Clinical Outcomes Following Percutaneous Ankle Fusion With Bone Graft Substitute.

Background: Percutaneous ankle fusion is an emerging technique with minimal published outcome data. The goal of the present study is to retrospectively review clinical and radiographic outcomes following percutaneous ankle fusion and provide technique tips to perform percutaneous ankle fusion. Methods: Patients >18 years of age, treated by a single surgeon, from February 2018 to June 2021, who underwent primary isolated percutaneous ankle fusion supplemented with platelet-derived growth factor B (rhPDGF-BB) and beta-tricalcium phosphate, with at least 1-year follow-up were included. Surgical technique consisted of percutaneous ankle preparation followed by fixation with 3 headless compression screws. Pre- and postoperative visual analog scale (VAS) and Foot Function Index (FFI) were compared using paired t tests. Fusion was assessed radiographically by the surgeon on postoperative radiographs and computed tomography (CT) at 3 months postoperatively. Results: Twenty-seven consecutive adult patients were included in the study. Mean follow-up was 21 months. Mean age was 59.8 years. Mean preoperative and postoperative VAS scores were 7.4 and 0.2, respectively (P < .01). Mean preoperative FFI pain domain, disability domain, activity restriction domain, and total score were 20.9, 16.7, 18.5, and 56.4, respectively. Mean postoperative FFI pain domain, disability domain, activity restriction domain, and total score were 4.3, 4.7, 6.7, and 15.8, respectively (P < .01). Fusion was achieved in 26 of 27 patients (96.3%) at 3 months. Four patients (14.8%) had complications. Conclusion: We found in this cohort with surgery performed by a surgeon highly experienced in minimally invasive surgery that percutaneous ankle fusion augmented with a bone graft supplement achieved a high rate of fusion (96.3%) and a significant improvement in pain and function postoperatively while associated with minimal complications. Level of Evidence: Level IV, case series.

Minimally Invasive HEROS (Higher External ROtator Sparing) Posterior-lateral Approach for Total Hip Arthroplasty: Surgical Technique and Preliminary Results.

BACKGROUND: Minimally invasive approaches for Total Hip Arthroplasty (THA) are extremely popular among both patients and surgeons. Even though many surgical techniques have been described with overall satisfactory results, one of the most feared complications that still burdens THA is early dislocation, particularly for the most popular, posterior-lateral, approach. OBJECTIVES: The purpose of this report is to describe an original, minimally invasive, posterior-lateral technique, which spares the proximal external rotator muscle tendons of the hip (Higher External ROtator-Sparing; HEROS), while presenting its preliminary clinical and radiographic results. METHODS: From 2018 to 2020, 100 patients underwent THA, performed by the same surgeon using the HEROS technique. In all cases, the same cementless prosthesis was implanted. The Modified Harris Hip Score (MHHS) was obtained before surgery and at the last follow-up visit. The osteointegration and orientation of the prosthetic components were radiographically evaluated, and the restoration of the femoral offset was analyzed. RESULTS: Seventy-seven patients were assessed at a mean follow-up of 28 months. At the time of surgery, the average age of the patients was 72 years. There were 36 females and 41 males with a mean BMI of 27. The diagnoses were primary arthritis, avascular necrosis of the femoral head and fracture of the femoral neck. The mean surgical time was 76 minutes. The average MHHS score at follow-up was excellent. The mean offset variation was approximately 1 mm. There was an intra-operative fracture and an early infection of the wound. There were no dislocations. All patients returned to activities of daily living and were satisfied with the cosmetic appearance of the wound. CONCLUSIONS: The present study confirmed that this simple, minimally invasive approach is effective for restoring pain-free joint function and preventing implant dislocation with a low incidence of complications.

Posterior Shoulder Dislocation with Engaging Reverse Hill-Sachs Lesion: A Retrospective Study of Ten Patients Treated with Arthroscopy or Open Reduction and Stabilization.

This study compares two surgical techniques used to treat patients with posterior shoulder dislocation with an engaging reverse Hill-Sachs lesion. We assessed ten patients who were treated at the Surgical Orthopedic and Traumatological Institute (ICOT) of Latina and the Clinic of Orthopedic and Traumatological Surgery of the ASST Sette Laghi of Varese between 2016 and 2019. The patients were divided into two groups: the first comprising six patients who underwent the open surgery McLaughlin procedure as modified by Neer, the second including four patients who underwent the arthroscopic McLaughlin procedure. All patients received postoperative rehabilitation to achieve the best possible functional recovery of the affected shoulder. We then assessed the shoulder range of motion, the pain level, and the impact on quality of life with four tests: the Constant Scale, the Simple Shoulder Test (SST), the OXFORD Scale, and The University of California-Los Angeles (UCLA) Shoulder Scale. The mean scores of the first group were: 81.3 ± 9.8 SD (Constant Scale), 10.8 ± 1.06 SD (SST), 42.5 ± 5.4 SD (Oxford Scale), 30.8 ± 3.02 SD (UCLA Shoulder Scale); we calculated the following mean scores in the second group: 80.25 ± 4.1 SD (Constant Scale), 11.5 ± 0.8 SD (SST), 42 ± 4.06 SD (Oxford Scale), 32 ± 2.9 SD (UCLA Shoulder Scale). We found no significant differences between the two groups.

