Sulcus-deepening trochleoplasty grants satisfactory results with minimal patellofemoral arthritis at 23-30 years of follow-up.

PURPOSE: The purpose of this study was to evaluate the radiographic and clinical outcomes of sulcus-deepening trochleoplasty at a minimum follow-up of 23 years. METHODS: The authors evaluated a retrospective series of 10 patients (11 knees) who underwent trochleoplasty between 1993 and 2000. All patients were assessed at a minimum follow-up of 23 years by an independent clinician who noted any patellar redislocations and collected the International Knee Documentation Committee (IKDC), Kujala scores and range of motion. Radiographic examination was performed to assess patellofemoral arthritis using the Iwano classification. RESULTS: A total of 11 knees, from five women and five men aged 25.6 ± 6.9 years (range, 15-47 years) underwent trochleoplasty during the inclusion period. All 11 knees underwent adjuvant procedures during trochleoplasty (100%): 10 had tibial tuberosity osteotomy (TTO) and vastus medialis plasty and 1 had only vastus medialis plasty (had prior TTO). At a follow-up of 24.4 ± 2.1 years (range, 23-30 years), two patients were lost to follow-up (18%). The Iwano classification was Grade 1 in three patients (33%), Grade 2 in four patients (44%) and Grade 4 in two patients (22%). The flexion range was 130 ± 8.7° and satisfaction was 9.2 ± 0.7, Kujala was 76.9 ± 8.5 and IKDC was 65.5 ± 13.8. CONCLUSION: At 23-30 years following sulcus-deepening trochleoplasty in this small series of 10 patients (11 knees), patients had satisfactory clinical scores, only 1 patient reported an episode of traumatic patellar dislocation, and two knees had patellofemoral arthritis of Iwano Grade >2 (22%). LEVEL OF EVIDENCE: Level IV.

The role of the most cranial trochlear orientation in patellar maltracking to better characterise trochlear morphology.

PURPOSE: The purpose of our study is to describe a magnetic resonance imaging quantitative parameter to assess the morphology of the trochlea that could be measurable from normal to high-grade trochlear dysplasia while evaluating the most proximal slice with trochlear cartilage. METHODS: Two groups of patients have been compared: patients with no patellofemoral pain, no previous trauma and undergoing surgery for a suspected isolated meniscal tears (group A) and patients with objective patellar instability (group B). The cranial trochlear orientation (CTO) angle is defined as the angle between the posterior bicondylar line and the most lateral and most medial points on the subchondral bone covered by cartilage digitised on the first and most cranial image with the trochlear cartilage clearly visible. RESULTS: The final cohort included 253 patients (109 in group A and 144 in group B). CTO was significantly higher in group B (-2.5 ± 8.4 vs. -10.8 ± 5,1; p < .001). Moreover, 75% of knees in group B had a CTO > -7°, while 75% of knees in group A had a CTO < -7°. CTO was measurable in all 253 knees, whereas the lateral trochlear inclination and the sulcus angle were measurable in only 202 knees. The entire cohort was also divided into knees with CTO ≤ 0° and CTO > 0°. All knees with a CTO > 0 were in group B, and 49% of knees with CTO < 0 were in group B. CTO was positively correlated with lateral patellar tilt. CONCLUSIONS: CTO is the only parameter that can be measured on the most cranial slice, in every patient, even in high-grade trochlear dysplasia. According to this new system, the axial trochlear shape may be divided into two types: a positive CTO and a negative CTO, with the trochlea serving, respectively, as a medial and lateral barrier. LEVEL OF EVIDENCE: Level III.

Sulcus-Deepening Trochleoplasty With Medial Patellofemoral Ligament Reconstruction: Outcomes at 10 to 20 Years.

