The tantalum screw for treating femoral head necrosis: rationale and results

Femoral head necrosis (FHN) is a progressive pathology due to the failure of blood supply to the proximal femoral epiphysis, with consequent necrosis of the sub-chondral bone and collapse of the articular cartilage and loss of congruity between the head and the acetabulum. Borrowing the biological and mechanical principles from the vascularized fibular graft technique for the femoral neck, the tantalum screws have been introduced. They show an extraordinary porosity, osteoconductivity, biocompatibility and very good osteoinductivity. Vitreous tantalum can be processed to take the form of a screw, with a round medial extremity and a 25 mm threaded lateral extremity that can be inserted into the neck of the femur, thereby supporting the articular cartilage, stimulating the repair process, interrupting the interface between necrotic and healthy tissue and favoring local vascularization. We have drawn up a treatment protocol for early-stage FHN, based on the insertion of a tantalum screw into the femoral neck. The implant has a cylindrical shape, with a 10 mm diameter in the smooth part and 15 mm in the threaded part. It is available in different sizes from 70 to 130 mm, with 5 mm increments. The aim of the study is to describe the clinical and instrumental results of the tantalum screw for FHN. From June 2004 to June 2006 we performed 15 implants. The tantalum screw was inserted with an incision on the trochanteric region with traction and under X-ray control. For the clinical evaluation of the hip, we used the Harris hip score (HHS). For diagnosis and staging we used standard X-rays in two views and/or MRI, using the Steinberg classification (J Bone Joint Surg Br 77:34–41, 1995) and CT. In all cases, the osteonecrosis extended to not more than 30% of the joint surface and the cartilage was intact with no collapse. To assess the results, we compared the pre-operative and the post-operative HHS, calculated the percentage differences between the two. We then compared X-rays, CT scans and MRI before and some time after the operation to assess whether the problem had been addressed, taking into account the intracancellous edema and the possible extension of necrosis. After an average follow-up period of 15.43 ± 5.41 months, ten implants (seven patients out of ten) were examined and all but one patient showed a marked improvement in HHS (the average increase was 127.9%), with no further progression of the disease. We believe that this procedure can be suitable for young patients with limited first or second stage osteonecrosis. The objective for the foreseeable future is to resolve the pain, improve the quality of life and prevent or at least postpone arthroplasty.     

The tantalum screw for treating femoral head necrosis: rationale and results

Femoral head necrosis (FHN) is a progressive pathology due to the failure of blood supply to the proximal femoral epiphysis, with consequent necrosis of the sub-chondral bone and collapse of the articular cartilage and loss of congruity between the head and the acetabulum. Borrowing the biological and mechanical principles from the vascularized fibular graft technique for the femoral neck, the tantalum screws have been introduced. They show an extraordinary porosity, osteoconductivity, biocompatibility and very good osteoinductivity. Vitreous tantalum can be processed to take the form of a screw, with a round medial extremity and a 25 mm threaded lateral extremity that can be inserted into the neck of the femur, thereby supporting the articular cartilage, stimulating the repair process, interrupting the interface between necrotic and healthy tissue and favoring local vascularization. We have drawn up a treatment protocol for early-stage FHN, based on the insertion of a tantalum screw into the femoral neck. The implant has a cylindrical shape, with a 10 mm diameter in the smooth part and 15 mm in the threaded part. It is available in different sizes from 70 to 130 mm, with 5 mm increments. The aim of the study is to describe the clinical and instrumental results of the tantalum screw for FHN. From June 2004 to June 2006 we performed 15 implants. The tantalum screw was inserted with an incision on the trochanteric region with traction and under X-ray control. For the clinical evaluation of the hip, we used the Harris hip score (HHS). For diagnosis and staging we used standard X-rays in two views and/or MRI, using the Steinberg classification (J Bone Joint Surg Br 77:34-41, 1995) and CT. In all cases, the osteonecrosis extended to not more than 30% of the joint surface and the cartilage was intact with no collapse. To assess the results, we compared the pre-operative and the post-operative HHS, calculated the percentage differences between the two. We then compared X-rays, CT scans and MRI before and some time after the operation to assess whether the problem had been addressed, taking into account the intracancellous edema and the possible extension of necrosis. After an average follow-up period of 15.43 +/- 5.41 months, ten implants (seven patients out of ten) were examined and all but one patient showed a marked improvement in HHS (the average increase was 127.9%), with no further progression of the disease. We believe that this procedure can be suitable for young patients with limited first or second stage osteonecrosis. The objective for the foreseeable future is to resolve the pain, improve the quality of life and prevent or at least postpone arthroplasty.     

Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34–90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM^® identifies patients with coagulopathy.     

An health education program for patients admitted to CCU for an acute coronary event

In spite of the broad recognition of the importance of health education, time for structured one-to -one initiatives of health education during the hospital stay is limited. The organization of an health education meeting for patients admitted to CCU for an acute coronary event is described. METHODS: The planning and implementation of the initiative lasted two years and involved 7 nurses and one doctor. The organization required efforts related to the event itself (preparation of training aids, identification or contents and methods for delivery) but also organizative changes. Dietitians in fact had to be involved because the healthy diet recommended was different from the hospital diet. The assessment of the effectiveness of the health education was also planned: administration of a questionnaire to explore lifestyles and knowledge of the illness before and after the meeting; phone interviews after 3, 6 and 12 months from the meeting. RESULTS: Since may 2003, in the first 3 years 74 meetings have been organised, involving 507 patients and 329 relatives. Each meeting lasts 2 hours and contents delivered encompass the coronary event, risk factors and their modification, healthy lifestyles. Initial preliminary results on the impact of the meeting on lifestyle changes are promising. Initiatives are ongoing to include this activity among officially recognised nursing activities.     

