Favorable early outcomes of medial unicompartimental knee arthroplasty in active patients presenting a degenerative medial meniscus root tear with meniscal extrusion and mild radiographic osteoarthritis.

INTRODUCTION: There is only limited literature available evaluating the preferable treatment for active mid-age or elderly patients presenting with a degenerative medial meniscus root tear (d-MMRT) with medial meniscal extrusion (MME) and early-phase radiographic osteoarthritis (OA), failing to provide solid evidence. The aim of this study was to evaluate early outcomes of medial unicompartimental arthroplasty (mUKA) in active patients presenting a d-MMRT with meniscal extrusion and mild radiographic OA of the knee. To prove this claim we hypothesized that (1) patients with a d-MMRT with initial grade 1-3 KL OA of the medial compartment of the knee present the same pre-operative symptoms as patients with an end-stage grade 4 K-L OA, and that (2) those patients with d-MMRT and low-grade OA achieve the same early clinical and functional outcomes when treated with mUKA compared to patients with end-stage medial OA. METHODS: We reviewed the prospectively collected data of 185 patients undergoing robotic-assisted image-based mUKA from January 2021 to July 2022 at a single Institution. We identified two different cohorts of non-consecutive patients: a group of 24 patients undergoing mUKA surgery following d-MMRT combined with K-L grades 1-3 OA (group 1), and a group of 161 patients who underwent mUKA but presenting with an end-stage bone-on-bone K-L grade 4 OA (group 2). Preoperative and postoperative clinical assessments at one-year follow-up included the Oxford Knee Score (OKS), 5-level EQ-5D version (EQ-5D-5L score), and a standard weight-bearing X-ray protocol. The paired t-test was used to compare clinical outcomes and radiologic values of the two cohorts and in-between the two cohorts. Statistical significance was set at p < 0.05. RESULTS: The mean follow-up for group 1 was 16.4 ± 2.5 months, and the mean age at the time of operation was 63 ± 8.6 years with a mean time from diagnosis to intervention of 53 ± 47.5 days. Preoperative impairment was greater in group 1 compared to group 2, but with no significant difference. Postoperatively, both groups showed excellent mean outcomes at 1-year follow-up, with no significant difference. The mean preoperative HKA, mPTA, and LDFA were 176.3 ± 3.1, 88.1 ± 2.3, and 86.6 ± 1.7 respectively. The mean postoperative HKA, coronal femoral component angle, and coronal tibial component angle were 179.1 ± 2.6, 87.2 ± 2.3, and 87.2 ± 3.3. No difference was found between preoperative age, BMI, between the two cohorts. CONCLUSIONS: Favorable early clinical outcomes were obtained after mUKA in active mid-age and elderly patients presenting with degenerative medial meniscus root tear and mild isolated medial OA. Patients with mild no bone-on-bone OA but with degenerative medial meniscus root tear and medial meniscal extrusion presented the same or worse pre-operative symptoms as patients with end-stage medial OA and benefit the same from mUKA.

A dual telescoping lag screw nailing system for intertrochanteric fractures: retrospective analysis of clinical and radiologic outcomes.

BACKGROUND AND PURPOSE: The aim of this study was to evaluate whether this system is associated with a reduced rate of failure and complications in patients treated for proximal femoral fractures with intramedullary nailing. MATERIALS AND METHODS: 742 Patients with AO-OTA 31-A intertrochanteric fractures were enrolled at a single Institution. Functional evaluation was assessed through the Functional Independence Measure (FIM™) instrument and Parker's New Mobility Score (NMS). Radiological follow-up included the degree of the reduction according to the Baumgartner criteria, the Tip-Apex Distance, and the shortening of the telescoping screws and its lateral protrusion. RESULTS: Pre-operative mean FIM™ and NMS were 4.3 (range 1-9) and 98.7 (range 22-126), respectively. At the 12-month follow-up the average FIM™ and NMS were 95.3 (range 22-126) and 3.7 (range 1-9), respectively. Mean shortening of the lag screws was 4.3 mm (range 1-8) and mean lateral protrusion was 1.7 mm (range 0-3). 3 Cases (0.70%) of non-consolidation requiring reoperation were recorded. 1 Case (0.24%) of these cases was also characterized by nail breakage. No case of cut-out has been reported at our follow-up. CONCLUSIONS: This dual telescoping nail system is effective and safe. The sliding of the telescoping screws within the barrel is able to decrease strain from the femoral head during weight bearing reducing the risk of cut-out.

Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study.

PURPOSE: The aim of this study was to evaluate the relationship between the Löwenstein Lateral view and the True Lateral view for the positioning of the cephalic hip screw, through a cadaveric study. MATERIALS AND METHODS: We placed two Kirschner wires in eight femur specimens using an Antero-Posterior view, Löwenstein Lateral view and True Lateral view. The distances between the Kirschner wires and the anterior, posterior, superior and inferior cortex were measured in all projections. The head of the femur was then sectioned, and the same macroscopic distances were measured. Finally, we could calculate the accuracy of the two radiographic lateral projections. RESULTS: When the Kirschner wire was placed in the center of the head using the Antero-Posterior and the True Lateral view, the accuracy of Antero-Posterior view was 0.9705 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1479 and 1.1584, respectively. When the Kirschner wire was placed superior on the Antero-Posterior and centrally on the True Lateral view, the accuracy of Antero-Posterior view was 0.9930 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1159 and 0.7224, respectively. CONCLUSION: When the Kirschner wire was positioned proximal in Antero-Posterior view and central in True Lateral view, only the True Lateral view showed high accuracy.

Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?

BACKGROUND: A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown. QUESTIONS/PURPOSES: (1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years? METHODS: Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series. RESULTS: Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years. CONCLUSION: VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Acetabular Morphology Predicts the Risk of Dislocation Following Hemiarthroplasty for Femoral Neck Fractures in the Elderly.

BACKGROUND: Hip hemiarthroplasty dislocation is a devastating complication. Among other preoperative risk factors, acetabular morphology has been rarely studied. The purpose of the study was to evaluate the influence of preoperative native acetabular morphology on hemiarthroplasty dislocation. METHODS: We retrospectively reviewed 867 patients who underwent hip hemiarthroplasty for femoral neck fracture between January 1, 2014 and January 1, 2019. The 380 included patients were treated with an anterior-based muscle-sparing approach. The central-edge angle (CEA) and acetabular depth-to-width ratio (ADWR) of the fractured hip were measured preoperatively on the anteroposterior pelvic view. Receiver operating characteristic curves were performed to analyze the optimal cutoff for CEA and ADWR. Hemiarthroplasty dislocation occurred in 18 patients (4.7%), and the remaining 362 patients were used as the control group. RESULTS: No significant differences in terms of sex, age, dementia, neuromuscular disease, and body mass index were found between the 2 groups. The 18 patients who had a hip dislocation had significantly smaller mean CEA than the control group (P = .0001) (mean 36.1 ± 7.5° and 43.2 ± 5.6°, respectively) as well as ADWR (mean 34 ± 6 versus 37 ± 4, respectively) (P = .001). Using the receiver operating characteristic analysis, we report significant cutoffs of 38.5° for CEA (P = .0001) and 34.5 for the ADWR (P = .017). CONCLUSION: Higher rates of hemiarthroplasty dislocation were observed in patients who had a preoperative CEA of less than 38.5° and an ADWR of less than 34.5. Patients who have preoperative acetabular morphological risk factors for dislocation might be better candidates for a total hip arthroplasty.

Salvage of limb salvage in oncological reconstructions of the lower limb with megaprosthesis: how much to push the boundaries?

