External jugular venous aneurysm-a case report.

Aneurysms of the external jugular vein (EJV) are uncommon vascular malformations. Due to their rarity, it is currently unclear what the risk of complications are and whether surgical management should be offered. The risks associated with the surgery need to be balanced with the risk of complications from the malformation. We present the case of a young woman who presented with a painful erythematous neck swelling who was found to have an aneurysm of the EJV with thrombophlebitis. This was successfully treated with surgical excision. We discuss current evidence for treatment of neck vein aneurysms and pitfalls.

Percutaneous treatment of radial neck fractures in adult patients.

INTRODUCTION: Radial neck fractures in adults are rare, but outcomes are often poor. Closed reduction and internal fixation (CRIF) technique has been advocated for the treatment of minimally displaced fractures in children, with a few reports on adult subjects. The aim of the present paper is to investigate mid-term results of a CRIF technique in adults with retrograde intramedullary K-wires in Mason's type II and III fractures. The proposed technique yields to good anatomical reduction of displaced neck fractures, faster rehabilitation, and easier hardware removal after fracture consolidation. MATERIAL AND METHODS: A consecutive series of 17 patients were treated with closed reduction and intramedullary osteosynthesis, and outcomes were retrospectively evaluated. Elbow X-ray (XR) and CT scan were obtained preoperatively. Objective assessment before surgery and at an average 36-month follow-up included active and passive elbow range of motion (ROM). Functional evaluation was carried out through the collection of the Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Elbow Self-Assessment Score (ESAS). XR at last follow-up was evaluated. RESULTS: The cohort included 10 males and seven females, with a mean age of 32 years. Patients returned for a follow-up evaluation at a mean of 36 months (range 6-43 m) form the surgery. The DASH score revealed good to excellent outcomes with a mean of 6.32 ± 10.24 points at last follow-up. The ESAS was 98.35 ± 1.89, indicating a non-restricted elbow function. Acceptable radiographic healing was achieved in all patients. CONCLUSIONS: The advocated technique is promising for obtaining good reduction and stabilization, and good to excellent satisfaction for patients. Given the challenging technique, the learning curve could be long and initial results unsatisfactory. More research with larger cohorts and improved study design could be carried out, comparing the technique with the current choice of treatment (ORIF, radial head resection).

IODA-shoulder®, a 3-dimensional automated software for glenoid bone loss quantification in shoulder instability. A validation study.

BACKGROUND: Glenoid bone loss (GBL) calculation in patients with shoulder instability has a wide variability in methods and their reliability. The purpose of this study was to describe and validate a new semi-automated software developed to improve GBL calculation using a 3D imaging modeling (IODA-shoulder) and to compare the method to the PICO area method. PATIENTS AND METHODS: A semi-automated software to assess GBL was preliminarily developed and validated on 7 fresh frozen specimens (scapulae with artificially created glenoid defect), using water displacement method. Afterwards, the software was retrospectively used on CT images of 20 patients affected by recurrent shoulder dislocation. Inclusion criteria were: unilateral dislocation, minimum 2 dislocation episodes. Exclusion criteria were bone reconstruction of the glenoid, failed shoulder stabilization, bilateral dislocation, shoulder arthritis. Three-dimensional computed tomography images of bilateral shoulder were retrieved for each patient. Two methods to determine GBL were compared. The PICO surface area method and the new IODA method. We assessed the intra- and inter-rater reliability of the two methods with the Intraclass Correlation Coefficient (ICC), the Bland-Alman analysis, and Lin's concordance correlation coefficient (CCC). RESULTS: We did not find a statistically significant difference between the mean volumes calculated with PICO and IODA methods, respectively 914 vs. 815 mm3, p=0.155. The analysis carried out by using the traditional PICO method showed a lower concordance rate among four observers than the higher concordance found using IODA method, regardless of the size and the location of the defect. The ICC agreement with PICO was significantly lower than with IODA (0.76 vs. 0.97). We found a poor CCC with PICO (from 0.65 to 0.81) and a substantial one with IODA (from 0.96 to 0.98). DISCUSSION: The intra- and inter-rater reliability using IODA method is significantly better than PICO method. The assessment of GBL using IODA method is time saving, avoiding significant inter- and intra-observer variation, mainly due to individual skill and experience in the method. LEVEL OF EVIDENCE: IV, experimental study.