BACKGROUND: Recent systematic reviews on the outcomes of sulcus-deepening trochleoplasty with adjuvant medial patellofemoral ligament (MPFL) reconstruction at a follow-up of 2 to 6 years have found that the procedure grants good clinical outcomes with low redislocation rates. However, there is a lack of evidence in the literature regarding mid- and long-term follow-ups. PURPOSE: To evaluate the radiographic and clinical outcomes of thick-flap sulcus-deepening trochleoplasty with MPFL reconstruction at a minimum follow-up of 10 years to assess the signs of patellofemoral arthritis, incidence of recurrent dislocation, and grade of patient satisfaction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors evaluated a retrospective series of 43 patients (48 knees) who underwent sulcus-deepening trochleoplasty between 2003 and 2013. All patients underwent thick-flap sulcus-deepening trochleoplasty with additional MPFL reconstruction. All patients were assessed at a minimum follow-up of 10 years by an independent clinician who noted any patellar redislocation or reoperations in the operated knee and collected the International Knee Documentation Committee (IKDC), Kujala, and satisfaction scores. Furthermore, a radiographic examination was performed to assess patellar height using the Caton-Deschamps index and patellofemoral arthritis using the Iwano classification. RESULTS: At a mean follow-up of 14.8 ± 2.1 years (range, 10-20 years), 4 patients (4 knees) were lost to follow-up (8.3%). The satisfaction, Kujala, and IKDC scores were 8.2 ± 1.6, 77.5 ± 14.4, and 65.7 ± 13.5, respectively. Only 1 patient reported a traumatic patellar dislocation (2%). Radiographs at the final follow-up were available for 34 knees, which revealed Iwano grade 1 in 14 knees (41%), Iwano grade 2 in 7 knees (21%), and no patellofemoral arthritis in 13 knees (38%). CONCLUSION: Sulcus-deepening trochleoplasty with MPFL reconstruction provides satisfactory results and prevents patellar redislocations with no or minimal patellofemoral arthritis.

Medial Closing-Wedge Patellar Osteotomy in Patients With Patellofemoral Instability.

Trochlear dysplasia is the main anatomical risk factor for objective patellar instability. Surgical correction of trochlea dysplasia via a trochleoplasty has been described with good clinical results reported. Concerns remain for who have abnormal patellofemoral tracking post a trochleoplasty due to incongruence between the two articulating surfaces. We described a medial closing wedge patellar osteotomy to improve congruency of the patellofemoral joint post-trochleoplasty.

In-label, off-label prescription, efficacy and tolerability of dalbavancin: report from a National Registry.

PURPOSE: Although dalbavancin is currently approved for the treatment of ABSSIs, several studies suggest its efficacy and tolerance as long-term therapy for other off-label indications requiring prolonged intravenous antibiotic administration. METHODS: We conducted a prospective nationwide study of dalbavancin use in real-life settings for both approved and off-label indications analysing for each case the clinical and microbiological characteristics of infection the efficacy and safety of treatments. RESULTS: During the study period (from December 2018 to July 2021), the ID specialists from 14 different centres enrolled 223 patients treated with dalbavancin [141 males (63%) and 82 females (37%); male/female ratio 1.72; mean age 59 (SD 17.2) years, (range 15-96). Most patients in the study population (136/223; 61.0%) came from community rather than health care facilities and most of them were visited in Infectious Diseases wards (93/223; 41.7%) and clinics (55/223; 24.7%) even though some patients were cured in other settings, such as surgery wards (18/223; 8.1%), orthopaedic wards (11/223; 4.9%), Emergency Rooms (7/223; 3.1%) and non-surgical other than ID wards (6/223; 2.7%). The most common ID diagnoses were osteomyelitis (44 cases/223; 19.7%; of which 29 acute and 15 chronic osteomyelitis), cellulitis (28/223; 12.5%), cutaneous abscess (23/223; 10.3%), orthopaedic prosthesis-associated infection (22/223; 9.9%), surgical site infection (20/223; 9.0%) and septic arthritis (15/223; 6.7%). CONCLUSION: In conclusion, by virtue of its PK/PD properties, dalbavancin represents a valuable option to daily in-hospital intravenous or outpatient antimicrobial regimens also for off-label indications requiring a long-term treatment of Gram-positive infections.

Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae.

Background: The aim of this study was to investigate the impact of computed tomography on the reliability of Boileau classification for proximal humerus fracture sequelae. Methods: A prospective study was designed using STARD guidelines. We included all patients diagnosed with proximal humerus fracture sequelae who underwent surgery at our institution between 2017 and 2021. Preoperative radiographs and computed tomography scans were reviewed by three independent observers. Intra- and inter-observer reliability and the diagnostic accuracy of radiographs and computed tomography scans in detecting chronic dislocation, nonunion, and severe greater tuberosity dislocation were assessed. Results: Fifty-two patients were included in the study. The overall interobserver agreement was low on both radiographs and computed tomography scans. On radiographic images, we found a sensitivity of 97%, 88.9%, and 84.1%, and a specificity of 58.3%, 40%, and 53.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively. On computed tomography scans we reported a sensitivity of 100%, 96.8%, and 93.7%, and a specificity of 91.7%, 86.7%, and 93.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively. Discussion: Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. However, even using a three-dimensional evaluation of the deformity, the Boileau classification had a poor interobserver reliability. Level of Evidence: I. Testing previously developed diagnostic criteria in a consecutive series of patients and a universally applied "gold standard."

