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In the last years considerable research and development activity have been expended to find new ceramic bone substitutes for the treatment of bone defects. However in many cases the drawback of synthethic bone substitutes are the slow graft incorporation and remodelling into the host bone. The purpose of this study was to analyze the kinetics of resorption and new bone formation of new calcium sulfate (CaSO 4 )/calcium phosphate (CaPO 4 ) bioceramic engineered to enhance its bone forming properties. We prospectively evaluated the results of a series of 15 hips with osteonecrosis of the femoral head (ONFH) treated at with core decompression and injection of the CaSO 4 /CaPO 4 composite. In all hips, a quantitative computed tomography (QTC) scan was taken within one week after the surgery, at 12 months, 2 years and finally with a minimum of 4 years follow-up. The mean HU in the immediate post-operative period was 1445 (Range 1388–1602); At one year the mean HU strongly decrease at 556.6 HU ( P  < 0.01); The mean HU at 2 years follow-up further decreased to 475.1. The mean HU at 4 years was unchanged. The quantitative and qualitative CT scan data of this series indicates that the CaSO 4 -CaPO 4 ceramic composite resorbs over a narrow timeframe and the gradual resorption of the graft within the defect provides an ideal environment for the direct new bone growth that propagates across the defect. Graphical Abstract

PurposeDuring the last decade, total hip arthroplasty has become a common procedure performed in young patients, as well as elderly ones. This has led to an increase in total hip arthroplasty revisions. Loosening of primary components with associated bone loss represents the major cause of total hip arthroplasty revision. This study evaluates the safety and performance of an enzyme-deantigenic equine-derived bone graft material in acetabular defect reconstruction.MethodsRecords of 55 patients who were treated for Paprosky type II or III acetabular bone defects with arthroplasty revisions using equine-derived bone and followed for an average of 34 months (range from 24 to 48 months) were analyzed.ResultsOf the 55 revisions, 49 (89%) were regarded as successful, showing good osteointegration without signs of mobilization. Failures included six cases (11%) of mobilization: five cases of aseptic mobilization (9.1% of revisions, 83% of failures) and one case of septic mobilization (1.9% of revisions, 17% of failures). These results are consistent with those of studies having a similar follow-up period for allografts used in combination with trabecular metal components.ConclusionsResults of the present study suggest that enzyme-treated equine-derived bone grafts may be a valid alternative to autogenous and homologous bone grafts in total hip arthroplasty revision.

PurposeThe use of tranexamic acid (TXA) in total hip arthroplasty (THA) can significantly reduce blood losses with many clinical and economical advantages. However, no consensus has been reached regarding the optimal regimen for TXA administration. The aim of this study is to analyse and compare the haemostatic effect of two different intravenous (IV) regimens of TXA.Materials and methodsWe planned a single-centre, prospective, randomized study including 80 patients who underwent primary unilateral minimally invasive THA because of a hip osteoarthritic degeneration. We divided patients into two groups: the G10 group received two IV doses of 10 mg/kg of TXA, and the G20 group received two doses of 20 mg/kg.ResultsNo significant differences in mean minimum levels of Hb and HcT stratified by days after surgery were uncovered between the two groups despite the use of two different dosages of TXA. Also the mean blood volume loss was statistically similar between two groups. No differences were also observed regarding the occurrence of adverse effects.ConclusionsIn two IV bolus regimens of TXA administration, the use of a dose of 10 or 20 mg/kg provides statistically similar results in blood loss sparing. Therefore, the use of two 10 mg/kg doses could be considered more advisable in order to reduce the potential thromboembolic risks related to this drug.