INTRODUCTION: Megaprosthesis represent the most commonly used limb salvage method after musculoskeletal tumor resections. Nevertheless, they are burdened by high complication rate, requiring several surgical revisions and eventually limb amputation. The aims of this study were to evaluate the effect of rescuing the limb with subsequent revisions on complication rates (a), incidence of amputations (b), and whether complications reduce functional outcome after the first surgical revision (c). MATERIALS AND METHODS: We retrospectively reviewed 444 lower limb megaprosthesis implanted for primary musculoskeletal tumors or metastatic lesions, from February 2000 to November 2017. 59 patients received at least one revision megaprosthesis surgery. MSTS score was used to assess final functional results. Complication-revision-amputation free survival rates were calculated both at 5 and 10 years of follow-up. RESULTS: Complication free survival, revision free survival and amputation free survival at 10 years were 47% and 53%, 61% and 67%, 90% and 86% among all 444 patients and the group of 59 revised patients, respectively. The incidence of further complications after the first complication was 26% in the group treated with no subsequent revision surgeries and 51% in the group with at least one revision surgery. We found a trend of inverse linear relationship between the number of complications needing subsequent revision surgeries and the final MSTS. CONCLUSION: The number of further revision surgeries after limb salvage with megaprosthesis increases the incidence of complications. Repeated surgical revisions, in particular after infection, increase the amputation rate. The most frequent causes of failure were structural failures and infections. MSTS score was superior for patients undergoing limb salvage than amputees. However, MSTS progressively decreased with multiple revisions becoming inferior to the functional score of an amputated patient.

The use of a standard-length conical tapered stem in hip revision arthroplasty to address Paprosky type I-II femoral defects: a prospective study of 87 patients.

INTRODUCTION: Low-grade femoral defects in revision total hip arthroplasty (rTHA) might be preferably treated with a primary implant. Almost no previous study reported the use of standard-length conical tapered (SLCT) stems in these cases. We analyzed a series of cases using a SLCT stem in rTHA with Paprosky type I-II femoral defects. The purpose of the study was to determine clinical and radiographic outcomes in this series of rTHA. MATERIALS AND METHODS: We prospectively followed 87 patients undergoing a femoral component rTHA: 53 Paprosky type I and 34 type II femoral defects. Patient-reported measures (Oxford Hip Score, EQ-5D, VAS pain during rest and activity) were administered at baseline, 1 and 2 years post-operatively. Radiographic subsidence overtime was scored. Kaplan-Meier curves were used to evaluate the subsidence over time, the complication-free survival, and the implant survivorship with reoperation and stem revision as endpoints. RESULTS: The mean follow-up was 72.5 (SD ± 23.9) months. All PROMs significatively improved over time. The average subsidence was 2.8 (SD ± 3.2), 3.6 (SD ± 4.4), and 4.0 (SD ± 4.9) mm at 4, 12, and 24 months respectively. 6 stems had subsidence > 10 mm. The survival without complication was 0.85 (95% CI 0.94-0.77), while the implant survival without reoperation was 0.83 (95% CI 0.95-0.72). The overall stem survival rate was 93.7% (95% CI 0.91-0.97) at 2 years. CONCLUSION: The use of a SLCT stem in rTHA with Paprosky type I-II femoral defects demonstrated good survival with low subsidence rates during the first 2 years after surgery. Surgeons should consider the use of this primary prosthesis as a potential treatment during stem revision in cases with limited femoral bone loss.

Stay Short or Go Long in Revision Total Hip Arthroplasty With Paprosky Type II Femoral Defects: A Comparative Study With the Use of an Uncemented Distal Fixating Modular Stem and a Primary Monobloc Conical Stem With 5-Year Follow-Up.

