Great tuberosity fixation does not affect healing and clinical outcomes in RSA performed in proximal humeral fractures in elderly patients.

PURPOSE: Aims of our study were to define whether the great tuberosity (GT) positioning fixation in reverse shoulder arthroplasty (RSA) after proximal humeral fracture (PHF) could predict tuberosity healing and its impact on clinical outcomes. METHODS: We enrolled 59 patients treated with cementless reverse shoulder arthroplasty after PHF in our institute between 2012 and 2018. The mean follow-up was 57 months (± 23.4). We divided patients into two groups according to GT positioning after fixation: Group 1 GT in contact and Group 2 GT detached at least 1 mm from humeral diaphysis. Clinical and radiographic evaluations were conducted at last follow-up. RESULTS: Overall GT healing rate was 64.4%, (Group 1 70.7%-Group 2 50%). A statistically significant difference (P = 0.047) was found in cortical thickness narrowing at one-third of stem length. We found a correlation between lateral cortical narrowing and GT fixation in non-anatomical position, but we observed no statistically significant differences about GT healing according to GT anatomical or non-anatomical fixation. No differences were found in shoulder function in patients whose tuberosity was healed or failed to heal. CONCLUSION: GT reduction is not a predictive factor for GT healing; external stress shielding, instead, seems to be decreased in patients with postoperative anatomically reduced GT. In our study, GT healing did not affect clinical outcomes or patient's satisfaction in elderly low-demanding patients.

Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis.

BACKGROUND: Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity. This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years. MATERIALS AND METHODS: OBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study. RESULTS: Four Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:- 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+- 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting. CONCLUSIONS: RSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements. LEVEL OF EVIDENCE: Level IV, Case series.

Midterm Clinical Outcomes After Arthroscopic Rotator Cuff Repair in Olympic Volleyball Players: Return to Sports and Return to Performance.

Background: The decision-making process and predicting the time to return to sport (RTS) and return to performance (RTP) after arthroscopic rotator cuff repair (ARCR) in elite volleyball players are difficult issues to address, even among experienced shoulder surgeons. Purpose/Hypothesis: The purpose of the study was to evaluate the results in Olympic-level volleyball players treated with arthroscopic supraspinatus repair and to report the RTS and the RTP. It was hypothesized that these athletes had higher RTS and faster RTP. Study Design: Case series; Level of evidence, 4. Methods: This study included 17 elite volleyball athletes (11 male, 6 female; mean age, 26.2 years) who underwent ARCR for partial- and full-thickness supraspinatus tears that did not improve despite nonoperative treatment. The clinical results were evaluated at 12 months postoperatively. The authors compared the athletes' preoperative, 6-month, and 12-month Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and the visual analog scale (VAS) for pain after competition and conducted 6- and 12-month isometric strength analyses. The athletes' RTS and RTP times were recorded. Results: All tears were on the dominant side (15 right, 2 left), and 82% were partial tears (14 partial thickness, 3 full thickness). The mean time from the onset of symptoms to surgery was 11.3 ± 6.7 months. While the mean Kerlan-Jobe Orthopaedic Clinic score was 31 preoperatively, it was 89 after 6 months (P < .001 vs preoperative) and 96 after 12 months (P = .003 vs 6 months). The mean VAS for pain was 7.9 preoperatively, 0.4 at 6 months (P < .001 vs preoperative), and 0.1 at 12 months (P = .02 vs 6 months). All athletes were able to reach their preinjury level, with RTS at a mean of 6.9 months and RTP at a mean of 12.4 months. Conclusion: ARCR appears to be an effective option for Olympic-level volleyball players who do not benefit from nonoperative treatment. All athletes returned to their preinjury level of sports. The surgeon and athlete can plan surgical decision-making and timing based on the mean RTS time of 6.9 months and mean RTP time of 12.4 months.

