To cast or not to cast? Postoperative care of ankle fractures: a meta-analysis of randomized controlled trials.

Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.

First Metatarsal Headphones-Like Lesion: A Case of Unreducible Sesamoid Complex Dislocation.

CASE: A 34-year-old woman sustained a direct trauma to the left hallux during a fall. Radiographs showed a dorsal dislocation of the first metatarsophalangeal joint and a wide separation of sesamoid complex. Closed reduction was tried: postreduction radiographs displayed reduction of first metatarsophalangeal joint and a complete sesamoid complex dislocation. The patient was scheduled for surgery. Through a medial approach, open reduction together with plantar structures release and repair were performed. Functional and radiographic outcomes were satisfactory at the last follow-up. CONCLUSION: In case of a "headphones-like lesion" surgery is required, together with plantar structures repair.

Long-term follow-up of adolescent idiopathic scoliosis surgery with Harrington instrumentations: a systematic review and meta-analysis.

PURPOSE: In the 1960s, Harrington instrumentation (HRI) revolutionized the surgical treatment of adolescent idiopathic scoliosis (AIS). Despite the transition to more innovative techniques, concerns regarding its impact on sagittal alignment, associations with low back pain, and correction loss have consistently persisted. The aim of this meta-analysis is precisely to evaluate the clinical and radiological outcomes, as well as the complications of patients treated with HRI over an extended follow-up period. A systematic search of articles about AIS patients who underwent HRI and reported long-term outcomes (> 10 years) was conducted on electronic databases according to PRISMA guidelines. Data regarding radiographic and clinical outcomes were extracted and meta-analyses were performed. Eleven studies comprising 644 patients were included. The mean follow-up ranged from 10.8 to 51.7 years. Radiographic analysis revealed a decrease in the main curve Cobb angle from 60.6° to 38.3°, with a correction loss of - 9.49° between postoperative and last follow-up. Concerning sagittal parameters, preoperative thoracic kyphosis was 19.65° at last follow-up, and preoperative lumbar lordosis was 42.94°. Additional spine surgeries were required in 42% of patients. Clinical outcomes varied among studies, but overall, HRI patients showed comparable quality of life and function to controls, although a higher incidence of low back pain was reported. Patients who underwent HRI exhibited suboptimal correction of rib deformity and a flattened sagittal spinal alignment. However, they generally displayed favourable long-term functional outcomes. Despite the implant's tendency to reduce lumbar curvature, patients achieved good clinical outcomes and functional scores comparable to age-matched individuals, suggesting that disability is not an inevitable consequence of lumbar flattening.

Adipose-derived stem cells applied to ankle pathologies: a systematic review.

The purpose of this systematic review was to analyze the current use of adipose-derived mesenchymal stem cells (ADMSCs) and present the available evidence on their therapeutic potential in the treatment of ankle orthopedic issues, evaluating the applications and results. A literature search of PubMed, Google Scholar, EMBASE and Cochrane Library database was performed. The review was conducted following PRISMA guidelines. Risk of bias assessment was conducted through the Methodological Index for Non-Randomized Studies (MINORS) criteria. Initial search results yielded 4348 articles. A total of 8 articles were included in the review process. No clinical evidence has demonstrated the effectiveness of one isolation method over the other, but nonenzymatic mechanical method has more advantages. In all studies included significant clinical outcomes improvement were recorded in patients affected by osteochondral lesion and osteoarthritis of ankle. All studies performed a concomitant procedure. No serious complications were reported. ADMSC injection, especially through the nonenzymatic mechanical methods, looks to be simple and promising treatment for osteochondral lesions and osteoarthritis of the ankle, with no severe complications. The current scarcity of studies and their low-quality level preclude definitive conclusions presently. LEVEL OF EVIDENCE: III.

Congenital metatarsus varus: early diagnosis and conservative treatment in 112 patients.