BACKGROUND: In the revisions for Paprosky type II femoral defects, diaphyseal fixating femoral stems are commonly used. To preserve bone stock, the use of a shorter primary conical stem could be an adequate alternative. The objective of this study is to compare the results of a primary conical stem to the more commonly used diaphyseal fixating modular revision stem in revision total hip arthroplasty surgery with Paprosky type II femoral defects. METHODS: A total of 59 consecutive patients with Paprosky type II femoral defects from our prospective revision registry were included. Thirty patients who received a long distal fixating modular stem (Revision Stem, Lima Corporate) and 29 patients who received a primary conical short stem (Wagner Cone, Zimmer) were prospectively followed. Minimal follow-up time was 2 years for subsidence and patient-reported outcome measures and 5 years for complications, reoperation, and revision. We compared subsidence, perioperative complications, reoperations, femoral component survival, Oxford Hip Score, EuroQol 5 Dimension, visual analog scale (VAS) for pain at rest, and VAS for pain during activity between stems. RESULTS: Both groups were comparable regarding demographic, clinical, and surgery-related characteristics. We found more perioperative complications and stem revisions with the modular revision stem than with the primary conical stem. There were no statistical differences in subsidence, EuroQol 5 Dimension, Oxford Hip Score, and VAS for pain at rest or during activity between both stems. CONCLUSION: In revision total hip arthroplasty with Paprosky type II femoral defects, uncemented primary monobloc conical femoral stems showed the same clinical result as distal fixating modular stems with fewer complications and fewer stem revisions.

Trabecular titanium cups in acetabular revision arthroplasty: analysis of 10-year survivorship, restoration of center of rotation and osteointegration.

AIMS: In case of severe bone loss, acetabular revision can be challenged using extra porous pure trabecular titanium (TT) revision cups designed to ensure enhanced iliac and ischiatic purchase. Aim of the study is to report on the clinical and radiological results of a TT acetabular component, evaluating functional outcome, restoration of the hip center of rotation and osteointegration. METHODS: 85 patients, who underwent acetabular revision with a TT revision cup system between October 2009 and December 2018, were included in a retrospective study. Clinical outcome were assessed with Harris Hip Score (HHS). The hip rotation center was measured using the Pierchon method on the AP pelvis film. Loosening of the cup was determined according to the Kosashvili modification of Gill's criteria. Kaplan- Meier survivorship curve was performed. Results The mean follow-up was 6.12 years. The average HHS improved from 54.7 points to 89.7 points (p < 0.05). Two acetabular components (2.3%) were re-revised after a mean of 5.6 years, for aseptic loosening and for infection, with a progressive radiolucency and a > 5 mm vertical migration, respectively. The radiographic evaluation of the position of the hip rotation center revealed a statistically significant difference (p < 0.05) between the pre- and post-operative values. The hip rotation center was correctly restored within 5% of the reference Pierchon values in a percentage of 85.4% relative to horizontal parameters and within 8% in a percentage of 66.7% relative to vertical parameters. 5-year and 10-year survivorships were, respectively, 100% and 88%. CONCLUSIONS: In case of severe bone loss, TT revision cup system allows for good restoration of center of rotation and osteointegration showing good 10-year survival rate.

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis.

INTRODUCTION: Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked. MATERIALS AND METHODS: We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes. RESULTS: Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections. CONCLUSION: Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.

Anorexia nervosa as a disorder of the subcortical-cortical interoceptive-self.

PURPOSE: Anorexia nervosa (AN) is characterized by a diminished capacity in perceiving the physiological correlates of interoceptive sensations, namely bodily self-consciousness. Given the neural division of self-processing into interoceptive-, exteroceptive- and mental-self, we hypothesize neural deficits in the interoceptive-processing regions in AN. METHODS: To prove this, we reviewed resting state (rs), task and rest-task studies in AN literature. RESULTS: Neuronal data demonstrate the following in AN: (i) decreased rs-functional connectivity (rsFC) of subcortical-cortical midline structures (SCMS); (ii) reduced rsFC between medial (default-mode network/DMN and salience network/SN) and lateral (executive-control network/ECN) cortical regions; (iii) decreased rsFC in mainly the regions of the interoceptive-self; (iv) altered activity with overall increased activity in response to sensory/body image stimuli, especially in the regions of the interoceptive-self; (v) lack of a clear task-related distinction between own's and others' body image. CONCLUSION: These data may indicate that rs-hypoconnectivity between SCMS, as neural correlate of a reduced intero-exteroceptive integration resulting in self-objectification, might be linked to overall increased activity in interoceptive regions during sensory/body image stimuli in AN, engendering an "anxious bodily self." LEVEL OF EVIDENCE: I: Systematic review.

