Dexamethasone versus Dexmedetomidine as Adjuvants in Ultrasound Popliteal Sciatic Nerve Block for Hallux Valgus Surgery: A Mono-Centric Retrospective Comparative Study.

Background and Aim: Ultrasound popliteal sciatic nerve block (UPSNB) is commonly performed in foot and ankle surgery. This study aims to assess the use of dexmedetomidine and dexamethasone as adjuvants in UPSNB for hallux valgus (HV) surgery, comparing their efficacy in producing motor and sensory block and controlling postoperative pain. The adverse event rate was also evaluated. Methods: This mono-centric retrospective study included 62 adult patients undergoing HV surgery: 30 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg and dexamethasone 4 mg (Group 1), whereas 32 patients received lidocaine 2% 200 mg, ropivacaine 0.5% 50 mg, and dexmedetomidine 1 mcg/Kg (Group 2). At first, the visual analogue scale (VAS) was evaluated after 48 hours. The other outcomes were time to motor block regression, evaluation of the first analgesic drug intake, analgesic effect, adverse effects (hemodynamic disorders, postoperative nausea and vomiting (PONV)) and patient satisfaction. The continuous data were analyzed with student's t-test and the continuous one with χ2. Statistical significance was set at a p-value lower than 0.05. Results: No significant difference was found in VAS after 48 hours (4.5 ± 1.6 vs 4.7 ± 1.7, p = 0.621) to motor block regression (18.9 ± 6.0 vs 18.7 ± 6, p = 0.922). The number of patients that took their first analgesic drug in the first 48 h (p = 0.947 at 6 hours; p = 0.421 at 12 hours; p = 0.122 at 24 hours and p = 0.333 at 48 hours) were not significant. A low and similar incidence of intraoperative hemodynamic disorders was recorded in both groups (hypotension p = 0.593; bradycardia p = 0.881). Neither PONV nor other complication was found. Patients in Group 1 reported a lower degree of interference with sleep (p = 0.001), less interference with daily activities (P = 0.002) and with the affective sphere (P = 0.015) along with a more satisfactory postoperative pain management (p < 0.001) as compared to Group 2. Conclusion: No significant differences were observed in the duration of motor and sensory blockade between patients in both groups. Additionally, both groups showed good pain control with a low rate of adverse effects, even if there was no clinical difference between the groups. However, patients who received dexamethasone reported experiencing less interference with their sleep, daily activities and overall emotional well-being, and overall pain control.

Arthroscopic Latarjet Versus Arthroscopic Free Bone Block Procedures for Anterior Shoulder Instability: A Proportional Meta-analysis Comparing Recurrence, Complication, and Reoperation Rates.

BACKGROUND: Several arthroscopic glenoid bone augmentation techniques have been introduced to treat patients affected by anterior shoulder instability associated with critical bone loss. The efficacy of the different arthroscopic bony procedures has not been compared yet. PURPOSE: To compare the recurrence, complication, and reoperation rates of the arthroscopic Latarjet (AL) and arthroscopic free bone block (ABB) procedures for anterior shoulder instability. STUDY DESIGN: Meta-analysis and systematic review; Level of evidence, 4. METHODS: A systematic search was conducted in MEDLINE/PubMed, Web of Science, and Embase to identify clinical studies reporting the outcomes of the AL and ABB procedures. The following search phrases were used: "Arthroscopic" AND "Bone Block" OR "Bone Graft," and "Arthroscopic" AND "Glenoid Augmentation" OR "Glenoid Reconstruction," and "Arthroscopic" AND "Latarjet" OR "Coracoid Graft" OR "Coracoid Transfer." Exclusion criteria were <24 months of minimum follow-up, sample size <10 cases, revision after previous glenoid bone grafting, epilepsy, and multidirectional instability. Data regarding the study design, patient characteristics, surgical technique, and outcomes were extracted and analyzed. A proportional meta-analysis was conducted to compare the complication, recurrence, and reoperation rates between the 2 groups. Multiple subgroup analyses were performed to analyze the incidence of each complication and assess the weight of different fixation methods (in the whole cohort) or different graft types (in the ABB group). The modified Coleman Methodology Score was used to assess the risk of bias. RESULTS: Of 5010 potentially relevant studies, 18 studies regarding the AL procedure (908 cases) and 15 studies regarding the ABB procedure (469 cases) were included. The 2 groups were comparable in age (P = .07), sex (P = .14), glenoid bone loss (P = .14), number of preoperative dislocations (P = .62), proportion of primary and revision procedures (P = .95), length of follow-up (P = .81), modified Coleman Methodology Score (P = .21), and level of evidence (P = .49). There was no difference in the recurrence (P = .88), reoperation (P = .79), and complication (P = .08) rates. The subgroup analyses showed a higher rate of hardware-related complications for screw fixation compared with flexible fixation (P = .01). CONCLUSION: The AL and ABB procedures had similar recurrence, reoperation, and complication rates. Screw fixation of the bone graft was related to an increased risk of complications compared with flexible fixation. REGISTRATION: CRD42022368153 (PROSPERO).