BIO-RSA vs. metal-augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

BACKGROUND: Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that (1) metal-augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to bony increased-offset (BIO)-RSA and (2) bone graft viability and healing in BIO-RSA patients become compromised over time. MATERIALS AND METHODS: Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal-augmented baseplate (metallic increased-offset [MIO]-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (ß angle) and retroversion were also measured. RESULTS: Delta scores of active anterior elevation were higher in the MIO-RSA group (P = .027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, and glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (P = .022), whereas the values of ß angle and postoperative retroversion were similar in the 2 groups. BIO-RSA group showed radiolucent lines <2 mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rates of humerus condensation lines in MIO-RSA patients (P = .01) and higher rates of cortical thinning and tuberosity resorption in the BIO-RSA group (P = .027 and P = .004, respectively). CONCLUSION: Metal-augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patients raise concern about the risk of baseplate loosening and requires further long-term studies.

The use of computer navigation in reverse shoulder arthroplasty revision: a case report.

Revision shoulder surgery is always a challenge, especially in the management of periprosthetic joint infection. Staged surgery with antibiotic-loaded cement spacer, seems to yield satisfactory and encouraging results. New technologies such as computer navigation are additional tools that could aid surgeons in particular conditions where the native anatomy is distorted. This study presents the unique experience of revision shoulder surgery with computer navigation assistance. Benefits related to this approach could lead to better prosthesis longevity and survivorship.

Navigation in reverse shoulder arthroplasty: how the lateralization of glenosphere can affect the clinical outcome.

INTRODUCTION: One of the main causes of RSA failure is attributable to the malpositioning of the glenoid component. Initial experiences with computer-assisted surgery have shown promising results in increasing the accuracy and repeatability of placement of the glenoid component and screws. The aim of this study was to evaluate the functional clinical results, in terms of joint mobility and pain, by correlating them with intraoperative data regarding the positioning of the glenoid component. The hypothesis was that the lateralization more than 25 mm of the glenosphere can led to better stability of the prosthesis but should pay in term of a reduced range of movement and increased pain. MATERIALS AND METHODS: 50 patients were enrolled between October 2018 and May 2022; they underwent RSA implantation assisted by GPS navigation system. Active ROM, ASES score and VAS pain scale were recorded before surgery. Preoperative data about glenoid inclination and version were collected by pre-op X-Rays an CT. Intraoperative data-inclination, version, medialization and lateralization of the glenoid component-were recorded using computer-assisted surgery. 46 patients had been further clinically and radiographically re-evaluated at 3-months, 6-months, 1-year, and 2-years follow-up. RESULTS: We found a statistically significant correlation between anteposition and glenosphere lateralization value (DM - 6.057 mm; p = 0.043). Furthermore a statistically significant correlation has been shown between abduction movement and the lateralization value (DM - 7.723 mm; p = 0.015). No other statistically significant associations were found when comparing the values of glenoid inclination and version with the range of motion achieved by the patients after reverse shoulder arthroplasty. CONCLUSION: We observed that the patients with the best anteposition and abduction results had a glenosphere lateralization between 18 and 22 mm. When increasing the lateralization above 22 mm or reducing it below 18 mm, on the other hand, both movements considered decreased their range. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Anatomically reduced fixation should always be considered when treating B and C proximal epiphyseal humeral fractures.

BACKGROUND: Proximal humeral fractures are commonly observed in elderly patients. Management of these injuries is controversial. Literature comparing locking plate fixation, arthroplasty, and conservative treatments show no clear advantages for any of these management strategies. Thus far, no study has considered anatomically reduced fractures obtained after locking plate treatment. To clarify the best surgical procedure in middle-aged patients, we considered outcomes and major complications leading to surgical revision following an anatomically reduced fracture fixed with locking plate and reverse shoulder arthroplasty (RSA) in the treatment of type B/C fractures in patients between 50 and 75 years of age. METHODS: This is a retrospective study including 59 patients between 50 and 75 years of age with type B/C proximal humeral fracture treated with RSA or with locking plate fixation (resulting in an anatomical reduction) between January 2010 and December 2018. Preoperative radiographs and computed tomography (CT) were evaluated in all patients. Clinical and radiologic follow-up was performed using range of motion (ROM), the Constant-Murley Score (CMS), the Oxford Shoulder Score (OSS), the Simple Shoulder Test (SST), the Subjective Shoulder Value (SSV), and visual analog scale (VAS). Major complications were considered. RESULTS: In the plate fixation group, ROM, CMS, SST, and VAS were higher than in the RSA group. Lower complication rates compared with the literature were observed in both groups. Anatomically reduced fracture fixed with plate and screw could outperform RSA in terms of outcome. In second-level centers where traumatology is performed by surgeons with great expertise in upper limb trauma, the choice between plate fixation and reverse arthroplasty should be made during surgery. CONCLUSION: Anatomically reduced fractures showed better outcomes compared with RSA in type B/C fractures. Surgeons should always try to perform a reduction of the fracture in order to understand if a plate fixation could be feasible. If it is impossible to perform an anatomical reduction, we suggest to consider RSA. This is a retrospective observational study.

