Publications by authors named "Luigi Murena"

55 Publications

Trabecular bone porosity and pore size distribution in osteoporotic patients - A low field nuclear magnetic resonance and microcomputed tomography investigation.

J Mech Behav Biomed Mater 2022 01 29;125:104933. Epub 2021 Oct 29.

Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, I-34149, Trieste, Italy.

The study of bone morphology is of great importance as bone morphology is influenced by factors such as age and underlying comorbidities and is associated with bone mechanical properties and fracture risk. Standard diagnostic techniques used in bone disease, such as Dual-Energy X-ray absorptiometry and ultrasonography do not provide qualitative and quantitative morphological information. In recent years, techniques such as High Resolution Computed Tomography (HR-CT), micro- CT, Magnetic Resonance Imaging (MRI), and Low Field Nuclear Magnetic Resonance (LF-NMR) have been developed for the study of bone structure and porosity. Data obtained from these techniques have been used to construct models to predict bone mechanical properties thanks to finite element analysis. Cortical porosity has been extensively studied and successfully correlated with disease progression and mechanical properties. Trabecular porosity and pore size distribution, however, have increasingly been taken into consideration to obtain a comprehensive analysis of bone pathology and mechanic. Therefore, we have decided to evaluate the ability of micro- CT (chosen for its high spatial resolving power) and LF-NMR (chosen to analyze the behavior of water molecules within trabecular bone pores) to characterize the morphology of trabecular bone in osteoporosis. Trabecular bone samples from human femoral heads collected during hip replacement surgery were from osteoporosis (test group) and osteoarthritis (control group) patients. Our data show that both micro- CT and LF-NMR can detect qualitative changes in trabecular bone (i.e., transition from plate-like to rod-like morphology). Micro- CT failed to detect significant differences in trabecular bone morphology parameters between osteoporotic and osteoarthritic specimens, with the exception of Trabecular Number and Connectivity Density, which are markers of osteoporosis progression. In contrast, LF-NMR was able to detect significant differences in porosity and pore size of trabecular bone from osteoporotic versus osteoarthritic (control) samples. However, only the combination of these two techniques allowed the detection of structural morphometric changes (increase in the larger pore fraction and enlargement of the larger pores) in the trabecular bone of osteoporotic specimens compared to osteoarthritic ones. In conclusion, the combined use of LF-NMR and micro- CT provides a valuable tool for characterizing the morphology of trabecular bone and may offer the possibility for a new approach to the study and modeling of bone mechanics in the context of aging and disease.
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http://dx.doi.org/10.1016/j.jmbbm.2021.104933DOI Listing
January 2022

Prognostic significance of unexplained left ventricular hypertrophy in patients undergoing carpal tunnel surgery.

ESC Heart Fail 2021 Nov 9. Epub 2021 Nov 9.

Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, Trieste, 34100, Italy.

Aims: Carpal tunnel (CT) syndrome is a recognized red-flag of cardiac amyloidosis (CA) and increased cardiovascular (CV) morbidity. We designed this study to characterize the CV profile of patients with CT syndrome at the time of first surgery and to identify high-risk presentations.

Methods And Results: We retrospectively reviewed 643 patients who underwent CT surgery between 2007 and 2019. Of them, 130 patients (77 years, 45% male patients, left ventricular ejection fraction 62%) with available CV characterization within ±12 months from CT surgery were included. Abnormal loading conditions causing cardiac left ventricular hypertrophy (LVH) were investigated to distinguish explained LVH (Ex-LVH) from unexplained LVH (Un-LVH). LVH was found in 66 (51%) patients, 33% of them presented Un-LVH. Compared with the others, Un-LVH patients were older (77 and 75 vs. 70 years in Un-LVH, Ex-LVH, and non-LVH, respectively; P = 0.002), had higher rates of electrocardiogram-echo discrepancy (70%, 14.3%, and 1.6%, respectively; P < 0.001) and of echocardiographic findings of CA (24%, 7%, and 0%, P < 0.001). Among Un-LVH patients, 9 (43%) experienced death and 7 (33%) developed heart failure (HF) at 3.8 and 2.4 years from CT surgery, respectively. Compared with the others, death and HF development rates were higher in Un-LVH patients both at unadjusted (P = 0.01 and P = 0.02, respectively) and adjusted analysis for age, gender, and renal insufficiency (P = 0.00038 and P = 0.050, respectively).

Conclusions: At the time of CT surgery, Un-LVH was found in more than 30% of patients with LVH, and 24% of them showed echocardiographic features suggesting an underdiagnosed CA. Un-LVH was associated with higher all-cause mortality and HF development.
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http://dx.doi.org/10.1002/ehf2.13606DOI Listing
November 2021

Is intraoperative neuromonitoring effective in hip and pelvis orthopedic and trauma surgery? A systematic review.

J Orthop Traumatol 2021 Oct 13;22(1):40. Epub 2021 Oct 13.