Tarsal coalition in adults.

Adult tarsal coalition consists in abnormal union of two or more tarsal bones. Reported incidence ranges between 1 and 13%. It is generally a congenital condition, due to dominant autosomal chromosome disorder, but with some acquired forms following trauma or inflammatory pathology. Poorly specific clinical signs and the difficulty of screening on conventional X-ray may lead to diagnostic failure. The present review of tarsal coalition addresses the following questions: how to define tarsal coalition? How to diagnose it? How to treat it? And what results can be expected? There are 3 types of tarsal coalition, according to the type of tissue between the united bones: bony in pure synostosis, cartilaginous in synchondrosis, and fibrous in syndesmosis. Location varies; the most frequent forms are talocalcaneal (TC) and calcaneonavicular (CN), accounting for more than 90% of cases. Cuneonavicular, intercuneal and cuboideonavicular locations are much rarer, at less than 10%. Tarsal coalition is classically painful, often with valgus spastic flatfoot in young adults. The pain is caused by the biomechanical disturbance induced by the bone, cartilage or fibrous bridges which partially or completely hinder hindfoot and/or midfoot motion. Conventional imaging, with weight-bearing X-ray and CT, is standard practice. Weight-bearing CT is increasingly the gold standard, displaying abnormalities in 3 dimensions. Functional imaging on MRI and tomoscintigraphy assess direct and indirect joint impact at the affected and neighboring joint lines. Non-operative treatment can be proposed, with orthoses, rehabilitation and/or injections. But surgery is the most frequent option: either resection of the bony, cartilaginous or fibrous constructs to restore optimally normal anatomy, or arthrodesis in the affected joint line or the entire joint. Surgery can be open, arthroscopic or percutaneous, depending on the severity of the biomechanical impact on the affected and neighboring joints. Resecting the abnormality is the standard practice in all locations if it affects less than 50% of the talocalcaneal joint line and there is no osteoarthritis to impair the functional outcome. Otherwise, fusion is required. Level of evidence: V; expert opinion.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis.

PURPOSE: The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA). METHODS: A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options. RESULTS: Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects. CONCLUSIONS: This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Virulent strains of Zymoseptoria tritici suppress the host immune response and facilitate the success of avirulent strains in mixed infections.

Plants interact with a plethora of pathogenic microorganisms in nature. Pathogen-plant interaction experiments focus mainly on single-strain infections, typically ignoring the complexity of multi-strain infections even though mixed infections are common and critical for the infection outcome. The wheat pathogen Zymoseptoria tritici forms highly diverse fungal populations in which several pathogen strains often colonize the same leaf. Despite the importance of mixed infections, the mechanisms governing interactions between a mixture of pathogen strains within a plant host remain largely unexplored. Here we demonstrate that avirulent pathogen strains benefit from being in mixed infections with virulent strains. We show that virulent strains suppress the wheat immune response, allowing avirulent strains to colonize the apoplast and to reproduce. Our experiments indicate that virulent strains in mixed infections can suppress the plant immune system, probably facilitating the persistence of avirulent pathogen strains in fields planted with resistant host plants.

Cavovarus Deformity: Why Weight-Bearing Computed Tomography Should Be a First-Line Imaging Modality.

