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The direct anterior approach to the hip is judged to be difficult and even after many solutions, such as special operating tables, have been proposed to perform it, in some reports the complication rate remains high. The complications reported are nerve lesions, dislocation, muscles damages, intraoperative fractures. We describe a modification of the anterior approach, undertaken keeping the patient in lateral decubitus, in order to gain a better range of leg movement and a significant reduction of the force applied to the retractors, the technique was named ALDI (anterior lateral decubitus intermuscular) approach. The surgeon starts behind the patient as in all the other traditional approaches, to maintain unchanged the acetabular view and the dexterity in cup implantation. For the femoral preparation, he moves in front of the patient to have a better visualization. In a series of 150 patients, with a mean operative time of 51.38minutes (range, 40-112), we had no intraoperative fractures, one (0.6%) lateral femoral cutaneous nerve temporary neurapraxia, one (0.8%) posttraumatic dislocation four years after the operation and, no revisions for aseptic loosening or infection. At the 5 years follow-up, the mean Oxford Hip score was 45.2 (range, 38-48; SD 2.6), the mean Harris Hip Score was 96,7 (range, 76-100; SD 2.8), and the mean UCLA score was 7 (range, 5-10; SD 1.4). The possibility to always obtain the optimal position of the surgical window with reduced tension on the muscles, and the unchanged initial surgeon position, could make the ALDI approach the ideal technique for the surgeons that decide to perform an anterior approach.

The three-point orthosis is the most commonly used brace in the conservative treatment of osteoporotic vertebral fractures. The SpinomedWe compared efficacy and safety of these two types of brace in treating osteoporotic vertebral fractures.One hundred forty patients, aged 65-93 years, sustaining osteoporotic vertebral fracture were consecutively recruited and divided into two groups, and treated with either three-point orthosis or dynamic corset. Patients were evaluated with Visual Analogue Scale, Oswestry Low Back Pain Disability Questionnaire, and measurement of forced expiratory volume in the first second. Regional kyphosis angle, Delmas Index, and height of the fractured vertebral body were also measured on full-spine X-rays. Follow-up intervals were 1, 3, and 6 months after trauma. The complications encountered during the 6-month follow-up were recorded.At the 3- and 6-month follow-ups, there was a significant difference (p 0.05) in pain, disability, and respiration in favor of the dynamic orthosis group. At 6-month follow-up, there was no significant difference (p 0.05) in all the radiological parameters between groups. Complications were reported for 28 patients in the three-point orthosis group, and for eight patients in the dynamic corset group (p 0.05).Biofeedback activation of back muscles is probably a key factor in improving functional outcome with dynamic orthosis.Compared to three-point orthosis, patients treated with dynamic orthosis had a greater reduction in pain and a greater improvement in quality of life and respiratory function, with equal effectiveness in stabilizing the fracture, and fewer complications.

Osteoarthritis (OA) is the most frequent joint disease, characterized by degradation of extracellular matrix and alterations in chondrocyte metabolism. Some authors reported that electromagnetic fields (EMFs) can positively interfere with patients affected by OA, even though the nature of the interaction is still debated. Human primary osteoarthritic chondrocytes isolated from the femoral heads of OA-patients undergoing to total hip replacement, were cultured in vitro and exposed 30 min/day for two weeks to extremely-low-frequency electromagnetic field (ELF) with fixed frequency (100 Hz) and to therapeutic application of musically modulated electromagnetic fields (TAMMEF) with variable frequencies, intensities and waveforms. Sham-exposed (S.E.) cells served as control group. Cell viability was measured at days 2, 7 and 14. After two weeks, cell lysates were processed using a proteomic approach. Chondrocyte exposed to ELF and TAMMEF system demonstrated different viability compared to untreated chondrocytes (S.E.). Proteome analysis of 2D-Electrophoresis and protein identification by mass spectrometry showed different expression of proteins derived from nucleus, cytoplasm and organelles. Function analysis of the identified proteins showed changes in related-proteins metabolism (glyceraldeyde-3-phosphate-dehydrogenase), stress response (Mn-superoxide-dismutase, heat-shock proteins), cytoskeletal regulation (actin), proteinase inhibition (cystatin-B) and inflammation regulatory functions (S100-A10, S100-A11) among the experimental groups (ELF, TAMMEF and S.E.). In conclusion, EMFs do not cause damage to chondrocytes, besides stimulate safely OA-chondrocytes and are responsible of different protein expression among the three groups. Furthermore, protein analysis of OA-chondrocytes treated with ELF and the new TAMMEF systems could be useful to clarify the pathogenetic mechanisms of OA by identifying biomarkers of the disease.