PURPOSE: To describe a conservative treatment algorithm to manage Congenital Metatarsus Varus. BACKGROUNDS: Congenital Metatarsus Varus is a congenital disorder with an estimated incidence of 1/1000 newborns. Despite the deformity being mostly an aesthetic problem, residual and incorrect forms may be responsible for abnormal in-toe gait and shoe-wearing issues. No consensus has still been gathered regarding its correct treatment algorithm. METHODS: Between May 2019 and September 2020, 2156 newborn patients underwent an orthopedic examination at birth. Patients affected by Congenital Metatarsus Varus were classified according to Bleck's classification as flexible, semi-flexible or non-flexible deformity. A conservative treatment algorithm was followed, based on the application of manipulations, Bebax-type braces or plaster cast. All patient were followed until the clinical resolution of the deformity. Complications were also recorded. RESULTS: One-hundred twenty-four patients were diagnosed Congenital Metatarsus Varus, with an overall prevalence of 5/1000. One-hundred twenty-two patients presented with a flexible or semi-flexible foot deformity and were firstly treated with manipulations: 52 patients reported good results, while 70 required additional treatment with Bebax-type braces for achieving correction. Two patients presented a non-flexible deformity at birth: one required plaster cast due to a non-flexible deformity, and one patient was firstly managed with Bebax-type braces due to a severe semi-flexible deformity. Only two patients presented superficial skin ulcerations, healed within a week. Two patients were lost during the follow-up. CONCLUSION: An early diagnosis allowed by an orthopedic examination in all newborns may be a valid instrument to avoid Congenital Metatarsus Varus misdiagnosis. Early treatment with manipulation and orthosis resulted in good clinical outcome, with only few complications.

A novel retrograde technique for ankle osteochodral lesions: the sub-endo-chondral regenerative treatment (secret).

PURPOSE: To describe a new surgical technique for osteochondral lesions of the ankle, using bone marrow concentrate on a scaffold and homologous bone graft positioned through a retrograde approach. Many surgical options for ankle osteochondral lesions have been described, and the ideal treatment is still debated. Bone marrow stimulating techniques are recommended for cystic lesions, with some concerns regarding the healing potential of the subchondral bone. In case of wide osteochondral defects, regenerative solutions are preferred but a massive chondral debridement is usually required. To overcome these problems, a novel technique is proposed. METHODS: The proposed technique was performed on patients affected by osteochondral lesions of the talus, either cysts with intact cartilage or wide osteochondral defects. A preoperative magnetic resonance imaging was obtained to localize the lesion. A 6-mm tarsal tunnel was retrogradely created toward the lesion, to allow a complete sub-endo-chondral debridement preserving the healthy cartilage. A hyaluronan scaffold soaked with a previously prepared bone marrow concentrate was retrogradely positioned under the cartilage surface and the tunnel was filled with homologous bone graft. Preoperative clinical scores and postoperative x-rays were registered. RESULTS: Four patients were treated using this technique. No intraoperative and postoperative complications occurred. Good bone remodeling was observed at 12-week postoperative x-rays. CONCLUSIONS: This technique combines the mini-invasiveness of retrograde drilling with the regenerative properties of biological scaffold soaked with bone marrow concentrate. Despite further research being needed, it seems a new viable solution to treat both subchondral cysts and large osteochondral defects of the ankle, whose management is still controversial.

Keller's arthroplasty for hallux rigidus: A systematic review.

BACKGROUND: Several surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique's suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus. METHODS: Selected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications. RESULTS: Seventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%). CONCLUSION: Despite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients' selection.

Covid-19 orthopedic trauma patients characteristics and management during the first pandemic period: report from a single institution in Italy.

PURPOSE: COVID-19 disease is a declared pandemic, affecting all aspects of healthcare, including orthopedics. The aim of this study is to describe the COVID-19 orthopedic trauma patients characteristics and management in a dedicated Orthopedic and Traumatology Hospital in Italy during the first pandemic period. MATERIAL AND METHODS: A cohort of 25 consecutive patients with suspected or confirmed COVID-19 infection were retrospectively analyzed. Health system rearrangement, patients' clinical presentation, diagnostic tools role, laboratory finding, treatment and outcomes were evaluated. RESULTS: Health system rearrangement was fast. There was no clear prevalence of comorbidity or surgery type between confirmed and suspected COVID-19 cases. Nine positive swabs tests and 14 cases with only suspected CT scan findings were recorded. Several laboratory changes have been reported since the onset of symptoms: anemia, leukocytosis, lymphopenia, coagulation abnormalities, alkaline phosphatase, liver enzymes and C-reactive protein alterations. Nineteen patients were treated by oxygen supplement, three patients were administered antivirals, eight antibiotic therapy, and nine hydroxychloroquine. The number of discharges reported in this study was greater than 52% and the number of deaths reached 20%. CONCLUSION: To our experience, the development of patient management algorithms allows the differentiation of the clinical pathways of negative and suspected/positive patients, reducing exposure, and virus spreading. The execution of swabs on all patients allows an early diagnosis and a more adequate management. Considering the different therapy patterns used, there were no significant differences, but anti-thromboembolic prophylaxis administered to all the orthopedic patients may have contributed to complications and mortality rates reduction.

