Primary cementless stems in septic hip revision: Indications and results

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Lumbar total disc arthroplasty: outdated surgery or here to stay procedure? A systematic review of current literature

Background: The purpose of this study was to summarize the available evidence about total lumbar disc replacement (TDR), focusing our attention on four main topics: clinical and functional outcomes, comparison with fusion surgery results, rate of complications and influence on sagittal balance. Materials and methods: We systematically searched Pubmed, Embase, Medline, Medscape, Google Scholar and Cochrane library databases in order to answer our four main research questions. Effective data were extracted after the assessment of methodological quality of the trials. Results: Fifty-nine pertinent papers were included. Clinical and functional scores show statistically significant improvements, and they last at all time points compared to baseline. The majority of the articles show there is no significant difference between TDR groups and fusion groups. The literature shows similar rates of complications between the two surgical procedures. Conclusions: TDR showed significant safety and efficacy, comparable to lumbar fusion. The major advantages of a lumbar TDR over fusion include maintenance of segmental motion and the restoration of the disc height, allowing patients to find their own spinal balance. Disc arthroplasty could be a reliable option in the treatment of degenerative disc disease in years to come. Level of evidence: II

What is the Current Evidence on Vertebral Body Osteonecrosis?: A Systematic Review of the Literature

Osteonecrosis (ON) is a clinical entity characterized by a pattern of cell death and complex process of bone resorption and formation. Studies related to ON have largely focused on certain anatomical sites; however, the evidence on vertebral body ON (VBON) is largely inconsistent and fragmented. The aim of this study was to clarify the pathophysiology, risk factors, imaging findings, and available treatment modalities for VBON. A systematic review of the relevant articles published in English was performed using PubMed, Embase, Medline, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases. A total of 81 articles were included in this study. Three main topics about VBON were identified: (1) pathophysiology and risk factors, (2) diagnosis, and (3) treatment. Forty-five studies were based on the pathophysiology, 52 on diagnosis, and 38 on the treatment options for VBON. The literature on VBON was limited and mainly focused on post-traumatic cases with a considerable overlap with nonunion and pseudoarthrosis

Porous metal cones: gold standard for massive bone loss in complex revision knee arthroplasty? A systematic review of current literature

Introduction: Revision knee arthroplasty is increasing, and in that case, bone loss management is still a challenging problem. In the last years, the body of literature and interest surrounding porous metal cones has grown, but few systematic evaluations of the existing evidence have been performed. The aim of our systematic review is to collect and critically analyze the available evidence about metal cones in revision knee arthroplasty especially focusing our attention on indications, results, complications, and infection rate of these promising orthopaedic devices. Materials and methods: We performed a systematic review of the available English literature, considering the outcomes and the complications of tantalum cones. The combinations of keyword were \u201cporous metal cones\u201d, \u201cknee revision\u201d, \u201cbone loss\u201d, \u201cknee arthroplasty\u201d, \u201cperiprosthetic joint infection\u201d, and \u201coutcome\u201d. Results: From the starting 312 papers available, 20 manuscripts were finally included. Only one included study has a control group. The main indication for metal cones is type IIb and III defects according AORI classification. Most of the papers show good clinical and radiological outcomes with low rate of complications. Conclusion: The examined studies provide encouraging clinical and radiological short-to-mid-term outcomes. Clinical studies have shown a low rate of aseptic loosening, intraoperative fractures, infection rate and a lower failure rate than the previous treatment methods. Higher quality papers are needed to draw definitive conclusions about porous metal cones

Metaphyseal sleeves in total knee arthroplasty revision: complications, clinical and radiological results. A systematic review of the literature

Introduction: Total knee arthroplasty revision (TKAr) is increasing of relevance in orthopaedic surgeon daily practice and will become more and more relevant in the future. The aim of this study is to summarize indications, complications, clinical and radiological mid-term results of metaphyseal sleeves in management of bone defects in TKAr. Methods: A systematic review of English literature was performed on Medline. Retrospective or prospective studies with 2 years of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Rates of intraoperative fractures, aseptic loosening, periprosthetic joint infection (PJI), reoperations and re-revisions were extrapolated by the papers. Results: 13 articles with a level of evidence of IV were included in the systematic review. 1079 TKAr (1554 sleeves) with a mean FU of 4.0 \ub1 1.1 years were analysed. The studies showed good clinical and functional outcomes. Sleeves allowed a stable metaphyseal fixation and osseointegration with an implant and sleeves aseptic survival rate of 97.7 and 99.2%, respectively. The incidence of PJI was 2.7 \ub1 2.4%. The estimated rate of reoperations and re-revisions were 14.2 \ub1 9.2 and 7.1 \ub1 4.8%, respectively. Conclusion: Metaphyseal sleeves represent a viable option in management of types IIb and III AORI bone defects in TKAr. Further high-quality log-term studies would better clarify complications, clinical and radiological results of this promising technique in total knee arthroplasty revision

