Recommendations for resuming elective hip and knee arthroplasty in the setting of the SARS‑CoV‑2 pandemic: the European Hip Society and European Knee Associates Survey of Members

The COVID-19 pandemic has disrupted the health care system around the entire globe. A consensus is needed about resuming total hip and knee procedures. The European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus statement on how the safe re-introduction of elective hip and knee arthroplasty should be undertaken. Methods A prospective online survey was done among members of EHS and EKA. The survey consisted of 27 questions. It includes basic information on demographics and details the participant’s agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). Recommendations focussed on pre-operative, perioperative, and post-operative handling of patients and precautions. Results A total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The participants were from 44 countries and 6 continents. Apart from adhering to National and Local Guidelines, the recommendations concerned how to make elective arthroplasty safe for patients and staf. Conclusion The survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the frst wave of the COVID-19 pandemi

The European multicenter trial on the safety and efficacy of guided oblique lumbar interbody fusion (GO-LIF)

Background: Because of the implant-related problems with pedicle screw-based spinal instrumentations, other types of fixation have been tried in spinal arthrodesis. One such technique is the direct trans-pedicular, trans-discal screw fixation, pioneered by Grob for spondylolisthesis. The newly developed GO-LIF procedure expands the scope of the Grob technique in several important ways and adds security by means of robotic-assisted navigation. This is the first clinical trial on the GO-LIF procedure and it will assess safety and efficacy. Methods/Design: Multicentric prospective study with n = 40 patients to undergo single level instrumented spinal arthrodesis of the lumbar or the lumbosacral spine, based on a diagnosis of: painful disc degeneration, painful erosive osteochondrosis, segmental instability, recurrent disc herniation, spinal canal stenosis or foraminal stenosis. The primary target criteria with regards to safety are: The number, severity and cause of intra-and perioperative complications. The number of significant penetrations of the cortical layer of the vertebral body by the implant as recognized on postoperative CT. The primary target parameters with regards to feasibility are: Performance of the procedure according to the preoperative plan. The planned follow-up is 12 months and the following scores will be evaluated as secondary target parameters with regards to clinical improvement: VAS back pain, VAS leg pain, Oswestry Disability Index, short form - 12 health questionnaire and the Swiss spinal stenosis questionnaire for patients with spinal claudication. The secondary parameters with regards to construct stability are visible fusion or lack thereof and signs of implant loosening, implant migration or pseudarthrosis on plain and functional radiographs. Discussion: This trial will for the first time assess the safety and efficacy of guided oblique lumbar interbody fusion. There is no control group, but the results, the outcome and the rate of any complications will be analyzed on the background of the literature on instrumented spinal fusion. Despite its limitations, we expect that this study will serve as the key step in deciding whether a direct comparative trial with another fusion technique is warranted

European multidisciplinary consensus statement on the use and monitoring of metal-on-metal bearings for total hip replacement and hip resurfacing.

Summary Introduction There is an ongoing debate about the optimal use of metal-on-metal (MoM) bearings in total hip replacement, since there are uncertainties about local and systemic adverse effects due to wear and corrosion of these bearings. Despite various national recommendations, efforts to achieve international harmonization of specific evidence-based recommendations for best practice are still lacking. Hypothesis An international consensus study group should be able to develop recommendations on the use and monitoring of MoM bearings, preferably at the European level, through a multidisciplinary approach, by integrating the perspectives of various stakeholders. Materials and methods Twenty-one experts representing three stakeholder groups and eight countries participated in this European consensus study, which consisted of a consensus meeting, subsequent structured discussion, and consensus voting. Results The current statement defines first of all benefits, local and systemic risks, as well as uncertain issues related to MoM bearings. Safety assessment after implantation of MoM comprises all patients. A closer follow-up is recommended for large head MoM (≥ 36 mm) and resurfacing. In these implants basic follow-up should consist of x-rays and metal ion measurement of cobalt in whole blood, performed with GF-AAS or ICP-MS. Clinical and/or radiographic abnormality as well as elevated ion levels needs additional imaging (ultrasound, CT-scan and/or MARS-MRI). Cobalt values less than 2 μg/L are probably devoid of clinical concern, the threshold value for clinical concern is expected to be within the range of 2–7 μg/L. Discussion This is the first multinational, interdisciplinary, and multiprofessional approach for developing a recommendation for the use and monitoring of MoM bearings in total hip replacement. The current recommendations are in partial agreement with previous statements regarding the extent of follow-up and imaging techniques. They however differ from previous communications regarding measurement of metal ions and especially the investigated medium, technique, and eventual threshold levels. Level of evidence Level V, expert opinion/agreement conference