Orthopaedics and Traumatology Unit, Cattinara Hospital-ASUGI, Strada di Fiume 447, 34149, Trieste, Italy.

Introduction: Sciatic nerve injury is an uncommon but potentially devastating complication in hip and pelvis surgery. Intraoperative nerve monitoring (IONM) was applied since the seventies in neurosurgery and spine surgery. Nowadays, IONM has gained popularity in other surgical specialities including orthopaedic and trauma surgery. Aim of this systematic review is to resume the literature evidences about the effectiveness of intraoperative monitoring of sciatic nerve during pelvic and hip surgery.

Methods: Two reviewers (GC and MD) independently identified studies by a systematic search of PubMed and Google Scholar from inception of database to 10 January 2021. Inclusion criteria were: (a) English written papers, (b) use of any type of intraoperative nerve monitoring during traumatic or elective pelvic and hip surgery, (c) comparison of the outcomes between patients who underwent nerve monitoring and patient who underwent standard procedures, (d) all study types including case reports. The present review was conducted in accordance with the 2009 PRISMA statement.

Results: The literature search produced 224 papers from PubMed and 594 from Google Scholar, with a total amount of 818 papers. The two reviewer excluded 683 papers by title or duplicates. Of the 135 remaining, 72 were excluded after reading the abstract, and 31 by reading the full text. Thus, 32 papers were finally included in the review.

Conclusions: The use of IONM during hip and pelvis surgery is debated. The review results are insufficient to support the routine use of IONM in hip and pelvis surgery. The different IONM techniques have peculiar advantages and disadvantages and differences in sensitivity and specificity without clear evidence of superiority for any. Results from different studies and different interventions are often in contrast. However, there is general agreement in recognizing a role for IONM to define the critical maneuvers, positions or pathologies that could lead to sciatic nerve intraoperative damage.

Level Of Evidence: Level 2.
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http://dx.doi.org/10.1186/s10195-021-00605-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8514601PMC
October 2021

Early weight bearing in acetabular and pelvic fractures.

Acta Biomed 2021 09 2;92(4):e2021236. Epub 2021 Sep 2.

Orthopaedics and Traumatology Clinic, Department of Medicine and Surgery, University of Parma (Italy)..

Background And Aim Of The Work: The incidence of pelvic and acetabular fractures is increasing during the years, counting 37 pelvic fractures per 100000 people annually. No weight bearing or toe touch weight bearing are usually chosen in the initial management to allow fracture and ligamentous healing and avoid fracture displacement and fixation failure. On the other hand, early weight bearing may stimulate fracture healing and allow prompt functional recovery, faster return to work and recreational activities and reduce complications linked to late rehabilitation.  Aim of the study is to review the literature about weight bearing indications for pelvic and acetabular fractures to highlight clinical and biomechanical evidence supporting early weight bearing.

Methods: Two independent reviewers independently extracted studies on early weight bearing of pelvic and acetabular fractures. All selected studies were screened independently based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts.

Results: 44 studies including reviews, meta-analysis, clinical and biomechanical studies were selected.

Conclusions: Despite biomechanical data, few clinical evidences can be found to support early weight bearing in pelvic and especially acetabular fractures treatment. The promising results of some clinical experiences, however, should direct further studies to clearly define the indications and limits of early weight bearing in these injuries. Recognizing intrinsic lesion stability and bone and fixation technique quality, together with patient age and compliance, should be the mainstay for post-operative management choice.
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http://dx.doi.org/10.23750/abm.v92i4.10787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477081PMC
September 2021

Bucket-handle meniscal tears in children under the age of 10: a literature review.

Acta Biomed 2021 07 26;92(S3):e2021020. Epub 2021 Jul 26.

Orthopaedics and Traumatology Unit, Cattinara Hospital – ASUGI, Trieste (Italy).

Background And Aim Of The Work: Traumatic meniscal tears are raising in skeletally immature patients due to increasing participation in sport activities. Nonetheless, meniscal tears remain a rare injury in children, with a lack of evidence regarding treatment and outcome. The aim of the study is to review the literature on BHMT in children aged under 10 years.

Methods: Two independent reviewers conducted a systematic search of Embase, Medline and Pubmed databases to report a summary of literature evidence about epidemiology, clinical presentation, diagnosis, treatment and outcome of BHMTs in children under the age of 10.

Result: Eight articles have been considered, including seven case reports and one case series. We found 21 cases of BHMTs in children under 10 years. The injury occurred in the medial meniscus in 8 cases (66,7%), while in 4 cases (33,3%) on a lateral discoid meniscus. The mean reported age is 4,6 years (range 2 years - 9 years), with prevalence of the female sex (62,5%).