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont.

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the '50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.

Hallux rigidus: How do I approach it?

Hallux rigidus is a degenerative disease of the first metatarsalphalangeal (MTP) joint and affects 2.5% of people over age 50. Dorsal osteophytes and narrowed joint space leads to debilitating pain and limited range of motion. Altered gait mechanics often ensued as 119% of the body force transmit through the 1st MTP joint during gait cycle. Precise etiology remains under debate with trauma being often cited in the literature. Hallux valgus interphalangeus, female gender, inflammatory and metabolic conditions have all been identified as associative factors. Clinical symptoms, physical exam and radiographic evidence are important in assessing and grading the disease. Non-operative managements including nonsteroidal antiinflammatory drugs, intra-articular injections, shoe modification, activity modification and physical therapy, should always be attempted for all hallux rigidus patients. The goal of surgery is to relieve pain, maintain stability of the first MTP joint, and improve function and quality of life. Operative treatments can be divided into joint-sparing vs joint-sacrificing. Cheilectomy and moberg osteotomy are examples of joint-sparing techniques that have demonstrated great success in early stages of hallux rigidus. Arthrodesis is a joint-sacrificing procedure that has been the gold standard for advanced hallux rigidus. Other newer procedures such as implant arthroplasty, interpositional arthroplasty and arthroscopy, have demonstrated promising early patient outcomes. However, future studies are still needed to validate its long-term efficacy and safety. The choice of procedure should be based on the condition of the joint, patient's goal and expectations, and surgeon's experience with the technique.

Age-Related Outcome of Mobile-Bearing Total Ankle Replacement.

The aim of this study was to investigate clinical and radiographic outcomes in patients 50 years and younger vs patients older than 50 years undergoing total ankle replacement. Seventy consecutive patients who underwent primary total ankle replacement were included in this retrospective study. Patients were assessed clinically and radiographically. There was a statistically significant difference between the 2 groups for the American Orthopaedic Foot & Ankle Society score at final follow-up. The younger group had significantly greater improvement compared with the older group. Total ankle arthroplasty is an effective treatment for young, active patients with symptomatic end-stage ankle arthritis. [Orthopedics. 2017; 40(3):e567-e573.].

Surgical dislocation for pediatric and adolescent hip deformity: clinical and radiographical results at 3 years follow-up.

INTRODUCTION: The aim of this study is to evaluate the clinical, radiographic short-term results and complications after surgical hip dislocation in young patients (≤18 years). MATERIALS AND METHODS: Clinical and radiographic outcomes were assessed in patients who underwent a surgical hip dislocation Ganz-type approach between 2008 and 2012. Diagnosis included Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, femoroacetabular impingement, osteonecrosis of the femoral head, multiple hereditary exostoses and pigmented villonodular synovitis. Clinical data, the modified Harris hip score, nonarthritic hip score, 12-item short form health survey, the Stulberg classification, morphometric indexes, signs of osteonecrosis and osteoarthrosis were used for the evaluation. RESULTS: After a mean 3 years follow-up (range 0.5-6 years), 53 hips (51 patients) were evaluated. The most common diagnoses were Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, femoroacetabular impingement and multiple hereditary exostoses. Mean age at surgery was 14 years (range 10-18 years). Through this approach femoral head-neck osteoplasty, Dunn-type osteotomy, labrum refixation, synovectomy, femoral head mosaicplasty open reduction and fixation for slipped capital femoral epiphysis were performed, finally in association with pelvic or intertrochanteric osteotomy. At follow-up, better outcome scores were obtained, progression of the osteonecrosis of the femoral head was observed in four cases and three further patients required the implant of a total hip prosthesis. CONCLUSIONS: After 3 years follow-up, results are comparable to previous studies and patients have a high rate of satisfaction, however the effectiveness of those procedures have to be proved on the long term. Results and complications seem to be related with preoperative lesion(s) and type of treatment. LEVEL OF EVIDENCE: Level IV, retrospective study, case series.