Increased Mortality in Metal-on-Metal versus Non-Metal-on-Metal Primary Total Hip Arthroplasty at 10 Years and Longer Follow-Up: A Systematic Review and Meta-Analysis

Analysis and Stochastic

Medicina legale orientata per problemi

L\u2019area delle discipline medico-legali vive oggi un rinnovato interesse, sia per gli aspetti di approfondimento dottrinario di tematiche che si pongono a ponte tra scienza e diritto, sia per quanto attiene l\u2019innovazione tecnologica delle scienze biomediche e il loro avanzamento applicativo; sembra cos\uec aprirsi un\u2019era di estremo e sempre pi\uf9 diffuso interesse verso questa disciplina di studio, unitaria nel metodo (la metodologia medico legale ) e nell\u2019approccio ( res medica sub specie iuris ), pur nella sua svariata congerie applicativa. Questo libro, utilizzando lo strumento pedagogico dell\u2019apprendere per problemi, si rivolge sia allo studente universitario di area sanitaria sia al medico gi\ue0 abilitato alla professione, che desidera orientarsi nella disciplina, avvalendosi di un approccio sintetico e razionale, che focalizza gli aspetti di pregnante interesse delle varie aree tematiche affrontate, cos\uec da fornire una risposta tempestiva, e insieme esauriente, ai sempre pi\uf9 numerosi interrogativi medico-legali emergenti nel concreto esercizio delle professioni sanitarie, in generale, e di quella medica in particolare, con un privilegiato riferimento all\u2019area dell\u2019emergenza ospedaliera. Lo sforzo degli Autori \ue8 comunque rivolto non soltanto alla sintesi, al compendio, ma anche allo sviluppo di un graduale livello di approfondimento che, si spera, possa essere incoraggiato nello studente e nel lettore, grazie a una ricca bibliografi a. Per sviluppare le aree tematiche specialistiche della disciplina, gli Autori si sono avvalsi della collaborazione di esperti particolarmente qualifi cati, che hanno illustrato gli aspetti di pi\uf9 rapido avanzamento scientifi co e culturale-metodologico dei settori di riferimento specialistico. Il testo cartaceo, gi\ue0 ricco di note esplicative e di approfondimento, \ue8 stato ulteriormente integrato da allegati e moduli, consultabili e scaricabili online, che completano e ampliano gli argomenti trattati nei diversi capitoli, al fi ne di renderli particolarmente aggiornati alle pi\uf9 recenti, e pubblicate in letteratura, conoscenze in materia, aderenti a una realt\ue0 in continua evoluzione e facilmente utilizzabili come supporto agli adempimenti documentali e professionali propri dell\u2019attivit\ue0 sanitaria

Results of 200 Consecutive Ceramic-on-Ceramic Cementless Hip Arthroplasties in Patients Up To 50 Years of Age: A 5-24 Years of Follow-Up Study

Background: Ceramic-on-ceramic (CoC) bearings due to their mechanical properties can be used in primary total hip arthroplasty (THA) especially in young patients requiring a long-lasting implant. The goal of this study is to analyze the results of a series of 200 consecutive CoC THAs in patients aged 50 years or less at the time of surgery. Methods: A retrospective study was conducted on the first 200 consecutive CoC arthroplasties performed using the direct lateral approach on 105 females and 81 males (14 bilateral cases) with an average age of 44.2 (16-50) years. The diagnosis was primary or post-traumatic osteoarthritis in 94 cases, avascular necrosis of the femoral head in 47, displaced intracapsular femoral neck fracture in 29, osteoarthritis secondary to developmental dysplasia of the hip/Legg-Calvè-Perthes disease/slipped capital femoral epiphysis in 20, and rheumatic diseases in 10 cases. The preoperative Harris Hip Score was 32.5 on average (range 15-55). All the implants were cementless. In 177 THAs the coupling was alumina-on-alumina, and in 23 cases the coupling was AMC-on-AMC (alumina matrix composite). Results: Twenty-five patients with 28 THAs were lost at the final follow-up, 2 stems were revised due to subsidence, 1 cup was revised due to malposition, 1 femoral head was changed because of impingement, and 1 THA was revised for periprosthetic infection. Three patients sustained a Vancouver B1 periprosthetic femoral fracture. At the final follow-up (mean 14.9 years; minimum 5 years to maximum 24 years), 172 THAs were eligible for clinical and radiographic evaluation: none was revised for wear and/or breakage of the ceramic components. Harris Hip Score rose up to a mean value of 90.1 (52-100). Conclusion: The present report demonstrates that CoC coupling offers excellent long-term results in THA performed in young patients with very low wear and no adverse effects caused by the material

Return to Sports After Total Hip Arthroplasty: A Survey Among Members of the European Hip Society.