Conclusion: BHMT is an uncommon lesion in children under 10 years old. It can be suspected after a history of knee trauma in patients with knee pain, effusion and locking. MRI is the best technique for the diagnosis. Current strategy of treatment is to preserve the meniscus through different arthroscopic suture techniques.
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http://dx.doi.org/10.23750/abm.v92iS3.11742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420820PMC
July 2021

Simultaneous bilateral olecranon fracture: a case report and review of the literature.

Acta Biomed 2021 07 26;92(S3):e2021029. Epub 2021 Jul 26.

Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUGI, Strada di Fiume 447, 34149 Trieste (Italy).

Background And Aim Of The Work: A bilateral fracture of the olecranon is a rare injury, with only few cases reported in the literature.

Methods: A single case of bilateral Mayo type II A olecranon fracture in a 88 years old woman is described. A research of all articles regarding simultaneous bilateral olecranon fracture was performed in the PubMed database.

Result: The reported case demonstrated good clinical and radiographic results at 5 months follow-up with surgical treatment. The literature search produced other 6 cases in 5 case reports. Except for one case of fatigue fracture that had been treated conservatively, the others received surgical treatment with satisfactory results.

Conclusion: Simultaneous bilateral olecranon fracture is very uncommon. Bilateral internal fixation yields good clinical and radiographic results in most cases.
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http://dx.doi.org/10.23750/abm.v92iS3.11744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420827PMC
July 2021

Distal femur periprosthetic knee fractures in elderly patients: clinical and radiographic outcome after internal fixation.

Acta Biomed 2021 07 26;92(S3):e2021028. Epub 2021 Jul 26.

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Background And Aim Of The Work: The incidence of periprosthetic knee fractures is steadily increasing, especially in the geriatric population. Surgical treatment in these patients must consider the poor bone quality and the risks of general complications related to age and comorbidities. The aim of the present study is to analyze the clinical and radiographic outcome of internal fixation for periprosthetic knee fractures of the distal femur in elderly patients (>75aa).

Methods: All patients treated at the Orthopedic and Traumatology Unit of Cattinara Hospital-ASUGI (Trieste, Italy) between September 2014 and September 2019 for distal femur periprosthetic fracture after total knee replacement were included in the study. Mortality, complications, radiographic healing and functional outcomes were retrospectively evaluated. Data collection was conducted by clinical database searching and telephone interview. Results were compared with the literature.

Results: The study population included 19 patients, F:M 16:3, mean age 84 years. Plate fixation was used in the majority of cases (90%). One-year mortality was 21.05%. Radiographic healing of the fracture occurred in 92% of cases. Nonetheless, 61% of patients saw a worsening in their functional outcome.

Conclusion: Internal fixation is a valuable and safe option for distal femur periprosthetic fracture treatment in the elderly. The significant impact of periprosthetic knee fractures on the medium- to long-term survival and quality of life of the elderly patient is confirmed.
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http://dx.doi.org/10.23750/abm.v92iS3.11770DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420835PMC
July 2021

Fibula fractures management.

World J Orthop 2021 May 18;12(5):254-269. Epub 2021 May 18.

Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy.

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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http://dx.doi.org/10.5312/wjo.v12.i5.254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152440PMC
May 2021

Perception of biological motion. No sensitivity differences between patients with Parkinson's disease and healthy observers.

Appl Neuropsychol Adult 2021 Apr 22:1-8. Epub 2021 Apr 22.

Department of Life Sciences, University of Trieste, Trieste, Italy.

The use of biological motion (BM) stimuli (point-light walkers PLW) may be a novel alternative to improve the clinical impact of Action Observation treatments in Parkinson's Disease, by directing the patient's attentional focus on gait kinematics. However, the recognition of biological motion in Parkinson's patients has thus far been controversial. To evaluate the clinical feasibility of using BM stimuli in Action Observation treatments, we aimed at investigating whether Parkinson's patients in the ON-state condition can identify and use gender-specific cues conveyed by the body structure and by the kinematics of gait of a PLW. 30 Parkinson's patients and 30 healthy elderly observers were tested in a gender identification task with PLW. Parkinson's patients were able to correctly identify the gender of PLW; no differences were found between the two groups of observers. While for both groups, the gender identification task was easier when it required a judgment on a healthy PLW. Lastly, we found that females were more sensitive than males in our identification task. Our study shows that Parkinson's patients in the ON-state condition are able to extract subtle structural and kinematic characteristics from biological motion stimuli, which is favorable to the use of BM in Action Observation treatments.
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http://dx.doi.org/10.1080/23279095.2021.1910511DOI Listing
April 2021

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy.

Acta Biomed 2020 12 30;91(14-S):e2020006. Epub 2020 Dec 30.

Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUGI, Department of Medical, Surgical and Life Sciences, Trieste University, Trieste (Italy).

Background And Aim Of The Work: complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

Methods: The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

Results: 65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

Conclusions: INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.
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http://dx.doi.org/10.23750/abm.v91i14-S.10784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944683PMC
December 2020

Management of acute bone loss following high grade open tibia fractures.

