Search Results (120)

Background and Clinical Significance: Thoracic endovascular aortic repair (TEVAR) involving zone 2 of the aortic arch frequently necessitates left subclavian artery (LSA) revascularization to reduce the risk of neurologic and ischemic complications. If endovascular methods are employed, conventional upper extremity access via the brachial or axillary artery often requires surgical cutdown and carries meaningful access-site morbidity. Distal radial (snuffbox) access offers a less invasive percutaneous alternative, yet its use for thoracic branch endoprosthesis (TBE) deployment has only rarely been reported; Case Presentation: We present two patients who underwent successful zone 2 TEVAR with TBE implantation and LSA revascularization using a femoral-to-distal radial through-and-through wire technique. In both cases, the branch component was deployed via the distal radial artery with excellent angiographic results and preserved antegrade flow to the LSA. Neither patient experienced access-related complications; Conclusions: These cases demonstrate the technical feasibility and safety of distal radial access for TBE deployment in zone 2 TEVAR. This approach offers a less invasive alternative to conventional upper extremity access, potentially reducing vascular complications and facilitating earlier recovery. Full article

Segmental bone loss after fracture-related infection (FRI) may require biological reconstruction, endoprosthetic replacement, or amputation. This narrative review examines antimicrobial management, surgical selection, and outcomes of megaprosthetic reconstruction, with emphasis on adult lower-limb periarticular defects. Evidence is distinguished as direct FRI evidence, mixed clinical evidence, or indirect evidence from oncological reconstruction and periprosthetic joint infection (PJI). Megaprostheses provide immediate structural stability and may facilitate early weight-bearing in selected patients with extensive joint involvement, limited capacity for prolonged rehabilitation, or failed biological reconstruction. However, infection, soft-tissue failure, and mechanical complications remain substantial concerns. The frequently cited PJI incidence of 15–43% comes from heterogeneous megaprosthesis populations and is not an estimate specific to reconstruction after post-traumatic FRI. Small FRI series report encouraging short-term infection control, whereas mixed and megaprosthesis PJI cohorts demonstrate recurrent infection and further salvage surgery. Staged reconstruction is commonly reported, but comparisons between surgical strategies are vulnerable to selection bias, small samples, and inconsistent outcome definitions. Biological reconstruction outcomes provide contextual benchmarks rather than evidence of comparative superiority. Overall, megaprosthetic reconstruction is a reasonable salvage option when the expected benefit of immediate stability and preservation of joint motion outweighs the risks of infection and later implant failure. Treatment should integrate adequate debridement, appropriate systemic and local antimicrobial therapy, viable soft-tissue coverage, host optimization, and shared decision-making; the available evidence does not establish a universally preferred reconstruction algorithm. Full article

This study assessed whether surface engineering can improve the durability of metal components in hip joint endoprostheses by reducing friction, abrasive wear, and corrosion at the head–socket interface. Single-layer TiN coatings and multilayer TiN + (Ti,N)₃P + Ti₃P + (Ti,Ni) coatings were deposited on Ti6Al4V alloy using plasma- and PVD-based processes and tested in combination with Chirulen 1020 ultra-high-molecular-weight polyethylene. Tribological performance, surface condition, microstructure, and chemical composition were evaluated before and after wear testing. The results showed that coating type and deposition method influenced the behavior of the friction pair. The most promising systems were Ti6Al4V coated with titanium nitride by sputtering or plasma spraying and Ti6Al4V with the multilayer coating, both paired with Chirulen 1020. The multilayer-coated Ti6Al4V head combined with a Chirulen 1020 cup provided the most favorable friction-pair performance, indicating its potential to reduce wear-product formation and extend implant service life. Full article

