Minimally invasive distal first metatarsal osteotomy can be an option for recurrent hallux valgus.

BACKGROUND: Recurrence rate of surgical treatment of hallux valgus ranges in the literature from 2.7% to 16%, regardless of used procedure. In this study, long-term results of a minimally invasive distal osteotomy of the first metatarsal bone for treatment of recurrent hallux valgus are described. METHODS: 32 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 26 patients for treatment of recurrent hallux valgus. Primary surgery had been soft tissue procedures in 8 cases (25%), first metatarsal or phalangeal osteotomies in 19 cases (59.4%) and Keller procedures in 5 cases (15.6%). RESULTS: Patients were assessed with a mean follow-up of 9.8±4.3 years. All patients reported the disappearance or reduction of the pain. The mean overall AOFAS score improved from 46.9±17.8 points to 85.2±14.9 at final follow-up. The mean hallux valgus angle decreased from 26.1±9.1 to 9.7±5.4°, the intermetatarsal angle decreased from 11.5±4.5 to 6.7±4.0°. No major complications were recorded with a re-recurrence rate of 3.1% (1 case). CONCLUSIONS: Percutaneous distal osteotomy of the first metatarsal can be a reliable and safe surgical option in the recurrent hallux valgus with low complication rate and the advantages of a minimally invasive surgery. LEVELS OF EVIDENCE: IV, Retrospective Case Series.

Percutaneous distal osteotomy of lesser metatarsals (DMMO) for treatment of metatarsalgia with metatarsophalangeal instability.

BACKGROUND: Clinical and radiological results of percutaneous distal metatarsal minimally invasive osteotomy (DMMO) of the lesser rays for surgical treatment of primary metatarsalgia due to plantar overpressure with metatarsophalangeal instability are described. The aim of this prospective study was to assess the efficacy, feasibility and safety of this minimally invasive surgical (MIS) technique, verifying the possibility to lower the complication rate related to surgical exposures, to reduce operating times with comparable functional and cosmetic results to those reported with traditional open procedures. METHODS: Hundred and six consecutive percutaneous distal osteotomies without fixation (DMMO) of the second, third or fourth metatarsal bones were performed in 57 patients (70ft) with a mean age at the surgery of 60.2 years (30-81) for treatment of metatarsalgia with metatarsophalangeal instability. Patients were clinically assessed with the AOFAS and Coughlin's Scores, the latter classifying the results in relation to the patient's subjective satisfaction. RESULTS: The mean follow-up was of 45.0±13.3months (24-68). All patients reported the disappearance or reduction of the pain that they had experienced prior to the operation around the metatarsal heads. The mean overall AOFAS score improved from 42.7±13.4 points (9-77) to 92.8±8.6 points (44-100) at the time of final follow-up. Patient subjective satisfaction according to Coughlin's classification was excellent in 62ft (88.6%), good in 7ft (10.0%), fair in 0ft and poor in one foot (1.4%). CONCLUSIONS: We consider the percutaneous distal lesser metatarsal osteotomy without fixation (DMMO) a reliable surgical option in metatarsalgia due to metatarsophalangeal instability in early stages as in grade I and II according to Coughlin classification.

MPFL reconstruction: indications and results.

BACKGROUND AND AIM: The medial patellofemoral ligament (MPFL) is the most important structure commonly injured during lateral patellar dislocation and its rupture accounts for 3% of total knee injuries. MPFL reconstruction (MPFLR) is a reliable procedure with good results but variable rates of recurrent instability. The aim of this study is to underline the proper indications for the MPFLR reconstruction and to explain all the pearls and pitfalls regarding the MPFLR both in our experience and found in the latest literature. METHODS: A comprehensive search in the latest literature using various combinations of the keywords MPFL, MPFLR, dislocation, treatment was performed. The following data were extracted: diagnosis methods, indications and contraindications for isolated MPFLR, type of management, recurrence of instability, outcomes and complications. RESULTS: History of multiple patellar dislocations is the most relevant indication for ligament reconstruction especially after a failed course of conservative treatment in presence of persistent patello-femoral instability. Gold standard technique for MPFLR has not been clearly defined yet. CONCLUSIONS: There is still poor literature about outcome comparisons, therefore it is challenging to decide which technique is the most appropriate as surgical procedures are continuously developing. The ideal candidates for MPFLR have to be decided after a throughout evaluation and careful planning and, with nowadays knowledge, it is possible to put indication for a reconstruction exposing the patient to minimal risks.

Fourth generation head fracture in ceramic-on-polyethylene bearing after hip revision surgery: a case report.

