Relationship Between the Lateral Collateral Ligament of the Elbow and the Kocher Approach: A Cadaver Study.

PURPOSE: The lateral ulnar collateral ligament (LUCL) is considered to be the portion of the lateral collateral ligament playing the most important stabilizing role. Iatrogenic forms of posterolateral rotatory instability have been described. The Kocher approach is a popular approach to the lateral side of the elbow. The aim of this study was to describe the relationship between the LUCL and the Kocher interval. METHODS: The Kocher interval was identified and marked in 20 cadavers. The LUCL was identified and the distance between the LUCL insertion on the tubercle of the cresta supinatoris and the Kocher interval was calculated (TK distance). This distance was considered 0 if the Kocher interval was directly above the tubercle, as a positive value if it was anterior to the tubercle, and as a negative value if it was posterior. Finally, the Kocher interval was sharply opened, and elbow stability was tested using the posterolateral rotatory drawer test. RESULTS: A discrete LUCL was identified in 16 specimens. The mean TK distance was -2.3 ± 4.4 mm (range, -11 to +10). The median TK distance was -3 mm. The posterolateral rotatory drawer test was positive for subluxation after the sharp incision of the Kocher interval in 15 specimens. The median TK distance was significantly higher in the stable group (+2 mm) than in the unstable group (-3 mm). CONCLUSIONS: The LUCL often lies beneath the Kocher interval and is at risk during the Kocher approach. CLINICAL RELEVANCE: Iatrogenic forms of posterolateral rotatory instability could result from this approach.

The Endolog technique for moderate to severe hallux valgus treatment: Clinical and radiographic analysis of 194 patients.

BACKGROUND: Endolog is an intra-medullary titanium device used for a minimally-invasive hallux valgus correction. The aim of this study was to evaluate clinical and radiographic outcomes of this device. METHODS: A retrospective study with a prospective data collection was conducted. Patients underwent to Endolog procedures from September 2009 to April 2017 were enrolled. Mild HV deformity (HVA ≤ 19° and IMA ≤ 13°) or associated procedure to Endolog technique were excluded. The radiological (HVA, IMA and PASA) and clinical (AOFAS score) pre and post-operative data were compared through Wilcoxon Signed-Rank test. RESULTS: 194 feet (144 moderate and 50 severe HV) underwent HV correction respecting study's criteria. AOFAS scores significantly improved from 31.0 ± 12.7 points preoperatively to 88.5 ± 8.0 at 24 months. Even all radiographic measurements significantly improved during 2 years' follow-up. Only 6 patients experienced complications: 4 cases of HV recurrence and 2 cases of intolerance device-related pain. CONCLUSIONS: Endolog technique proved to be a valid option in the moderate-to-severe hallux valgus treatment, comparable to other surgical techniques described in literature.

All-inside technique in ACL reconstruction: mid-term clinical outcomes and comparison with AM technique (Hamstrings and BpTB grafts).

PURPOSE: The aim of this study was to define the subjective and objective clinical results of all-inside surgical technique at a medium-term follow-up and to compare these results with those obtained from antero-medial (AM) ACL reconstruction technique using hamstrings (HS) or bone-patellar tendon-bone (BpTB) grafts to detect eventual superiority of one technique to another. METHODS: A retrospective analysis of routinely collected data was conducted. Inclusion criteria were ACL reconstruction through all-inside technique or AM technique with HS or BpTB performed between January 2015 and May 2018; age between 15 and 30 year old; minimum 24 months' available follow-up. Exclusion criteria were contralateral ACL reconstruction; need for any other associated procedures during surgery. Clinical outcomes were assessed with KOOS, Lysholm, Tegner scores and KT-1000 device. RESULTS: According to the selection criteria, 157 patients were enrolled and divided subsequently into 3 groups: all-inside (51 patients), AM-HS (53 patients) and AM-BpTB (53 patients). A significant postoperative improvement of each score in all groups was detected. The mean KT-1000 was 3.1 ± 1.0 mm in all-inside group, while 3.3 ± 1.4 mm and 2.5 ± 0.4 mm in AM-HS and AM-BpTB groups, respectively. Comparing the results obtained, no statistically significant difference was found between the three techniques (p = 0.27). Statistically significant differences were highlighted in surgical duration: all-inside method was the longest (117'), followed by AM-BpTB surgery (101') and AM-HS technique (87'). CONCLUSIONS: The all-inside technique showed good postoperative results at medium-term follow-up. It could be a valuable solution for ACL reconstruction, especially in young patients due to its less invasiveness, despite surgical skills and time needed. LEVELS OF EVIDENCE: Level IV.

Pediatric flexible flatfoot: Does obesity influence the outcomes of arthroereisis?