Chondroblastoma in adult age

Purpose

Chondroblastoma (CB) is a rare benign tumor that occurs most commonly in the second decade of life. No studies on CB in adulthood have been reported. Our purposes were to report a single-institution experience on CB in adults and to discuss the clinical and imaging findings, type of treatment, oncologic and functional outcomes.

Patients and methods

All patients diagnosed and treated for CB from 1981 to 2014 were reviewed. The main inclusion criterion was patients above their 30 years of age at diagnosis. Clinical presentation, imaging, surgical treatment, complications and functional outcome were evaluated. Local recurrences were recorded.

Results

There were 15 males (65%) and 8 females (35%) with a mean age of 40 years (range 30–59 years). Tumor involved the small bones (talus, calcaneus, acromion, cuneiform, metatarsals) in 15 patients (65%) and the long bones in eight patients (35%). Treatment consisted of curettage only (6 cases), curettage plus phenol (13 cases), curettage plus radiotherapy (one patient with vertebral tumor), resection (two patients with CB of the acromion) and chopart amputation (one patient with a metatarsal tumor). At a mean follow-up of 8.4 years (range 3–30 years), twenty patients (87%) remained continuously disease-free, whereas three had local recurrences. None of the patients received chemotherapy.

Conclusion

This study confirms that the occurrence and outcome of adult patients with CB are similar with those affecting younger patients. The main difference consists of the involved bones; flat bones and short tubular bones of the foot, especially the talus and calcaneus, are most commonly involved as opposed to long tubular bones.

Level of evidence

Therapeutic study, level IV-1 (case series).

     

Osteoblastoma of the elbow: analysis of 13 patients and literature review

Purpose

To analyze the clinical and radiographic characteristics, treatment, and outcome of patients with elbow osteoblastoma.

Patients and methods

We present 13 patients (7 males and 6 females; mean age, 28 years) diagnosed and treated for an elbow osteoblastoma from 1975 to 2012. Mean follow-up was 29 months (range 12–60 months). Clinical presentation, imaging, surgical treatment, complications, range of elbow motion, and functional outcome were evaluated. The MSTS, DASH, and OXFORD scores were used.

Results

Main symptom was pain (all patients) accompanied by stiffness (8 patients) and swelling or tumefaction (7 patients), with a median duration of symptoms of 32 months (range 6–96 months). Distal humerus was affected in 10 patients, proximal ulna in 2 patients, and proximal radius in one patient. All patients underwent surgical therapy that consisted of curettage of the lesion (7 patients), curettage and bone allografting (3 patients), wide resection (2 patients; total distal humerus and resection of the radial head), and radiofrequency thermal ablation (1 patient). One patient experienced a recurrence after surgical treatment. The mean MSTS score after treatment was 87% (range 50–100%), which corresponds to excellent results.

Conclusions

Intralesional surgery is successful in tumor control in most patients with osteoblastoma of the elbow. Thermal ablation may be successful for smaller lesions. Most of the patients had a good-to-excellent functional outcome even if they had tumor-related elbow stiffness at diagnosis.

Level of evidence

Therapeutic study, Level IV-1.

     

Spontaneous bilateral Achilles tendon rupture in a patient treated with oral levofloxacin

A case of bilateral rupture of the Achilles tendon in a patient treated with levofloxacin for cystitis is reported. A 76-year-old woman suddenly developed painful ankles one day after levofloxacin treatment. Drug therapy was switched to amoxicillin/clavulanate on the fourth day. Sonography revealed a serious condition of tendinosis with complete bilateral full-thickness rupture on day 6. Tendons were both repaired in the same surgical session. Pathological anatomy of the specimens reported fatty tissue lobules with panniculitis and histiocytosis. Ankles were immobilized postoperatively with a plaster cast. Achilles tendon rupture may occur as an adverse side effect of short-term use of levofloxacin, a fluoroquinolone antibiotic. This adverse effect is a rare and poorly understood complication of this antibiotic therapy. A review of the literature is provided.     

Le fratture di avambraccio

Fractures of the forearm in the growing skeleton in a common event, accounting for 10% of the overall fracture and at the third place for long bone fractures. Most of these fractures present a simple line. There are several classification but the most widely use is the anatomo-radiological one. The majority of the fracture require closed reduction and immobilization in a long arm cast, with the elbow flexed at 90°, since residual defect that can occur are well tolerate. Under the age of nine angulation deformities lesser than 15° have the possibility to remodell completely. Over the age of nine the toleration is lower than 10°. The time of immobilization has to be at least of 8 weeks, in order to reduce the high risk of refracture. The surgical management of these fracture must to be reserved in case of unstable fractures or impossibility to gain good reduction by closed means. The best surgical solution nowadays is stabilization with elastic stable intramedullary nail. Open reduction and plate osteosynthesis must to be reserved for late adolescent, very near to skeletal maturity. External fixation has limited indication, expecially in politrauma and very high grade of open fractures.