Acta Biomed 2020 12 30;91(14-S):e2020012. Epub 2020 Dec 30.

Department of traumatology, UMC Ljubljana, Slovenia.

Introduction: Optimal treatment for acute post-traumatic bone loss in the tibia remains unclear. Distraction osteogenesis (DO) and induced membrane technique (IM) have been established as the mainstays of treatment. Aim of this article is to review the current evidence regarding the use of these two methods.

Methods: A review of the MEDLINE database was performed with strict inclusion and exclusion criteria focusing on treatment of the acute bone loss after open tibia fractures with DO and IM. Bone union rate was taken as the primary outcome and infection rate as secondary outcome.

Results: Four studies out of 78 on the use of the DO and three studies out of 18 on the use of the IM technique matched the inclusion criteria. Union rate in the DO group ranged between 92% and 100%, with infection rates between 0 and 4%. In the IM group, union was reached in 42% to 100% of cases, with septic complications occurring in 12% to 43%. Differences in union rate and infection rate reached statistical significance.

Discussion: We found a considerable evidence gap regarding treatment of bone loss in high grade open tibia fractures. The limitations of our study prevented us from drawing clear causative conclusions on the results. Although our study points to higher union rates and lower infection rate with the use of the DO technique, the results remain preliminary and further high-level evidence is needed to establish the roles of DO and IM in treatment of acute bone loss in open tibia fractures.
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http://dx.doi.org/10.23750/abm.v91i14-S.10890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944690PMC
December 2020

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont.

Orthop Rev (Pavia) 2020 Jun 25;12(Suppl 1):8659. Epub 2020 Jun 25.

Orthopaedic and Trauma Unit, Department of Medicine, Surgery and Health Sciences, University Hospital University of Trieste.

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the '50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.
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http://dx.doi.org/10.4081/or.2020.8659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7459385PMC
June 2020

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war.

Int Orthop 2020 08 26;44(8):1453-1459. Epub 2020 Jun 26.

Department of Orthopaedics and Orthopaedic Oncology, University of Padova, Padua, PD, Italy.

Background: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed.

Methods: The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019).

Results: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe.

Conclusions: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.
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http://dx.doi.org/10.1007/s00264-020-04637-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319215PMC
August 2020

Predictive value of valgus head-shaft angle in identifying Neer 4-part proximal humerus fractures. A radiographic and CT-scan analysis of 120 cases.

Acta Biomed 2020 05 30;91(4-S):217-223. Epub 2020 May 30.

Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUITS, Strada di Fiume 447, 34149 Trieste (Italy).

Background And Aim Of The Work: Understanding the fracture morphology and its relation to the expected outcome and risk of complications is fundamental for proximal humerus fractures (PHFs) management. Most Neer 3- and 4-part fractures may deserve surgical treatment. Unfortunately, plain x-rays may not be able to differentiate between a 3- or 4-part fractures unless an axillary or analogue projection is carried out. Aim of the present study is to evaluate whether a high valgus head-shaft angle degree is predictive of a Neer 4-part rather than a 3-part fracture.

Methods: The study included 120 3-(75 cases) and 4-(45 cases) part PHFs (valgus displaced in 98 cases), M:F ratio = 1:2.6, mean age 65.7 years, classified on CT scan images. The humeral head shaft angle was calculated on AP x-rays and statistically correlated with 3 and 4-part fractures to identify values predictive of 4-part fracture.

Results: Valgus head/shaft angle was significantly higher in 4-part fractures, especially in the valgus displaced group (p < 0.001). A cutoff value of 168.5° was identified as predictive of a 4-part fracture with a sensibility of 74% and specificity of 78%. Increasing by 1 degree the humeral head-shaft angle, the chance to have a 4-part fracture increases of 3% in the whole population and of 11% in the valgus sub-group.

Conclusion: The severity of PHF can be predicted analysing valgus head shaft angle on AP x-rays with a sensibility of 74% and specificity of 78% in identifying a 4-part fracture with a cutoff value of 168.5°.
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http://dx.doi.org/10.23750/abm.v91i4-S.9717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944809PMC
May 2020

Epidemiology and risk factors for contralateral proximal femur fracture: a single center retrospective cohort study on 1022 patients.

Acta Biomed 2020 05 30;91(4-S):115-121. Epub 2020 May 30.

Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUITS, Strada di Fiume 447, 34149 Trieste (Italy).

Summary.

Background And Aim Of The Work: Given the high impact of proximal femur fractures (PFFs) on elderly patients and healthcare systems, the burden of contralateral PFFs might be overlooked. Aim of the study is to analyze the epidemiology and risk factors of contralateral proximal femur fractures. Secondary aim is to detect mortality rate differences in first and contralateral PPF.