Canine appendicular osteosarcoma (OSA) is typically managed by limb amputation. However, this approach may be suboptimal in dogs with concurrent osteoarthrosis (OA). Limb-sparing surgery using three-dimensional (3D)-printed patient-specific implants (PSIs) may be an alternative, although evidence on implant durability and revision strategies remains limited, in particular for proximal humeral reconstructions. This report describes a 9-year-old, overweight dog referred for a 4-week history of persistent left forelimb lameness. Computed tomography (CT) confirmed a lesion affecting the proximal humerus and severe bilateral hip OA. Fine-needle aspiration cytology supported a presumptive diagnosis of OSA. Limb-sparing surgery with 3D-printed PSIs was chosen instead of amputation due to overweight status and OA. Patient-specific guides (PSGs) and endoprosthesis (PSE) were designed based on preoperative CT. Histopathology of the resected tumour confirmed OSA with complete surgical margins. Postoperative functional recovery was favorable, with progressive return to weight-bearing and mild residual lameness up to 8 months. At 9 months, implant failure occurred due to fracture at the distal humeral fixation region. Revision surgery was performed using a novel 3D-printed modular PSE integrating the retained proximal component, allowing restoration of limb function for an additional 6 months. The dog was euthanized at 15 months due to pulmonary metastases. Post-mortem macroscopic and histological visual semi-quantitative assessment of peri-implant tissue suggested advanced osseointegration, with no local recurrence or infection. This report suggests that PSI-based limb-sparing reconstruction may be feasible in proximal humeral OSA and highlights mechanical fatigue as a key limitation. The modular revision approach suggests the potential of additive manufacturing for salvage strategies after implant failure. Full article

This is a retrospective, single-center cohort study comparing the long-term radiographic osseointegration and aseptic loosening between a 3D-printed EPORE^® collar and a prior generation HA-coated collar in endoprosthetic reconstructions. Achieving stable bone integration in endoprosthetic reconstructions remains challenging, with hydroxyapatite (HA)-coated collars being the only option available in the past. Earlier studies from our center have shown reliable and accelerated osseointegration at the bone–collar interface using a novel highly porous 3D-printed EPORE^® collar system compared to a previously used HA-coated collar. Methods: Twenty-eight patients who underwent an implantation of endoprostheses utilizing the novel 3D-printed EPORE^® collar system were case-matched to 24 patients who had previously undergone surgeries using a HA-coated collar. The mean age at surgery was 65.2 years (range: 17–95 years). Patients in the HA-coated collar group had a mean age of 63.8 years (range: 17–86 years), while those in the 3D-printed collar group had a mean age of 66.7 years (range: 32–95 years), with no statistically significant difference between groups (p = 0.876). A minimum radiological and clinical follow-up of 2 years was available in all included cases. Osseointegration was evaluated using postoperative plain radiographs in two planes based on a previously validated semi-quantitative score. Results: When aseptic loosening was used as the primary endpoint, no failures occurred in the 3D-printed EPORE^® group during the study period. The overall rate of stem loosening (including both aseptic and septic causes) was 7% (2/28) in the 3D-printed group and 16% (4/24) in the HA-coated group. All cases of loosening in the 3D-printed cohort were related to septic failure. This translates into a 2-year aseptic-loosening-free survival of 100% in the 3D-printed group. When the radiographic osseointegration was analyzed as the endpoint, the rate of successful osseointegration was significantly higher in the 3D-printed group (92.9%, 26/28; 95% CI 76.5–99.1%) compared with the HA-coated group (70.8%, 17/24; 95% CI 48.9–87.4%; p = 0.04). The distribution of ongrowth scores also differed significantly between groups. The highest ongrowth score (grade 4) was achieved in 82.14% of 3D-printed implants (23/28; 95% CI 63.1–93.9%), compared with 37.5% of HA-coated implants (9/24; p = 0.0002). The time to achieve grade 4 ongrowth was significantly shorter in the 3D-printed cohort, with a median of 470 days (IQR 360–610), compared with 1482 days (IQR 1020–1860) in the HA-coated group (p < 0.0001). In addition, patients in the 3D-printed implant group had a significantly higher mean body mass index compared with the HA-coated group (32.51 vs. 28.36, p = 0.01). Conclusions: These results show that the novel highly porous 3D-printed EPORE^® collars reduce aseptic loosening and accelerate extracortical bridging in endoprosthetic replacements. This benefit persisted even in higher BMI or revision contexts when compared to the previously used HA-coated collars. Full article

