Rigid iatrogenic hallux varus: a decades' worth experience with arthrodesis of the metatarsophalangeal joint.

PURPOSE: Arthrodesis of the first ray metatarsophalangeal joint (MPJ) is the gold standard in iatrogenic hallux varus (IHV) in the presence of stiffness and osteoarthritis. The purpose of this study is to collect clinical and radiographic results and complications of MPJ arthrodesis in rigid iatrogenic HV. METHODS: A retrospective evaluation of rigid iatrogenic HV undergoing arthrodesis with a minimum follow-up (FU) of two years was performed. The clinical parameters assessed were visual analog scale (VAS), the AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale score and the satisfaction scale. The radiological parameters evaluated the first to second metatarsal angle (IMA) and the angle of hallux valgus (HVA). Complications were also analysed. RESULT: A total of 18 patients (19 procedures) with a mean FU of 5.5 ± 2.5 years were included. The mean VAS improved from 7.3 ± 1.6 to 1.3 ± 1.2 (p < 0.05) at the last FU. Similarly, the AOFAS Hallux Metatarsophalangeal-Interphalangeal scale score significantly improved to 82 ± 9.2 (p < 0.05). Radiological evaluation demonstrated a 1-2 IMA improvement from 4.4 ± 2.2° preoperatively to 8.9 ± 2.4° at 3 months post-operatively. Similarly, there was a significant (p < 0.05) improvement of the HVA from - 22.7 ± 4.1° to 13.1 ± 4.1° at three months post-operative (p < 0.05). No signification loss of correction was noted at the last follow-up (p > 0.05). In one case, a delayed fusion at the arthrodesis site required surgical revision to promote fusion. No patient experienced pain with stress from the first MTP joint arthrodesis site or identified the arthrodesis site as a source of pain. No patient required implant removal. Re-operation and revision rates were 5.3%. The overall complications rate was 15.8%. CONCLUSIONS: MPJ fusion effectively corrects Iatrogenic Hallux Varus in cases of rigid and fixed deformities in the medium- to long-term follow-up, with lasting improvements in AOFAS and VAS scores. The procedure is characterised by a non-negligible risk of complications, reoperations and revisions. LEVEL OF EVIDENCE: Level IV, case series.

Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature.

BACKGROUND: Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO. METHODS: A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included. RESULTS: Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed. CONCLUSION: AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD. LEVEL OF EVIDENCE: Level IV.

Adult spinal deformity correction surgery using age-adjusted alignment thresholds: clinical outcomes and mechanical complication rates. A systematic review of the literature.

PURPOSE: Adult spinal deformity (ASD) surgery gives good clinical outcomes but has a high rate of mechanical complications (MC). In 2016, Lafage described the age-adjusted alignment thresholds (AAAT) to adapt the correction in relation to patient's age proposing less aggressive corrections for the elderly population. The aim of this review was to clarify the effectiveness of AAAT to achieve good health-related quality of life (HRQoL) and their relationship with post-operative MC. MATERIALS AND METHODS: We performed a review of the literature, including articles reporting data on post-operative HRQoL and MC rates in relation to the AAAT. Data were stratified according to whether they matched the AAAT, dividing the population in undercorrected (U), matched (M) and overcorrected (O). The quality of the included studies was assessed using the GRADE and MINORS systems. RESULTS: Six articles reporting data from 1,825 patients were included. The different categories (U, M and O) had homogeneous pre-operative sagittal parameters (p > 0.05) that became statistically different after surgeries (p < 0.05). Proximal junctional kyphosis (PJK) was more frequent in the O group compared to U (p = 0.05). Post-operative HRQoL parameters were similar in the 3 groups (p > 0.05). The quality of the included studies was generally low with a high bias risk. CONCLUSION: The results extrapolated from this review are interesting, as for the same HRQoL the U group had a lower MC rate. Unfortunately, the results are inconsistent, mainly because of the low quality of the included studies and the lack of reporting of some important patient- and surgery-related factors.

GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature.

PURPOSE: In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article. MATERIALS AND METHODS: Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score's overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems. RESULTS: Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal-Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria. CONCLUSION: The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.

Bone impaction grafting and anti-protrusio cages in high-grade acetabular defects: a 22-year single centre experience.

PURPOSE: Report clinical and radiological long-term follow-up (FU) outcome of bone impaction grafting (BIG) and anti-protrusio cage (APC) technique in hip revision surgery. MATERIALS AND METHODS: We analysed data on complications, as well as the clinical and radiological outcome of patients treated using this technique at our institution. We evaluated the acetabular bone stock renovation, acetabular component stability and its radiological migration. The clinical parameters considered were the Visual Analogue Scale (VAS) and the modified Harris Hip Score (mHHS). RESULTS: Forty hips, with a mean 14.3-year FU, were included. This technique showed good clinical long-term results in an elderly and low-demanding population (mean age at surgery 71.4 ± 12.1 years). The radiological results were not as good as clinical results: 67.5% of cases had a radiographic evidence of resorption of less than 1/3 of the bone graft; 27.5% had a resorption ranging from 1/3 and ½ of the graft, and 5% had more than ½ of the graft. Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC (p < 0.001). The survival rate was 95% and a 2.5% rate of septic failure was recorded. CONCLUSION: Impaction grafting with femoral head and APC is an effective technique for treating high-grade acetabular defects. APC reconstructs the hip centre of rotation, avoiding loading forces on the underlying bone graft that can be correctly integrated. At long-term FU, satisfactory clinical results, not strictly correlated to radiological signs of integration, were observed; Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC.

Long-term follow-up of a low profile, coated, press-fit cup: the trabeculae oriented pattern (T.O.P.) acetabular system.

PURPOSE: Total hip arthroplasties (THAs) are rising worldwide, as the functional request of patients who undergo this procedure. The trabeculae oriented pattern (TOP) is a modern cup, which follows the philosophy of the tissue sparing surgery (TSS). Focusing on clinical and radiological results and complications, the authors aim to highlight the outcomes of the TOP at a long-term follow-up (FU). METHODS: A retrospective analysis was completed on THA performed with the TOP cup between 1997 and 2015. Five hundred and eighty-eight patients sustained surgery, for a total of 662 cup implanted. Four hundred and sixty patients (524 hips) were examined. Mean FU was 12 ± 4.9 years (range 5-22). Clinical (HHS, OHS and VAS) and radiological data were obtained. Every complication, reoperation or revision was recorded and analyzed. RESULTS: Clinical evaluation revealed a HHS of 87.1 ± 13.8 an OHS of 41.3 ± 5.4, and a VAS of 1.2 ± 1.1. Acetabular osteolysis was observed in 53 hips. Overall survival rate of the cup was 90.5% (50 revisions), the main causes of cup substitution being aseptic loosening (AL) of the cup combined with the stem (26), of the cup only (13 cases) and periprosthetic joint infection (7 cases). CONCLUSION: TOP cup has demonstrated a good overall survivorship at a long-term FU, even compared with other coated cups, providing excellent clinical result with low rate of complications. Its association with a neck sparing stem permits a physiologic load transmission, reducing the stress shielding effect that could cause early implant mobilization.

ALIF in the correction of spinal sagittal misalignment. A systematic review of literature.