The Femoral Sulcus Deepening Trochleoplasty of Lyon.

The sulcus deepening trochleoplasty procedure has been described for the management of patellofemoral instability in patients with severe trochlear dysplasia. Here, we describe the updated Lyon sulcus deepening trochleoplasty technique. This technique with a stepwise approach allows one to prepare the trochlea, remove the subchondral bone, osteotomize the articular surface, and fix the facets with 3 anchors while minimizing the risk of complications.

Long-Term Survival and Predictors of Failure of Opening Wedge High Tibial Osteotomy.

OBJECTIVE: High tibial valgus osteotomy (HTO) is a widely accepted procedure indicated for varus knee with symptomatic osteoarthritis of the medial compartment. However, there is a lack of studies evaluating long term results of this procedure. The primary aim of this study was to evaluate the long-term survival of opening wedge high tibial osteotomy (HTO) for isolated osteoarthritis in the medial compartment of the knee. The secondary objective was to identify independent predictors of conversion to total knee arthroplasty (TKA). METHODS: This is a long term retrospective study of 296 cases of open wedge HTOs performed at a single center (level of evidence IV) between January 2005 and August 2015. Opening wedge medial HTO was always performed after diagnostic arthroscopy. Eighty-three percent of the population (233 patients, 247 procedures) was followed up at a mean 11.6 years (6-17) by telephone interview, to evaluate the possible conversion to TKA. Mean age at the index operation was 42.8 years (range 15-70) and most patients were male (70%). Associated procedures (e.g., platelet rich plasma supplementation, microfractures, meniscectomy, etc.) were carried out at the time of the HTO in 80 (32%) cases. Survival of HTO and its association with age, sex, body mass index, smoking habit, preoperative severity of varus deformity, cartilage status at surgery, and associated procedures were evaluated. Kaplan-Meier and Cox regression analyses were performed. RESULTS: Thirty-three of the 247 HTOs (13.4%) were converted to knee replacement, with 86.6% of the original procedures surviving at a mean 12-year follow-up. Kaplan-Meier survival estimates at 17 years for HTO were 75.5% (95% confidence interval [CI] 66.7-84.3). There was significant difference (P < 0.001) in the 17-year survival rate between obese (55.5%; 95% CI 35.3-75.6) and non-obese (79.7%; 95% CI 70.1-89.2) patients. The determinants of conversion to knee arthroplasty detected at multivariate Cox regression analysis were body mass index, severity of cartilage degeneration in the medial compartment (Outerbridge grade), and age. CONCLUSION: The long-term survival of open wedge HTO for osteoarthritis in the medial compartment of the knee is satisfactory. The risk of conversion to TKA is significantly increased in obese patients. Advanced age and severity of pre-existing cartilage damage may also contribute to the risk of conversion to TKA.

Bösch osteotomy for hallux valgus correction: results at a mean 10-year follow-up.

INTRODUCTION: Bösch osteotomy (BO), which is a first metatarsal subcapital osteotomy stabilised with a K-wire, is a surgical option to correct hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution with such osteotomy. METHODS: In this retrospective monocentric single-surgeon cohort study, we included 58 HVs (46 patients) who underwent HV correction by BO and were followed at a minimum of 7 years. The range of motion (ROM), the American Orthopaedic Foot and Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA), and the Lateral Sesamoid Position (LSP) were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed. RESULTS: At a mean follow-up of 10 ± 2 (7-17) years, mean ± standard deviation AOFAS-FS and VAS were 89 ± 11 (67-93) and 2.1 ± 2.8 (0-7) points, respectively. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9° ± 6.7 to 18.8° ± 5.6, p < 0.001), in the IMA (14.2° ± 3.1 to 9.4° ± 2.7, p < 0.001), in the DMAA (from 30.3° ± 6.8 to 11.5° ± 5.1, p < 0.001) and in LSP (median value from 3 to 1, p < 0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Minor complications occurred in six (10%) cases, which did not require any further surgery at the longest follow-up. CONCLUSION: Bösch technique provided satisfactory clinical and radiographic outcomes in the treatment of hallux valgus which persisted at a mean 10-year follow-up. The complication rate did not differ from more recent techniques described in literature. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Gamma nail versus percutaneous compression plate for the treatment of intertrochanteric hip fractures: a multicenter pair-matched study.