Methods: A population of 1022 patients admitted for proximal femur fractures in a single center was studied. Prevalence at admission as well as incidence of contralateral PFF during a 18 to 36 months follow-up was recorded. Epidemiology of contralateral PFF was studied recording number of events, time to second fracture and fracture type. Mortality at 1-year was recorded for all patients and compared between first and second PFF patients. Comorbidities, pharmacotherapy, BMI, MNA and SPMSQ were studied as possible risk factors.

Results: Prevalence and incidence of contralateral PFFs were 9.4% and 6.5% respectively. Median time to second fracture was 12 months. One-year mortality of contralateral PFFs was significantly lower (20.5% vs 25.1%, p 0.003) than first PFF. Contralateral fracture patients had a significantly lower BMI and a significantly lower proportion of malnourished patients.

Conclusions: The incidence and prevalence of contralateral PFFs is relevant. Mortality of contralateral PFFs results to be lower than first PFF. Patients with higher BMI and malnourished patients have a lower risk of contralateral PFF.
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http://dx.doi.org/10.23750/abm.v91i4-S.9716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944826PMC
May 2020

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients.

Orthop Rev (Pavia) 2020 Apr 28;12(1):8559. Epub 2020 Apr 28.

Orthopedic and Trauma Unit, University Hospital "Maggiore della Carità", Department of Health Sciences, University of East Piedmont, Novara, Italy.

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon's experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.
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http://dx.doi.org/10.4081/or.2020.8559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206366PMC
April 2020

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

Eur J Orthop Surg Traumatol 2020 May 1;30(4):671-680. Epub 2020 Jan 1.

Orthopaedics and Trauma Unit, Cattinara Hospital, ASUITS, Strada di Fiume 447, 34149, Trieste, Italy.

Background: Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs.

Methods: The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded.

Results And Conclusion: Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.
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http://dx.doi.org/10.1007/s00590-019-02619-9DOI Listing
May 2020

Fracture of Cobalt-Crome Modular Neck in Total Hip Arthroplasty.

Acta Biomed 2019 12 5;90(12-S):187-191. Epub 2019 Dec 5.

Orthopaedics and Traumatology Unit, Cattinara Hospital - ASUITS, Strada di Fiume 447, 34149 Trieste (Italy).

Despite the advantages of modular total hip arthroplasty in terms of neck version, offset and length precise reproduction, titanium necks breakage became a concern. Consequently, titanium has been replaced by cobalt-chrome (Co-Cr). However, four cases of Co-Cr modular neck breakage have been reported in the literature. In the present paper, two cases of Co-Cr modular neck fractures are described together with a literature review. The aim of this work is to discuss the risk factors and characteristics of this rare complication. We described two cases of fracture of long varus Co-Cr modular femoral neck connected with cementless press-fit stem. Some risk factors, such as long varus type of modular neck, overweight and/or high demanding physical activity, might have contributed to implant failure.
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http://dx.doi.org/10.23750/abm.v90i12-S.8941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233721PMC
December 2019

Osteoporotic distal femur fractures in the elderly: peculiarities and treatment strategies.

Acta Biomed 2019 12 5;90(12-S):25-32. Epub 2019 Dec 5.

Orthopaedics and Traumatology Unit, Cattinara Hospital, Department of Medical, Surgical and Life Sciences, Trieste University, Trieste, Italy..

Distal femur fractures account for 4-6% of osteoporosis related fractures of the femur in the elderly population. They represent a relevant cause of morbidity and mortality in the geriatric population with a reported 1-year mortality reaching 30%. Non-displaced fractures or even displaced fractures in patients with high operative risk can be treated conservatively. However, operative treatment is the most widely accepted management option for displaced fractures. The advantage resides in early mobilization and weight-bearing, reducing risks related with a prolonged immobilization when compared with conservative treatment. On the other hand, the intrinsic difficulty of fixing an osteoporotic bone is a major concern. The presence of osteosynthesis devices or prosthetic implants in the femur can make the surgical treatment more challenging, sometimes limiting therapeutic options. Aim of the present paper is to review the most recent literature about osteoporotic distal femur fractures in the elderly, including periprosthetic and other hardware related fractures, to highlight current evidence on management options and related results as a guide for the daily clinical practice.
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http://dx.doi.org/10.23750/abm.v90i12-S.8958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233703PMC
December 2019

Post-operative periprosthetic humeral fractures after reverse shoulder arthroplasty: a review of the literature.

Acta Biomed 2019 12 5;90(12-S):8-13. Epub 2019 Dec 5.

Orthopaedics and Traumatology Unit, Cattinara Hospital, Department of Medical, Surgical and Life Sciences, Trieste University, Trieste (Italy).

Background And Aim Of The Work: Post-operative periprosthetic shoulder fractures incidence is gradually raising due to aging of population and increasing of reverse total shoulder arthroplasty (RTSA). Management of this complication represents a challenge for the orthopedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of post-operative periprosthetic humeral  fractures occurring on RTSA.

Methods: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed.

Results: 31 studies including reviews, meta-analysis, case reports, clinical and biomechanical studies were selected.