Autologous micro-fragmented adipose tissue associated with arthroscopy in moderate-severe knee osteoarthritis: outcome at two year follow-up.

BACKGROUND: Adipose tissue has recently gained growing interest in the treatment of osteoarthritis (OA). The aim of the present study was to evaluate the efficacy of a single injection of autologous micro-fragmented adipose tissue (aMFAT) associated with arthroscopy (cartilage debridement/meniscal regularization or selective meniscectomy/micro-drilling) for symptomatic knee OA. METHODS: This retrospective, single-center study included 49 patients (50 knees) affected by knee OA (radiographic Kellgren-Lawrence III-IV) treated with a single injection of autologous micro-fragmented adipose tissue and knee arthroscopy. Knee Injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) score were the primary outcome measures and were collected at one and 2 years post-operatively. Patients were divided into clusters based on age, complexity of arthroscopic procedures and chondral lesion grade. RESULTS: Four patients underwent knee replacement (8%). No major adverse events were reported. Minimal Clinically Important Difference (MCID) for KOOS and IKDC was reached by 84 and 74% of all cases at 1 year and by 80 and 76% at 2 years, respectively. High grade chondral lesions negatively affected the outcome at 2 years follow-up (p < 0.05 for IKDC, KOOS overall and 3 out of 5 subscales). CONCLUSION: The injection of micro-fragmented adipose tissue associated with arthroscopy demonstrated to be a safe and effective procedure for the treatment of knee OA, with a substantial improvement in IKDC and KOOS scores and without major complications.

Autologous Marrow Mesenchymal Stem Cell Driving Bone Regeneration in a Rabbit Model of Femoral Head Osteonecrosis.

Osteonecrosis of the femoral head (ONFH) is a progressive degenerative disease that ultimately requires a total hip replacement. Mesenchymal stromal/stem cells (MSCs), particularly the ones isolated from bone marrow (BM), could be promising tools to restore bone tissue in ONFH. Here, we established a rabbit model to mimic the pathogenic features of human ONFH and to challenge an autologous MSC-based treatment. ON has been originally induced by the synergic combination of surgery and steroid administration. Autologous BM-MSCs were then implanted in the FH, aiming to restore the damaged tissue. Histological analyses confirmed bone formation in the BM-MSC treated rabbit femurs but not in the controls. In addition, the model also allowed investigations on BM-MSCs isolated before (ON-BM-MSCs) and after (ON+BM-MSCs) ON induction to dissect the impact of ON damage on MSC behavior in an affected microenvironment, accounting for those clinical approaches foreseeing MSCs generally isolated from affected patients. BM-MSCs, isolated before and after ON induction, revealed similar growth rates, immunophenotypic profiles, and differentiation abilities regardless of the ON. Our data support the use of ON+BM-MSCs as a promising autologous therapeutic tool to treat ON, paving the way for a more consolidated use into the clinical settings.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up.

BACKGROUND: Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up. MATERIALS AND METHODS: In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated. RESULTS: In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected. CONCLUSIONS: Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries. LEVEL OF EVIDENCE: Level IV-case series.

A Long-Term Follow-Up of Post-Operative Periprosthetic Humeral Fracture in Shoulder Arthroplasty.