The number of patients who require endoprosthetic treatment related to osteoporosis has increased in recent years. Vitamin D3 supplementation has long been standard practice in osteoporosis treatment, while vitamin K2 has gained importance. Using our in vitro model, we compared the osteogenic behaviour of primary healthy human osteoblasts (hOBs) and primary osteoporotic human osteoblasts (hopOBs) under unchanged conditions, with vitamin K2, vitamin D3 and the combined addition. Fluorescence microscopy examinations on a plastic surface and a rough titanium surface structure revealed morphological differences. A quantitative analysis of mineralisation and differentiation was performed using an alizarin red S assay and analysis of alkaline phosphatase activity. It was shown that the hopOBs behave differently morphologically on the titanium surface, while hopOBs are particularly noticeable due to the higher number of cell–cell interactions with vitamin K2. The rough surface led to more pronounced mineralisation of the hopOBs. This effect was pronounced under vitamin K2. Vitamin D3 had an effect in the initial phase of hopOB differentiation. Overall, vitamin K2 had a greater influence on the mineralisation of hopOBs than expected. It must be assumed that vitamin K2 plays a significantly greater role in the metabolism of hopOBs than previously assumed. Full article

The long-term success of orthopedic implants is fundamentally dependent on the synergy between mechanical performance and biological integration. Thus, a comprehensive investigation of both mechanical characteristics and microstructural parameters is essential for the development of reliable implant systems in hip arthroplasty, both in human medicine and veterinary practice. The present study provides a detailed analysis of the mechanical properties, microstructure, and chemical composition of a Ti-6Al-4V-based femoral implant using nanoindentation, scanning electron and optical microscopy, and energy-dispersive X-ray spectroscopy. Then, using finite element analysis, the influence of Young’s modulus on the stress–strain state of the endoprosthesis was evaluated. Dynamic loading conditions were considered by analyzing an impact on a cantilever beam, simulating an animal’s jump onto a supporting limb. For reliable numerical simulation, the model geometry was constructed utilizing computed X-ray microtomography. The numerical simulations were performed for three material cases: reference Ti-6Al-4V, experimentally characterized Ti-6Al-4V (with properties determined by nanoindentation), and CoCrMo alloy, which is also widely used in endoprosthetic applications. The influence of the founded mechanical characteristics on the stress–strain state of the prostheses was assessed. In particular, the results indicate that under dynamic loading conditions, the load-bearing capacity of CoCrMo is lower by approximately 30% and 21% compared to the reference and experimentally characterized Ti-6Al-4V, respectively. Full article

Background: Anesthetizing frail patients for hip surgery is challenging; spinal (SA) and general anesthesia (GA) often cause hemodynamic instability. Traditional nerve blocks provide analgesia but rarely complete surgical anesthesia without motor block. We evaluate the clinical feasibility of the SAFE (Subarachnoid-alternative Anaesthesia For Endoprosthesis) protocol—combining Anterior Pericapsular Nerve Group (A-PENG), POsterior pericapsular Nerve Group (PONG), and Local Infiltration Analgesia (LIA) under intravenous sedation—as a primary anesthetic preserving motor function and avoiding SA/GA. Methods: This single-center retrospective series analyzed patients undergoing elective or trauma-related hip surgery using the SAFE protocol between September 2022 and April 2026. The primary outcome was success rate (completion without SA/GA conversion). Secondary outcomes included procedural timings, recovery room (RR) transit, and motor preservation. Variables are reported as medians [IQR]. Results: We included 48 patients (median age 83.5 years [IQR: 68.7–87.2]; 66.7% female) undergoing hip hemiarthroplasty (n = 28) or total hip arthroplasty (n = 20). The success rate was 100%, without SA/GA conversion or advanced airway management. Median anesthetic preparation and surgical durations were 55 [IQR: 50–76.2] and 85 min [IQR: 74–110], respectively. RR transit times (recorded for 35 patients) were brief (40 min [IQR: 34.0–67.5]). Crucially, lower-limb motor capacity was preserved in 100% of cases. The technique also proved opioid-sparing, substantially reducing postoperative opioid consumption. Conclusions: The SAFE protocol is a clinically feasible primary anesthetic strategy for hip surgery. By preserving motor function and enabling rapid fast-tracking, it aligns with ERAS pathways, offering a promising alternative to conventional anesthesia for elective and frail trauma patients. Randomized controlled trials are warranted to validate these outcomes. Full article