Post-operative management after total ankle arthroplasty: A systematic review of the literature.

BACKGROUND: Currently, there is no consensus on the most appropriate post-operative management for patients undergoing total ankle arthroplasty. The aim of this study is therefore to offer a systematic review of the pertaining literature to identify current post-operative protocols and describe possible differences. METHODS: A systematic review to identify recent studies concerning the post-operative management after total ankle arthroplasty was conducted. Five topics were analyzed: length of hospital stay, type and duration of immobilization, weight-bearing management, post-operative pharmacological therapies, adopted rehabilitation scheme. RESULTS: Eighty-four studies met the inclusion criteria and were included in the review process. Most of the papers appear to have conflicting opinions with no consensus and homogeneous protocols. CONCLUSION: Due to various methodological limitations, it is not possible to provide sufficiently supported evidence-based recommendations, and it is therefore difficult to determine the superiority of one post-operative protocol over the others after total ankle arthroplasty.

A new ligament-compatible patient-specific 3D-printed implant and instrumentation for total ankle arthroplasty: from biomechanical studies to clinical cases.

BACKGROUND: Computer navigation and patient-specific instrumentation for total ankle arthroplasty have still to demonstrate their theoretical ability to improve implant positioning and functional outcomes. The purpose of this paper is to present a new and complete total ankle arthroplasty customization process for severe posttraumatic ankle joint arthritis, consisting of patient-specific 3D-printed implant and instrumentation, starting from a ligament-compatible design. CASE PRESENTATION: The new customization process was proposed in a 57-year-old male patient and involved image analysis, joint modeling, prosthesis design, patient-specific implant and instrumentation development, relevant prototyping, manufacturing, and implantation. Images obtained from a CT scan were processed for a 3D model of the ankle, and the BOX ankle prosthesis (MatOrtho, UK) geometries were customized to best fit the model. Virtual in silico, i.e., at the computer, implantation was performed to optimize positioning of these components. Corresponding patient-specific cutting guides for bone preparation were designed. The obtained models were printed in ABS by additive manufacturing for a final check. Once the planning procedure was approved, the models were sent to final state-of-the-art additive manufacturing (the metal components using cobalt-chromium-molybdenum powders, and the guides using polyamide). The custom-made prosthesis was then implanted using the cutting guides. The design, manufacturing, and implantation procedures were completed successfully and consistently, and final dimensions and location for the implant corresponded with the preoperative plan. Immediate post-op X-rays showed good implant positioning and alignment. After 4 months, clinical scores and functional abilities were excellent. Gait analysis showed satisfactory joint moment at the ankle complex and muscle activation timing within normality. CONCLUSIONS: The complete customization process for total ankle arthroplasty provided accurate and reliable implant positioning, with satisfactory short-term clinical outcomes. However, further studies are needed to confirm the potential benefits of this complete customization process. LEVEL OF EVIDENCE: 5.

Trends in surgical management of the infected total ankle arthroplasty.

OBJECTIVE: We performed a systematic review of surgical treatment of the infected total ankle arthroplasty. The purpose of this investigation was to describe the current trends and to perform a critical analysis of the evidence reported in the existing literature. MATERIALS AND METHODS: A comprehensive search for all relevant articles published in English was conducted. Scientific databases were accessed to identify papers dealing with the management of the infected total ankle arthroplasty. We identified and collected every patient that underwent a surgical management of infected ankle arthroplasty. Data extracted were summarized and reported. A descriptive analysis was performed; when possible, a statistical analysis was accomplished. RESULTS: Thirty-two papers (152 infected ankle arthroplasty) published in the last 20 years were identified. Twenty-seven patients (17.76%) were treated with irrigation and debridement, revision total ankle arthroplasty was performed in 72 cases (47.37%), arthrodesis was performed as a primary treatment in 30 patients (19.74%), 12 patients (7.89%) underwent a spacer arthroplasty while amputation was performed as a primary treatment in 9 patients (5.92%). CONCLUSIONS: Our study reveals the improvement of the surgical management of the infected total ankle arthroplasty through the last 20 years. Irrigation and debridement and two-stage revision represent the most viable treatment in acute postoperative and late chronic infections respectively. We noted a trend towards maintaining articularity through a two-stage revision. The quality of evidence is weak with biases both in reporting and selection process. High quality randomized controlled trials are required to compare different treatments in order to introduce an evidence-based treatment protocol.