Dual-mobility total hip arthroplasty in patients younger than 55 years old: a systematic review.

Total hip arthroplasty (THA) is regarded as one of the most successful and cost-effective orthopedic procedures. However, THA is a surgical procedure with potential intraoperative and postoperative risks. Dislocation is one of the common postoperative complications and remains one of the main indications for THA revision. The purpose of this systematic review was to evaluate the role and the outcomes of dual-mobility implant to prevent dislocation in patients younger than < 55 years in primary THA. In this systematic review, we included observational, prospective, and retrospective studies that evaluated the outcome and the complications of the dual-mobility cup in < 55-year-old patients. After applying exclusion criteria (femoral neck fractures or THA revision, case series, reviews, and meta-analyses), ten articles were included in the study. The overall number of participants in all the studies was 1530. The mean age of the participants was 50 years. The mean follow-up was 11.7 years. A total of 46 patients (2.7%) reported intraprosthetic dislocations, in which the polyethylene liner dissociates from the femoral head, while 4.8% of revision was due to aseptic loosening. The mean revision rate at twelve years was 11%. The mean value of Harris Hip Score increased from 50.9 pre-operatively to 91.6 after surgery. Dual mobility is a valid option for young patients with extended survivorship and low rates of instability and dislocation after primary THA.

Length of Hospital Stay after Total Knee Arthroplasty: A Correlation Study on 1200 Patients.

In countries with a high average population age, total knee arthroplasty is still carried out in an inpatient setting. The roadmap to performing major surgery on an outpatient basis passes through the understanding of those perioperative features that correlate with higher lengths of hospital stay (LOS). A retrospective database of 1200 patients was reviewed for retrieving preoperative and perioperative factors including anthropometric and demographic data, comorbidities, preoperative laboratory assessment, and surgical time. Considering the LOS as a discrete series, data were analyzed by means of logistic regression with multiple univariate and multivariate models. The results showed a median length of hospital stay of 3 (IQR 3, 4) days. According to multiple univariate analysis, arterial hypertension (p = 0.008), diabetes mellitus (p = 0.028), CCI score (p < 0.001), ASA score (p = 0.006), surgical time (p < 0.001) and intraoperative blood loss (p < 0.001) were significantly associated with the duration of hospital stay in days. Moreover, preoperative hemoglobin value was inversely correlated to the LOS (p = 0.008). Multivariate analysis showed a significant correlation between LOS and surgical time and intraoperative blood loss. Many factors influence the permanence of the inpatient and acting on those variables, by stabilizing comorbidities and optimizing laboratory values, may reduce the overall healthcare burden.

The post-traumatic meniscal extrusion, sign of meniscotibial ligament injury. A case series.

BACKGROUND: Medial meniscal extrusion (ME) has been found to be associated to anterior cruciate ligament (ACL) injury. Post-traumatic extrusion is mainly attributed to meniscotibial ligament (MTL) tear. The aim of this retrospective study was to assess the incidence of MTL tear associated with meniscal extrusion, evaluate arthroscopic findings and the associated clinical findings. HYPOTHESIS: The medial meniscal extrusion, when associated to ACL injury, is related to a tear of the MTL. PATIENTS AND METHODS: Patients who underwent to primary or revision ACL reconstruction with associated medial meniscal rise and/or meniscotibial tear or insufficiency were retrospectively identified over a 5-year period (from 2015 to 2019). Twenty-four patients were included in this study with preoperative magnetic resonance imaging (MRI) carried out at our institution Each MRI was evaluated by the senior author for the presence of meniscal extrusion and also for the additional pathology of meniscotibial ligament. Patient medical records were reviewed to obtain demographic information, including age, gender, and arthrometric evaluation of anteroposterior laxity. RESULTS: All included patients underwent arthroscopic ACL reconstruction using autograft tissue, (19 primary and in 5 revision ACL reconstruction). The mean age was 31.2 years (range: 15-57; SD: 12.3 years) at the time of surgery. ME was identified at MRI in all cases preoperatively and confirmed arthroscopically. No correlation was found between meniscal extrusion and anteroposterior translation (ρ=-0.270; p=0.202). Neither between having more than 3mm of extrusion and gender (χ2=0.80; p=0.371), acute/chronic lesion (χ2=0.91; p=0.341) and primary/revision reconstructions (χ2=0.83; p=0.364). In the last three patients, arthroscopic treatment of meniscal extrusion was carried out through outside-in repair of medial meniscus at its capsular junction. Reduction of meniscal extrusion has been verified by MRI, performed at 3-month follow-up. DISCUSSION: A high prevalence of ME was found at MRI in patients with ACL injury and MTL tear. Therefore, ME may be associated to acute or chronic ligamentous injury involving the MTL, and its tear can be considered as the main determinant of extrusion. Further research is needed to increase evidence concerning MTL incidence and surgical outcomes. LEVEL OF EVIDENCE: IV, retrospective case series.