Background: There are still insufficient studies based on large patient cohorts that evaluate both functional and surgical outcomes after internal hemipelvectomy and 3D-printed endoprosthesis implantation. This study aimed to determine how the method of pelvic bone defect reconstruction determines early functional, surgical, and radiographic outcomes. Methods: The aims of the study were achieved based on retrospective observations of 49 patients who underwent surgical treatment at several centres in Poland. All patients underwent internal hemipelvectomy and implantation of 3D-printed prostheses. Surgical parameters were assessed, including operative time, blood loss, and surgical complications (infections, implant loosening, dislocations), as well as bone osseointegration. Functional outcomes were assessed using the HHS and MSTS-93 scales, and pain intensity was measured using the VAS. Outcomes were stratified according to implant design and fixation method based on the West China Classification. Results: The most commonly performed procedures were internal hemipelvectomies of Enneking Type I + II and II + III, with reconstructions most frequently classified as WChC-Aa (15%) and WChC-Bb (44%). Functional assessments revealed significant improvement across all patients. Both the HHS and MSTS-93 values demonstrated marked progress from preoperative averages of 44 (HHS) and 12 (MSTS-93) to 64, 70.2, and 76 (HHS) and 19, 20, and 20.2 (MSTS-93) after 6 weeks, 3 months, and 6 months, respectively. Correspondingly, pain intensity decreased from a mean preoperative VAS score of 8.5 to 4.4, 3.4, and 3.2 after surgery. Osseointegration occurred in 53%, 75%, and 83% of patients after 6 weeks, 3 months, and 6 months, respectively. Wound-healing complications were observed in 6 patients, while deep infection developed in 4 cases. In 3 patients, the implant was removed. Implant loosening was noted in imaging studies in 7 patients (14%) and 8 patients (16%) at 3 and 6 months postoperatively, respectively. Local tumour recurrence was observed in 6 cases. Conclusions: The extent of pelvic tumour resection and the reconstruction method appear to influence surgical parameters, the risk of complications, and operative time. Functional outcomes measured using VAS, HHS, and MSTS-93 scales showed improvement following surgical treatment and tended to improve over time; however, these findings should be interpreted with caution given the relatively short follow-up period and the lack of assessment of minimal clinically important difference (MCID). The use of 3D-printed implants may facilitate precise pelvic reconstruction and enable early mobilization and rehabilitation. Full article

Background and Objectives: Total femoral replacement (TFR) was originally developed for limb salvage following the resection of malignant tumors. Over time, its indications have expanded, now serving as a reconstructive option for failed endoprosthetic replacements and severe trauma cases. Despite its advantages, TFR is a highly complex surgical procedure associated with significant complication rates. This study aims to analyze the management of complications and propose strategies to mitigate associated risks. Materials and Methods: This is a retrospective study conducted on patients from two independent hospitals who underwent TFR for different reasons. Results: Nineteen patients were included: eight underwent TFR for oncological indications, while 11 had the procedure as a revision following failed endoprosthetic arthroplasty or trauma. Postoperative complications were observed in 10 patients (53%), including hip dislocation (21%), mechanical implant failure (11%), infection (21%), wound healing complications (26%), and metal allergy symptoms (5%). Revision surgery was required in six patients (32%), but no cases necessitated amputation. Conclusions: TFR is associated with a high risk of complications, with infection and wound healing issues being the most prevalent. In our experience effective complication management strategies should include early intervention, considering TFR at an earlier stage in non-oncological patients to minimize multiple revision surgeries; allergy screening, assessing for potential metal hypersensitivity preoperatively; dislocation prevention, implementing dual mobility bearings to reduce instability; infection control, utilizing intraoperative local antibiotic therapy in revision cases; and wound management, applying vacuum-assisted closure (VAC) therapy postoperatively to enhance wound healing. Implementing these strategies may improve patient outcomes and reduce the burden of complications associated with TFR. Full article