BACKGROUND: During the last decades, the growing number of shoulder replacement has increased the associated complications. Periprosthetic fractures have a low incidence but can be a severe clinical condition, especially in elderly population. There are still no guidelines to define the best treatment protocol for post-operative periprosthetic humeral fractures. Factors associated to these fractures and consequently the decision-making for the best treatment seem to be patient-related but also correlated with the type of implant. The aim of this study is to analyze the patient's risk factors, fracture pattern, implant type and treatment, evaluating the outcome with a long-term follow-up. METHODS: A retrospective study was performed on more than 2700 shoulder prostheses implanted over 10 years in two specialized centers, identifying 19 patients who underwent surgery for post-operative periprosthetic fracture. Gender, age, comorbidities, type of prosthetic implant, type of fracture, and cortical index of each patient were evaluated. All patients underwent surgery and were evaluated with a mean follow-up of 5 years with radiographic controls and functional assessment with the Constant-Murley score. RESULTS: Complete healing was achieved in 18 of 19 patients. All patients presented a lower Constant-Murley score than the pre-fracture score, there were no significant differences between prosthetic implants, and the cortical index was lower than the threshold level in more than 60% of cases. CONCLUSION: The results of this study showed that a correct preoperative planning is essential to evaluate the type of implant and possible signs of stem mobilization. With a stable stem, it is preferable to maintain it and proceed to a synthesis. The decision process is more complex in periprosthetic fractures with a reduced cortical index, when some radiolucency lines are present in stems with high primary stability, because it is not always indicative of an unstable stem. LEVEL OF EVIDENCE: Therapeutic III.

Microfragmented adipose tissue is associated with improved ex vivo performance linked to HOXB7 and b-FGF expression.

INTRODUCTION: Adipose tissue (AT) has become a source of mesenchymal stromal/stem cells (MSC) for regenerative medicine applications, in particular skeletal disorders. Several enzymatic or mechanical procedures have been proposed to process AT with the aim to isolate cells that can be locally implanted. How AT is processed may impact its properties. Thus, we compared AT processed by centrifugation (C-AT) to microfragmentation (MF-AT). Focusing on MF-AT, we subsequently assessed the impact of synovial fluid (SF) alone on both MF-AT and isolated AT-MSC to better understand their cartilage repair mechanisms. MATERIALS AND METHODS: MF-AT and C-AT from the same donors were compared by histology and qRT-PCR immediately after isolation or as ex vivo cultures using a micro-tissue pellet system. The in vitro impact of SF on MF-AT and AT-MSC was assessed by histological staining and molecular analysis. RESULTS: The main AT histological features (i.e., increased extracellular matrix and cellularity) of the freshly isolated or ex vivo-cultured MF-AT persisted compared to C-AT, which rapidly deteriorated during culture. Based on our previous studies of HOX genes in MSC, we investigated the involvement of Homeobox Protein HOX-B7 (HOXB7) and its target basic Fibroblast Growth Factor (bFGF) in the molecular mechanism underlying the improved performance of MF-AT. Indeed, both these biomarkers were more prominent in freshly isolated MF-AT compared to C-AT. SF alone preserved the AT histological features of MF-AT, together with HOXB7 and bFGF expression. Increased cell performance was also observed in isolated AT-MSC after SF treatment concomitant with enhanced HOXB7 expression, although there was no apparent association with bFGF. CONCLUSIONS: Our findings show that MF has a positive effect on the maintenance of AT histology and may trigger the expression of trophic factors that improve tissue repair by processed AT.

Computer-Assisted Surgery in Reverse Shoulder Arthroplasty: Early Experience.