Results of Simultaneous Unicompartmental Knee Arthroplasty and Anterior Cruciate Ligament Reconstruction: A Systematic Review.

This systematic review aimed to investigate the clinical and functional outcomes and complication rate of simultaneous anterior cruciate ligament reconstruction (ACLR) and unicompartmental knee arthroplasty (UKA). A systematic search in PubMed-Medline, Cochrane Library, and Google Scholar was carried out to identify eligible randomized clinical trials, observational studies, or case series that reported on clinical and functional results of combined ACLR and UKA in adults with a unicompartmental knee osteoarthritis and ACL deficiency. Four retrospective studies and three prospective studies were included in this review. A total of 169 patients were included with a mean follow-up of 6.3 years. The Mean Oxford Knee Score improved from 29.4 to 43.9 at the final follow-up. All the other reported scores significantly improved after surgery. The overall revision rate was 3.5%. The MINORS score ranged from 8 to 14. Association analysis of MINORS score and year of publication, through Pearson's coefficient, showed no significant association (p = -0.089). Simultaneous ACLR and UKA is a safe procedure with a significant postoperative improvement of functional and clinical outcomes for patients with ACL injury that complain of knee instability and isolated medial compartment pain.

Anomalous insertion of anterior and posterior horns of medial meniscus. Case report.

BACKGROUND: Anatomical variations of the attachment of medial meniscus are a common finding. However, anomalies of the posterior horn are extremely rare. Only two cases of posterior root anomaly have been described prior to the routine use of arthroscopy for evaluation and treatment of meniscal pathology. In this report, we present an anomaly of both the anterior and posterior roots of the medial meniscus that posed both a diagnostic and therapeutic dilemma. CASE PRESENTATION: The patient is young male soccer player who is currently 16 years of age and began having the atraumatic onset of pain and symptoms that limited performance starting at age 14 and was referred for failure of response to nonoperative treatment. Diagnostic arthroscopy revealed the presence of an anteromedial meniscofemoral ligament whereas the posterior root showed no bony attachment. The radiographic and arthroscopic findings are described. The clinical decision was made after to proceed with observation, reassurance, and gradual return to full activity with physiotherapy guidance. DISCUSSION AND CONCLUSION: The absence of injury, the mild complaints reported by the patient, his age, skeletal immaturity, and remaining growth led us to adopt a conservative approach to treating this anatomic variant and currently the patient is able to participate fully in sports without symptoms or restrictions.

Outcomes of Computer-Assisted Total Knee Arthroplasty Compared to Conventional TKA: A Bicentric Controlled Retrospective Clinical Study.