Background Isolated acetabular revisions using standard cups are at risk of dislocation. The introduction of a nonconstrained dual-mobility cup was designed to improve prosthetic stability without increasing loosening rates, but it is unclear whether the risk of dislocation is reduced. Questions/purposes We therefore determined: (1) if the rate of dislocation in isolated acetabular revisions is lower with a dual-mobility cup, (2) implant survival, (3) patient function, and (4) radiographic incidence of migration, loosening, and osteolysis. Methods We prospectively followed 33 selected patients who underwent isolated acetabular revisions with a minimum of 2 years’ followup (mean, 3 years; range, 2–5 years). In 24 patients a stainless steel dual-mobility cup was cemented into an antiprotrusio cage, whereas in nine we used a hyaluronan dual-mobility revision cup with a foramen hook and superior and posterior flanges screw fixations. We determined Harris hip (HHS) and WOMAC scores and examined radiographs for migration, loosening, and osteolysis. Results There were no dislocations. Survivorship rates of the femoral and acetabular components were 97% at 5 years; the rerevision rate for any reason was 3%. At last followup, the mean HHS increased from 48 points preoperatively to 86 points. No patients had progressive osteolysis, component migration, or loosening on radiographs. Conclusion In this select group of isolated acetabular revisions, our data suggest the use of a dual-mobility cup reduced the risk of dislocation without increasing loosening from 2 to 5 years. Level of Evidence Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Purpose The purpose of our study is to describe the rationale, the surgical technique and the early clinical and radiographic results of the treatment of patients with early stage osteonecrosis of the femoral head (ONFH) by performing: core decompression, injection of autologous bone marrow concentrate and the use of a new composite injectable bone substitute (PRO-DENSE ® ), as a mechanical supplementation associated with decompression. Methods The study included 37 hips (31 patients, 14 females, 17 males; mean age 43.9 years, range 24–56 years) with stages IC–IIIA ONFH. The outcome was determined by the changes in the Harris hip score (HHS), by progression in radiographic stages and by the need for hip replacement. The mean follow-up was 20.6 months (range 12–32 months). Results At final follow-up the mean HHS increased from 68 points pre-operatively to 86 points post-operatively. The radiological results showed that 29 hips (78.4  %) improved or had no further collapse. The overall clinical success rate of the procedure was 86.5 %, with three conversions to THA, and a failure rate of only 3.3 % in the pre-collapse group. Conclusions We are encouraged by these early results using core decompression, injection of the autologous bone marrow concentrate and backfilling the defect with an injectable bioceramic for the treatment of early stages of ONFH; as far as a conclusion can be drawn from the current data, this treatment seems to relieve hip pain and prevent the progression of ONFH in the majority of the cases.

Purpose Two-stage revision represents the gold standard in the treatment of infected total knee arthroplasty. Different techniques have been proposed, mostly not preserving range of motion. An articulated antibiotic-loaded cement spacer made in association with two unicompartmental implants has been used as an alternative to a static spacer in an effort to retain as much movement as possible between the stages in young, high-demand patients with preserved ROM. Methods We evaluated nine consecutive patients with a mean age of 66.5 years. The second stage was performed after lab tests returned to normal and culture proved negative. Mean follow-up was 4.6 years. Results Mean ROM from a preoperative value of 105.6° was 103.5° after the first stage, and improved to 110.0° after the definitive implant. Mean Knee Society score was 27.6 preoperatively improving to 86.4 points postoperatively. WOMAC score showed that six patients were very satisfied with the overall result of their reimplanted knee, three subjects were somewhat satisfied. No recurrence of infection, no significant radiolucent lines or osteolysis were recorded at clinical and radiological follow-up and the patients were satisfied with the outcome. Conclusions Results indicated that this technique may ensure the advantages of a static spacer, but allow a greater ROM and better functional recovery. It may be considered as a viable option in selected cases even though the higher costs of two unicompartmental implants should be considered in the light of other aspects, such as prolonged hospital stay and rehabilitation in revision of infected total knee arthroplasty.

Proximal humerus fracture in elderly osteoporotic patients usually leads to severe displaced and multifragmentary fractures. Associated comorbidities may limit surgical options and conservative treatment is commonly indicated, however, with variable results. In most cases, surgery is the treatment of choice in order to restore anatomical integrity, and allow early functional recovery. Several techniques were used over the years, each with specific indication. Percutaneous pinning after closed reduction, a mini-invasive technique and fixation by use of K-wires is not preferred commonly. We present our experience with this approach, focusing on its indications and advantages. A study group of 41 consecutive patients with a mean age of 65.5 years were evaluated clinically (VAS, Constant-Murley score, range of motion), and with radiological analysis: 35 patients finally completed a minimum followup of 24 months. K-wires were removed after a mean interval of 4 weeks. Clinical and radiographic healing occurred in a mean time of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score of 87.6 points, mean VAS of 2.3. In 33 patients, the reduction was considered satisfactory. In two cases, reduction was poor, but the patients however presented acceptable functional outcome. Percutaneous pinning may represent a suitable option of treatment for 2-or 3-part proximal humerus fractures in selected subjects.

