No neurovascular damage after creation of an accessory anteromedial portal for arthroscopic reduction and fixation of coronoid fractures.

PURPOSE: Arthroscopic reduction and internal fixation for coronoid process fractures has been proposed to overcome limitations of open approaches. Currently, arthroscopy is most frequently used to assist insertion of a retrograde guide wire for a retrograde cannulated screw. The present anatomical study presents an innovative arthroscopic technique to introduce an antegrade guide wire from an accessory anteromedial portal and evaluates its safety and reproducibility. METHODS: Six fresh-frozen cadaver specimens were obtained and prepared to mimic an arthroscopic setting. The coronoid process was localized and a 0.9 mm Kirschner wire was introduced from an accessory anteromedial portal, located 2 cm proximal to the standard anteromedial portal. At the end of the procedure, a lateral radiograph was taken to verify the Kirschner wire position and open dissection was conducted to evaluate possible damage to neurovascular structures. RESULTS: The Kirschner wire was drilled without complications in the coronoid process of all six specimens. Damage of the brachial artery, the median nerve, and the ulnar nerve did not occur in any specimen. A corridor between the brachialis muscle, the median intermuscular septum, and the pronator teres could be identified as suitable for the wire passage. CONCLUSION: This study presents a safe and reproducible technique combining the possibility to introduce a guide wire from the anteromedial part of the coronoid, under direct visual control, with a completely arthroscopic approach. This wire can guide the introduction of a retrograde cannulated screw from the dorsolateral ulna to the tip of the coronoid. This new arthroscopic approach permits to obtain improved visual control over coronoid process fixation, without endangering neurovascular structures.

A combination of an anteromedial, anterolateral and midlateral portals is sufficient for 360° exposure of the radial head for arthroscopic fracture fixation.

PURPOSE: Arthroscopic fixation of radial head fractures is an alternative to open reduction and internal fixation; the latter, however, presents the advantage of minimal soft-tissue damage. The exposure of the radial head for adequate screw placement can be technically challenging. The aim of this study was to evaluate the inter-observer agreement on the effective contact arc in the axial plane of the radial head of three different elbow arthroscopy portals. METHODS: A fresh-frozen cadaver specimen was obtained and prepared in an arthroscopic setting. Standard anterolateral (AL), anteromedial (AM), and midlateral (ML) portals were established and a circular reference system was marked on the radial head. Ten orthopaedic surgeons were then asked to move the forearm from maximal supination to maximal pronation and indicate with a Kirschner wire from each portal the extension in which they would feel confident in placing a cannulated screw passing through the centre of the articular plane of the radial head (axial contact arc). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the sample. A coefficient of variation (CoV) was calculated to determine agreement among observers. RESULTS: The average arc of axial contact arc that could be contacted from the AM portal measured 150 ± 14.1°, or 41.7% of the radial head circumference; the one from the AL portal measured 257 ± 29.5°, or 71.4% of the radial head circumference; that from the ML portal measured 212.5 ± 32.6°, or 59.0% of the radial head circumference. Considering all three portals, the whole radial head circumference could be contacted. The AM portal showed the smallest CoV (9.4%) as compared to the AL (11.5%), and the ML (15.3%) portals. CONCLUSIONS: With an appropriate use of the standard AL, AM, and ML portals, the whole radial head circumference can be effectively exposed for adequate fixation of radial head fractures. The contact arc of the AM portal presents the smallest variability among different observers and the AL portal shows a superiority in axial contact arc. This information is important for pre-operative planning, and helps to define the limits of arthroscopic radial head fracture fixation.

The posterior interosseous nerve crosses the radial head midline and increases its distance from bony structures with supination of the forearm.

BACKGROUND: This study investigated whether forearm movements change the relative position of the posterior interosseous nerve (PIN) with respect to the midline of the radial head (Rh) under direct arthroscopic observation. METHODS: The PIN was identified in 10 fresh frozen cadaveric specimens dissected under arthroscopy. The forearm was moved first in full pronation and then in full supination, and the displacement of the PIN from medial to lateral with respect to the midline of the Rh was recorded. The shortest linear distance between the nerve and the most anterior part of the Rh was measured with a graduated calliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination. RESULTS: The PIN was identifiable in all specimens. In all cases the PIN crossed the Rh midline with forearm movements, moving from medial in full pronation to lateral in full supination. The distance between the PIN and Rh is significantly greater in supination than in the neutral position and pronation (P = .0001). CONCLUSIONS: This study confirms that the PIN movement described in open surgery (medialization with pronation) also occurs during arthroscopy. The role of pronation in protecting the PIN in extra-articularprocedures is therefore confirmed. Supination, however, increases the linear distance between the PIN and Rh and should therefore be considered to increase the safe working volume whenever intra-articular procedures are performed on the anterolateral aspect of the elbow.