Fourth generation ceramic bearings (BIOLOX delta, CeramTec AG; Phlochingen, Germany) were developed to reduce wear debris and improve fracture resistance. A case of a fourth generation head fracture in ceramic-on-polyethylene (COP) coupling after hip revision surgery is reported. A 58-year-old man was admitted to our department for increasing hip pain following a direct trauma which occurred during skiing activity 4 months before. Six years earlier, he had undergone a right cementless revision surgery with a 36-mm BIOLOX delta femoral head on polyethylene liner for metallosis and foreign body reaction after primary total hip replacement for hip osteoarthritis. At admission, radiological evaluation revealed a fracture of ceramic femoral head requiring a new revision surgery. Extensive synovectomy, lavage and capsulectomy were performed. Both acetabular cup and femoral stem were well fixed with no damage of trunnion, and therefore they were retained. A 36-mm internal diameter polyethylene acetabular liner was inserted along a 36-mm BIOLOX delta head with a BioBall adapter XL. The postoperative course was uncomplicated. At 1-year follow-up, the patient had a complete functional recovery. To our knowledge, BIOLOX delta ceramic femoral head fracture after COP hip revision surgery has not been previously reported.

Facing complications of direct anterior approach in total hip arthroplasty during the learning curve.

BACKGROUND: This study aims to evaluate complications and early postoperative clinical outcomes of direct anterior approach (DAA) in total hip arthroplasty (THA). METHODS: Ninety-one consecutive patients who underwent primary elective unilateral THA between January 2013 and December 2019 were identified. Collected data included age of patient, BMI, ASA score, EBL (estimated blood loss), LOS (length of stay), operating time, and intra/postoperative complications. The recorded complications included prolonged wound drainage without infection, superficial and deep infection, dislocation, periprosthetic fracture, aseptic loosening or failure of osteointegration and nervous damage. Any reoperation, with or without prosthetic component revision, was recorded. RESULTS: Fourteen complications (15,4%) and 12 (13,18%) postoperative anemizations were observed in this series. No deep infection was reported. Most common complications were nerve damage (3/91;3,29%), greater trochanter fracture (3/91; 3,29%), and wound trouble (3/91; 3,29%). Two (2,19%) dislocations were reported. One (1,09%) intraoperative periprosthetic fracture was treated with cerclage wiring. One (1,09%) revision was needed for an acetabular mobilization. One patient (1,09%) had severe periprosthetic ectopic ossifications (Brooker 4), needing reintervention because of severe limitations of the range of motion (ROM). CONCLUSIONS: Complications rate in this study with THA by DAA is comparable to those reported in literature. DAA is a safe, efficient procedure but it needs a steep learning curve. (www.actabiomedica.it).

Mesenchymal Stem Cells injection in hip osteoarthritis: preliminary results.

BACKGROUND AND AIM OF THE WORK: Osteoarthritis will become even more common in the near future since the average life span is steadily growing. Pain and loss of function are the main complaints reported by patients, inevitably leading towards a worsened daily life performance. New modern techniques have been developed with advanced cell based therapies. Mesenchymal stem cells (MSC) have the inner ability to mature into different types of cells depending on the stimuli they undergo. This technique has already been proven successful in the knee and, with this retrospective study, we would like to assess its feasibility in the hip joint. METHODS: 6 consecutive patients affected by hip osteoarthritis were treated by intra-articular injection of autologous adipose-derived MSC between June 2017 and June 2018. Our study included only patients with constant hip pain resistant conservative treatment and OA graded 0-2 on the Tonnis grading scale. All 6 patients were evaluated in the preoperative setting and at the 6 months post-operative mark. RESULTS: The HHS showed an improvement from the pre-operative baseline mean value of 67.2±3.4 to the 84.6±6.3 post-operative value. Moreover, the WOMAC score dropped from a baseline score of 36.3±4.7 to 19.8±3.4 at 6 months' post-op follow up visit. CONCLUSIONS: MSC Lipogems is a fairly easy technique. No adverse effects were recorded in our experience. Preliminary results showed a positive outcome according to all the grading systems used in this study even though a longer follow up is needed to validate this technique.

Evolution of TKA design.

The use of Total Knee Arthroplasty (TKA) in treatment of chronic degenerative pathologies of the knee boasts of an experience of 50 years. During this period the collaboration between surgeons and engineers produced many developments in the design of the prosthesis. Today this procedure is safe and established even if in continuous development. The progress in technologies and the use of new materials let researches try again old-fashioned techniques from the past in order to be improved. This enthusiasm for those discovers is not always going hand to hand with scientific validation: many open questions remains Every different concept of the design tries to answer to special needs as the reach of the highest ROM, the reduction of pain and debris, articular geometry, the type of fixation, the modularity of augments and stems, the types of constraints,  knee kinematic and of course costs.

The biocompatibility of bone cements: progress in methodological approach.