BACKGROUND: In the last decade, new technologies have been applied to shoulder arthroplasty. The aim of this work was to show that navigated RSA allows the surgeon to reach the planned version/inclination in all cases. In this article are shown preliminary data, advantages, disadvantages and limits of the technique. METHODS: Eighteen computer-assisted reverse shoulder arthroplasty were performed. Preoperative glenoid version and inclination were evaluated with preoperative CT scan using Orthoblue® (Exactech, Gainesville, FL,USA) software, as well as baseplate type, planned glenoid component seating, planned postoperative version, planned postoperative inclination, intraoperative glenoid version/inclination, screw length and surgical time. A senior shoulder surgeon has analyzed the advantages, disadvantages and limitation of this kind of surgery. RESULTS: Mean surgical time of the primary implants was 92 ± 12 min (min 75-max 110). Mean preoperative inclination was + 2.6° ± 6.4, mean preoperative version was - 7.6° ± 8.4. Mean planned postoperative inclination was - 2.7° ± 2.3, mean planned postoperative version was - 1.6° ± 2.9 and mean planned glenoid seating was 89% ± 8%. Planned settings were reached in all cases during surgery. Baseplate implanted were in nine cases 8° posterior augmented, in six cases standard and in three cases 10° superior augmented. Mean screw length was 33.5 mm ± 4.2 mm. No GPS system failure has been recorded. One coracoid fracture occurred during the first case. DISCUSSION: Intraoperative navigation system is a reliable and user-friendly technology that allows the surgeon to reach planned glenoid positioning during surgery. Furthermore, this technology will allow the surgeon to compare clinical outcomes to component positioning data. The lack of humeral implant navigation is the main limit of this technique.

Supracondylar fractures in children: management and treatment.

Supracondylar humeral fractures are widely considered the most common elbow fracture in children. Gartland classification plays a fundamental role in decision-making regarding management and prognosis. Recent literature recommends conservative management for non or minimally displaced fractures, whereas there seems to be a trend towards surgical treatment for all displaced fractures. The preferred treatment for displaced Gartland II and Gartland III fractures is closed reduction and percutaneous fixation with lateral pins. In particular patterns medial pin is recommended for obtain a stable construct. Neurovascular complications are mostly associated with Type III fractures and sometimes surgical exploration with fracture reduction is needed. Correct diagnosis and proper management protocol is mandatory for avoid early and late complications such as neurovascular impairment and malunion.

Surgical tips and tricks for coronal shear fractures of the elbow.

INTRODUCTION: Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns. MATERIALS AND METHODS: From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score. RESULTS: Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients. CONCLUSION: Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up. LEVEL OF EVIDENCE: Therapeutic III.

Navigated, soft tissue-guided total knee arthroplasty restores the distal femoral joint line orientation in a modified mechanically aligned technique.

PURPOSE: To investigate the femoral component alignment in patients undergoing soft tissue-guided, navigated total knee arthroplasty (TKA). It was hypothesized that with a mechanically aligned tibial component, the soft tissues tensioned and symmetric medial and lateral gaps in flexion/extension, the femoral component would be aligned to the preoperative distal femoral joint line, as measured on knee radiographs. METHODS: Between 2015 and 2017, 77 patients (78 knees) underwent navigated soft tissue-guided TKA at a single centre. Pre and postoperative radiographs were collected and varus knees were taken into account. The tibial cut was performed with navigation in neutral alignment. The femoral cuts were adjusted based on tensioned soft tissues, aiming for equal medial and lateral gaps in flexion and extension. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Knee Society Score (KSS) were collected pre and postoperatively as a secondary outcome measure. RESULTS: A total of 58 TKAs on varus knees were assessed. On average, the femoral component was placed at 1.7° (SD 1.7) varus in the coronal plane. The comparison between the radiographic native distal femoral alignment and the orientation of the femoral component coronal cut demonstrated a statistically significant (p < 0.0001), linear inverse relationship (r = 0.5). Satisfactory knee function and excellent pain remission were demonstrated by KOOS and KSS scores at a mean of 2.8 years (SD 0.5) follow-up. One TKA was revised, resulting in a 98.3% survivorship at three years. CONCLUSION: The proposed soft tissue-guided, navigated technique, aiming to preserve the integrity of the ligaments and a neutrally aligned tibial cut, provided a joint line respecting femoral coronal cut and encouraging short-term clinical results. LEVEL OF EVIDENCE: III.

Volar PEEK plate for distal radius fracture: analysis of adverse events.