Translation, cross-cultural adaptation, and validation of the Italian version of the Oxford Shoulder Instability Score.

PURPOSE: The Oxford Shoulder Instability Score (OSIS) is self-reported outcome measurement developed to evaluate shoulder instability taking into account also adaptive strategies. Valid, reliable, reproducible, and user-friendly translations of outcome measure instruments are needed to allow comparisons of international study results. METHODS: The Italian translation and cultural adaptation of the OSIS were completed using a "translation-back translation" method and the final version was administered to a sample of 25 consecutive Italian-speaking patients. The psychometric properties of this adaptation were evaluated in terms of feasibility, reliability, construct validity, and responsiveness. RESULTS: No major differences occurred between the OSIS translations into Italian and back into English, and no content- or linguistic-related difficulties were reported. The Cronbach's alpha for the total OSIS was 0.897. Intraclass correlation coefficient value for inter-rater reliability was 0.805, while for intra-rater reliability was 0.586. Spearman rank correlation coefficient between the OSIS and the Rowe score was 0.548 (p = 0.005) and between OSIS-I and SF-12 was 0.488 (p = 0.013). CONCLUSIONS: The Italian version of the OSIS is a reliable, valid, and reproducible outcome measure for clinical evaluation of patients affected by shoulder instability, which remains simple and user-friendly as the original version. LEVEL OF EVIDENCE: Prospective cohort study, Level II. CLINICAL RELEVANCE: The availability of a validated translation of the OSIS will help surgeon to share their data on shoulder instability diagnostic and treatment in a more reproducible and comparable fashion.

Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol.

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

The Use of Supra-Hemodiafiltration in Traumatic Rhabdomyolysis and Acute Kidney Injury: A Case Report.

Oliguric acute kidney injury due to traumatic rhabdomyolysis can be potentially lethal if the proper medical therapy combined with extracorporeal detoxification is not performed. Different extracorporeal techniques are available to overcome this syndrome. Here, we report the first case of removal of myoglobin and successful recovery from acute kidney injury in an elderly septic patient using supra-hemodiafiltration with endogenous reinfusion technique (HFR-Supra) combined with the medical therapy.

Chevron osteotomy with lateral release and adductor tenotomy for hallux valgus.

BACKGROUND: Distal chevron osteotomy is a procedure widely performed for the surgical treatment of painful hallux valgus. The risks and benefits of a lateral capsular release and adductor tenotomy combined with chevron osteotomy are still debated. The aim of our study was to report the clinical and radiographic outcomes of this combined procedure in mild and moderate incongruent bunion deformities, with a hallux valgus angle (HVA) up to 40 degrees and an intermetatarsal angle (IMA) up to 20 degrees. MATERIALS AND METHODS: Forty-two patients (52 feet) who consecutively underwent chevron osteotomy combined with lateral release and adductor tenotomy were reviewed 24-36 months after surgery. The mean age of the patients was 53.5 (range, 43 to 64) years. All the deformities were mild to moderate, with a mean preoperative value of 28 degrees in the HVA (range, 16 degrees to 40 degrees) and of 13 degrees in the IMA (range, 9 degrees to 20 degrees). RESULTS: At followup, the AOFAS hallux score improved from an average of 46 to an average of 88. The HVA and IMA had an average postoperative decrease respectively of 12 degrees and 6 degrees; lateral sesamoid displacement decreased by a mean of 15%. In no case did we observe infection or nonunion of the osteotomy. In one case, painless avascular necrosis of the first metatarsal head developed. CONCLUSION: Our short-term results show that distal chevron osteotomy combined with lateral release and adductor tenotomy is a feasible surgical option to address mild to moderate hallux valgus deformity, even with an IM angle between 15 and 20 degrees. Clinical and radiographic outcomes are generally good and patient satisfaction is generally high.

Isolated Madelung's deformity: long-term follow-up study of five patients treated surgically.