Cavovarus foot is a complex three-dimensional deformity, which includes a wide range of clinical conditions from subtle deformities to disabling feet. In this article, the authors discuss the role of weight-bearing computed tomography, which might enable to avoid double imaging (radiographs + tomography) in patients for which a detailed osteoarticular assessment is required, with the advantage to obtain tomographic images in standing position and a reduction of radiation exposure.

Role of fibular autograft in ankle arthrodesis fixed using cannulated screws: a proportional meta-analysis and systematic review.

Ankle arthrodesis is commonly performed to treat end-stage ankle osteoarthritis. The aim of this study was to determine whether the use of fibular autograft might increase the fusion rate and decrease the complication rate in ankle arthrodesis (AA) fixed using cannulated screws. To perform this PRISMA-compliant proportional meta-analysis, multiple databases were searched for studies in which patients undergone AA (using exclusively cannulated screws and augmented with fibular bone graft) were followed. The characteristics of the cohort, the study design, surgical details, the nonunion and complication rate at the longest follow-up were extracted and recorded. The modified Coleman Methodology Score (mCMS) was applied to appraise the quality of studies. Two groups were built: arthrodeses fixed with screws combined with cancellous autograft (G1) and arthrodeses fixed with screws combined with cancellous autograft and augmented with a lateral fibular onlay (G2). A third group (arthrodeses fixed with screws and no graft, G3) was extracted from previous literature for a further comparison. Overall, we included 306 ankles (296 patients) from ten series (ten studies). In G1 and G2 there were 118 ankles (111 patients) and 188 ankles (185 patients), respectively. In patients where cancellous autograft was used, a further augmentation with a fibular lateral strut autograft did not change significantly the nonunion (4% [95% CI 1-9] in G1 vs. 2% [95% CI 0-5) in G2, p = 0.99) nor the complication rate (18% [95% CI 0-36] in G1 vs. 13% [95% CI 6-21) in G2, p = 0.71). Upon comparison with 667 ankles (659 patients, G3) in which arthrodeses had been performed without grafting, the nonunion and complication rates did not differ significantly either (pooled estimates: 3% [95% CI 1-3) in G1 + G2 vs. 3% [95% CI 2-4] in G3, p = 0.73 for nonunion; 15% [8-23] in G1 + G2 vs. 13% [95% CI 9-17] in G3, p = 0.93 for complications). In ankle arthrodesis fixed with cannulated screws combined with cancellous autograft at the fusion site, a construct augmentation with a distal fibular onlay strut graft positioned laterally at the ankle joint does not reduce the risk of nonunion or complication. In general, the use of bone graft does not influence significantly the nonunion nor the complication rate as compared to non-grafted screw-fixed ankle arthrodeses.Kindly check and confirm the corresponding author mail id is correctly identified.It's all correct.

Scaphoid fracture non-union: a systematic review of the arthroscopic management.

BACKGROUND AND AIM: There is no consensus regarding the most appropriate treatment of scaphoid nonunion. This systematic review aimed to investigate whether wrist arthroscopy exerts a positive influence on bone union and clinical outcomes. METHODS: We searched the literature on Medline (PubMed), Web of Science, Embase and Scopus databases using the combined keywords "scaphoid" AND "arthroscopy" AND "pseudoarthrosis" OR "nonunion". Eighteen studies were finally included in our review. The quality of the studies was assessed using the Coleman Methodological Score. RESULTS: Our systematic review has shown that arthroscopic management of scaphoid nonunion achieves a high rate of union and satisfactory clinical outcomes with minimal complications. CONCLUSIONS: There is need to perform randomized controlled trials reporting on the use of arthroscopy. In addition, the different pattern of pseudoarthrosis should be better classified to manage the patients who will benefit after the management.

The Twenty-Five Most Cited Articles About Adductor Canal Block: A Bibliometric Analysis from 1980 to 2022.