Background The evaluation of left ventricular (LV) flow dynamics is a novel approach to assessing LV function that goes beyond traditional metrics. This approach has been applied to patients with heart failure (HF), providing valuable insights that are discussed in this review, with the aim of enhancing our understanding of LV function in the context of the HF syndrome. Methods The analysis of LV flow dynamics is typically conducted using ultrasound and magnetic resonance imaging (MRI) techniques, primarily including particle image velocimetry echocardiography, Vector Flow Imaging, HyperDoppler, and four-dimensional flow MRI. A variety of parameters can be obtained that describe the geometry of the LV vortex, vorticity, kinetic energy, energy dispersion, as well as the amplitude and direction of the hemodynamic forces within the LV cavity. Results In normal subjects, vortex formation plays a crucial role in optimizing LV filling, diastolic-systolic coupling, and energy transfer during systolic ejection. In patients with HF, alterations in vortex structure and dynamics have been associated with both systolic and diastolic LV dysfunction, demonstrating the potential to diagnose early LV dysfunction. Furthermore, these alterations have been linked to LV remodeling and thrombus formation. Several studies have also explored intracardiac flow metrics as biomarkers for guiding HF treatments, including pharmacological interventions, cardiac resynchronization therapy, and LV assist devices. Conclusions Currently available data suggest that the evaluation of LV flow dynamics can have diagnostic and prognostic utility in HF. However, large-scale, multicenter, and prospective studies are needed, particularly to validate therapeutic implications. Graphical abstract HDFs: hemodynamic forces. KE: kinetic energy. LA: left atrium. LV: left ventricle. LV-EF: left ventricular ejection fraction. LVOT: left ventricular outflow tract.

Oxidative stress due to excess superoxide anion ( O 2 ⋅ − ) produced by dysfunctional mitochondria is a key pathogenic event of aging and ischemia-reperfusion diseases. Here, a new O 2 ⋅ − -scavenging Mn II complex with a new polyamino-polycarboxylate macrocycle (4,10-dimethyl-1,4,7,10-tetraazacyclododecane-1,7-diacetate) containing 2 quinoline units (MnQ2), designed to improve complex stability and cell permeability, was compared to parental Mn II complex with methyls replacing quinolines (MnM2). MnQ2 was more stable than MnM2 (log K  = 19.56(8) vs. 14.73(2) for the equilibrium Mn 2+  + L 2− , where L = Q2 and M2) due to the involvement of quinoline in metal binding and to the hydrophobic features of the ligand which improve metal desolvation upon complexation. As oxidative stress model, H9c2 rat cardiomyoblasts were subjected to hypoxia-reoxygenation. MnQ2 and MnM2 (10 μmol L −1 ) were added at reoxygenation for 1 or 2 h. The more lipophilic MnQ2 showed more rapid cell and mitochondrial penetration than MnM2. Both MnQ2 and MnM2 abated endogenous ROS and mitochondrial O 2 ⋅ − , decreased cell lipid peroxidation, reduced mitochondrial dysfunction, in terms of efficiency of the respiratory chain and preservation of membrane potential (Δψ) and permeability, decreased the activation of pro-apoptotic caspases 9 and 3, and increased cell viability. Of note, MnQ2 was more effective than MnM2 to exert cytoprotective anti-oxidant effects in the short term. Compounds with redox-inert Zn II replacing the functional Mn II were ineffective. This study provides clues which further our understanding of the structure-activity relationships of Mn II -chelates and suggests that Mn II -polyamino-polycarboxylate macrocycles could be developed as new anti-oxidant drugs.