l trattamento della pseudoartrosi di scafoide con innesto osseo vascolarizzato da radio volare

Introduzione: Il trattamento delle pseudoartrosi di scafoide con innesti ossei non vascolarizzati ha una percentuale di fallimento compresa tra il 10 ed il 20%, salendo al 50% nei casi di necrosi del polo prossimale dello scafoide. Gli innesti ossei vascolarizzati garantendo un apporto ematico allo scafoide hanno percentuali di successo più alte. Quello utilizzato nella nostra serie si basa sull'utilizzo di un auto innesto di radio distale irrorato dalla arteria volare carpale epifisaria che decorre lungo il margine distale del pronatore quadrato. Nel gruppo di controllo i pazienti sono stati trattati coninnesto osseo non vascolarizzato da cresta iliaca. Materiali e Metodi: In questo studio prospettico riportiamo la nostra casistica di 9 pazienti affetti da pseudoartrosi dello scafoide carpale, trattati con innesto osseo vascolarizzato dalla arteria volare carpale come procedura primaria Il gruppo di controllo è formato da 12 pazienti trattati con innesto osseo non vascolarizzato da cresta iliaca. Tutti i pazienti sono stati valutati con scale funzionali (DASH, Mauo Wrist score, VAS), valutazione dinamometria della forza di presa e range articolari . La conferma della consolidazione è stata valutata con esame TAC. Risultati: La percentuale di pazienti che ha ottenuto una consolidazione della pseudoartrosi è stata dell' 88% (8/9). Il consolidamento della pseudoartrosi è stato ottenuto in tutti i casi in un arco temporale di 8-11 settimane e confermato dall’esame TAC. I pazienti hanno mostrato un miglioramento nelle scale funzionali, nella forza e nel range articolare. I pazienti del gruppo di controllo hanno mostrato un tasso di consolidazione più basso (75%, 9/12 pazienti) e tempi di consolidazione più lunghi. Discussione: il trattamento delle pseudoartrosi con innesto osseo vascolarizzato da radio volare si dimostra una valida opzione nel trattamento primario delle pseudoartrosi di scafoide. La tecnica attraverso una singola incisione, e quindi con bassa morbidità del sito donatore, permette di eseguire la procedura in regime di ricovero di day surgery. Nessun paziente ha riportato complicanze post operatorie. I risultati ottenuti dalla nostra serie sono sovrapponibili a quellipubblicati. Conclusioni: l’innesto osseo vascolarizzato utilizzato nel presente studio rappresenta una valida opzione nel trattamento primario delle pseudoartrosi di scafoide, garantendo ottime percentuali di consolidazioe in minor tempo. E’ tuttavia necessaria una buona dimestichezza con le tecniche di dissezione microchirurgica

Sonication of antibiotic-loaded cement spacers in a two-stage revision protocol for infected joint arthroplasty

Background. Culturing of the sonication fluid of removed implants has proven to be more sensitive than conventional periprosthetic tissue culture for the microbiological diagnosis of prosthetic joint infection. Since bacteria surviving on antibiotic-loaded cement spacers used in a two-stage exchange protocol for infected arthroplasties may cause the persistence of infection, in this study we asked whether the sonication also could be used to identify bacteria on antibiotic-loaded cement spacers removed at the second surgical stage during a two-stage exchange procedure to confirm whether or not the prosthetic joint infection had been eradicated. Methods. We cultured the sonication fluid of cement spacers that had been originally implanted in a two-stage exchange protocol in 21 patients (mean age, 66 years) affected by prosthetic joint infection (16 total knee prostheses and 5 hip prostheses). The cement spacers were vortexed for 30 seconds and then subjected to sonication (frequency 35–40 KHz). The resulting sonicate fluid was cultured for aerobic and anaerobic bacteria. Results. The sonication fluid culture of the removed spacer was positive in six patients (29%), with isolation of methicillin-sensible Staphylococcus Aureus (MSSA) in three cases, methicillin-resistant Staphylococcus Aureus (MRSA) in one case and Pseudomonas Aeruginosa in two cases. In three of these positive cases, the traditional culture of periprosthetic tissue was negative. Two patients with positive sonication culture of the spacer were successfully treated by early debridement of the revision prosthesis and systemic antibiotic therapy. In three patients a knee arthrodesis was planned and performed as the second surgical stage. In two of them the infection was caused by highly resistant Pseudomonas Aeruginosa. The other patient with a MSSA infection had been poorly compliant with the systemic antibiotic therapy due to her mental impairment. The patient originally affected by MRSA infection of his primary hip arthroplasty developed recurrent infection of his revision prosthesis and eventually underwent Girdlestone arthroplasty. Conclusions. The sonication culture can be used to discover any bacteria on the antibiotic-loaded cement spacer during a two-stage exchange protocol, thus permitting the adoption of timely treatment options, such as the early prosthetic debridment