Conclusions: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation and revision arthroplasty are both valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.
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http://dx.doi.org/10.23750/abm.v90i12-S.8974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233712PMC
December 2019

Carpal Tunnel Syndrome Associated with Bifid Median Nerve and Palmaris Profundus - Case Report and Literature Review.

J Hand Surg Asian Pac Vol 2019 Jun;24(2):238-242

1 Orthopaedics and Traumatology Unit, Cattinara Hospital, ASUITS, Trieste, Italy.

The anatomic variations of the median nerve and of the muscles of the wrist have been widely reported in literature. It is essential for the surgeon to be familiar with these variations in order to avoid accidental injury to the nerve during surgery. We report a rare case of bifid median nerve accompanied by an anomalous tendon of palmaris profundus discovered during the surgical release of carpal tunnel. The transverse carpal ligament was dissected and the anomalous tendon was left in situ because any direct compression over the median nerve was noticed intraoperatively. The patient was evaluated one year postoperatively clinically and radiologically (with MRI). At the follow up the resolution of symptoms was complete and the sleep disturbance was solved. The patient achieved a postoperative QuickDASH score of 9.1 and a Michigan Hand Questionnaire outcome score of 90 points.
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http://dx.doi.org/10.1142/S2424835519720123DOI Listing
June 2019

The sooner the better? Patients' satisfaction following ortho-plastic treatment of lower limb open fractures within and after one week from injury.

J Plast Reconstr Aesthet Surg 2019 Aug 9;72(8):1418-1433. Epub 2019 Apr 9.

Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, Italy; Plastic Reconstructive and Aesthetic Surgery Department, Ospedale di Cattinara, ASUITs, Trieste, Italy.

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http://dx.doi.org/10.1016/j.bjps.2019.03.025DOI Listing
August 2019

Antibacterial drug release from a biphasic gel system: Mathematical modelling.

Int J Pharm 2019 Mar 2;559:373-381. Epub 2019 Feb 2.

Department of Engineering and Architecture, Trieste University, via Valerio 6, I-34127 Trieste, Italy. Electronic address:

Bacterial infections represent an important drawback in the orthopaedic field, as they can develop either immediately after surgery procedures or after some years. Specifically, in case of implants, they are alleged to be troublesome as their elimination often compels a surgical removal of the infected implant. A possible solution strategy could involve a local coating of the implant by an antibacterial system, which requires to be easily applicable, biocompatible and able to provide the desired release kinetics for the selected antibacterial drug. Thus, this work focusses on a biphasic system made up by a thermo-reversible gel matrix (Poloxamer 407/water system) hosting a dispersed phase (PLGA micro-particles), containing a model antibacterial drug (vancomycin hydrochloride). In order to understand the key parameters ruling the performance of this delivery system, we developed a mathematical model able to discriminate the drug diffusion inside micro-particles and within the gel phase, eventually providing to predict the drug release kinetics. The model reliability was confirmed by fitting to experimental data, proposing as a powerful theoretical approach to design and optimize such in situ delivery systems.
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http://dx.doi.org/10.1016/j.ijpharm.2019.01.055DOI Listing
March 2019

Bent femoral intramedullary nail: a case report and review of the literature.

Acta Biomed 2019 01 10;90(1-S):187-191. Epub 2019 Jan 10.

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Intramedullary nailing is considered the gold standard technique for the treatment of femoral shaft fractures. A rare complication of this technique is nail bending after a new trauma. In these cases nail removal might be really challenging. The present paper provides a brief review of surgical techniques purposed in the literature for bent nail removal and describes a clinical case.
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http://dx.doi.org/10.23750/abm.v90i1-S.8072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503421PMC
January 2019

Dual mobility total hip arthroplasty in the treatment of femoral neck fractures: a retrospective evaluation at mid-term follow-up.

Acta Biomed 2019 01 10;90(1-S):98-103. Epub 2019 Jan 10.

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Background And Aim Of The Work: Partial or total hip replacement is the method of choice for displaced femoral neck fractures (FNF) treatment. Dislocation is a major complication, accounting for about 3.8% of cases for hemiarthroplasty (HA) and 10% for total hip arthroplasty (THA). Dual-mobility (DM) socket in total hip arthroplasty showed a very low rate of dislocation in both primary and revision setting THA. Some literature reports show good results with low dislocation rates also in FNF treatment at short term follow-up. Aim of the study was to evaluate clinical and radiographic results of DM-THA in FNF treatment at mid-term follow up.

Methods: Study population counted 31 implants in 30 patients treated with DM-THA for FNF between January 2010 and December 2012. Dislocation rate was identified, and HHS and OHS were completed. Twenty-four patients underwent also radiographic evaluation to assess cup integration and sings of loosening.

Results: No episodes of hip dislocation nor intraprosthetic dislocation were found. Other postoperative complications were recorded in 9,67%. HHS and OHS showed a mean value of 81,22 and 37,37, respectively. There were no cases of clinical and radiographic signs of implant loosening.