Zone 2 thoracic endovascular aortic repair (TEVAR) frequently requires left subclavian artery (LSA) preservation to maintain vertebrobasilar and upper-extremity perfusion while obtaining a durable proximal seal. Dedicated single-branch endografts were developed to standardize this step and to facilitate a reproducible fully endovascular strategy. Two main device concepts currently shape this field: integrated unibody branch platforms, represented by Castor and the second-generation Cratos, and modular retrograde-branch systems, represented by the Gore TAG Thoracic Branch Endoprosthesis (TBE). The Castor/Cratos evidence base is broader and older, and is mainly centered on type B aortic dissection, with prospective multicenter and real-world data showing favorable branch patency and aortic remodeling. By contrast, TBE evidence is expanding rapidly and is supported by prospective midterm data in arch aneurysms as well as by increasingly large post-commercial series and comparative analyses across zones 0–2. Beyond outcomes, the two platforms differ substantially in branch directionality, potential contribution to proximal fixation, modularity, branch diameter range, proximal landing requirements, access profile, and regulatory/off-the-shelf availability, all of which have direct consequences for anatomical suitability in dissection, aneurysm disease, and trauma. This narrative review synthesizes current evidence and proposes an anatomy-first, pathology-aware framework for selecting between Castor/Cratos and TBE in totally endovascular zone 2 TEVAR with LSA revascularization. Full article

Background: Limb-salvage surgery using extendable distal femoral endoprostheses has become the standard reconstruction following tumor resection in skeletally immature patients, allowing continued growth and improved function. However, mechanical complications, particularly tibial pain, remain challenging and poorly understood. This study aimed to identify radiographic predictors of tibial pain and evaluate their potential utility in early risk detection. Methods: A retrospective cohort study was conducted of 29 skeletally immature patients (mean age 10.4 years) who underwent expandable distal femoral endoprosthetic replacement between 2008 and 2018 at a tertiary orthopedic oncology center. Standardized radiographs were analyzed at 6 months and final follow-up (mean 75 months) to assess cortical thickness, stem-to-cortex distances, stem migration, stress shielding, pedestal formation, and periosteal reaction. Associations between radiographic parameters and tibial pain were assessed using multivariable logistic regression, t-tests, and chi-square analyses. Results: Seventeen patients (58.6%) developed activity-limiting tibial pain requiring analgesics, as documented during follow-up. Mean medial and lateral cortical thickness increased from 3.0 mm and 3.4 mm to 4.1 mm and 5.1 mm, respectively. The logistic regression model demonstrated strong explanatory power (Pseudo R² = 0.57, p = 0.004). Medial cortical thickness at last follow-up was the only significant independent predictor of tibial pain (p = 0.042), and was significantly associated with tibial pain. Patients with tibial pain exhibited greater medial cortical thickening (p < 0.001). Stem migration (φ = 0.421, p = 0.065), stress shielding (φ = 0.476, p = 0.044), pedestal formation (φ = 0.608, p = 0.004), and periosteal reaction (φ = 0.569, p = 0.008) were also associated with pain. Conclusions: Medial cortical hypertrophy emerged as a potential radiographic biomarker for tibial pain. after expandable distal femoral endoprosthesis in growing patients. The findings suggest that cortical remodeling, stress shielding, and pedestal formation collectively reflect stem micromotion and bone adaptation. Early radiographic surveillance of these parameters warrants further investigation in prospective studies to determine their clinical utility. Larger multicenter studies are warranted to validate these predictors and refine postoperative monitoring protocols. Full article