BACKGROUND: The aim of the present retrospective study was to evaluate complications following carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) volar plating in distal radius fracture in a large cohort of patients. As an alternative to conventional metallic devices, CFR-PEEK plates have been introduced over the last few years. METHODS: We performed a retrospective study including all patients who were treated for distal radius fracture using a volar fixed-angle plate DiPHOS-RM (Lima Corporate, Udine, Italy). All CFR-PEEK plates implanted were reviewed between May 2012 and December 2017. Plate removal, second surgery and adverse events were collected by reviewing medical records. A total of 110 patients were included with a mean follow-up of 4 years. RESULTS: Adverse side effects were observed in 9 cases (8%), developed during or after treatment. The most frequent complication was represented by intraoperative plate rupture (4%). Infection was reported in one case. DISCUSSION: The rate of complications of PEEK volar plates seems to be similar to those occurring with plates of different materials. Advantages of PEEK plates are the absence of the cold-welding phenomenon and the absence of exuberant bone callus on the plate, ensuring an easy hardware removal. Intraoperative rupture remains the main complication correlated with PEEK material. These complications can be reduced with an accurate surgical technique, especially at the beginning of the learning curve. LEVEL OF EVIDENCE: Therapeutic IV.

The GLAD Lesion: are the definition, diagnosis and treatment up to date? A Systematic Review.

INTRODUCTION: Although GLAD lesions are quite common, only sporadic case reports describe surgical techniques and clinical outcomes. Even if cartilage defects can result from various pathogenic mechanisms, the resulting defect has some similarities with GLAD, and its management can be a starting point to treat both types of lesion. Aim of the present study is to find a commonly accepted definition for GLAD lesions in order to understand its pathogenesis, diagnosis and possible treatments. METHODS: A search of PubMed (MEDLINE) database has been performed in June 2020 to identify relevant articles including a combination of the following search terms: "GlenoLabral Articular Disruption" OR "GLAD" AND "shoulder" AND "cartilage, articular". RESULTS: Abstract evaluation included 31 articles in the full-text review. Various studies showed that the performance of MR arthrography in the detection of glenohumeral cartilage lesions, including GLAD lesions, was moderate. Different therapeutic solutions have been described. Arthroscopic debridement of the lesion and reattachment of the labrum have been often used. In case of large articular defects, the labrum could be advanced in the cartilage defect to cover it. In case of cartilage flap with reparable margins, this could be reattached with different suture constructs. Neglected GLAD lesions following a chronic trauma or shoulder instability have not been described in literature. CONCLUSIONS: The definition of GLAD injury has changed over the time. Many authors associate this lesion with shoulder instability, with trauma in abduction and extra rotation, while Neviaser's original definition described stable shoulders following a trauma in adduction.

Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear.

BACKGROUND: The aim of this study was to determine the lateral ulnar collateral ligament (LUCL) injury associated with isolated radial head fracture (RHF) and the relationship of the ligament injury with the displacement of the fragment-loss of contact-in unstable displaced partial articular RHF in individuals without any history of ulnohumeral dislocation. METHODS: We retrospectively identified 131 consecutive patients who underwent open reduction and internal fixation of isolated closed Mason type II RHF performed at our institution. We identified 3 subsets by the pattern of RHF and the position of the unstable fragment (anterior or posterior) relative to the capitulum humeri: displaced stable (group I), displaced anterior unstable (group II), and displaced posterior unstable (group III). Standard radiographs were obtained preoperatively and postoperatively. The pattern of lateral collateral ligament avulsion and its distribution were inferred from intraoperative records. RESULTS: Preoperative radiographs of the 131 patients showed 101 nonseparated fractures (77%, group I) and 30 unstable fractures (23%). Anterior displacement of the fragment was found in 18 elbows (14%, group II) and posterior displacement in 12 (9%, group III). LUCL avulsion was found in 18 of 30 unstable RHFs (60%) and in 1 of 60 stable RHFs (1.6%). CONCLUSION: RHF is a complex fracture often associated with soft tissue lesions. It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability. The RHF pattern and classification as stable or unstable can help the surgeon in the identification and treatment of LUCL lesions.