Femoral neck fracture: the reliability of radiologic classifications.

BACKGROUND: Femoral neck fractures (FNF) are one of the most common injury in the elderly. A valid radiographic classification system is mandatory to perform the correct treatment and to allow surgeons to facilitate communication. This study aims to evaluate reliability of 2018 AO/OTA Classification, AO/OTA simplified and Garden classification. METHODS: Six Orthopaedic surgeons, divided in three groups based on trauma experience, evaluated 150 blinded antero-posterior and latero-lateral radiography of FNF using Garden classification, 2018 AO/OTA and simplified AO/OTA classification. One month later, the radiographs were renumbered and then each observer performed a second evaluation of the radiographs. The Kappa statistical analysis was used to determine the reliability of the classifications. Cohen's Kappa was calculated to determine intra and inter observer reliability. Fleiss' Kappa was used to determine multi-rater agreement. RESULTS: The k values of interobserver reliability for Garden classification was from 0,28 to 0,73 with an average of 0,49. AO classification showed reliability from 0,2 to 0,42, with average of 0,30. Simplified AO/OTA classification showed a reliability from 0,38 to 0,58 with an average of 0,48. The values of intra observer reliability for Garden classification was from 0,48 to 0,79 with an average of 0,63. AO classification showed reliability from 0,2 to 0,64 with an average of 0,5. Simplified AO/OTA classification showed a reliability from 0,4 to 0,75 with an average of 0,61. CONCLUSION: The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. The simplified AO/OTA classification show a reliability similar to Garden classification, with a moderate interobserver reliability. The experience of the surgeons seems not to improve reliability. No classification has been shown to be superior in terms of reliability.

Small joints replacement for hand osteoarthritis: a systematic review.

INTRODUCTION: Small joints replacement is a valid treatment for moderate to severe osteoarthritis of the hand. Several design and materials are now available for prostethic procedures with very different clinical and functional outcomes. SOURCES OF DATA: An online search was carried out using Medline, Cochrane and Google scholar online databases, searching for studies on small joints replacement in hand surgery. AREAS OF AGREEMENT: Good functional and clinical outcomes can be achieved with silicone and pyrolitic carbon implants, either for trapeziometacarpal and metacarpophalangeal joints. In particular, the silicone spacer seems to be very effective for trapeziometacarpal osteoarthrosis, while the pyrolitic carbon total joint prosthesis produces excellent outcomes if used for metacarpophalangeal replacement. Major complications, such as persistent pain and implant loosening, have still a variable rate of occurrence. AREAS OF CONTROVERSY: Heterogeneity in the methodology of the assessments in the studies reviewed and the implants and techniques involved makes it difficult to carry out a complete and effective comparative analysis of the data collected. GROWING POINTS: Larger cohorts treated with the same implant should be investigated in better designed trials, to draw more clinically relevant conclusions from the evidences presented. Better methodology is also a goal to achieve, since the average Coleman Methodology Score measured for the articles included was 54.9 out of 100. RESEARCH: More and better designed studies are needed to produce clear guidelines to define the better implant in terms of clinical outcomes, function and complications for trapeziometacarpal and metacarpophalangeal joints.

Pharmacological interventions for the treatment of Achilles tendinopathy: a systematic review of randomized controlled trials.

INTRODUCTION: Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy. SOURCES OF DATA: We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias. AREAS OF AGREEMENT: Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90. AREAS OF CONTROVERSY: There was no significant evidence of remarkable benefits provided by any of the therapies studied. GROWING POINTS: There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy. RESEARCH: There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments.

Hamstring Tendon Regeneration After Harvest for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To assess whether the portions of the semitendinosus and gracilis tendons harvested for anterior cruciate ligament reconstruction have the potential to regenerate and, if so, to evaluate the histologic properties and actual function of this newly formed tissue. METHODS: We performed a comprehensive search of CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, the Cochrane Central Registry of Controlled Trials, and SPORTDiscus from inception of the databases to July 2014, using various combinations of keywords. Studies focusing on hamstring tendon and muscle regeneration through imaging and histology, as well as on the related functional outcomes, were selected. We included studies assessing evidence of tissue regeneration with imaging (magnetic resonance imaging, 3-dimensional computed tomography, ultrasonography) or with histologic examination of biopsy samples (or a combination thereof). RESULTS: Nineteen articles were included in this review, with a total of 400 patients observed. The overall rate of tissue regeneration was 86.0%, with similar values shown in most studies regardless of the methodology of the assessment. Biopsy confirmed that the tissue found at the site in 74% of the cases showed typical histologic features of the tendon. The mean modified Coleman Methodology Score of the studies included was 52.7 points, showing a modest methodologic quality for the studies published to date. CONCLUSIONS: In over 85% of the cases analyzed, regeneration signs of the harvested tendon were found through different imaging and histologic methodologies. A torque deficit in deep knee flexion is always present postoperatively, but the cause for this is still unclear. There is a need for better-designed trials featuring a higher level of evidence to further investigate this matter, and the effects of postoperative care and the surgical approach used on the regeneration process should be analyzed in the future. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Complications involving the extensor mechanism after total knee arthroplasty.

PURPOSE: To overview the complications involving extensor apparatus of the knee following total knee arthroplasty (TKA) and to summarize which are the lines of treatment available and their reported outcomes in literature. METHODS: A comprehensive search of several databases was performed using as basic keywords "complications after TKA", "extensor mechanism disruption", "periprosthetic patellar fracture", "quadriceps tendon rupture", "quadriceps tendon rupture" isolated or combined with other terms by using Boolean operators. The methodological quality of each article was also evaluated using the Coleman methodology score (CMS). RESULTS: Twenty-nine studies were evaluated. The mean CMS of the studies selected was 33.1/100. Patellar fractures, requiring surgical treatment when there is rupture of the extensor mechanism or loosening of the patellar component, were treated surgically in 28.1 % of patients. The patellar and quadriceps tendon ruptures were surgically treated with reconstruction or augmented repair, respectively, in 98.6 and 76.5 %. CONCLUSION: Complications involving the extensor apparatus of the knee following a TKA need early and appropriate management to avoid their devastating influence on joint functionality. Management has to be evaluated very carefully based on the site of the lesion, integrity of the prosthetic components and surrounding tissue to restore, and the patients' individual characteristics. The surgical approach for comminuted periprosthetic fractures and reconstruction of torn tendons of the extensor apparatus are needed to restore function and decrease pain, but, given the poor methodological quality of the studies published so far, it is not clear which surgical technique or graft leads to better outcomes. Therefore, there is an absolute need for better designed comparative trials producing clearer and stronger evidence on this critical matter. LEVEL OF EVIDENCE: IV.

Anterior cruciate ligament reconstruction and return to sport activity: postural control as the key to success.

PURPOSE: The risk for re-tear following anterior cruciate ligament (ACL) reconstruction is influenced by several hormonal, neuromuscular, biomechanical and anatomic factors. One of the most important negative prognostic factors that markedly increase the risk for ACL re-tear is the presence of high knee-abduction moment (KAM), which can be measured immediately by landing on both feet after a vertical jump. We evaluated the effect in postoperative values for KAM according to the type of graft used for ACL reconstruction (hamstring vs patellar tendon) and a specific rehabilitation protocol focusing on recovery of muscular strength, proprioception and joint stabilisation. METHODS: From November 2010 to September 2012, we enrolled 40 female recreational athletes with clinical and imaging evidence of ACL tear and randomised them in two groups. One group of patients underwent reconstruction with a hamstring-tendon graft and the second with a patellar-tendon graft. A custom rehabilitation programme focusing on proprioception was adopted. Clinical outcomes [International Knee Documentation Committee (IKDC) and Lysholm scores] and performance in functional test for stability (single-leg hop, timed hop, crossover triple hop, KAM test) were assessed preoperatively at three and six months postoperatively. RESULTS: All patients showed statistically significant clinical improvements postoperatively when compared with preoperative values (P < 0.0001). No significant intergroup difference was observed in all clinical scores and functional tests, with the exception of the value registered for the KAM test (P < 0.0001). CONCLUSIONS: ACL reconstruction using patellar-tendon graft followed by rehabilitation centred on strength, proprioception and stability restoration can produce satisfactory values for KAM within the physiological range. The surgical strategies should be adapted to the patient on the basis of a multidisciplinary approach.

Metallic or bioabsorbable interference screw for graft fixation in anterior cruciate ligament (ACL) reconstruction?

BACKGROUND: Approximately 100,000 anterior cruciate ligament (ACL) reconstructions are performed in the USA each year. Interference screw fixation is considered the standard for rigid fixation of the graft and provides higher fixation strength compared with other devices such as staples or buttons. The present study summarizes the latest evidence comparing the effectiveness of the available classes of interference screws for fixation of ACL grafts. SOURCES: A comprehensive search of the CINAHL, PubMed, Google Scholar, Embase Biomedical databases and the Cochrane Central Registry of Controlled Trials was performed in March 2013. Twelve studies met our inclusion criteria. AREAS OF AGREEMENT: Most studies showed no intergroup difference in terms of outcomes measured with validated clinical scores such as IKDC (International Knee Documentation Committee), Lysholm score and Tegner activity level. There was no significant difference regarding range of motion. Knee stability as evaluated with pivot shift and KT arthrometer showed a significant difference only in one study, favouring metallic interference screws. Tunnel widening is much more evident and marked patients who underwent ACL reconstruction with bioabsorbable screws, with no influence on the final clinical results achieved. Complication rates between the two screw classes were similar. The average modified Coleman methodology score was 74.67. AREAS OF UNCERTAINTY/RESEARCH NEED: The data comparing the outcomes achieved by two different materials for fixation, bioabsorbable and metallic, to be used during single-bundle ACL reconstruction, showed no significant difference in the final patient outcomes, in terms of clinical scores, clinical evaluation and imaging.

The arthroscopic treatment of shoulder instability: bioabsorbable and standard metallic anchors produce equivalent clinical results.

PURPOSE: To investigate whether there are any differences in clinical outcomes and complications between absorbable and nonabsorbable suture anchors in the treatment of shoulder instability. METHODS: We performed a comprehensive search of Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Central Registry of Controlled Trials, from inception of the databases, using various combinations of keywords. Only studies focusing on clinical outcomes of patients who underwent arthroscopic shoulder stabilization with suture anchors were selected. Two authors (R.P. and L.D.B.) then evaluated the methodologic quality of each article using the Coleman Methodology Score. RESULTS: Ten articles were included. Four were prospective randomized studies, 2 were prospective cohort studies, and 4 were case series. The mean modified Coleman Methodology Score was 76.2. CONCLUSIONS: Given the overall good results reported after arthroscopic stabilization of the shoulder using different suture anchors, it is not possible to draw a definite and solid suggestion on which class of device is better advised for routine use. Thus the decision to use one of the anchor systems available may mostly depend on its cost-effectiveness, which should be the focus of future comprehensive research. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Meniscal root tears: from basic science to ultimate surgery.

BACKGROUND: In meniscal root tears (MRTs), the disruption of collagen fibers that provide hoop strength results in extrusion of the menisci, altering their biomechanical properties. Clinical diagnosis is difficult, but magnetic resonance imaging usually allows to identify the lesion. Located into the vascularized zone of the meniscus, management is preferentially arthroscopic, aimed at repairing the lesions with arthroscopic transosseous sutures or suture anchors. SOURCES OF DATA: PubMed, Cochrane Library, Google Scholar and Ovid Medline were searched in July 2012 to find literature on MRT tears. We reviewed the literature on biomechanics, imaging features and current treatments of these tears. Twenty-seven appropriate articles were identified and included in the study: 6 biomechanical studies, 11 imaging-based investigations for diagnosis, 1 study on clinical diagnosis and 9 studies about treatment. AREAS OF AGREEMENT: MRTs are infrequent, accounting for 10.1% of all arthroscopic meniscectomies. When the damage occurs to the roots, the transmission of the circumferential hoop tension is impaired and, consequently, the menisci tend to be displaced anteriorly and posteriorly, altering the biomechanics and possibly the kinematics of the knee. AREAS OF CONTROVERSY: Although the importance of the integrity of the meniscal roots is well established, their diagnosis and treatment are still controversial. GROWING POINTS: Biomechanical and clinical studies demonstrate that surgical repair of acute, traumatic meniscal root injuries fully restores the biomechanical features of the menisci, leading to pain relief and functional improvement. The current available surgical techniques for the meniscal root repair (suture anchors and pullout repair) are comparable. Level of evidence IV.

Scaffolds for partial meniscal replacement: an updated systematic review.

INTRODUCTION: Meniscectomy, a most common orthopaedic procedure, results in increased contact area of the articular surfaces of tibia and femur leading to early osteoarthritis. We systematically review the literature on clinical outcomes following partial meniscal replacement using different scaffolds. SOURCES OF DATA: We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials. The reference lists of the selected articles were then examined by hand. Only studies focusing on investigation of clinical outcomes on patients undergoing a partial meniscal replacement using a scaffold were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS). AREAS OF AGREEMENT: Fifteen studies were included, all prospective studies, but only 2 were randomized controlled trials. Biological scaffolds were involved in 12 studies, 2 studies investigated synthetic scaffolds, whereas 1 remaining article presented data from the use of both classes of device. The mean modified CMS was 64.6. AREAS OF CONTROVERSY: Several demographic and biomechanical factors could influence the outcomes of this treatment modality. GROWING POINTS: Partial replacement using both classes of scaffolds achieves significant and encouraging improved clinical results when compared with baseline values or with controls when present, without no adverse reaction related to the device. RESEARCH: There is a need for more and better designed randomized trials, to confirm with a stronger level of evidence the promising preliminary results achieved by the current research.

Augmentation techniques for rotator cuff repair.

INTRODUCTION: There is a high rate of recurrence of tear and failed healing after rotator cuff repair. Several strategies have proposed to augment rotator cuff repairs to improve postoperative outcome and shoulder performance. We systematically review the literature on clinical outcome following rotator cuff augmentation. SOURCES OF DATA: We performed a comprehensive search of Medline, CINAHL, Embase and the Cochrane Central Registry of Controlled Trials, from inception of the database to 20 June 2012, using various combinations of keywords. The reference lists of the previously selected articles were then examined by hand. Only studies focusing on clinical outcomes of human patients who had undergone augmented rotator cuff repair were selected. We then evaluated the methodological quality of each article using the Coleman methodology score (CMS), a 10 criteria scoring list assessing the methodological quality of the selected studies (CMS). AREAS OF AGREEMENT: Thirty-two articles were included in the present review. Two were retrospective studies, and 30 were prospective. Biologic, synthetic and cellular devices were used in 24, 7 and 1 studies, respectively. The mean modified Coleman methodology score was 64.0. AREAS OF CONTROVERSY: Heterogeneity of the clinical outcome scores makes it difficult to compare different studies. GROWING POINTS: None of the augmentation devices available is without problems, and each one presents intrinsic weaknesses. There is no dramatic increase in clinical and functional assessment after augmented procedures, especially if compared with control groups. RESEARCH: More and better scientific evidence is necessary to use augmentation of rotator cuff repairs in routine clinical practice.

Home-based vs supervised rehabilitation programs following knee surgery: a systematic review.

INTRODUCTION: Following knee surgery, rehabilitation can dramatically affect the postoperative course and the final outcomes of the procedure. We systematically reviewed the current literature comparing clinical outcomes of home-based and outpatient supervised rehabilitation protocols following knee surgery. SOURCES OF DATA: We searched Medline, CINAHL, Embase, Google Scholar, The Cochrane Library and SPORTDiscus. The reference lists of the previously selected articles were then examined by hand. Only studies comparing clinical outcomes of patients who had undergone knee surgery followed by different rehabilitation programs were selected. Then the methodological quality of each article was evaluated using the Coleman methodology score (CMS), a 10-criterion scoring list assessing the methodological quality of the selected studies. AREAS OF AGREEMENT: Eighteen studies were evaluated in the present review. Three were retrospective studies. The remaining 15 studies were prospective randomized clinical trials. The supervised and home-based protocols did not show an overall significant difference in the outcomes achieved within the studies reviewed. The mean CMS was 77.2. AREAS OF CONTROVERSY: The heterogeneity of the rehabilitation protocols used in the studies reviewed makes it difficult to draw definite conclusion on the subject. GROWING POINTS: Supervision and location does not seem to directly determine the final outcomes. Numerous variables, including comorbidities and motivation, could influence the results and deserve to be accounted for in future investigations. RESEARCH: Better designed studies are needed to show a clear superiority of one rehabilitation approach over another and its applicability to the various surgical procedures involving the knee.

Is there a role for endothelial dysfunction in the pathogenesis of lumbar disc degeneration? A hypothesis that needs to be tested.

Low back pain is a painful condition affecting most people at least once in their life. It can be the expression of lumbar disc degeneration, a condition whose progression is influenced by environmental, individual and genetic factors. The pathogenesis of this condition implies the reduction of sustenance for the tissues within the intervertebral disc (ID) due to a decreased blood flow in the local microcirculation. In fact, it is known that the ID is an avascular structure that receives nutritive molecules and exchanges waste products through a process of osmotic diffusion from the capillaries located at the ID-vertebral body interface. The maintenance of a correct oxygen supply is essential for the health of disc cells also because ID is subjected to continuous compression stress due to its bearing function between vertebral bodies. This vital condition is guaranteed by proper dilation of blood vessels in response to mechanical stress, thanks to a finely balanced homeostasis between vasodilatory factors, such as nitric oxide, and vasoconstrictive substances produced by the endothelium. Endothelial dysfunction may disrupt this delicate equilibrium, causing a reduced oxygen supply eventually resulting in ID degeneration. Our hypothesis is that endothelial dysfunction, a systemic condition of reduced vessel dilation in response to mechanical stress, should be considered as an important pathological factor implicated intervertebral disc degeneration. This relationship may pave the way for a change in therapeutic approach to low back pain, especially in the early stages.

Complications of osteotomies about the knee.

High tibial osteotomy and distal femoral osteotomy are 2 popular techniques for the treatment of monocompartmental osteoarthritis of the knee joint in young patients. Injury to the popliteal neurovascular bundle is still considered to be the most severe complication during an osteotomy procedure even if the rate of occurrence is very low. Loss of correction and hardware failures are more frequent, but not as devastating. Patella baja and modification of tibial slope are associated with high tibial osteotomy. In contrast, complications most commonly associated with distal femoral osteotomy include nonunion and failure of the internal fixation. In general with evolution of techniques and fixation devices, complication rates seem to be reduced. A summary and literature review of complications associated with knee osteotomies will be discussed in this paper.