Anterior Longitudinal Osteotomy of the Greater Trochanter in Total Hip Arthroplasty.

The extra-articular impingement of the greater trochanter against the ileum is an underrated cause of early dislocation in total hip arthroplasty. In this preliminary study, the authors assess the effectiveness of an anterior longitudinal osteotomy of the greater trochanter for preventing dislocation. A total of 115 patients underwent a total hip arthroplasty through a posterolateral approach. All patients underwent clinical and radiological follow-up at 1, 3, and 6 months. No dislocation was reported. All patients demonstrated fast recovery of range of motion and walking. No trochanter fractures were observed. The osteotomy of the greater trochanter is an effective surgical technique that decreases anterior impingement and consequently lowers the dislocation rate in primary total hip arthroplasty. [Orthopedics. 2015; 38(8):490-493.].

Assessment of mortality risk in elderly patients after proximal femoral fracture.

Mortality after hip fracture is a major problem in the Western world, but its mechanisms remain uncertain. This study assessed the 2-year mortality rate after hip fracture in elderly patients by including hospital factors (eg, intervention type, surgical delay), underlying health conditions, and, for a subset, lifestyle factors (eg, body mass index, smoking, alcohol). A total of 828 patients (183 men) 70 to 99 years old experiencing a hip fracture in 2009 in the province of Varese were included in the study. The risk factors for death were assessed through Kaplan-Meier analysis and Cox proportional hazards analysis. Hip fracture incidence per 1000 persons was higher in women (8.4 vs 3.7 in men) and in elderly patients (12.4 for 85-99 years vs 4.4 for 70-84 years). The mortality rate after 1, 6, 12, and 24 months was 4.7%, 16%, 20.7%, and 30.4%, respectively. For the province of Varese, sex (hazard ratio, 0.39 for women), age group (hazard ratio, 2.2 for 85-99 years), and Charlson Comorbidity Index score (hazard ratio, 2.06 for score greater than 1) were found to be statistically significant. The 2-year mortality rate in hip fractures is associated with sex, age, and comorbidities. Male sex, age older than 85 years, and Charlson Comorbidity Index score greater than 1 are associated with a higher risk. Surgical delay was significant in the Kaplan-Meier survival time analysis but not in the Cox hazard analysis, suggesting that early surgery reduces risk in patients with numerous comorbidities.

The "Double-Pulley" Technique for Arthroscopic Fixation of Partial Articular-Side Bony Avulsion of the Supraspinatus Tendon: A Rare Case of Bony PASTA Lesion.

We report the use of the double-pulley technique for arthroscopic fixation of the bony PASTA (partial articular surface tendon avulsion) lesion. Arthroscopic examination documented a 15-mm-long and 8-mm-wide comminuted bony avulsion with 2 main fragments. Two double-loaded suture anchors were placed with a transtendinous technique at the anterior and posterior edges of the lesion respecting the tendon insertion to the avulsed fragment. The medial sutures were retrieved through the intact supraspinatus tendon medially to the fracture. The sutures were initially coupled in a double-pulley configuration generating 2 sutures oriented from anterior to posterior; then a simple suture for each anchor oriented from medial to lateral was obtained. At the end of the procedure, the adequacy of reduction and stability of the fragments were confirmed. At 2 months from surgery, radiographic healing of the fracture was noted and integrity of the supraspinatus tendon insertion to the footprint was confirmed by arthro-magnetic resonance imaging, with full recovery of daily activities and complete active range of motion confirmed at 6 and 12 months. The double-pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures. Moreover, it creates a waterproof reduction of the fragments, protecting the fracture site from synovial fluid.

The Use of Modularity in Total Hip Arthroplasty.

Modularity is defined as separation of a system into independent parts or modules that can be treated as logical and may be separated and recombined. Historically, the modularity represents the evolution of the concept of "low friction arthroplasty" developed by Sir J. Charnely in 1960. The disadvantage of a one-piece stem is the difficulty of restoring the biomechanical feature of the hip. Thus, the natural evolution was the introduction of modularity on both sides, the acetabulum and the femur. Modularity allows the surgeon to accurately match the anatomic characteristics of each patient to obtain improved range of motion, joint stability, abductor strength, and leg length equality. Disadvantages are related to the introduction of different interfaces, which could be sites of wear and corrosion. In accordance with the most recent literature, in primary total hip arthroplasty (THA) the modularity can be reduced to the head and the acetabular component, while a one-piece stem can manage the majority of cases. On the other hand, we believe that during revision surgery, a complete modularity is necessary.

Arthroscopic treatment of fractures of the radial head.