Five patients with isolated Madelung's deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas the average age at follow-up was 53 years. The deformity was bilateral in four patients and unilateral in one, for a total of nine deformities. At diagnosis, in all the patients the typical radial deviation of the hand was observed, with dorsal prominence of the distal end of the ulna. Pain and limitation of the range of motion were present in all the wrists except two, which were painless but presented marked functional impairment. In no patient did we observe growth disorders of the other bones or deformities typical of osteochondrodysplasias. Surgical correction was sought by both the families and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At follow-up, the range of motion of the wrists was improved, and all the patients were pain-free and satisfied with the final results. No significant radiographic osteoarthritis was present in any of the operated wrists, although four of the five patients were above 50 years of age.

Arthroscopic Reinsertion of Lateral Collateral Ligament, Anterior Capsular Plication, and Coronoid Tunneling Technique for Chronic Elbow Posterolateral Rotatory Instability.

Posterolateral rotatory instability (PLRI) of the elbow is a chronic condition that results from lateral collateral ligament complex injury and presents with pain, clicking, and subluxation within the flexion and extension arcs of elbow motion. The primary cause involves a lesion of the lateral collateral ligament complex and its avulsion from the lateral epicondyle. In most cases, it is the result of trauma such as a fall on an outstretched hand or any other mechanism that imparts axial compression, valgus force, and supination. Several surgical techniques have been described for the treatment of PLRI, but there is no consensus regarding the ideal surgical treatment. The advantages of an arthroscopic approach for the treatment of PLRI are first diagnostic. Arthroscopy allows for visualization and diagnosis of every compartment of the elbow. The main steps of the surgical procedure consist of reinsertion of the lateral collateral ligament, anterior capsular plication, and coronoid tunneling. By use of this technique, it is possible to perform an anatomic repair and provide stability of the elbow.

Arthroscopic fixation of coronoid process fractures through coronoid tunnelling and capsular plication.

PURPOSE: the purpose of this study is to describe a new arthroscopic technique for reduction and fixation of coronoid process fractures (CPFs) and report clinical and functional results in 4 patients after a 24-month follow-up. METHODS: four patients underwent arthroscopic reduction and fixation of isolated CPFs (acute or non-unions, type I or type II according to the Regan-Morrey classification) performed using a new technique based on coronoid tunnelling and capsular plication. The patients were evaluated 6, 12 and 24 months after surgery, using the Disability of the Arm, Shoulder and Hand scale (DASH), the Mayo Elbow Performance Index (MEPI), and a visual analog scale (VAS); elbow range of motion (ROM) and joint stability were also evaluated and the rate of complications was reported. RESULTS: all 4 patients completed the follow-up. At 6, 12 and 24 months, respectively, they recorded mean DASH scores of 22, 14 and 7, mean MEPI scores of 74, 82 and 94, and mean VAS scores of 4, 2 and 1. The mean ROM increased in all directions (at 6, 12 and 24 months, respectively: flexion: 112°, 125°, 144°; extension: 3°, 5°, 6°; pronation: 76°, 84°, 91°; supination: 78°, 82°, 86°). No signs of instability were observed and no complications were reported. CONCLUSIONS: the new all-arthroscopic coronoid tunnelling and capsular plication technique here proposed can restore elbow function, ROM and stability and allows anatomical reconstruction of the joint after type I or type II CPFs. If performed by an experienced arthroscopist, it is a valid alternative to open reduction and external fixation. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A new mechanism of gastroesophageal reflux in hiatal hernia documented by high-resolution impedance manometry: a case report.

Gastroesophageal reflux disease (GERD) is recognized to be a multifactorial disease and several mechanisms leading to reflux have been described, nevertheless its pathophysiology has not been fully clarified. Hiatus hernia is a known risk factor for GERD since it impairs the esophagogastric junction, leading to: reduction in lower esophageal sphincter pressure; increase in the frequency of the transient lower esophageal sphincter relaxation; and impairment of esophageal clearance. Last generation diagnostic techniques have improved the understanding of these mechanisms. A 72-year-old woman with hiatus hernia and GERD underwent a high resolution impedance manometry (HRIM) after a partial response to treatment with pantoprazole. None of the proposed pathophysiological mechanisms for GERD could explain the presence of reflux: HRIM showed normal lower esophageal sphincter (LES) pressure and contractile integral, complete bolus clearance in all test swallows, and absence of transient LES relaxation. However, after the end of each peristaltic wave, as the LES pressure returned to resting values, a gastroesophageal reflux was detected until the following swallow. We describe an interesting case of a patient with a sliding hiatus hernia, with symptoms suggestive of GERD, in which HRIM revealed a new possible mechanism through which hiatus hernia may lead to GERD.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines.

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.