Background: We present our experience of carrying out endovascular therapy (EVT) of a pseudo-aneurysm of the posterior tibial artery (PTA) with an associated arteriovenous fistula (AVF). We also present results of a systematic review which was carried out to cast light on endovascular treatment modalities. Methods: A 31-year-old patient with a history of war trauma presented with pain of increasing severity in the lower leg. A CT angiogram confirmed an aneurysm of the PTA with an AVF. With a bidirectional endovascular approach, the aneurysm was occluded with coils and excluded with a Viabahn endoprosthesis. Aspirin and clopidogrel were recommended postoperatively. After 18 months of follow-up, the patient was free of symptoms, with patent endoprosthesis. Multiple databases (Scopus, Pubmed, Medline, OVID) were systematically searched using MeSH terms. The studies were scrutinized, and data on demographics, procedural details, and follow-up were collected and aggregated. Results: A total of 44 studies (56 patients) were eligible and were included. Average age was 50 (15–87 years). The most common etiology was trauma (iatrogenic 29/56 (51.7%); non-iatrogenic 15/56 (26.7%)). EVT strategies included coil embolization (n = 29), stent implantation (n = 25), and a combination of both (n = 2). Median stent diameter was 3 mm (2.5–6). The follow-up period ranged from 1 week to 60 months. Aggregated reported primary patency was 18/27 (66.6%) with no documented complications—an observation that likely reflects reporting and publication bias, rather than a true absence of adverse events. Conclusions: EVT offers a feasible and safe alternative to simple ligation or occlusion of crural aneurysms, to preserve distal flow to the foot. Dedicated stents for crural arteries are not available. Studies with long-term follow-up are lacking. Full article

Objectives: This study evaluated the anatomical suitability of two single-branched thoracic stent grafts—the Castor (Endovastec, China) and the Thoracic Branch Endoprosthesis (TBE, Gore, USA)—for proximal landing in aortic arch zone 2, including the left subclavian artery (LSA), in patients with acute type B aortic dissection (TBAD). While the TBE is currently available as an off-the-shelf device (26 main bodies, 8 branch configurations), the study also aimed to define the minimal number of configurations needed to treat most patients. The same approach was applied to the Castor stent graft, currently only available as a custom-made device (CMD), to assess its potential for off-the-shelf adaptation. Methods: A retrospective analysis was performed on computed tomographic angiographies of TBAD patients treated between 2004 and 2023. Exclusion criteria included type A or non-A-non-B dissections, isolated abdominal dissections, intramural hematomas, and lack of consent. Morphometric measurements were conducted using centerline analysis software. Suitability was defined per manufacturers’ criteria and reported with 95% confidence intervals. Results: Among 100 TBAD cases, 82% (95% CI: 73.3–88.3%) were suitable for the Castor CMD with 74 configurations. Main causes of exclusion were short landing zones and atypical arch anatomies. With adjunctive procedures, 13 Castor configurations covered all morphologies; 34% could be treated off-the-shelf, and 48% required additional interventions. For the TBE, off-the-shelf suitability was 22%, increasing to 78% with adjunctive procedures (six main bodies, five branches). Conclusions: Both stent grafts are promising for proximal extension in TBAD. Reduced configuration availability necessitates more adjunctive procedures, impacting efficiency and cost. Full article

Osteoarthritis (OA) is a severe and progressive joint disease that usually affects elderly people. The consequence of this disease in its advanced stage is the need for total knee arthroplasty (TKA). Over the years, there has been a constant increase in the number of TKA procedures, with a predicted increase to 1.26 million procedures by 2030. Diagnostics are based on conventional radiography, although advanced techniques such as radiostereometry, SPECT/CT and PET/CT, which enable early detection of micromigration, are gaining increasing recognition. Vibroarthrography (VAG) is a proposed supplement to diagnostics, enabling the assessment of the characteristics of vibrations and friction of joint surfaces, thus supporting the process of early detection of endoprosthesis instability. The combination of conventional and alternative diagnostic methods, including vibroarthrography, may improve the detection of early TKA loosening. This may also result in increased implant durability. The aim of this article is to review the current state of knowledge on the classification and analysis of endoprosthesis loosening mechanisms. In addition, classic and modern methods of detecting and monitoring loosening are discussed, with particular emphasis on vibroarthrography as a potential tool for early diagnosis. Full article