Mechanical loading and hydrostatic pressure (HP) regulate chondrocytes’ metabolism; however, how mechanical stimulation acts remain unclear. MicroRNAs (miRNAs) play an important role in cartilage homeostasis, mechanotransduction, and in the pathogenesis of osteoarthritis (OA). This study investigated the effects of a cyclic HP (1–5 MPa), in both normal and OA human chondrocytes, on the expression of miR-27a/b, miR-140, miR-146a/b, and miR-365, and of their target genes (MMP-13, ADAMTS-5, IGFBP-5, and HDAC-4). Furthermore, we assessed the possible involvement of Wnt/β-catenin pathway in response to HP. Chondrocytes were exposed to HP for 3h and the evaluations were performed immediately after pressurization, and following 12, 24, and 48 h. Total RNA was extracted and used for real-time PCR. β-catenin was detected by Western blotting analysis and immunofluorescence. In OA chondrocytes, HP induced a significant increase (p < 0.01) of the expression levels of miR-27a/b, miR-140, and miR-146a, and a significant reduction (p < 0.01) of miR-365 at all analyzed time points. MMP-13, ADAMTS-5, and HDAC-4 were significantly downregulated following HP, while no significant modification was found for IGFBP-5. β-catenin levels were significantly increased (p < 0.001) in OA chondrocytes at basal conditions and significantly reduced (p < 0.01) by HP. Pressurization did not cause any significant modification in normal cells. In conclusion, in OA chondrocytes, HP restores the expression levels of some miRNAs, downregulates MMP-13, ADAMTS-5, and HDAC-4, and modulates the Wnt/β-catenin pathway activation.

Objective To assess the diagnostic performance of ultrasound (US), x-rays, and microscopic analysis of synovial fluid (SF) for calcium pyrophosphate dihydrate crystal deposition disease (CPPD) using histology as a reference standard Methods We enrolled consecutive patients with osteoarthritis waiting to undergo knee replacement surgery. Each patient underwent US of the knee, focusing on menisci and the hyaline cartilage, the day before surgery. During surgery, SF, menisci and condyles were retrieved and examined microscopically. For the meniscus and cartilage microscopic analysis, 8 samples were collected from each specimen and knee radiographs, performed up to 3 months before surgery, were also assessed. A dichotomous score was given for the presence/absence of CPP for each method. Microscopic findings of the specimens were considered the reference standard. All the procedures followed were in accordance with the ethical standards of the local responsible committee. Results 42 patients (14 males) were enrolled. All patients underwent US, 34 had eligible radiographs and 32 had SF analysis. 25 patients (59.5%) were positive for CPP at US, 15 (44.1%) at X-ray and 14 (43.7%) at SF. Sensitivity and specificity values were 96% and 87% for US, 75% and 93% for radiography and 77% and 100% for SF respectively. There were no statistically significant differences between the diagnostic performance across single tests. Conclusion US proved to be at least as accurate as SF analysis for the diagnosis of CPPD. US, which is feasible and harmless, could be considered the first exam of choice for CPPD diagnosis.