Joint replacement for the management of haemophilic arthropathy in patients with inhibitors: A long-term experience at a single Haemophilia centre.

INTRODUCTION: The association between haemophilia and the so-called 'inhibitors', alloantibodies against the infused factor able to neutralize its clotting activity, is a very rare condition. Those sporadic patients suffer of an even more severe arthropathy and performing primary or revision arthroplasty become truly challenging. Literature about this topic is scarce, consisting in small case series, high rates of complications and mid-term follow-ups. AIM: The purpose of this study is the assessment of the long-term outcomes of primary and revision arthroplasty performed in a population of patients with inhibitors, the more consistent to date reported at a single haemophilia centre. METHODS: We reviewed the records of 18 patients with inhibitors (26 procedures) between 1999 and 2017, divided in two groups. Group A [primary total Knee-Hip arthroplasty (TKA-THA)]: 13 patients underwent 19TKA and 2THA; and B (revision): 5 subjects underwent 3rTKA and 2rTHA. All patients received the same haematological prophylaxis (rFVIIa). Haemophilic Joint Health score and VAS, and X-rays were recorded pre- and postoperatively. The survival rate of all primary implants was assessed. RESULTS: The median follow-up was 12.2 years (3-21) for group A, 8.6 years (4-12) for B. Few complications have been reported; the overall survival rate was 94.7% at 15 years. All patients reported satisfaction, pain reduction and improved functional ability. CONCLUSION: Primary and revision TKA/THA in haemophilic subjects and inhibitors may be nowadays considered safe and effective if performed in dedicated multidisciplinary centres. The use of continuous infusion of rFVIIa showed an adequate haemostatic effect and low rate of complications. As expected, revisions are more prone to complications compared to primary arthroplasty.

The impact of COVID-19 epidemic on eating disorders: A longitudinal observation of pre versus post psychopathological features in a sample of patients with eating disorders and a group of healthy controls.

OBJECTIVE: the aim of this longitudinal study was to evaluate the impact of COVID-19 epidemic on Eating Disorders (EDs) patients, considering the role of pre-existing vulnerabilities. METHOD: 74 patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) and 97 healthy controls (HCs) were evaluated before lockdown (T1) and during lockdown (T2). Patients were also evaluated at the beginning of treatment (T0). Questionnaires were collected to assess psychopathology, childhood trauma, attachment style, and COVID-19-related post-traumatic symptoms. RESULTS: A different trend between patients and HCs was observed only for pathological eating behaviors. Patients experienced increased compensatory exercise during lockdown; BN patients also exacerbated binge eating. Lockdown interfered with treatment outcomes: the descending trend of ED-specific psychopathology was interrupted during the epidemic in BN patients. Previously remitted patients showed re-exacerbation of binge eating after lockdown. Household arguments and fear for the safety of loved ones predicted increased symptoms during the lockdown. BN patients reported more severe COVID-19-related post-traumatic symptomatology than AN and HCs, and these symptoms were predicted by childhood trauma and insecure attachment. DISCUSSION: COVID-19 epidemic significantly impacted on EDs, both in terms of post-traumatic symptomatology and interference with the recovery process. Individuals with early trauma or insecure attachment were particularly vulnerable.

Partial rupture of anterior cruciate ligament: preliminary experience of selective reconstruction.

