based on the design of the cup. With line-to-line fit, screws fixation, press-fit of 1 to 2 mm which is obtained by an oversized hemispherical cup, initial stability can be achieved with the dual-radius press-fit cups, which have an equatorial diameter 1 to 2 mm greater than that of the polar diameter, to ensure a good press-fit and to provide adequate initial stability for bone ingrowth to occur reliably.Between January 2002 and January 2008, 400 total hip replacements (THRs) were carried out. We examined the first 150 consecutive primary THRs. In all hips, the acetabular component was the dual radius Trident AD shell (Stryker Orthopaedics, Mahwah, New Jersey).The median duration of follow-up was 6,2 yrs (range, 5 to 7 yrs). The median post-operative Harris Hip Score for 150 hips was 90.5 (range, 51 to 98). At the time of the latest follow-up, there was a bony incorporation of all components; we found no definite evidence of radiographic loosening and no signs of radiolucency.According to the encouraging results of the present study we conclude that the Trident cup is a valid choice for acetabular replacement.

Background Acetabular cup loosening is the primary reason of revision in total hip arthroplasty; this usually occurs as a result of implant fixation failure. There are a variety of surgical hardware and strategies available to address this problem that is one of the most challenging circumstances in hip surgery. The purpose of this prospective nonrandomized study is to present our preliminary results in the Ist Orthopaedic and Traumatology Unit of Pisa University with Regenerex™ revision shell.

Summary Background Defects of the distal third of the lower leg with exposed tendons or bone require either local or free flap coverage. Several flaps have been developed, and the distally pedicled peroneus brevis muscle flap has been proven to be a valid local flap alternative. Patients and methods Peroneus brevis muscle is dissected from the lateral surface of the fibula from proximal to distal, but no further than approximately 3–6cm proximally to the lateral malleolus, where the most distal vascular pedicle from the peroneal artery enters the muscle consistently. This allows the muscle to be transposed to more distal lesions. The muscle is then covered with meshed split-skin graft. Between 2002 and 2008, 10 patients with defects of the lower leg in the distal lower third have been treated using this muscle flap. The defects were located over the Achilles tendon, the medial and lateral malleolar, the anterior region of the ankle and the heel area. Each patient was examined through assigning clinical demerit points according to a modified Weber scale, and through Olerud–Molander ankle score to analyse postoperative ankle stability and functionality after reverse peroneus brevis flap reconstruction of the defect. Results All flaps survived completely, and no secondary local flap was required. In our experience, no complication or patient discomfort was noted. Donor-site morbidity was acceptable and restricted to the scar in the lateral lower leg. As demonstrated by the two score evaluations, the functions of foot eversion and plantar flexion as well as ankle functionality and stability were maintained due to preservation of peroneus longus muscle. Conclusion The reverse peroneus muscle flap is ideally suited for small-to-moderate defects of the distal third of the lower leg. This flap offers a convincing alternative for covering defects in the distal leg region. Its arc of rotation allows coverage of more anterior defects of the ankle, of defects of the Achilles tendon and of the heel area as well as of lateral and medial malleolus areas. It is simple to raise and is often transposed easily within the wound without further dissection. As long as the peroneus longus is preserved, ankle instability is not expected.