Introduction: Loco-regional anesthesia role is increasingly important in surgery, especially in postoperative pain control. Using ultrasound-guided techniques has made the loco-regional approach increasingly safe and manageable, guaranteeing excellent analgesic results and patient compliance. This bibliometric research aimed to identify the most influential papers on the adductor canal blocks and outline their characteristics. Methods: All articles published from 1980 to 2022 were included in the Web of Science, PubMed, and Scopus databases and found using the keywords "Adductor canal block" or "Saphenous nerve block" or "Peripheral nerve block" or "Hunter canal block" or "Subsartorial canal block" or "ACB" or "Knee" or "TKR" or "TKA" or "Analgesia" or "Arthroplasty" or "Replacement" in the title section had bibliometric analysis performed. The first 25 papers were selected and analyzed by the number of citations. The correlation between numerical variables was evaluated using the Pearson Correlation coefficient. Results: Literature screening found 252 publications. One hundred ten were only about the adductor canal block. Of these, 25 articles were selected for our bibliometric study, published in 8 different journals and with a total number of citations equal to 1.457. "Regional Anesthesia and pain medicine" journal - with 9 articles - was the one that produced the most. There was a significant strong correlation between the n. of citations and the citation rate (R = 0.84, p < 0.001). Conclusion: The purpose of this study is to be a guide on regional anesthesia and, particularly, on adductor canal block, making the most effective as well as the most cited articles available to anesthesiologists or other researchers interested in this topic.

Ankle Joint Bone Density Distribution Correlates with Overall 3-Dimensional Foot and Ankle Alignment.

BACKGROUND: Altered stress distribution in the lower limb may impact bone mineral density (BMD) in the ankle bones. The purpose of the present study was to evaluate the spatial distribution of BMD with use of weight-bearing cone-beam computed tomography (WBCT). Our hypothesis was that BMD distribution would be even in normal hindfeet, increased medially in varus hindfeet, and increased laterally in valgus hindfeet. METHODS: In this study, 27 normally aligned hindfeet were retrospectively compared with 27 valgus and 27 varus-aligned hindfeet. Age (p = 0.967), body mass index (p = 0.669), sex (p = 0.820), and side (p = 0.708) were similar in the 3 groups. Hindfoot alignment was quantified on the basis of WBCT data sets with use of multiple measurements. BMD was calculated with use of the mean Hounsfield unit (HU) value as a surrogate. The HU medial-to-lateral ratio (HUR), calculated from tibial and talar medial and lateral half-volumes, was the primary outcome of the study. RESULTS: The 3 groups significantly differed (p < 0.001) in terms of tibial HUR (median, 0.91 [interquartile range (IQR), 0.75 to 0.98] in valgus hindfeet, 1 [IQR, 0.94 to 1.05] in normal hindfeet, and 1.04 [IQR, 0.99 to 1.1] in varus hindfeet) and talar HUR (0.74 [IQR, 0.50 to 0.80] in valgus hindfeet, 0.82 [IQR, 0.76 to 0.87] in normal hindfeet, and 0.92 [IQR, 0.86 to 1.05] in varus hindfeet). Linear regression showed that all hindfoot measurements significantly correlated with tibial and talar HUR (p < 0.001 for all). The mean HU values for normally-aligned hindfeet were 495.2 ± 110 (medial tibia), 495.6 ± 108.1 (lateral tibia), 368.9 ± 80.3 (medial talus), 448.2 ± 90.6 (lateral talus), and 686.7 ± 120.4 (fibula). The mean HU value for each compartment was not significantly different across groups. CONCLUSIONS: Hindfoot alignment and medial-to-lateral BMD distribution were correlated. In varus hindfeet, an increased HU medial-to-lateral ratio was consistent with a greater medial bone density in the tibia and talus as compared with the lateral parts of these bones. In valgus hindfeet, a decreased ratio suggested greater bone density in the lateral as compared with the medial parts of both the tibia and the talus. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic joint infection in total ankle replacement: which are the current diagnostic criteria?