BACKGROUND: Childhood obesity has emerged in the last decades as an important public health problem worldwide. Although relationships between obesity and flatfoot have been shown, no studies have investigated the influence of obesity on arthroereisis outcomes. AIM: To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants. METHODS: This retrospective study included one hundred and sixty-nine pediatric patients (10-14 years old) who underwent subtalar arthroereisis (PEEK PitStop® device) for severe flexible flatfoot. Exclusion criteria were additional procedures, revision of previous corrective surgeries, rigid flatfoot with severe deformity, and neurological or post-traumatic flatfoot. Preoperative/postoperative European Foot and Ankle Society (EFAS) and visual analogue scale (VAS) scores were determined; radiographic assessment was conducted on weight-bearing foot X-rays: Kite angle, first metatarsal-talus angle, Meary angle, calcaneal pitch angle and lateral talo-calcaneal angle were analyzed. RESULTS: EFAS and VAS scores improved post-operatively in the whole population. Only seven cases with complications were reported. Radiographic assessment revealed an improvement in all angles. Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes: Relationships were reported between BMI and postoperative EFAS/VAS scores, postoperative calcaneal pitch angle, Kite angle, Meary angle and talo-first metatarsal angle. CONCLUSION: Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children, obesity significantly influences clinical and radiographic outcomes of arthroereisis, and obese children tend to perceive more pain and discomfort.

Usefulness of modular neck adapter in partial hip revision.

Background and Objective: Modular neck adapters allow different length and offset changes to reach a stable total hip arthroplasty (THA) and permit a quick partial hip revision procedure without removing the existing components. The literature is poor on this matter and about the long-term related outcomes. This narrative review summarizes the most recent literature about these devices as an option of surgical treatment in partial total hip arthroplasty revision (THAr) focusing on indications, clinical and radiological outcomes, and related complications. Methods: The narrative review of the current available literature was conducted in December 2022 through electronic database. The terms used were: "Head neck taper" OR "Merete BioBall" AND "revision Total Hip Arthroplasty (MeSH Terms)". The timeframe was limited between 01/01/2000 and 01/12/2022. The studies regarding the clinical use of the Merete BioBall® system in hip revision surgery were included, while all the papers concerning modular stem prosthesis were excluded. Key Content and Findings: The surgical procedure is safe, quick and allows the surgeon to correct a well-fixed stem version, length and offset, besides retensioning soft tissues. Clinical and radiological outcomes are good with low complications rates. Conclusions: The modular neck adapter system seems to be a good surgical procedure for recurrent dislocation of THA, especially in case of a second THAr surgery. However, the main indication of adapter use remains the isolated acetabular cup revision. The related complications are rare: the worst is the re-dislocation due to an insufficient stem version and length correction. Re-dislocation rates reported in literature vary from 5.2% to 15%. Corrosion or fretting of the modular system are not reported in literature.

3D-Printed Surgical Guiding System for Double Derotational Osteotomy in Congenital Torsional Limb Deformity: A Case Report.

CASE: A 19-year-old woman with persistent anterior knee pain was diagnosed with a complex tibial and femoral torsional deformity (26° of femoral anteversion and 49° of tibial external rotation). To achieve the correct realignment of the lower limb, rotational double osteotomies were needed. After planning the correction on the computed tomography scan and three-dimensional (3D) model, a custom-made 3D-printed guiding system was produced to support the surgery. CONCLUSION: The 3D-printed planning model and the surgical guiding system are crucial elements to achieve optimal results for complex malalignment cases. The "tailored" guides led to a perfect match between the planned correction and the intraoperative result.

Gait analysis: Comparative evaluation of conventional total knee replacement and modular distal femoral megaprosthesis.

BACKGROUND: Gait alterations have been studied with computer-assisted gait analysis after megaprosthetic replacement for tumors around the knee. It has never been proven that megaprostheses affects gait more than total knee arthroplasty (TKA); this study aims to compare via gait analysis patients who underwent megaprosthesis with patients with TKA. METHODS: We analyzed 26 patients with a megaprosthetic replacement of the distal femur and 21 patients with a standard TKA. For each subject computerized gait analysis was performed. Range of motion (ROM) of the knee was recorded, Quality of Life and functional evaluation in the oncologic group were assessed with the Musculoskeletal Tumor Society (MSTS) questionnaire, while Short Form-36 (SF-36) scores were calculated for both groups. RESULTS: All patients walked slower than healthy people (P < 0.05). Gait analysis showed a lower cadence than in the healthy population but no significant difference between the two groups. A longer swing and a shorter stance phase were detected in the megaprosthetic sample. The osteoarthritis group showed greater flexion during the phase of loading response, even if this was lower than the contralateral limb or healthy population. There was a statically significant difference between the healthy limb and the operated one in both groups regarding ROM, but no significant difference was registered between the two implants. MSTS score and most of SF-36 parameters showed no significant differences compared with literature data. CONCLUSIONS: Gait analysis shows little discrepancy between the two groups; gait pattern abnormalities do not affect patients with a megaprosthetic replacement more significantly than patients undergoing TKA.