Despite the globally ascertained success of Total Knee Arthroplasty (TKA) procedure, 20% of patients are still unsatisfied with the surgery results. The purpose of the study is to identify the functional and radiological outcomes of the computer-assisted (CAS) TKA compared to the conventional technique. The clinical databases and medical records of both clinical sites were retrospectively analyzed, and then according to study time-lapse, inclusion, and exclusion criteria, eligible patients were retrieved and included. A total of 42 patients that underwent to CAS TKA (NAVI) and 61 patients that underwent to Conventional TKA (CONV) were included. The NAVI group reported a statistically significant higher surgical time. A lower intraoperative blood loss was found in the computer-assisted group, though this difference was not statistically significant. Implant survival analysis at two years did not show differences between groups during the follow-up period. At two years, follow-up postoperative intergroup analysis showed no statistically significant difference between groups. According to the radiologic analysis, the NAVI group showed comparable outcomes to the conventional group. The present study showed that there was no clinical and radiological difference between CAS arthroplasty and conventional technique.

Return to Sport Activity in the Elderly Patients after Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis.

In patients with knee osteoarthritis, when only medial or lateral compartment of the knee is involved, unicompartimental knee arthroplasty (UKA) is a reliable option for addressing the symptoms and restore function. The main aim of the present review is to systematically collect the available evidence concerning the return to sport activity in the elderly patients after UKA. An electronic search was carried out on the following databases; Pubmed-Medline, Cochrane central, and Scopus, searching for randomized controlled trials, prospective cohort studies, retrospective case-control studies, and case series. Data concerning the evaluation of the return to sport (RTS) and of functional outcomes in the elderly patients after UKA surgery. MINORS score was used to assess the risk of methodological biases. Odds ratios and raw proportions were used to report the pooled effect of UKA on the return to sport in comparative and non-comparative studies, respectively. Same level RTS in elderly patients was of 86% (pooled return proportion 0.86, 95%CI 0.78, 0.94), showing also better relative RTS and time to RTS of patients undergoing UKA, in comparison to those undergoing TKA. Sport-specific RTS showed that higher return rates were observed for low-impact sports, whereas high-impact sports prevented a full return to activities. UKA is a valid and reliable option for elderly patients to satisfactorily resume their sport practice, especially for low impact activities. The rate of return to sports following UKA is higher than TKA.

The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent two of the most common procedures in orthopedic surgery. The growing need to avoid physical impairment in elderly patients undergoing this kind of surgery puts the focus on the possibility to undertake a preoperative physical activity program to improve their fit and physical health at the time of surgery. A systematic review has been carried out with online databases including PubMed-Medline, Cochrane Central and Google Scholar. The aim was to retrieve available evidence concerning preoperative physical activity and exercise, before total knee or total hip arthroplasty in patients older than 65 years, and to clarify the role of this practice in improving postoperative outcomes. Results of the present systematic analysis showed that, for TKA, most of the studies demonstrated a comparable trend of postoperative improvement of Visual Analogue Scale (VAS), range of movement (ROM) and functional scores, and those of quality of life. There is insufficient evidence in the literature to draw final conclusions on the topic. Prehabilitation for patients undergoing TKA leads to shorter length of stay but not to an enhanced postoperative recovery. Concerning THA, although currently available data showed better outcomes in patients who underwent prehabilitation programs, there is a lack of robust evidence with appropriate methodology.

Biohumoral Indicators Influenced by Physical Activity in the Elderly.

In the scientific landscape, there is a growing interest in defining the role of several biomolecules and humoral indicators of the aging process and in the modifications of these biomarkers induced by physical activity and exercise. The main aim of the present narrative review is to collect the available evidence on the biohumoral indicators that could be modified by physical activity (PA) in the elderly. Online databases including Pubmed, Web of science (Medline), and Scopus were searched for relevant articles published in the last five years in English. Keywords and combination of these used for the search were the following: "biological", "indicators", "markers", "physical", "activity", and "elderly". Thirty-four papers were analyzed for inclusion. Twenty-nine studies were included and divided into four categories: cardiovascular (CV) biomarkers, metabolic biomarkers, inflammatory markers-oxidative stress molecules, and other markers. There are many distinct biomarkers influenced by PA in the elderly, with promising results concerning the metabolic and CV indexes, as a growing number of studies demonstrate the role of PA on improving parameters related to heart function and CV risk like atherogenic lipid profile. Furthermore, it is also a verified hypothesis that PA is able to modify the inflammatory status of the subject by decreasing the levels of pro-inflammatory cytokines, including interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α). PA seems also to be able to have a direct effect on the immune system. There is a strong evidence of a positive effect of PA on the health of elderly people that could be evidenced and "quantified" by the modifications of the levels of several biohumoral indicators.