BACKGROUND AND AIM: Periprosthetic joint infection (PJI) is among the most common complications of Total Ankle Replacement (TAR) and its management may be challenging. We set out to define which are the criteria currently used to diagnose PJI after TAR. METHODS: This PRISMA-compliant systematic review was registered in the Open Science Framework. Multiple databases were searched including clinical studies in which PJI after TAR was diagnosed and treated. Data were harvested regarding the cohort, the study design and the diagnostic criteria for PJI. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). RESULTS: Six papers (122 infected TARs) published between 2012 and 2022 were included in this review. Ankle pain with swelling and unexplained increased local temperature were the most common clinical findings leading to a suspicion of PJI. In 100% of cases the diagnosis was confirmed through synovial fluid analysis associated with positive blood tests. In all the revision surgeries intraoperative cultures (at least 3) were performed. In 109 ankles (90%) there was a microbiological isolation. Out of these, 38 (35%) were single organism infections by Staphylococcus coagulase negative and 37 (34%) were single organism infections by Staphylococcus Aureus. The mean mCMS was 37.6 out of 100. CONCLUSIONS: There is a lack of diagnostic criteria specific for PJI after TAR. Clinical and laboratory tests inspired to the knowledge in total knee and total hip arthroplasty are generally adopted in the field of ankle arthroplasty. The quality of evidence for studies included in this review was poor.

Role of Patrick-FABER test in detecting sacroiliitis and diagnosing spondyloarthritis in subjects with low back pain.

OBJECTIVES: To evaluate sensitivity, specificity, and predictive value of Patrick-FABER test in assessing magnetic resonance imaging (MRI) sacroiliitis and addressing the diagnosis of spondyloarthritis (SpA) in subjects with low back pain (LBP). METHODS: Subjects with LBP were consecutively enrolled. The assessors were blinded to patients' clinical, laboratory, or imaging data. All subjects underwent sacroiliac joint MRI to detect presence of sacroiliac oedema or structural changes. RESULTS: One hundred and ten subjects were included in the study [males (61.8%); median age of 45 (21-69) years; LBP duration of 78 (3-240) months]. Patrick-FABER test sign's sensitivity was 76.2% (95% CI: 60.5-87.9%), specificity was 66.2% (95% CI: 53.6-77.2%), positive predictive value (PPV) was 58.1% (95% CI: 44.1-71.3%) and negative predictive value (NPV) was 81.8% (95% CI: 69.1-90.9%) for the diagnosis of sacroiliitis, with an overall diagnostic accuracy of 70%. At the univariate and multivariate analysis, Patrick-FABER test sign was associated with inflammatory lesions of sacroiliitis at MRI and SpA diagnosis. Univariate and multivariate analysis showed an association between smoking status (p=0.01), sacroiliitis, and SpA diagnosis. The odds of having sacroiliitis was 2.7 higher in smokers (OR: 2.7; 95% CI: 1.1-7) as compared to non-smokers and 6.3 higher in those with a positive Patrick-FABER test sign (OR: 6.3; 95%CI: 2.5-15.6) as compared to those with a negative sign. CONCLUSIONS: Our study shows that Patrick-FABER test positivity could represent a useful clinical test for addressing the use of sacroiliac joints MRI and SpA diagnosis in subjects with LBP. Further, smoking habit could represent an associate anamnestic element for addressing the use of sacroiliac MRI.

Tetra-block: ultrasound femoral, lateral femoral-cutaneous, obturator, and sciatic nerve blocks in lower limb anesthesia: a case series.

BACKGROUND: The gold standard anesthesiologic procedure for urgent femur fracture surgery is Spinal Anesthesia. It is not always feasible because of patients' severe comorbidities and difficulties in optimizing drug therapy in the appropriate time frame such as discontinuation of anticoagulant drugs. The use of four peripheral nerve blocks (tetra-block) can be a winning weapon when all seems lost. CASE PRESENTATION: We present, in this case series, three Caucasian adult femur fractures (an 83-year-old woman, a 73-year-old man, and a 68-year-old woman) with different and major comorbidities (cardiac or circulatory disorders on anticoagulants therapy that were not discontinued on time; breast cancer and others) underwent the same anesthesiologic approach in the urgent setting. Ultrasound peripheral nerve blocks, that is femoral, lateral femoral cutaneous, obturator, and sciatic with parasacral approach were successfully performed in all patients who underwent intramedullary nailing for intertrochanteric fracture. We evaluated the adequacy of the anesthesia plane, postoperative pain control with the VAS scale, and the incidence of postoperative side effects. CONCLUSIONS: Four peripheral nerve blocks (Tetra-block) can be alternative anesthesiologic management in urgent settings, in patients where drug therapy cannot be optimized, as in antiplatelet and anticoagulant therapy.

Analysis of the 50 Most Cited Articles on Achilles Tendon Injury.