PURPOSE: We aim at analysing the impact of anterior lumbar interbody fusion (ALIF) in restoring the main spinopelvic parameters, along with its potentials and limitations in correcting sagittal imbalance. MATERIALS AND METHODS: The 2009 PRISMA flow chart was used to systematically review the literature; 27 papers were eventually selected. The following spinopelvic parameters were observed: pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), segmental lumbar lordosis (LLseg) and sagittal vertical axis (SVA). Papers reporting on hyperlordotic cages (HLC) were analysed separately. The indirect decompression potential of ALIF was also assessed. The clinical outcome was obtained by collecting visual analogue scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) scores. Global fusion rate and main complications were collected. RESULTS: PT, SS, LL, LLseg and SVA spinopelvic parameters all improved postoperatively by - 4.3 ± 5.2°, 3.9 ± 4.5°, 10.6 ± 12.5°, 6.7 ± 3.5° and 51.1 ± 44.8 mm, respectively. HLC were statistically more effective in restoring LL and LLseg (p < 0.05). Postoperative disc height, anterior disc height, posterior disc height and foraminal height, respectively, increased by 58.5%, 87.2%, 80.9% and 18.1%. Postoperative improvements were observed in VAS back and leg and ODI scores (p < 0.05). The global fusion rate was 94.5 ± 5.5%; the overall complication rate was 13%. CONCLUSION: When managing sagittal imbalance, ALIF can be considered as a valid technique to achieve the correct spinopelvic parameters based on preoperative planning. This technique permits to obtain an optimal LL distribution and a solid anterior column support, with lower complications and higher fusion rates when compared to posterior osteotomies.

Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review.

The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92-95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ2 = 271.4, df = 72, p < 0.001; I2 = 73.5%, τ2 = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.

Incidence, diagnosis and management of sacroiliitis after spinal surgery: a systematic review of the literature.

The sacroiliac joint (SIJ) is a possible source of persistent or new onset pain after lumbar or lumbosacral fusion. The aim of this paper is to systematically review and analyze the available literature related to the incidence, diagnosis and management of sacroiliitis after spinal arthrodesis. The authors independently screened the titles and abstracts of all articles identified concerning sacroiliac joint pain after lumbar or lumbosacral fusion, to assess their suitability to the research focus. The average incidence of sacroiliitis after lumbar or lumbosacral arthrodesis was found to be 37 ± 28.48 (range 6-75), increasing directly to the number of fused segments involved, especially when the sacrum is included. The most accurate evaluation is the image-guided injection of anesthetic solutions in the joint. Surgery treatment may be considered when conservative therapy fails, with open surgery or with minimally invasive SIJ fusion. Although the risk of developing SIJ degeneration is unclear, the results indicate that pain and degeneration of SIJ develop more often in patients undergoing lumbosacral fusion regardless of the number of melting segments. The treatment of sacroiliitis appears to be independent of his etiology, with or without previous instrumentation on several levels.

Metaphyseal cones and sleeves in revision total knee arthroplasty: Two sides of the same coin? Complications, clinical and radiological results-a systematic review of the literature.

Revision total knee arthroplasty (rTKA) is increasing of relevance in orthopaedic surgeon daily practice and this trend is likely to continue in the years ahead. The aim of this systematic review of English literature is to summarize and compare indications, complications, clinical and radiological results of metaphyseal cones and sleeves in management of bone loss in rTKA. Retrospective or prospective studies with at least 1 year of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Clinical and radiological results, rates of intraoperative fractures, aseptic loosening, periprosthetic joint infection, septic failure, reoperations and re-revisions were extrapolated by the papers. Thirty-seven articles were included in the systematic review. Results of 927 cones (mean FU of 3.6 ± 1.4 years) and 1801 sleeves (mean FU of 4.5 ± 1.6 years) were analysed. The studies showed good clinical and functional outcomes. Cones and sleeves allowed a stable metaphyseal fixation. The aseptic survivorship of the implants was 97.3% in cones group and 97.8% in sleeves group. Metaphyseal cones and sleeves represent a viable option in management of type IIb and III AORI bone defects in aseptic and septic TKAr with overlapping survival rate. Further high-quality long-term studies would better clarify complications, clinical and radiological results of these promising techniques in revision total knee arthroplasty.

Management of ramp lesions of the knee: a systematic review of the literature.