Conclusions: The present study confirms the good clinical results, low complications and very low dislocation rate with DM THA for FNF treatment.
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http://dx.doi.org/10.23750/abm.v90i1-S.8070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503413PMC
January 2019

Poor nutritional status but not cognitive or functional impairment per se independently predict 1 year mortality in elderly patients with hip-fracture.

Clin Nutr 2019 08 31;38(4):1607-1612. Epub 2018 Aug 31.

Department of Medical, Surgical and Health Sciences, University of Trieste, Italy. Electronic address:

Background & Aims: Hip fractures are strongly associated with mortality in the elderly. Studies investigating predisposing factors have suggested a negative impact of poor nutritional, cognitive and functional status on patient survival, however their independent prognostic impact as well as their interactions remain undefined. This study aimed to determine whether poor nutritional status independently predicts 1 year post-fracture mortality after adjusting for cognitive and functional status and for other clinically relevant covariates.

Methods: 1211 surgically treated hip fracture elderly (age ≥ 65) patients consecutively admitted to the Orthopaedic Surgery Unit of the "Azienda Sanitaria Universitaria Integrata Trieste" (ASUITs), Cattinara Hospital, Trieste, Italy and managed by a dedicated orthogeriatric team. Pre-admission nutritional status was evaluated by Mini Nutritional Assessment (MNA) questionnaire, cognitive status by Short Portable Mental Status Questionnaire (SPMSQ) and functional status by Activity of Daily Living (ADL) questionnaire. All other clinical data, including comorbidities, type of surgery, post-operative complications (delirium, deep vein thrombosis, cardiovascular complications, infections, need for blood transfusions) were obtained by hospital clinical records and by mortality registry.

Results: Poor nutritional status (defined as MNA ≤23.5), increased cognitive and functional impairment were all associated with 3-, 6- and 12 month mortality (p < 0.001). Both cognitive and functional impairment were associated with poor nutritional status (p < 0.001). Logistic regression analysis demonstrated that the association between nutritional status and 3-, 6- and 12- month mortality was independent of age, gender, comorbidities, type of surgery and post-operative complications as well as of cognitive and functional impairment (p < 0.001). In contrast, the associations between mortality and cognitive and functional impairment were independent (p < 0.001) of demographic (age, gender) and clinical covariates but not of malnutrition. Kaplan-Meier analysis showed a lower mean survival time (p < 0.001) in patients with poor nutritional status compared with those well-nourished.

Conclusions: In hip fracture elderly patients, poor nutritional status strongly predicts 1 year mortality, independently of demographic, functional, cognitive and clinical risk factors. The negative prognostic impact of functional and cognitive impairment on mortality is mediated by their association with poor nutritional status.
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http://dx.doi.org/10.1016/j.clnu.2018.08.030DOI Listing
August 2019

Proposal of a New Dynamic Distraction Device to Treat Complex Periarticular Fractures of the Metacarpophalangeal Joint of Long Finger.

Hand (N Y) 2020 01 17;15(1):87-91. Epub 2018 Jul 17.

University Hospital of Pisa, Italy.

Complex periarticular fractures of the metacarpophalangeal joint (MCPJ) are often challenging to treat. Conservative and operative treatments are often burdened with stiffness, loss of function, and poor clinical outcome. These phenomena could be a direct consequence of long period of immobilization. To promote a short time of immobilization and a quick return to daily activities, it is mandatory to stabilize the fracture maintaining the active range of motion (AROM) of the ray. A simple solution is to reduce the fragments by means of dynamic ligamentotaxis. The authors propose a new dynamic distraction device (DDD) for the MCPJ. The DDD for the MCPJ was made of Kirschner wires bent and connected to counteract dislocation forces and to allow mobilization of the joint. The DDD was tested on a cadaver model under a simulated load in physiological conditions, and also in metacarpal and proximal phalanx (P1) fracture patterns. The effectiveness of the device was evaluated under fluoroscopy. The data showed that DDD is able to achieve fracture reduction through ligamentotaxis and primary fragments stability and to avoid secondary dislocation during AROM of complex periarticular fractures of the MCPJ. The frame could be an alternative option to treat periarticular fractures of the MCPJ. The DDD implant has several advantages: It is time efficient because assembly and application take only few minutes. Furthermore, it is very versatile; indeed, it can be used in all metacarpal and phalanx bones, even in the central rays.
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http://dx.doi.org/10.1177/1558944718787859DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6966295PMC
January 2020

Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients.

Arch Orthop Trauma Surg 2018 Mar 23;138(3):351-359. Epub 2017 Dec 23.

Department of medical surgical and health sciences of Trieste University, Orthopaedics and Traumatology Unit, Cattinara Hospital-ASUITS, Strada di Fiume 447, 34149, Trieste, Italy.