Background: Achilles tendon injuries represent one of the most common reasons for referral to orthopaedic surgeons. Purpose: To outline the characteristics, examine trends in publication, and evaluate the correlation between citations and study quality of the 50 most cited articles on Achilles tendon injury. Study Design: Cross-sectional study. Methods: After searching the Web of Science for articles published in orthopaedic journals, we identified the 50 most cited articles on Achilles tendon injury and abstracted their characteristics. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Multiple bivariate analyses (Pearson or Spearman correlation coefficient) were used to evaluate the association among number of citations, citation rate (citations/year), 2020 journal impact factor (JIF), year of publication, level of evidence (LoE), study type (tendon rupture or chronic tendinopathy), sample size, and mCMS. Results: The top 50 articles were cited 12,194 times. Each article had a mean ± SD 244 ± 88.8 citations (range, 157-657) and a citation rate of 12.6 ± 5.4 per year (range, 3-28). A total of 35 studies (70%) were published between 2000 and 2010. The citation rate of the 16 most recent studies was almost double that of the 16 oldest studies (17.5 vs 9.9; P < .001). Nineteen studies (49%) were classified as having poor quality (mCMS <50 points). The mean JIF of the 9 journals that published the studies was 5.1. The citation rate correlated with the number of citations (r = 0.56; P < .001), publication year (r = 0.60; P < .001), and LoE (r = -0.44; P = .005). The publication year correlated with the LoE (r = -0.40; P = .01). Study quality in terms of mCMS correlated with the JIF (r = 0.35; P = .03) and LoE (r = -0.48; P = .003) but not the citation rate (P = .15). Conclusion: The mean LoE and the citation rate of the most cited articles on Achilles tendon injury both significantly increased over time. Although the JIF was positively correlated with study quality, almost half of the studies had poor-quality methodology.

Does the Number of Screws Influence the Union Rate in Ankle Arthrodesis? A Meta-analysis and Systematic Review.

OBJECTIVE: The purpose of this study was to determine whether the number of cannulated screws used during ankle arthrodesis (AA) might influence the union and complication rate. METHODS: In this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant PROSPERO-registered systematic review, multiple databases were searched including studies in which patients undergone AA using cannulated screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion, and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Two groups were built (arthrodeses fixed with 2 screws [group 1, G1] vs arthrodeses fixed with 3 screws [group 2 G2]) and compared. RESULTS: Fifteen series of patients from 15 studies (667 ankles) were selected (G1 = 458 ankles and G2 = 209). The pooled proportion estimate revealed a similar nonunion rate in the 2-screw group as compared with the 3-screw group (4% vs 3%; P = .68). The pooled proportion of complications was higher in G1 (19%) than in G2 (8%), but it was not significantly different either (P = .45). After exclusion of "symptomatic hardware and screw removal," the difference was still not significant (P = .28) although it resulted lower in G1 than in G2 (4% vs 8%, respectively). CONCLUSIONS: Using 3 cannulated screws during AA as compared with a 2-screw construct does not significantly reduce the risk of nonunion nor the risk of complications. LEVEL OF EVIDENCE: Level IV, Systematic review of level IV.

Can Weight-Bearing Computed Tomography Be a Game-Changer in the Assessment of Ankle Sprain and Ankle Instability?

Ankle sprain and chronic lateral ankle instability are complex conditions and challenging to treat. Cone beam weight-bearing computed tomography is an innovative imaging modality that has gained popularity, with a body of literature reporting reduced radiation exposure and operating time, and shortened examination time and a decreased time interval between injury and diagnosis. In this article, we make clearer the advantages of this technology and encourage researchers to investigate the area, and clinicians to use it as a primary mode of investigation. We also present clinical cases provided by the authors to illustrate those possibilities using advanced imaging tools.

CLINICAL RESULTS OF COLLAGENASE TREATMENT FOR DUPUYTREN'S DISEASE: A CASE SERIES STUDY WITH 2-YEARS FOLLOW-UP.