BACKGROUND: Partial lesions of the anterior cruciate ligament (ACL) are more common than is generally thought, accounting for about 10-12% of ACL injuries. Selective reconstruction may be considered as an option in isolated bundle rupture. The purpose of this study is to evaluate both subjective and objective clinical results, as well as functional recovery time, after selective arthroscopic single-bundle reconstruction in a consecutive series of patients affected by partial ACL rupture. MATERIALS AND METHODS: Thirty-six patients undergoing selective reconstruction of a single ACL bundle were retrospectively evaluated from a series of 354 ACL reconstructions performed over a 3-year period. Although the suspicion of partial lesions was present at clinical and magnetic resonance imaging (MRI) evaluation, final diagnosis was obtained during arthroscopy. All patients were operated using the same technique and type of fixation, and undergoing the same functional recovery protocol. RESULTS: Mean follow-up was 64 months (48-84 months). All patients but one achieved good functional recovery and returned to their sports within a mean period of 6.1 months. A single patient complained of postoperative instability 1 year after the index operation and needed further surgery. No complications were recorded. CONCLUSIONS: Selective reconstruction of partial ACL injury is a method to bear in mind because it offers quick functional recovery. Specific technical and diagnostic steps should be performed and discussed with patients preoperatively. LEVEL OF EVIDENCE: Level 4, retrospective study.

Total Knee Arthroplasty in Patients With Extra-Articular Deformity: Restoration of Mechanical Alignment Using Accelerometer-Based Navigation System.

BACKGROUND: Total knee arthroplasty (TKA) in patients with post-traumatic extra-articular deformity (EAD) is difficult to manage using conventional instrumentation techniques. In this study, we evaluate whether accelerometer navigation system can be a valuable option to make accurate bone resections and restore the neutral mechanical axis in complex TKA patients with EAD. METHODS: From May 2015 to June 2017, 18 consecutive TKA were performed in 18 patients with knee osteoarthritis with associated EAD. An accelerometer-based navigation system was used to guide tibial and femoral resection in the coronal and sagittal plane. Postoperative lower limb alignment in coronal plane and component position in coronal and sagittal plane was measured through full-leg weight-bearing X-ray. Clinical score were recorded using the Knee Society Score at the final follow-up. RESULTS: The mean hip-knee-ankle angle was 0.9° ± 1.4° varus alignment. The coronal alignment of the femoral component was 89.2° ± 1.9°, and the coronal alignment of the tibial component was 89.4° ± 2.1°. The sagittal alignment of the femoral component was 93.2°± 1.9°, and the sagittal alignment of the tibial component was 84.4° ± 3.1°. At the final follow-up, the Knee Society Score was 89 points (range, 82-100), and the functional score was 86.7 points (range, 60-100). No intraoperative and postoperative surgical complications were reported using this technology. CONCLUSION: Accelerometer-based navigation is accurate in achieving neutral mechanical alignment and optimal implant position after TKA in patients with EAD. This system should be considered a valuable option to the more complex technique of computer navigation or robotic surgery.

Post-operative 3D CT feedback improves accuracy and precision in the learning curve of anatomic ACL femoral tunnel placement.