An original technique for the arthroscopic diagnosis and treatment of the fractures of the radial head is proposed and described. The elbow arthroscopy is started with a 4.5-mm 30 degrees arthroscope from the proximal anteromedial portal and the anterior elbow is examined; then a proximal anterolateral portal is created and a full-radius blade inserted to take out the hematoma and to allow visualization of the radial head that is explored through the whole range of motion to visualize the fracture fragment. The fragment is manipulated by means of arthroscopic tools to reduce the anteromedial surface of the radial head. The arthroscope is now switched to the posterolateral portal and the posterior aspect of the humeral radial joint is visualized. The soft spot portal is used to insert a periosteal elevator to complete the reduction and firmly hold the fragment in the reduced position. An anterolateral portal is now created to allow the safe insertion of a guidewire, angled 45 degrees to the longitudinal axis of the radius, to pierce the fragment with. A 14-mm long cannulated screw is inserted along the guide after specific drilling. Finally, the reduction and the stability of the fixation are checked with during full rotation of the elbow. The described procedure has been performed in 6 patients. Short-term preliminary results show a satisfactory functional outcome. Among the advantages of the technique are the minimally invasive approach, the direct visualization of the fracture, and the benefits derived from the radiation-free procedure.

Acetabular revision surgery with the LOR cup: three to 8 years' follow-up.

A retrospective review was conducted to evaluate the mid-term results of the Längsovalen Revisionspfanne oblong revision cup. From July 1995 to March 2000, 41 acetabular revision surgeries were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3B, according to Paprosky's criteria. Morselized bone grafts were used in 19 cases (45.2%) to fill cavitary defects. The mean postoperative follow-up was 63.5 months (range, 40-99 months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 46 points preoperatively to 82.2 points postoperatively, whereas the x-ray examination did not show any sign of loosening of the cups. Data analysis showed that significantly better results were correlated with restoring the hip rotation center and reducing leg length discrepancy.

Arthroscopic treatment of acute acromioclavicular joint dislocation.

An original technique for the treatment of acute acromioclavicular (AC) joint dislocations is proposed. It consists of a closed reduction and stabilization of the AC joint, positioning a cannulated screw between the clavicle and the coracoid under arthroscopic control, without any exposure to x-rays. The conoid and trapezoid ligaments are not sutured or reconstructed. The screw is finally removed under local anesthesia 12 weeks after surgery. The described procedure has been performed in 9 patients. Short-term preliminary results show an excellent functional outcome without any residual pain. Among the advantages of the technique are that it does not require specific instrumentation, is a minimally invasive approach, has the possibility of searching the glenohumeral joint for associated lesions and eventually treating them, and has the benefits of not exposing the patient or surgical team to ionizing radiation.

Coventry Award paper. Backsurface wear and deformation in polyethylene tibial inserts retrieved postmortem.

Wear and deformation were characterized at the backsurface of 25 posterior cruciate-retaining total knee arthroplasty polyethylene inserts retrieved postmortem from 20 subjects. The mean implantation time was 64.1 months (range, 4-156 months). The backsurface of the inserts was inspected using a stereomicroscope with a digital optical system. Coronal histologic sections of 13 proximal tibias were inspected for the presence and extent of penetration of granuloma. Damage to the backsurface was limited. Polishing was recorded on 21 (84%) of the inserts and abrasive wear on five (20%) inserts. Pitting was present in 21 (84%) components, but involved less than 1% of the area in all but one of these components. Delamination and cracking were not observed. Extrusions were seen in all 10 of the components that had screw holes in the tibial tray. A correlation was found between the depth of penetration of the granuloma along the posteromedial screw and the height of the corresponding extrusion. The anteroposterior profiles showed a concave deformation of the backsurface in 24 (96 %) of the cases. The concave deformation of tibial inserts may facilitate accumulation and transportation of wear debris to the tibial bone-implant interface through the screw holes in implants designed for cementless fixation.

The double-twist knot: a new arthroscopic sliding knot.

A safe and easy-to-tie sliding knot is necessary for arthroscopic repair of rotator cuff tears and glenoid labrum lesions. We describe the double-twist knot (DTK) technique, having tested the knot's tensile strength and compared it with other commonly used arthroscopic knots. The DTK is a modified Lark's head knot that can be tied only on a double suture. A No. 2 braided polyester suture was used to test the DKT against the Tennessee slider knot and Snyder's knot by means of a material testing system. Results showed a statistically significant (P <.001) higher tensile strength with the DTK than with the other 2 knots. The rationale for using a stitch with a double suture is to double the tensile strength while using the same number of surgical steps and operating time as with single-suture stitches.