How to prevent dislocation after revision total hip arthroplasty: a systematic review of the risk factors and a focus on treatment options.

BACKGROUND: Dislocation represents the most common complication after revision total hip arthroplasty (rTHA). Understanding risk factors for dislocation has a great clinical relevance for every hip surgeon in order to consider all surgical options for effective planning. The aim of this systematic review was to answer two main questions-(1) what are the risk factors for instability after rTHA? and (2) what are the best preoperative assessments and surgical options to avoid dislocation after rTHA? MATERIALS AND METHODS: Scientific databases were accessed to identify papers dealing with prevention and treatment of dislocation after rTHA. We performed a search using the keywords 'revision hip arthroplasty' and 'dislocation', 'instability', 'outcome', 'failure', 'treatment'. After removal of duplicates and exclusion of works published in different languages, 33 articles were reviewed completely. RESULTS: Risk factors were analysed in order to establish the most relevant and evidence-based treatments available in the current literature. CONCLUSIONS: The risk of dislocation after rTHA can be reduced using some precautions inferred from the literature. The use of a larger femoral and acetabular component, elevated rim liner and dual mobility implants can significantly reduce the risk of dislocation after rTHA. However, care must be taken regarding patient-related risk factors since these cannot be addressed and modified. Hence, a complete evaluation of risk factors should be performed for each patient and procedure before starting rTHA.

Cardiac resynchronization therapy: a comparison among left ventricular bipolar, quadripolar and active fixation leads.

We evaluated the performance of 3 different left ventricular leads (LV) for resynchronization therapy: bipolar (BL), quadripolar (QL) and active fixation leads (AFL). We enrolled 290 consecutive CRTD candidates implanted with BL (n = 136) or QL (n = 97) or AFL (n = 57). Over a minimum 10 months follow-up, we assessed: (a) composite technical endpoint (TE) (phrenic nerve stimulation at 8 V@0.4 ms, safety margin between myocardial and phrenic threshold <2V, LV dislodgement and failure to achieve the target pacing site), (b) composite clinical endpoint (CE) (death, hospitalization for heart failure, heart transplantation, lead extraction for infection), (c) reverse remodeling (RR) (reduction of end systolic volume >15%). Baseline characteristics of the 3 groups were similar. At follow-up the incidence of TE was 36.3%, 14.3% and 19.9% in BL, AFL and QL, respectively (p < 0.01). Moreover, the incidence of RR was 56%, 64% and 68% in BL, AFL and QL respectively (p = 0.02). There were no significant differences in CE (p = 0.380). On a multivariable analysis, "non-BL leads" was the single predictor of an improved clinical outcome. QL and AFL are superior to conventional BL by enhancing pacing of the target site: AFL through prevention of lead dislodgement while QL through improved management of phrenic nerve stimulation.

Bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot.

Flatfoot is a common condition in growing-age patients. Despite its common presentation, nowadays surgical indications and treatments are still debated. Arthroereisis is a widely used technique, and several implants designs have been proposed over time. Despite the good results shown in the literature, the main drawback of these techniques has always been the need for a second surgery for implant removal. Bioabsorbable devices have been introduced to overcome this necessity.Correct approach to the patient, indications and contraindications and available studies on bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot were analyzed in this narrative review. Even if only a few studies have been published in the literature, bioabsorbable implants showed good clinical results comparable to non-absorbable implants and with a rare necessity for implant removal or revision. When correct indications and proper surgical technique are followed, arthroereisis with bioabsorbable implants appears to be an effective solution for the treatment of pediatric flexible flatfoot.

Dietary intake and major food sources of polyphenols in people with type 2 diabetes: The TOSCA.IT Study.