BACKGROUND The study's aim was to summarize the recommendations given by members of the European Hip Society (EHS) regarding sport activities after total hip arthroplasty (THA). METHODS Members of the EHS were invited to complete an online web-based questionnaire including recommendations for 47 sports disciplines. The questions regarding the specific sports were also divided into 4 subcategories: "allowed," "allowed when experienced," "not allowed", and "no opinion." Four intervals for resuming the sports activities after THA were evaluated: within 6 weeks after THA, 6 to 12 weeks after THA, 12 weeks to 6 months after THA, and more than 6 months after THA. Consensus on resuming sports was analyzed. RESULTS A total of 150 (32.9%) EHS members participated in the survey. Agreement was found for 5 sports activities in the first 6 weeks after THA, for 10 activities, 6 to 12 weeks after surgery, for 26 activities, 3 to 6 months after THA, and for 37 of 47 activities, 6 months after surgery. Sports activities which were not allowed after THA were handball, soccer and football, basketball, full contact sports, and martial arts. CONCLUSION This is the first report describing the recommendations of European hip arthroplasty surgeons on resuming sport activity after THA. Most physical activities were allowed for the patients 6 months after THA. The experience of the patient in performing a distinct sport activity did not influence the recommendations to return to former sports activities. European surgeons are progressively mitigating restrictions to sports after THA. Further studies should evaluate the effects of this trend on patients' outcome and implant survival

Stability of housekeeping genes in human intervertebral disc, endplate and articular cartilage cells in multiple conditions for reliable transcriptional analysis

Quantitative gene expression analysis is widely used to evaluate the expression of specific tissue markers. To obtain reliable data it is essential to select stable housekeeping genes whose expression is not influenced by the anatomical origin of cells or by the culture conditions. No studies have evaluated housekeeping gene stability in intervertebral disc (IVD) cells and only few studies using cartilaginous endplate (CEP) and articular cartilage (AC) cells are present in the literature. We analysed the stability of four candidate housekeeping genes (GAPDH, TBP, YWHAZ and RPL13A) in human cells isolated from nucleus pulposus (NP) and annulus fibrosus (AF), CEP and AC. Cell isolation, expansion, cryoconservation, and differentiation in 3D pellets were tested. GeNorm, NormFinder, BestKeeper tools and the comparative ΔCt method were used to evaluate housekeeping gene stability. In each cell population, TBP alone or combined with YWHAZ was identified as the best normaliser in both monolayer and 3D pellets. GAPDH was the best performer only for AC cells in monolayer. In most culture conditions considering groups of two or more cell types, TBP was the most stable and YWHAZ was the second choice. GAPDH was the best performer only in 3D pellets with factors for AC and AF combined with CEP cells. RPL13A was the most stable only for AF with CEP cells at isolation. Our findings will be useful to properly design the experimental set-up of studies involving IVD, CEP or AC cells in different culture conditions, in order to obtain accurate and high quality data from quantitative gene expression analysis

Stability of housekeeping genes in human intervertebral disc, endplate and articular cartilage cells in multiple conditions for reliable transcriptional analysis

Quantitative gene expression analysis is widely used to evaluate the expression of specific tissue markers. To obtain reliable data it is essential to select stable housekeeping genes whose expression is not influenced by the anatomical origin of cells or by the culture conditions. No studies have evaluated housekeeping gene stability in intervertebral disc (IVD) cells and only few studies using cartilaginous endplate (CEP) and articular cartilage (AC) cells are present in the literature. We analysed the stability of four candidate housekeeping genes (GAPDH, TBP, YWHAZ and RPL13A) in human cells isolated from nucleus pulposus (NP) and annulus fibrosus (AF), CEP and AC. Cell isolation, expansion, cryoconservation, and differentiation in 3D pellets were tested. GeNorm, NormFinder, BestKeeper tools and the comparative ΔCt method were used to evaluate housekeeping gene stability. In each cell population, TBP alone or combined with YWHAZ was identified as the best normaliser in both monolayer and 3D pellets. GAPDH was the best performer only for AC cells in monolayer. In most culture conditions considering groups of two or more cell types, TBP was the most stable and YWHAZ was the second choice. GAPDH was the best performer only in 3D pellets with factors for AC and AF combined with CEP cells. RPL13A was the most stable only for AF with CEP cells at isolation. Our findings will be useful to properly design the experimental set-up of studies involving IVD, CEP or AC cells in different culture conditions, in order to obtain accurate and high quality data from quantitative gene expression analysis