Femoral revision with primary cementless stems: a systematic review of the literature

The use of primary cementless stems in femoral revision has gained popularity, but no clear consensus about the correct indication is still present. The aim of our systematic review is to: (1) summarize the available literature focused on the use of cementless primary stem in revision total hip arthroplasty (THA); (2) evaluate whether the use of cementless primary stems could represent a feasible option in hip revision; (3) define the proper indication of this surgical approach. A systematic literature review was performed about the use of cementless primary stems in revision THA. The PRISMA 2009 checklist was considered to edit our review. A total of nine articles were included. The current evidence is primarily Level IV. A total of 439 patients (454 hips) underwent THA revision with primary cementless stem. Partial cementless porous coated stems were used in 246 hips (54.2%). The majority of patients were affected by type I or II Paprosky femoral defects. The mean stem-related survival rate is 95.6% \ub1 3.8 with a mean follow-up of 4.7 years \ub1 1.3. Poor standardization of methodological analysis was observed. Current literature shows lacking evidence about primary cementless stems in revision THA. Despite these limitations, we can affirm that primary cementless stems in femoral revision surgery represent a viable option in selected patients. The proper indication is a patient with femoral Paprosky defect types I or II, with low number of previous surgeries and a previous cementless stem

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

Introduction: In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe. Materials and methods: A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty. Results: The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C. Conclusions: One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union

Extreme lateral interbody fusion in spinal revision surgery: clinical results and complications

Purpose of the study: To evaluate clinical outcomes and complications of extreme lumbar interbody fusion (XLIF) in spinal revision surgery comparing our data with the available literature evidence about other fusion techniques. Materials and methods: Retrospective analysis of patients underwent revision surgery with XLIF as interbody fusion technique. Demographic, comorbidity, surgical data, clinical results, and intraoperative and postoperative complications were recorded. Results: 36 patients, with a minimum follow-up of 28 \ub1 11.5 months, were included in the analysis. 41 levels were fused with XLIF. The mean number of previous spine surgery was 1.5 \ub1 0.7. Mean improvement in back pain and leg pain on VAS was 5.6 \ub1 1.4 (p < 0.01) and 3.5 \ub1 2 (p < 0.01), respectively. Mean improvement in the ODI score was 30.3 \ub1 7.3 (p < 0.01). 1 vertebral endplate fracture during interbody space preparation was reported during lateral approach. 5 patients (13.8%) complained quadriceps weakness and anterior thigh hypoesthesia fully recovered after 3 months from surgery, and in one case, a transient contralateral radiculopathy was observed. No implant failure was detected at final follow-up. Conclusions: XLIF is a reasonably safe and effective fusion technique in revision surgery that allows valid arthrodesis avoiding scarred tissue created by previous surgical approaches. Especially, XLIF reduces the risk of nerve root lesions, postoperative radiculitis, and durotomies compared to posterior fusion techniques

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

Purpose: To present a classification system for vertebral body osteonecrosis (VBON) based on imaging findings and sagittal alignment and consequently to propose treatment guidelines. Methods: Chart 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. Results: The 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\u2013posterior 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. Conclusions: The 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 abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.]

Total disc replacement for lumbar degenerative disc disease: single centre 20 years experience

Purpose To report clinical and radiographic outcomes, rate of complications and influence on spinal alignment on long-term follow-up (FU) of patients who underwent lumbar total disc arthroplasty (TDR), bringing some evidence to determine the profile of the most well-suited patients for TDR. Methods A retrospective review of patients underwent TDR for low back pain from degenerative disc disease (DDD) resistant to conservative treatment was performed. Demographic features, surgical data, clinical and radiographic outcomes, complications and spinopelvic parameters were evaluated. Results Thirty patients (32 TDR) were included with a mean FU of 164 \ub1 36.5 months. The clinical outcomes measured by visual analogue scale and Oswestry Disability Index showed a significant improvement between preoperative and 1-year FU (p < 0.01). No significant temporal variance has been identified between 1-year and long-term follow-up (p > 0.05). The surgical revision rate was 10%. The overall rate of complications was 20%. At final follow-up, the mobility of the prosthesis was preserved in 68.75% of the cases, and 73.3% of the patients were globally well aligned. Conclusion The optimal surgical indication is crucial to achieve excellent clinical and radiological outcomes. According to the literature and to our experience, we underline the importance of a coronal deformity < 15\ub0 Cobb angle and a Roussouly type 1 or 2 as the profile of the most well-suited patient for TDR. Our long-term results confirm the existing evidence about efficacy and safety of TDR as a reliable option, in optimal surgery indication, to treat DDD