PURPOSE: Proper evaluation of polyphenols intake at the population level is a necessary step in order to establish possible associations with health outcomes. Available data are limited, and so far no study has been performed in people with diabetes. The aim of this work was to document the intake of polyphenols and their major food sources in a cohort of people with type 2 diabetes and in socio-demographic subgroups. METHODS: We studied 2573 men and women aged 50-75 years. Among others, anthropometry was measured by standard protocol and dietary habits were investigated by food frequency questionnaire (EPIC). The intake of polyphenols was evaluated using US Department of Agriculture and Phenol-Explorer databases. RESULTS: The mean total polyphenol intake was 683.3 ± 5.8 mg/day. Non-alcoholic beverages represented the main food source of dietary polyphenols and provided 35.5% of total polyphenol intake, followed by fruits (23.0%), alcoholic beverages (14.0%), vegetables (12.4%), cereal products and tubers (4.6%), legumes (3.7%) and oils (2.1%); chocolate, cakes and nuts are negligible sources of polyphenols in this cohort. The two most important polyphenol classes contributing to the total intake were flavonoids (47.5%) and phenolic acids (47.4%). Polyphenol intake increased with age and education level and decreased with BMI; furthermore, in the northern regions of Italy, the polyphenol intake was slightly, but significantly higher than in the central or southern regions. CONCLUSIONS: The study documents for the first time the intake of polyphenols and their main food sources in people with diabetes using validated and complete databases of the polyphenol content of food. Compared with published data, collected in people without diabetes, these results suggest a lower intake and a different pattern of intake in people with diabetes.

Modified minimally invasive direct anterior approach through a bikini incision for total hip arthroplasty: technique and results in young female patients.

Direct anterior approach for THA has gained popularity over the last years. However, concerns have been raised regarding the cosmetic, related to the incision that does not respect the Langer's skin tension line and may produce hypertrophic scars. The aim of this study was to analyze the preliminary results in 22 young female patients undergoing THA through a minimally invasive direct anterior approach using a modified oblique bikini incision. Clinical evaluations showed an improvement of WOMAC, UCLA and Harris Hip Score at 5-month follow-up. The technique ensured proper implant positioning and showed advantages in terms of complications, transfusion rates, hospital length of stay and functional recovery. From the aesthetic point of view, the expected cosmetic results were obtained. Minimally invasive direct anterior approach using a modified oblique bikini incision represent a viable option for THA, combining both the advantages of a minimal invasive procedure with a better aesthetic appearance.

Direct vertebral rotation and differently shaped dual rod translation technique in adolescent idiopathic scoliosis.

Direct vertebral rotation (DVR) is widely used to correct the axial deformity in adolescent idiopathic scoliosis (AIS). Indirect rotation techniques may help DVR in order to improve outcome. Vertebral translation technique combined with the use of two differently shaped rods resulted effective in reducing the rib hump deformity. The aim of this study is to describe the technique and evaluate the efficacy of combined DVR and vertebral translation technique on axial deformity correction. Mean follow-up was 2.7 years. Cobb angle, kyphosis angle, apical vertebrae axial rotation angle, SRS-22 questionnaire of 30 AIS patients treated with combined DVR and differently shaped dual rods translation technique were collected and compared preoperatively and postoperatively. At the last follow-up no screw pull-out, nonunion or loss of correction were recorded. The combination of DVR and differently shaped dual rods translation technique in AIS can provide good three-dimensional correction and improvement of patient's quality of life.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period.

Main surgical approaches to the hip have been modified during last decades, in an effort to reduce invasiveness of the surgical procedure and allow a faster rehabilitation. Direct anterior approach is the only approach, which does not require muscle detachment, thus theoretically leading to reduced post-operative pain and allows earlier recovery. The aim of this study was to report a comparison between patients operated with direct anterior approach and postero-lateral approach in terms of immediate post-operative and in-hospital records. Pain, operative time, intra- and post-operative complications, blood loss, hospitalization, motor component of the Functional Independence Measure (M-FIM), timed up and go (TUG) test were measured between the two groups and compared. Direct anterior approach showed better results in M-FIM, TUG, hospitalization and blood loss, without any significant difference for intra- and post-operative complications between the 2 groups. This study shows that early post-operative recovery is influenced by the chosen approach. Direct anterior approach showed better outcomes when compared to postero-lateral approach, limited to hospitalization, blood loss, and functional scores. Further comparisons are needed to evaluate direct anterior approach to maintain advantages over postero-lateral approach on longer follow-up period.