Background. The sensitivity and the specificity of different methods to detect periprosthetic infection have been questioned. The current study aimed to investigate the kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in patients undergoing uncomplicated elective total hip arthroplasty (THA), to provide a better interpretation of their levels in noninfectious inflammatory reaction.Methods. A total of 51 patients were included. Serum CRP and PCT concentrations were obtained before surgery, on the 1st, 3rd, and 7th postoperative days and after discharge on the 14th and 30th days and at 2 years.Results. Both markers were confirmed to increase after surgery. The serum CRP showed a marked increase on the 3rd postoperative day while the peak of serum PCT was earlier, even if much lower, on the first day. Then, they declined slowly approaching the baseline values by the second postoperative week. PCT mean values never exceed concentrations typically related to bacterial infections.Conclusions. CRP is very sensitive to inflammation. It could be the routine screening test in the follow-up of THA orthopaedic patients, but it should be complemented by PCT when there is the clinical suspicion of periprosthetic infection.

Osteoarthritis (OA) is the most frequently occurring rheumatic disease, caused by metabolic changes in chondrocytes, the cells that maintain cartilage. Treatment with electromagnetic fields (MF) produces benefits in patients affected by this pathology. Isolated human osteoarthritic (OA) chondrocytes were cultured in vitro under standard conditions or stimulated with IL-1beta or IGF-1, to mimic the imbalance between chondroformation and chondroresorption processes observed in OA cartilage in vivo. The cells were exposed for a specific time to extremely low frequency (ELF; 100-Hz) electromagnetic fields and to the Therapeutic Application of Musically Modulated Electromagnetic Fields (TAMMEF), which are characterized by variable frequencies, intensities, and waveforms. Using flow cytometry, we tested the effects of the different types of exposure on chondrocyte metabolism. The exposure of the cells to both systems enhances cell proliferation, does not generate reactive oxygen species, does not cause glutathione depletion or changes in mitochondrial transmembrane potential and does not induce apoptosis. This study presents scientific support to the fact that MF could influence OA chondrocytes from different points of view (viability, ROS production and apoptosis). We can conclude that both ELF and TAMMEF systems could be recommended for OA therapy and represent a valid non-pharmacological approach to the treatment of this pathology.

We present the case of a 78 year-old man who developed a spontaneous rupture of the lumbar artery leading to a retroperitoneal hematoma while receiving fondaparinux therapy after a total hip replacement. A selective angiographic embolization stopped the bleeding. Fondaparinux was discontinuated and the patient presented a complete resolution of his medical status. Spontaneous hematomas has been well described during low molecular weight heparin (LMWH) treatment, expecially in elderly patients, but there are no previous reports of hematomas induced by fondaparinux. We reviewed the literature to identify the possible risk-factors of bleeding. Our review shows that even if many works suggest that fondaparinux is a safe and effective alternative to LMWH in the prevention of venous thromboembolism following major orthopaedic surgery, it should carefully be used in elderly people and patients with renal disfunction.

The purpose of this prospective study was to give a customized guide, describing the hospitalization period and the postoperative exercise program, to patients scheduled for total hip arthroplasty (THA) and to show its effectiveness on functional recovery and on patient's satisfaction with the rehabilitation care and with the in-hospital discharge planning after surgery.This trial included 365 consecutive subjects with osteoarthritis who underwent THA at the Orthopaedic and Traumatology Clinic of Siena (Italy). The Harris Hip Score (HHS), a disease specific measure, was determined before and after surgery. Postoperative evaluations, associated with a Satisfaction Questionnaire, were carried out at the time of discharge and after 3 months.The overall satisfaction level was very high, both at discharge (81+/-28) and at follow-up (90+/-17). The HHS results showed a significant (por =0.05) improvement over time in patients with higher scores 3 months after surgery in comparison with baseline.Patients reported high levels of satisfaction at the 3 month postoperative follow-up and good levels at discharge. After surgery, the highest improvements were shown in bodly pain and physical function scores. The current study showed that a customized guide was well accepted by patients with THA and satisfie their need of information. It was also effective in improving patient's satisfaction and early recovery of physical function after surgery.