PURPOSE: To compare functional outcomes, complication rates, and survival in patients with intertrochanteric fracture treated with percutaneous compression plate (PCCP) or gamma nail (GN). METHODS: A retrospective study of prospectively collected data of patients treated with PCCP or GN for AO/OTA 31.A1 or AO/OTA 31.A2 fractures was conducted. Sixty-eight consecutive patients treated with PCCP between 2018 and 2020 were enrolled and matched with 68 patients with comparable characteristics treated with GN. The activities of daily living (ADL) index and specific scales for walking ability and need for walking aids at 4 months and 1 year after fracture fixation were chosen as primary outcomes. Postoperative complications and one-year survival were recorded and compared between the two groups. RESULTS: Walking ability and ADLs index decreased and the need for walking aids increased in both groups compared to the prefracture state at both follow-up intervals (p < 0.001), regardless of the treatment received. There was no difference between the two implants in the rate of implant-related complications. One-year survival rate was 78.9% (95% CI 67.0-86.9) and 82.4% (95% CI 71.0-89.5) in patients undergoing PCCP or GN, respectively, with no significant difference between the two groups. CONCLUSIONS: Walking ability, ADLs, complication rate, and 1-year survival are not significantly different when patients undergoing PCCP or GN are compared. The choice of implant may not be decisive for the outcome of treatment of intertrochanteric fractures, provided that stable fixation is ensured.

Lateral extra-articular tenodesis and anterior cruciate ligament reconstruction in young patients: clinical results and return to sport.

Lateral extra-articular tenodesis (L.E.T.) have been proposed to reduce the tibia's anterior translation and internal rotation in concomitant to Anterior cruciate ligament (A.C.L.) reconstruction. Recent studies show that the addition of L.E.T. to A.C.L. reconstruction results in a statistically significant reduction in graft failure. The purpose of the present study was to evaluate the clinical outcomes, complications, and rate of return to preinjury sports level in pediatric patients who underwent combined A.C.L. reconstruction with L.E.T. at a minimum 2-year follow-up. The authors retrospectively evaluated 42 pediatric patients at high risk of graft failure who experienced ACLR connected to L.E.T. IKDC and Tegner-Lysholm Knee Scores Scale were used to assess clinical outcomes, and the Tegner Activity Scale to evaluate the return to sport. No graft failure or subsequent surgery related to A.C.L. reconstruction occurred. Furthermore, 88% of patients returned to the sport. Satisfactory clinical results were obtained on a short and medium-term follow-up. These findings help to consider this procedure for active adolescents at a high risk of graft failure to enhance A.C.L. reconstruction.

Long-Term Survival and Results at a Mean Follow-Up Period of 24 Years of a Tapered Straight, Collarless, Grit-Blasted, Titanium Alloy Stem.

BACKGROUND: There is limited evidence on the survivorship of patients who undergo cementless stem implantation, beyond 20 years of the hip arthroplasty. We report implant survival and results of the CLS Spotorno femoral stem until 30 years from implantation. METHODS: Survival analysis of 147 CLS Spotorno stems in 119 patients for an average period of 24 years (20-30) from the date of implantation was performed. During the course of the follow-up period, 33 patients (39 hips) died. The information on the survival of their hip implant at the time of death was gathered from their relatives and general practitioners. Sixty-six patients (86 hips) undertook the complete survey along with radiographic examination, while 18 subjects (20 hips) were interviewed over the telephone. The factors influencing survival, functional outcomes, and level of satisfaction with surgery were evaluated. RESULTS: The overall estimated survival of the stems was 89.9% after 30 years (95% confidence interval [CI] 83.5-93.9). Survival with femoral revision for aseptic loosening as an end point was 93.1% (95% CI 87.1-96.4). In the worst-case scenario, an overall implant survival of 77.2% (95 CI% 80.3-82.7) was observed after 24 years. Patients who were older than 50 in age at the time of surgery had better survival rates (P = .026). The mean Harris Hip Score at follow-up was 83.1 (range 43-100) and the level of satisfaction was 9/10. The main determinant of postsurgical satisfaction was Harris Hip Score, whereas radiographic alterations explained little with respect to the variation in the outcomes. CONCLUSION: The cementless CLS Spotorno stem displayed satisfactory results 24 years after implantation and high estimated survival until 30 years from surgery. However, patients below the age of 50 at the time of surgery have an increased risk of undergoing revision of their femoral stem.