The computational modelling and 3D technology are finding more and more applications in the medical field. Orthopedic surgery is one of the specialties that can benefit the most from this solution. Three case reports drawn from the experience of the authors’ Orthopedic Clinic are illustraded to highlight the benefits of applying this technology.

Drawing on the extensive experience gained within the authors’ Operating Unit, three cases regarding different body segments have been selected to prove the importance of 3D technology in preoperative planning and during the surgery. A sternal transplant by allograft from a cryopreserved cadaver, the realization of a custom made implant of the glenoid component in a two-stage revision of a reverse shoulder arthroplasty, and a case of revision on a hip prosthesis with acetabular bone loss (Paprosky 3B) treated with custom system. In all cases the surgery was planned using 3D processing software and models of the affected bone segments, printed by 3D printer, and based on CT scans of the patients. The surgical implant was managed with dedicated instruments.

The use of 3D technology can improve the results of orthopedic surgery in many ways: by optimizing the outcomes of the operation as it allows a preliminary study of the bone loss and an evalutation of feasibility of the surgery, it improves the precision of the positioning of the implant, especially in the context of severe deformity and bone loss, and it reduces the operating time; by improving surgeon training; by increasing patient involvement in decision making and informed consent.

3D technology, by offering targeted and customized solutions, is a valid tool to obtain the tailored care that every patient needs and deserves, also providing the surgeon with an important help in cases of great complexity.

Infections represent a devastating complication in orthopedic and traumatological surgery, with high rates of morbidity and mortality. An early intervention is essential, and it includes a radical surgical approach supported by targeted intravenous antimicrobial therapy. The availability of parenteral antibiotics at the site of infection is usually poor, so it is crucial to maximize local antibiotic concentration using local carriers. Our work aims to describe the uses of one of these systems, Stimulan®, for the management and prevention of infections at our Institution.

Analysing the reported uses of Stimulan®, we identified two major groups: bone substitute and carrier material for local antibiotic therapy. The first group includes its application as a filler of dead spaces within bone or soft tissues resulting from traumatic events or previous surgery. The second group comprehends the use of Stimulan® for the treatment of osteomyelitis, post-traumatic septic events, periprosthetic joint infections, arthroplasty revision surgery, prevention in open fractures, surgery of the diabetic foot, oncological surgery and for all those patients susceptible to a high risk of infection.

We used Stimulan® in several complex clinical situations: in PJIs, in DAPRI procedure and both during the first and the second stage of a 2-stage revision surgery; furthermore, we started to exploit this antibiotic carrier also in prophylaxis of surgical site infections, as it happens in open fractures, and when a surgical site remediation is required, like in osteomyelitis following ORIF. Stimulan® is an extremely versatile and polyhedric material, available in the form of beads or paste, and can be mixed to a very broad range of antibiotics to better adapt to different bacteria and their antibiograms, and to surgeon's needs. These properties make it a very useful adjuvant for the management of complex cases of infection, and for their prevention, as well.

Introduction and Objective

The aim of this study was to evaluate whether CT-based pre-operative planning, integrated with intra-operative navigation could improve glenoid baseplate fixation and positioning by increasing screw length, reducing number of screws required to obtain fixation and increasing the use of augmented baseplate to gain the desired positioning. Reverse total shoulder arthroplasty (RSA) successfully restores shoulder function in different conditions. Glenoid baseplate fixation and positioning seem to be the most important factors influencing RSA survival. When scapular anatomy is distorted (primitive or secondary), optimal baseplate positioning and secure screw purchase can be challenging.

Introduction and Objective

Some periprosthetic femoral fractures (PFFs) present history and radiographic aspect consistent with an atypical femoral fracture (AFF), fulfilling the criteria for AFF except that PFFs by themselves are excluded from the diagnosis of AFFs. The aim of this study was to evaluate in a single Institution series of PFFs if any of them could be considered a periprosthetic atypical femoral fracture (PAFF), and their prevalence.

Introduction and Objective

In recent years, along with the extending longevity of patients and the increase in their functional demands, the number of annually performed RSA and the incidence of complications are also increasing. When a complication occurs, the patient often needs multiple surgeries to restore the function of the upper limb. Revision implants are directly responsible for the critical reduction of the bone stock, especially in the shoulder. The purpose of this paper is to report the use of allograft bone to restore the bone stock of the glenoid in the treatment of an aseptic glenoid component loosening after a reverse shoulder arthroplasty (RSA).

Introduction : The purpose of the study is to compare in a randomised clinical double blind trial two methods of hamstring ACL reconstruction, the SIngle Bundle (SB) and the Double Bundle (DB).