PURPOSE: The purpose of this systematic review is to evaluate the current literature and to assess the clinical outcomes following meniscal ramp lesion treatment and anterior cruciate ligament (ACL) reconstruction. A consensus of the treatment of this pattern of tears is still lacking. METHODS: A systematic review of the literature was performed with a comprehensive search on Medline through PubMed, CINAHL, Cochrane, Embase and Google Scholar databases. The PRISMA 2009 flowchart and checklist were considered to edit the review. The included studies were evaluated based on indications, management, surgical technique and clinical results. RESULTS: Seven studies (two level II and five level IV evidence) were identified that met inclusion criteria, including a total of 509 patients. The overall main follow-up was 23.6 months. Treatment failure occurred in 8.3% of patients receiving ACL repair and ramp lesion treatment. The repair of ramp lesion is the most used approach in the literature. CONCLUSION: There is a lack of literature focused on the management of ramp lesion and ACL injuries. The repair resulted in the most used approach with good clinical results and low failure rate. However, further high-quality studies evaluating the long-term outcomes of different surgical strategies are needed.

What is the clinical evidence on regenerative medicine in intervertebral disc degeneration?

PURPOSE: This review aims to explore and summarize the current clinical evidence about the use of regenerative medicine such as mesenchymal stem cells or platelet-rich plasma in intervertebral disc regeneration, in order to clarify the state of art of these novel approaches. MATERIALS AND METHODS: We performed a research of the available literature about regenerative medicine strategies aiming to prevent intervertebral disc degeneration. All preclinical trials and in vitro studies were excluded. Only clinical trials were critically analysed. RESULTS: The manuscript selection produced a total of 7 articles concerning the use of regenerative therapies in intervertebral disc degeneration, covering the period between 2010 and 2016. Articles selected were 4 about the injection of mesenchymal stem cells-related results and 3 using platelet-rich plasma. The total population of patients treated with regenerative medicine strategies were 104 patients. CONCLUSIONS: Regenerative medicine, such as the use of mesenchymal stem cells or platelet-rich plasma, in intradiscal disc degeneration has shown preclinical and clinical positive results. Randomized clinical trials studying the potential of MSCs intradiscal injection have not been conducted, and PRP effect has been studied only preliminarily. Additional more powered high-quality studies are needed to really appreciate the long-term safety and efficacy of regenerative medicine approaches in IDD.

Comparison of clinical, MRI and arthroscopic assessments of chronic ACL injuries, meniscal tears and cartilage defects.

PURPOSE: The aim of this study was to compare the accuracy of clinical examination to that of MRI evaluated by two independent radiologists for the diagnosis of meniscal tears and chronic anterior cruciate ligament injuries and to assess the MRI accuracy in the diagnosis of cartilage defects. METHODS: Seventy-six consecutive patients with suspected intra-articular knee pathology were prospectively evaluated by objective examination, 1.5 T MRI, re-examined by trained radiologist and arthroscopy. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value were calculated. Agreement analysis with kappa (К) coefficient values was performed for meniscal and ACL tears. RESULTS: No differences were found between diagnostic accuracy of clinical examination, the first and second MRI reports in diagnosis of medial meniscus (84 vs 96 vs 97 %) and anterior cruciate ligament injuries (93 vs 78 vs 89 %). For the lateral meniscal tears, the accuracy of the second radiologist was significantly higher than those of the first (96 vs 75 %; p < 0.01) and clinical examination (96 vs 86 %; p = 0.02). High diagnostic values were obtained for the diagnosis of full-thickness chondral defects with sensitivity of 100 %, specificity of 95 % and accuracy of 95 %. CONCLUSION: Clinical and MRI evaluations have no differences in the diagnosis of medial meniscus and anterior cruciate ligament injuries. A trained radiologist obtained better sensitivity, specificity and accuracy in the diagnosis of lateral meniscus. 1.5 T MRI does not represent the technique of choice in the evaluation of chondral defect but demonstrated high diagnostic accuracy for detection of full-thickness chondral defects. LEVEL OF EVIDENCE: Diagnostic prospective study, Level II.