Background: Cut-out is the most common mechanical complication of the osteosynthesis of pertrochanteric fractures. This complication determines a significant increase in morbidity in elderly patient. Cut-out is defined as the varus collapse of the femoral head-neck fragment with the extrusion of the cephalic screw. Surgical treatment of cut-out might lead to further complications, longer rehabilitation, increased social burden and healthcare system costs. The aim of the study is to identify the predictors of cut-out to prevent its occurrence.

Materials And Methods: Study population included all patients affected by extracapsular fracture of the proximal femur who were admitted and treated with short cephalomedullary nailing at the Cattinara Hospital-ASUITS of Trieste between 2009 and 2014. A retrospective analysis of clinical and radiographic data was carried out and cut-out cases recorded. The data collected on the study population were analyzed to find an eventual correlation with the occurrence of cut-out. The independent variables were age, gender, side of the fracture, ASA class, Evans classification, nailing system, quality of reduction, TAD, CalTAD, and Parker ratio.

Results: The study population counted 813 cases, with an F:M ratio of 4:1 and a mean age of 84.7 years. The cut-out was recorded in 18 cases (2.2%). There was no statistically significant association between cut-out and age, sex, side of fracture, ASA class, and nailing system. The Evans classification, the quality of reduction, the TAD, the CalTAD, and the Parker's ratio demonstrated a significant correlation at univariate analysis with cut-out. The results of multivariate analysis confirmed that TAD, Parker AP, and quality of reduction were independently significantly correlated to cut-out.

Conclusion: The results of the present study demonstrate that good quality of reduction and correct position of the lag screw are likely to decrease the risk of cut-out complication. A nomogram for cut-out prediction is proposed for clinical validation.
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http://dx.doi.org/10.1007/s00402-017-2863-zDOI Listing
March 2018

Treatment of dorsal fracture-dislocation of the proximal interphalangeal joint using the Ligamentotaxor device: clinical and radiographic preliminary results.

Acta Biomed 2017 10 18;88(4S):90-95. Epub 2017 Oct 18.

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Background And Aim Of The Work: Fracture-dislocations of the proximal interphalangeal joint are complex injuries, often difficult to treat. Several treatment options have been described. Among them dynamic external fixation proved to be a safe technique leading to good results in many authors experience. The principles of this treatment are to avoid edema, prevent stiffness and tendon adhesions, promote joint remodelling and facilitate rehabilitation. The Ligamentotaxor® device is a simple and reproducible dynamic external fixation system that has been used in recent years to treat proximal interphalangeal joint fracture-dislocations, with favourable results. The aim of the present study is to evaluate our preliminary results with the Ligamentotaxor® device for treatment of these complex lesions.

Methods: Four patients between December 2015 and January 2017 were treated at our institution with the Ligamentotaxor® device. Clinical and radiographic results were evaluated at mean 6 months follow-up.

Results: Clinical results were meanly good and appeared to be comparable to most recent literature. Mean range of motion was 60,5°, mean extension lag 18,5°. Mean QuickDASH and Michigan Hand Questionnaire scored 21.6 and 72 respectively. Radiographic evaluation showed fracture healing in all cases. No relevant complications were noted.

Conclusion: The Ligamentotaxor® device is simple to implant, provides good stability and allows an immediate gentle active movement. According to present work the preliminary results are encouraging.
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http://dx.doi.org/10.23750/abm.v88i4 -S.6799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357656PMC
October 2017

Potential Applications of Nanocellulose-Containing Materials in the Biomedical Field.

Materials (Basel) 2017 Aug 21;10(8). Epub 2017 Aug 21.

Department of Engineering and Architecture, University of Trieste, Via Valerio 6/A, I-34127 Trieste, Italy.

Because of its high biocompatibility, bio-degradability, low-cost and easy availability, cellulose finds application in disparate areas of research. Here we focus our attention on the most recent and attractive potential applications of cellulose in the biomedical field. We first describe the chemical/structural composition of cellulose fibers, the cellulose sources/features and cellulose chemical modifications employed to improve its properties. We then move to the description of cellulose potential applications in biomedicine. In this field, cellulose is most considered in recent research in the form of nano-sized particle, i.e., nanofiber cellulose (NFC) or cellulose nanocrystal (CNC). NFC is obtained from cellulose via chemical and mechanical methods. CNC can be obtained from macroscopic or microscopic forms of cellulose following strong acid hydrolysis. NFC and CNC are used for several reasons including the mechanical properties, the extended surface area and the low toxicity. Here we present some potential applications of nano-sized cellulose in the fields of wound healing, bone-cartilage regeneration, dental application and different human diseases including cancer. To witness the close proximity of nano-sized cellulose to the practical biomedical use, examples of recent clinical trials are also reported. Altogether, the described examples strongly support the enormous application potential of nano-sized cellulose in the biomedical field.
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http://dx.doi.org/10.3390/ma10080977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5578343PMC
August 2017
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