Materials and methods: Seventy patients, with a chronic ACL insufficiency, were randomized to receive a unilateral single or double bundle ACL reconstruction. All the operations were performed by the same surgeon using the same two incision outside-in technique. The tibial guide wire was introduced with a 65 degrees Howell guide in extension to avoid impingment. To introduce the second tibial wire (posterolateral wire) a prototype guide that lets you place the wire with a fixed angulation and a fixed distance (9 mm) from the first was used. On the femoral side we used a modified Rear Entry guide. In a SB reconstruction the 10.00 o’clock position (right knee), intermediate between the two anatomic bundles, was used. In a DB reconstruction the first wire was placed in the anteromedial insertion area, close to the “over the top” position on the lateral wall and for the second wire the same prototype guide that gives you the correct angulation and distance with the first (10 mm) was used. The direction was chosen in order to exit 5 mm close to the posterior cartilage. The graft was prepared and pretensioned as to have two arms of the same diameter. It was fixed on the cortex of the tibia by means of a titanium ring bridge when doing a SB and looped around a cortical bony bridge when doing a DB. Tensioning and femoral fixation of the SB was done at 20 degrees, while in the DB tensioning and fixation of the PL bundle was achieved first after cycling at 10–15 degrees and of the AM bundle at 40–45 degrees. Femoral fixation was obtained via RCI titanium interference screws and one additional cortical titanium staple. The same moderately aggressive rehabilitation was utilized in both groups. Outcome assessment was performed by an indipendent observer, blinded to the involved leg and type of reconstruction, using the new IKDC form, the KOOS score, the KT-1000 arthrometer.

Results: All patients reached a minimum follow-up of one year. No difference was found in terms of overall KOOS and IKDC subjective scores. A significant difference was found (p< .001) in KT data and in IKDC final ojective scores (Excellent-A-result: 73% SB and 95% DB). he DB group showed a tred to less pivot shift (glide).

Conclusion: In the short period the DB reconstruction offered better knee stability and better objective results than the 10.00 o’clock SB. Longer follow up and accurate instrumented in vivo rotational stability assessment is probably needed to further disclose small but important differences.

Purpose: Prospectively compare 3 different techniques of ACL reconstruction with autologous hamstrings graft.

Material and methods: 3 comparable groups of 25 knees each were selected. An arthroscopic single incision reconstruction was performed in all groups. In group A, a single bundle graft was inserted. In group B a double bundle reconstruction was performed with 1 tibial and 2 femoral tunnels. In group C, 2 tibial and 2 femoral tunnels were drilled. Fixation was achieved in all knees with Endobutton CL proximally and Washerloc screw distally. Outcome assessment was performed at 4 and 12 months postoperatively by an independent observer, using new IKDC evaluation form, the KT-1000 arthrom-eter, and a radiographic investigation.

Results: At 12 months FU the subjective score was 81 in group A, 76 in group B, and 89 in group C. The final IKDC score was satisfactory (A+B) in over 90% of the patients. The KT-1000 anterior tibial translation was 2.3, 2.5 and 1.9 mm in group A, B, and C respectively. The radiographic study showed no differences between the 3 groups in terms of incidence of tunnel widening.

Conclusions: At a minimum FU of 1 year we could not show a statistically advantage of the two bundle compared to the single bundle.

In the last few years the number of women who practise sport activities has substantially increased and this has led to an increase in the incidence of ACL tear in females. The aim of this study is to assess outcome differences at a minimum 3-year follow-up after ACL reconstruction in women using either a patellar tendon (BPTB) or a quadrupled-looped hamstring (DSTG) autograft fixed with modern devices.

Fifty women with a chronic, isolated ACL tear were randomised to receive a DSTG or BPTB graft for ACL reconstruction. Both groups were comparable as to age, injury-surgery, activity level, meniscal tears, surgical technique and reabilitation. All patients were prospectively evaluated by an independent observer using the IKDC form, the FKSAKP Score, the KT-1000 arthrometer and the Cybex NORM dynamometer. A radiographic study was performed to investigate tunnel widening.

All but two patients were satisfied with the reconstruction. The average side-to-side difference in anterior tibial translation was 2.4 mm in the BPTB group and 2.5 mm in the DSTG group. The final result was A (normal knee) in 56% and in 60% of the BPTB and the DSTG knees, respectively. A failure (4%) was present in each group. Muscle strength deficits at 60°/s, 120°/s and 180°/s were within 10% for extensors and within 5% for flex-ors in both groups. No statistically significant differences were found in terms of subjective satisfaction, objective evaluation, knee stability and muscle strength recovery. The BPTB group showed a higher incidence of postoperative kneeling discomfort (p< 0.05) and a larger area of decreased skin sensitivity (p< 0.001). The DSTG group showed a higher incidence of femoral tunnel widening (p=0.02).

Using strong and stiff fixation devices, ACL reconstruction in women is not influenced by the graft choice.