The ideal bone graft substitute should have certain properties and there are many studies dealing with mixture of polymethylmetacrilate (PMMA) and ß-tricalciumphospate (ß-TCP) presenting the best characteristics of both. Scanning Electron Microscopy (SEM), for ultra-structural data, resulted a very reliable in vivo model to better understand the bioactivity of a cement and to properly evaluate its suitability for a particular purpose. The present study aims to further improve the knowledge on osteointegration development, using both parameters obtained with the Environmental Scanning Electron Microscopy (ESEM) and focused histological examination. Two hybrid bone graft substitute were designed among ceramic and polymer-based bone graft substitutes. Based on ß-TCP granules sizes, they were created with theoretical different osteoconductive properties. An acrylic standard cement was chosen as control. Cements were implanted in twelve New Zealand White (NZW) rabbits, which were sacrificed at 1, 2, 3, 6, 9 and 12 months after cement implantation. Histological samples were prepared with an infiltration process of LR white resin and then specimens were studied by X-rays, histology and Environmental Scanning Electron Microscopy (ESEM). Comparing the resulting data, it was possible to follow osteointegration's various developments resulting from different sizes of ß-TCP granules. In this paper, we show that this evaluation process, together with ESEM, provides further important information that allows to follow any osteointegration at every stage of develop.

Antibiotic-Loaded Spacer for Two-Stage Revision of Infected Total Knee Arthroplasty.

Infection of total knee arthroplasty (TKA) is a challenge in orthopedic surgery. In literature TKA infection is classified according to the time after surgery: acute postoperative; late chronic; acute hematogenous; positive intraoperative microbiological growth. The purpose of this study is to present the results of the use of a preformed antibiotic-loaded spacer in TKA infections, treated by a two-stage revision procedure. A series of 19 consecutive patients (20 knees) with a diagnosis of infected TKA were treated from January 2003 to February 2012. Two-stage reimplantation protocols were completed only in 16 patients and these data were included in the study. We lost three patients at follow-up. An antibiotic-loaded preformed articulating polymethylmethacrylate spacer was applied. Patients were observed 1, 3, and 6 months postoperatively and then yearly for clinical and radiographic examination. The mean American Knee Society Score improved from 68.4 preoperatively (range, from 34 to 108) to 112.7 at final follow-up (range, from 49 to 180). The pain was evaluated as part of clinical score. It improved from an average of 19.3 preoperatively (range, from 10 to 30) to 34.3 at final follow-up (range, from 10 to 50). The average range of motion improved from 40.1 degrees (range, from 6 to 90 degrees) to 79.3 degrees (range, from 45 to 125 degrees). The use of the spacer allows obtaining a reduction of pain, an improvement of quality of life in the period of time between the two surgical stages and an easier reimplantation of TKA.

Hip arthroscopy in osteoarthritis consequent to FAI.

BACKGROUND: Femoral Acetabular Impingement (FAI) means a set of alterations involving the acetabulum, proximal femur, or both of these components that can results in osteoarthritis. Arthroscopy is a choice for the treatment of initial stages of osteoarthritis (OA) in order to reduce evolution of the degenerative processes; advanced degrees of osteoarthritis are absolute contraindications. MATERIALS AND METHODS: 40 patients affected by osteoarthritis in FAI  underwent hip arthroscopy between May 2010 and March 2015. In all 40 cases OA secondary to FAI was diagnosed. All patients were clinically and instrumentally analyzed pre-operatively and then post-operatively after 3, 6, and 12 months. We evaluated the degree of OA using the Tonnis classification; our study included only patients affected by Tonnis grade 0-2 osteoarthritis. RESULTS: The mean modified Harris Hip Score showed an evolution from 54.7 points to an average value of 89,1 points after 12 months. The Lower Extremities Functional Scale evolved by 43 points to an average value of 65,28 points. CONCLUSIONS: Based on the data of this study, supported by the concordance with recent literature reviews, in degrees Tonnis 0 and 1 an arthroscopic treatment is recommended. Instead the therapeutic algorithm in Tonnis grade 2 is still being discussed. We detect a significant response to arthroscopic intervention which leads us to suggest that validation of this method needs further confirmatory studies.

Bone transport and compression-distraction in the treatment of bone loss of the lower limbs.

A clinical series of 17 adult patients operated due to significant by bone loss of the long bones of the lower extremity (3 femurs and 11 tibias), is presented. Their management consisted of 6 bone transports (6 tibias) and 11 compression distraction procedures (3 femurs and 8 tibiae) using monolateral external fixators. Bone loss ranged from 3.9 cm to 14.7 cm. Mean healing time was 301 days with a mean healing index of 45.6 days for cm of lengthening achieved. The clinical and radiological results were excellent in 9, good in 6 and fair in 2 patients according to the utilised criteria of assessment. Consolidation was achieved in all but one patient who developed an aseptic stiff non-union. Two patients developed residual limb-length discrepancy less than 1.5 cm, three tibias ended up with less than 5° of valgus deviation. In two cases the half-pins were re-inserted due to early loosening. In two cases reoperation was needed for late bending of the callus after fixator removal. Three cases of bone transport and 1 case of compression distraction needed bone grafting at the docking site. Bone transport and compression-distraction are effective methods for treating bone loss in the lower extremity. It is suggested that the compression-distraction technique is preferable, since this is associated with a lower incidence of complications than bone transport procedures. The deciding factor, however, is the actual extent of the bone loss.