Arthroscopic primary repair of the anterior cruciate ligament in adults: a systematic review.

BACKGROUND: The most common procedure to manage a torn anterior cruciate ligament (ACL) is surgical reconstruction. Primary repair of the ACL is returning on the forefront in the management of acute ACL, aiming to be less invasive and preserve the original ligament. Several techniques have been reported; the present systematic review investigates the clinical outcomes of ACL primary repair in adults. SOURCES OF DATA: Following an electronic search through Medline, Cochrane and Google Scholar databases, articles of interest were retrieved and evaluated, including case series, retrospective studies, case-control studies and randomized controlled trials. The main outcome data were extracted and summarized in tables and text. The methodology of the studies was assessed using the Coleman methodology score (CMS). AREAS OF AGREEMENT: Of the articles included, one was of level I, two of level III and the remaining of level IV. The direct intraligamentary stabilization technique was the most widely and accurately reported technique, with acceptable success and improvement of functional outcomes. The CMS averaged 58.75 (range 48 to 69), with no significant association with year of publication (Pearson's regression r = -0.397, P = 0.207). AREAS OF CONTROVERSY: Concerning stump sutures and suture anchors repair, although leading to good results, also in comparison with ACL reconstruction, no sufficient evidence was available to support these techniques. GROWING POINTS: The overall good results were reported also for other techniques are not supported by adequate evidence. More and better trials are required to improve our knowledge and understanding in this controversial area.

Should evoked potential monitoring be used in degenerative cervical spine surgery? A systematic review.

BACKGROUND: Intraoperative somatosensory evoked potential (SSEP) and transcranial motor evoked potential (tcMEP) monitoring are frequently used in spinal as well as spinal cord surgery for so-called intraoperative neuromonitoring (IONM), while the combination of these techniques is known as concomitant multimodal intraoperative monitoring (MIOM). The aim of this review is to collect available evidence concerning use of IONM and MIOM in cervical decompression surgery in the degenerative setting and attempt to identify the best practice to be advocated. MATERIALS AND METHODS: A review of the PubMed and MEDLINE databases and Cochrane Central Registry of Controlled Trials was performed. Studies were included if they involved patients who underwent cervical spine decompression surgery for degenerative stenosis with use of IONM or MIOM and where sensitivity/specificity was reported. RESULTS: In the identified studies, the sensitivity of SSEP was estimated to be between 22 and 100% with constant specificity of 100%. In the included studies, the sensitivity of MEP was estimated to be between 78 and 100% with specificity ranging from 83.2 to 100%. CONCLUSIONS: On the basis of available evidence, MIOM could be a helpful tool in decompression cervical spine surgery in patients affected by degenerative spinal stenosis, since it is associated with high specificity and sensitivity for detection of intraoperative neural damage. However, evidence is still lacking regarding patient selection to identify individuals in whom monitoring is indicated. LEVEL OF EVIDENCE: IV (systematic review of studies with LOE II to IV).

No difference between cemented and cementless total knee arthroplasty in young patients: a review of the evidence.

PURPOSE: The present piece of work provides improved knowledge about the evidence related to TKA in patients 60 years of age or younger, with special focus on fixation methods. Main concern of the review is to analyse the difference of survival rate and complications of cemented and cementless implants. METHODS: An electronic search was carried out between October and December 2015, through CINAHL, PubMed and the Cochrane Central Registry of Controlled Trials web databases. Articles in English, Italian, French and Spanish were considered for inclusion. Only peer-reviewed studies with adult patients aged 60 years or less, with diagnosis of osteoarthritis in more than 90% of the subjects, were considered for inclusion. All studies had to report outcomes after TKA with either cemented or cementless fixation technique. RESULTS: No significant differences in terms of clinical, functional and radiological outcomes were found between cemented and cementless implants. Good clinical and functional results were obtained in terms of the Knee Society score and Western Ontario and McMaster Universities Osteoarthritis Index for both techniques. Radiographic results showed that radiolucent lines of <2 mm in width were detected at radiographs, without difference between cemented or cementless implants. Well-conducted trials on cemented versus cementless TKA were carried out in few papers. A survival rate of over 90% was reported in the majority of the studies at a mean follow-up of 8.6 years (range 5-18 years). CONCLUSION: Similar results were observed in terms of functional outcome and survival rates for both cemented and cementless TKAs. High survival rates were reported for both operative techniques and cemented TKA did not offer additional benefit. Assuming that cementless prosthesis allows a stable fixation and reduces the time of operation, the authors recommend the cementless fixation as a primary choice in the investigated patient population. However, evidence is low, and further research is needed. LEVEL OF EVIDENCE: IV.

Surgical Treatment for Failure of Repair of Patellar and Quadriceps Tendon Rupture With Ipsilateral Hamstring Tendon Graft.

Tears of the patellar and quadriceps tendon are common in the active population, especially in athletes. At present, several techniques for surgical repair and reconstruction are available. When reruptures occur, a reconstruction is mandatory. In the present paper, we describe a surgical technique for patellar and quadriceps tendon reconstruction using ipsilateral hamstring autograft. After routine hamstring tendon harvesting, the tendon ends are prepared using a whip stitch. A transverse tunnel is drilled in the midportion of the patella, the hamstring graft is passed through the patella, and firmly secured to the patellar tunnel openings with sutures. The details of the technique are fully described. Autologous ipsilateral hamstring tendon grafts provide a secure sound means to manage these challenging injuries.

Surgical management of osteonecrosis of the humeral head: a systematic review.

PURPOSE: Osteonecrosis of the humeral head is a rare diagnosis. The aim of this systematic review was to identify published studies and analyse the best clinical evidence available related to the surgical management of osteonecrosis of the humeral head. METHODS: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. Published studies that reported the outcomes for adult patients treated surgically for osteonecrosis of the humeral head were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was followed. RESULTS: Twelve studies were included: five prospective case series and seven retrospective case series. A total of 309 patients, comprising 382 shoulders, were included. Three main surgical procedures were evaluated: core decompression, hemi-arthroplasty and total shoulder arthroplasty. CONCLUSIONS: Based on the current available data, core decompression is a safe and effective option for treating low-grade osteonecrosis of the humeral head, while hemi-arthroplasty and total shoulder arthroplasty should be considered for high-grade osteonecrosis. More studies and better-designed trials are needed in order to enrich the evidence and enable researchers to draw stronger conclusions. Since osteonecrosis is an uncommon, though challenging disease, a proper knowledge of its treatment is needed. LEVEL OF EVIDENCE: IV.

Tibiotalocalcaneal arthrodesis using an intramedullary nail: a systematic review.

PURPOSE: Tibiotalocalcaneal arthrodesis is aimed to block the ankle joint motion in cases of severe osteoarthritis, avascular necrosis of the talus and/or failure of arthroplasty operations. This systematic review was carried out to evaluate the clinical outcome after tibiotalocalcaneal arthrodesis using intramedullary nail either open and arthroscopically assisted. Focus was on the success rate of the procedure in terms of union and complications and on the comparison between the techniques. METHODS: The databases PubMed (Medline), EMBASE and Cochrane Library were searched in order to retrieve relevant studies. All therapeutic level 1-4 studies involving humans with intramedullary nail fixation technique were included. Only studies written in English, Italian, French, Spanish and German were included. Data related to the type of surgery, complications and clinical outcomes were extracted and analysed. RESULTS: A total of 83 studies were identified, of which 32 studies were eligible for inclusion; 31 case series and one randomized controlled trial. The main reported outcome score was the American Orthopaedic Foot and Ankle Society scale. Almost, all the included studies reported higher than 50% union rates and a significant improvement in terms of the clinical and mechanical ankle function after treatment. CONCLUSIONS: Results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal arthrodesis using intramedullary nailing. Low complication rates contribute to make this a safe procedure. No comparison can be done between arthroscopic and open technique, due to the lack of scientific works on the first one. LEVEL OF EVIDENCE: IV.