CLINICAL RESULTS OF COLLAGENASE TREATMENT FOR DUPUYTREN’S DISEASE: A CASE SERIES STUDY WITH 2-YEARS FOLLOW-UP

ABSTRACT Objectives: This study aims to report our experience with Clostridium Histolyticum collagenase (CCH) to support the importance of its clinical use and assess its clinical efficacy, complications, and recurrences. Methods: This prospective observational study of 66 patients with a 2-year follow-up. Patients with an extension lag major of 20° at the metacarpophalangeal joint (MPJ) and/or proximal interphalangeal joint (PIPJ) were included. We collected data on demographic and anamnestic details, MPJ and PIPJ contracture degrees, DASH score, complications, and recurrences. Results: The mean pre-injection contracture was 34° for MPJ and 31° for PIPJ. At the 2-year follow-up, the mean contracture for the MPJ and PIPJ were respectively 3° and 14.5°. The mean DASH score decreased from 21.8 before injection to 10,4 after 2 years. The disease recurrence occurred in 34.8% of the patients, all with PIPJ contracture. The main complication was skin breakage (25.7%). Conclusion: The CCH injections remain a consistent option in treating DD; withdrawal from the European market deprives surgeons and patients of low invasiveness and safe tool for treating DD. Level of evidence IV, Therapeutic study investigating treatment results, Case series

Wrist arthroscopy in the management of articular distal radius fractures

Introduction Fractures of the distal radius account for 15% of all fractures. The use of arthroscopy is increasingly popular in the last years, with the goal to achieve a better anatomical reduction of the articular fragments. Sources of data We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'wrist', 'distal radial fracture', 'distal radius fracture' and 'arthroscopy'. Twenty-eight studies were identified. The quality of the studies was assessed using the Coleman Methodological Score. Areas of agreement Arthroscopy allows to detect intra-articular, ligamentous and triangular fibrocartilage complex injuries in an acute setting with a better prognosis. Arthroscopy increases the quality of the intra-articular reduction compared to fluoroscopy. Areas of controversy The main limitation of the selected studies is the short follow-up: the average follow-up in 20 studies was 12 months, a period long enough to assess functional outcomes, but not to assess the occurrence of post-traumatic degenerative changes and their impact on function. Better stratification of the fracture population is needed. Growing points The shorter recovery time and the low incidence of adverse effects are the main advantages of this new technology. Areas timely for developing research There is need to perform randomized controlled trials reporting on the use of volar locking plates as, at the present time, they are the standard management for these fractures. In addition, the different pattern of fracture should be better classified to manage the patients who will benefit after the management

Collagenase clostridium histolyticum in Dupuytren's contracture: A systematic review

Introduction In the last few years, the use of collagenase clostridium histolyticum for management of Dupuytren's contracture has increased. The procedure of enzymatic fasciectomy has become popular because it is non-invasive, safe and fast to perform. Sources of data A systematic search was performed on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'Dupuytren collagenase' and 'Dupuytren clostridium histolyticum'. Forty-three studies were identified. The quality of the studies was assessed using the Coleman Methodological Score. Areas of agreement The use of collagenase clostridium histolyticum provides better outcomes in patients with mild-moderate joint contracture, with lower complications and side effects than open fasciectomy. Manipulation can be performed 2-7 days after the injection. The use of collagenase is cost-effective. Areas of controversy Most of the studies did not report patient-related outcomes. The role of dynamic splint has to be investigated with randomized clinical trials. Growing points The shorter recovery time and the low incidence of serious or major adverse effects are the main advantages of this new technology. Areas timely for developing research There is a need to perform studies with longer follow-up because the recurrence rate seems to increase with time. Further investigations are necessary to assess whether it is safe and effective to inject two or more cords at the same time

Partial trapeziectomy and pyrocarbon interpositional arthroplasty for trapeziometacarpal joint osteoarthritis: results after minimum 2 years of follow-up

A prospective study was undertaken to assess the outcomes of a series of patients treated using pyrocarbon implant arthroplasty after partial trapeziectomy for trapeziometacarpal joint osteoarthritis. We analysed the results of this procedure in 27 trapeziometacarpal joints of 25 patients. The mean follow-up interval was 34 months (range 26–52). The study showed that pyrocarbon interpositional arthroplasty provided excellent pain relief and high patient satisfaction. Overall function, according to disabilities of the arm, shoulder and hand (DASH) score, improved from 48 points preoperatively to 14 points at the last follow-up assessment. Key pinch strength recorded in the operated hands was comparable with the results obtained in the contralateral hand and in healthy individuals from the same population. No further operations were performed in the study group. Partial trapeziectomy with pyrocarbon arthroplasty may prove to be a successful option for the treatment of trapeziometacarpal joint osteoarthritis. Further long-term comparative studies are warranted