Objectives: This study aims to report our experience with Clostridium Histolyticum collagenase (CCH) to support the importance of its clinical use and assess its clinical efficacy, complications, and recurrences. Methods: This prospective observational study of 66 patients with a 2-year follow-up. Patients with an extension lag major of 20° at the metacarpophalangeal joint (MPJ) and/or proximal interphalangeal joint (PIPJ) were included. We collected data on demographic and anamnestic details, MPJ and PIPJ contracture degrees, DASH score, complications, and recurrences. Results: The mean pre-injection contracture was 34° for MPJ and 31° for PIPJ. At the 2-year follow-up, the mean contracture for the MPJ and PIPJ were respectively 3° and 14.5°. The mean DASH score decreased from 21.8 before injection to 10,4 after 2 years. The disease recurrence occurred in 34.8% of the patients, all with PIPJ contracture. The main complication was skin breakage (25.7%). Conclusion: The CCH injections remain a consistent option in treating DD; withdrawal from the European market deprives surgeons and patients of low invasiveness and safe tool for treating DD. Level of evidence IV, Therapeutic study investigating treatment results, Case series .

Objetivos: O objetivo deste estudo é relatar nossa experiência com Clostridium Histolyticum colagenase (CCH) para apoiar a importância de seu uso clínico e para avaliar sua eficácia clínica, complicações e recidivas. Métodos: Estudo observacional prospectivo de acompanhamento por 2 anos em 66 pacientes com um atraso de extensão maior de 20° na articulação metacarpofalângica (MPJ) e/ou articulação interfalângica proximal (PIPJ). Foram coletados dados sobre detalhes demográficos e anamnésicos, graus de contração da MPJ e PIPJ, escore de DASH, complicações e recidivas. Resultados: A média da contração pré-injeção foi de 34° para a MPJ e 31° para a PIPJ. Com 2 anos de acompanhamento, a contração média para a MPJ e PIPJ foi de 3° e 14,5° respectivamente. A pontuação média do DASH diminuiu de 21,8 antes da injeção para 10,4 após 2 anos. A recorrência da doença ocorreu em 34,8% dos pacientes, todos com contração de PIPJ. A principal complicação foi a quebra da pele (25,7%). Conclusão: As injeções de CCH continuam sendo uma opção consistente no tratamento do DD; a retirada do medicamento do mercado europeu priva os cirurgiões e pacientes de uma ferramenta pouco invasiva e segura para o tratamento do DD. Nível de evidência IV, Estudo terapêutico que investiga os resultados do tratamento, série de casos .

Irritation from metalwork after ankle arthrodesis fixed using screws: a proportional meta-analysis and systematic review.

OBJECTIVE: Ankle arthrodesis (AA) is often fixed using cannulated screws. The irritation from metalwork is a relatively common complication, but there is no consensus regarding the need to remove the screws on a systematic basis. The aim of this study was to determine (1) the proportion of screws removed after AA and (2) whether predictors of screw removal could be identified. METHODS: This PRISMA-compliant systematic review was part of a larger previous protocol registered on the PROSPERO platform. Multiple databases were searched including studies in which patients undergone AA using screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). RESULTS: Forty-four series of patients from thirty-eight studies (1990 ankles, 1934 patients) were selected. The average follow-up was 40.8 months (range 12-110). In all studies, hardware was removed due to symptoms reported by patients and related to the screws. The pooled proportion of removal of metalwork was 3% (95% CI 2-4). The pooled proportion of fusion was 96% (95%CI 95-98), while the pooled proportion of complications and reoperations (excluding the removal of metalwork) stood at 15% (95% CI 11-18) and 3% (95% CI 2-4), respectively. The mean mCMS (50.8 ± 8.1, range 35-66) revealed only an overall fair quality of studies. The univariate analysis and the multivariate model showed that the year of publication (R = - 0.004; p = 0.01) and the number of screws (R = 0.08; p = 0.01) were associated with the screw removal rate. Specifically, we found that over time the removal rate decreased by 0.4% per year and that the use of three screws instead of two reduced the risk of removal of metalwork by 8%. CONCLUSIONS: In this review, removal of metalwork after ankle arthrodesis using cannulated screws was needed in 3% of cases at an average follow-up of 40.8 months. It was indicated only in case of symptoms related to soft tissue irritation from screws. The use of three screws was paradoxically related to a reduced risk of removal of screws as compared to two-screw constructs. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV.