Treatment of femoral head osteonecrosis in mini invasive surgical approach with regenerative medicine (bone marrow concentrate, platelet rich fibrin and demineralized bone matrix)

Background Scopo del progetto di ricerca è valutare se l'utilizzo della core decompression associata a medicina rigenerativa (gel piastrinico, concentrato midollare autologo e matrice ossea demineralizzata) è sicuro ed efficace nel trattamento dell'osteonecrosi della testa del femore, anche per gli stadi più avanzati Materiali e metodi Inclusi in due protocolli di ricerca (ON-08 e AVN-13) sono stati trattati più di 50 pazienti, dei quali 29 con adeguato follow up (29 anche trattate). Nella stessa procedura il midollo osseo viene aspirato e concentrato, poi si procede alla core decompression ed il materiale rigenerativo (demineralizzato, concentrato midollare e gel piastrinico) vengono introdotti all'interno della lesione con approccio mini invasivo. I pazienti vengono poi valutati clinicamente e con radiografie standard e risonanza magentica nucleare ogni 3 mesi. L'outcome primario è stato valutare la sopravvivenza al trattamento (intesa come non conversione in artroprotesi) mentre gli obiettivi secondari sono stati la valutazione dei sintomi (dolore), della clinica (funzione) e la valutazione degli esami strumentali. Results La progressione radiografica è stata riscontrata in 7 anche. Complicazioni in 2 pazienti (una frattura ed una infezione). 16 anche hanno invece riportato risultati buoni o eccellenti con HHS > 80 a 2 anni di follow up. La protesi è stata indicata in 8 casi (27%). Nei casi falliti, lo stadio di nerosi era IIB in 6 e IIA in uno, mentre stadio III in 2 pazienti. Conclusioni I risultati preliminari sono promettenti in quanto sovrapponibili a quelli disponibili in letteratura. In particolare ottimi risultati clinico-funzionali nei pazienti giovani, affetti da neoplasie ematologiche. Ad ogni modo, è necessario un follow up maggiore ed una corte più ampia di pazienti per confermare i buoni risultati ottenuti.Background We aim to assess whether the use of core decompression and the application of autologous bone marrow concentrate (BMC) along with demineralized bone matrix (DBM) and Platelet Rich Fibrin (PRF) in the treatment of osteonecrosis of the femoral head (ONFH) is safe and effective and whether this technique is indicated in advanced stages. Methods Twenty-nine patients (30 hips) were enrolled in this clinical trial at the Rizzoli Orthopaedic Institute. In the same procedure bone marrow was aspirated and concentrated, then core decompression was performed and BMC mixed with DBM and PRF was introduced into the lesion. Patients were assessed postoperatively with X-Ray and MRI. Primary outcome was the survival rate of hips not converted to total hip arthroplasty (THA). The secondary outcomes were radiographic evolution and clinical symptoms evaluated with Harris Hip Score (HHS). Results Radiographic progression was found in 7 hips. There were complications in 2 hips (one fracture and one deep infection). Sixteen hips with successful treatment had good to excellent functional results at 2-year follow-up (HHS > 80). THA were indicated in 8 hips (27%). In failed cases, the Ficat stage was IIB in 6 and 1 IIA and III respectively in the other two patients. Conclusions The early outcomes of our procedure are similar compared to the literature with promising results in post collapse stages, particularly in young patients treated for haematological malignancies. However, a longer follow-up and more selective study criteria are needed to confirm the present dat

Periacetabular Tumour Resection under Anterosuperior Iliac Spine Allows Better Alloprosthetic Reconstruction than Above: Bone Contact Matters

Periacetabular resections are more affected by late complications than other pelvic resections. Reconstruction using bone allograft is considered a suitable solution. However, it is still not clear how the bone-allograft contact surface impacts on mechanical and functional outcome

SARS-CoV-2 vaccination modelling for safe surgery to save lives : data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.Peer reviewe

SELNET clinical practice guidelines for bone sarcoma

Bone sarcoma are infrequent diseases, representing < 0.2% of all adult neoplasms. A multidisciplinary management within reference centers for sarcoma, with discussion of the diagnostic and therapeutic strategies within an expert multidisciplinary tumour board, is essential for these patients, given its heterogeneity and low frequency. This approach leads to an improvement in patient's outcome, as demonstrated in several studies. The Sarcoma European Latin-American Network (SELNET), aims to improve clinical outcome in sarcoma care, with a special focus in Latin-American countries. These Clinical Practice Guidelines (CPG) have been developed and agreed by a multidisciplinary expert group (including medical and radiation oncologist, surgical oncologist, orthopaedic surgeons, radiologist, pathologist, molecular biologist and representatives of patients advocacy groups) of the SELNET consortium, and are conceived to provide the standard approach to diagnosis, treatment and follow-up of bone sarcoma patients in the Latin-American context

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Custom Reconstruction Around the Knee

With rapid prototyping technique, an individual-based solution can be performed on the patient anatomy and his clinical needs. Different products can be obtained starting from custom-made prostheses and specifc instruments. 3D printing allows to design an architecture with similar mechanical characteristic of bone [8], able to induce osteointegration and decrease the stress-shielding phenomenon due to the porosity and the elasticity of trabecular titanium [9]. Moreover, rapid prototyping can be used to develop specifc instruments for each single step, minimizing the approach and bone loss, reducing the time of surgery and improving the reconstruction. The aim of our research is to develop a new customized implant for knee repair to treat wide defects that alternatively may require commercial implants such as UKA, TKA, modular prostheses or massive allograft transplantation. The idea is an hybrid prosthesis composed by a metallic frame with poly-caprolactone (PCL), a biodegradable material on the joint surface that be considered as a scaffold with similar mechanical characteristic of the implant itself in the short term, but potentially able to be substituted from the regenerative activity of the patient during time confguring a sort of biological prosthesis. This procedure allows to preserve the most bone stock possible, respecting the stability given by soft tissue (ligaments) and maintaining the articular surface on the opposit

Sterno clavicular joint dislocation: A case report of a surgical stabilization technique

Sterno Clavicular Joint (SCJ) dislocations are rare injuries of the shoulder girdle. Their management is controversial due to a not guaranteed outcome after any kind of treatment (conservative or open). Open reduction is challenging because of the anatomical site, while the conservative treatment does not always improve pain or instability discomfort. We report a case of traumatic and painful anterior SCJ dislocation of a young policewoman treated with open reduction by a new surgical technique. Functional result is extremely good at 2 years of follow-up. \ua9 2010 Springer-Verlag

Alloprosthetic Composite is a Suitable Reconstruction After Periacetabular Tumor Resection

BACKGROUND:Resection of a tumor of the pelvis is most disabling when the acetabulum is excised and a durable reconstruction of the defect is hard to achieve. All available methods are associated with frequent complications. Few large series have been published, and fewer have focused entirely on complete resections of the acetabulum. The use of an allograft-prosthetic composite allows customization on the operating table. However, while such composites restore anatomy and function of the pelvis the use of pelvic allografts is controversial and the durability is unknown. QUESTIONS/PURPOSES: We therefore examined (1) the frequency of allograft and prosthetic failure, (2) positive and negative factors influencing the survival of the allograft prosthetic composite, and (3) function of patients with this reconstruction. PATIENTS AND METHODS: We retrospectively evaluated 35 patients who had resection of the entire acetabulum and reconstruction with an allograft-prosthetic composite. Function was scored by the Musculoskeletal Tumor Society system. Followup in 24 survivors averaged 120 months (range, 61-188 months). RESULTS: Greater than 75% of the allografts were still in place at last followup, and the original prosthetic reconstruction was still in place in 56%. Infection was an important negative factor for allograft survival. The average functional score was 72%, with better mean scores for patients who had reconstruction with a stemmed cup and an artificial ligament (average 89%). CONCLUSIONS: An allograft-prosthetic composite provides a versatile substitution of the pelvis and hip, with functional scores approximately 75% of normal

Computer Navigation and 3D Printing in the Surgical Management of Bone Sarcoma

The long-term outcomes of osteosarcoma have improved; however, patients with metastases, recurrence or axial disease continue to have a poor prognosis. Computer navigation in surgery is becoming ever more commonplace, and the proposed advantages, including precision during surgery, is particularly applicable to the field of orthopaedic oncology and challenging areas such as the axial skeleton. Within this article, we provide an overview of the field of computer navigation and computer-assisted tumour surgery (CATS), in particular its relevance to the surgical management of osteosarcom