PURPOSE: To evaluate the feedback from post-operative three-dimensional computed tomography (3D-CT) on femoral tunnel placement in the learning process, to obtain an anatomic anterior cruciate ligament (ACL) reconstruction. METHODS: A series of 60 consecutive patients undergoing primary ACL reconstruction using autologous hamstrings single-bundle outside-in technique were prospectively included in the study. ACL reconstructions were performed by the same trainee-surgeon during his learning phase of anatomic ACL femoral tunnel placement. A CT scan with dedicated tunnel study was performed in all patients within 48 h after surgery. The data obtained from the CT scan were processed into a three-dimensional surface model, and a true medial view of the lateral femoral condyle was used for the femoral tunnel placement analysis. Two independent examiners analysed the tunnel placements. The centre of femoral tunnel was measured using a quadrant method as described by Bernard and Hertel. The coordinates measured were compared with anatomic coordinates values described in the literature [deep-to-shallow distance (X-axis) 28.5%; high-to-low distance (Y-axis) 35.2%]. Tunnel placement was evaluated in terms of accuracy and precision. After each ACL reconstruction, results were shown to the surgeon to receive an instant feedback in order to achieve accurate correction and improve tunnel placement for the next surgery. Complications and arthroscopic time were also recorded. RESULTS: Results were divided into three consecutive series (1, 2, 3) of 20 patients each. A trend to placing femoral tunnel slightly shallow in deep-to-shallow distance and slightly high in high-to-low distance was observed in the first and the second series. A progressive improvement in tunnel position was recorded from the first to second series and from the second to the third series. Both accuracy (+52.4%) and precision (+55.7%) increased from the first to the third series (p < 0.001). Arthroscopic time decreased from a mean of 105 min in the first series to 57 min in the third series (p < 0.001). After 50 ACL reconstructions, a satisfactory anatomic femoral tunnel was reached. CONCLUSION: Feedback from post-operative 3D-CT is effective in the learning process to improve accuracy and precision of femoral tunnel placement in order to obtain anatomic ACL reconstruction and helps to reduce also arthroscopic time and learning curve. For clinical relevance, trainee-surgeons should use feedback from post-operative 3DCT to learn anatomic ACL femoral tunnel placement and apply it appropriately. LEVEL OF EVIDENCE: Consecutive case series, Level IV.

Effectiveness of extracorporeal shockwave therapy in three major tendon diseases.

BACKGROUND: Extracorporeal shockwave therapy is a conservative treatment for several painful musculoskeletal disorders. The aim of the study was the assessment of the relief from pain by the shockwave therapy in a population of consecutive patients affected by specific pathologies. MATERIALS AND METHODS: A group of consecutive patients were studied and treated. They were affected by calcific tendonitis of the shoulder (129 patients), chronic Achilles tendinopathy (102 patients), and lateral epicondylitis of the elbow (80 subjects). Each patient had 3 applications with a monthly interval, and was followed up at 1, 6, and 12 months after treatment. Results were evaluated by the numeric rating scale (NRS) in all cases, the Constant Murley Score for the assessment of the shoulder function, the American Orthopaedic Foot and Ankle Society Score for subjects affected by chronic Achilles tendinopathy, and the Oxford Elbow Score for those affected by a lateral epicondylitis of the elbow. RESULTS: One year after treatment, the results were considered satisfactory with an almost complete resolution of symptoms. There were statistically significant results at the 12-month follow-ups regarding the mean NRS score (from 6.25 to 0.2), the Constant Murley Score (from 66.7 to 79.4), the Oxford Elbow Score (from 28 to 46), and the AOFAS (from 71 to 86). CONCLUSIONS: Extracorporeal shockwave therapy may be considered a safe, economic, and effective treatment for several chronic musculoskeletal disorders, allowing satisfactory pain relief and improvement of function ability. LEVEL OF EVIDENCE: Level IV.

Techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions: a narrative review.

Background and Objective: Proximal femoral replacement due to revision hip arthroplasty or catastrophic proximal femur fracture fixation failures with considerable proximal femur bone loss can lead to a substantial loss of function of the soft tissue around the hip and the abductor muscles in particular. Surgical techniques of gluteus medius repair and/or abductor mechanism reattachment/reconstruction are widely debated in the literature, but it is quite rarely dealt with in the context of megaprosthesis and femoral reconstruction, particularly in non-oncologic patients. The aim of this study is to present a narrative review of the literature on techniques for abductor reattachment in proximal femoral replacement for non-oncological reconstructions. Methods: MEDLINE, Embase, and Cochrane databases were searched by two researchers independently from inception until February 1st, 2023 (923 for MEDLINE and 963 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date). Articles examining proximal femoral reconstruction with megaprosthesis or allograft prosthesis were included. Studies concerning cadaver and oncologic patients were excluded. If the researchers failed to find an agreement on whether to include a study, the senior researcher would make a final decision in such cases. Data were extracted and stored, and qualitative synthesis was performed. Key Content and Findings: A total of 1,157 articles from MEDLINE, 11,187 articles from Embase, and 0 articles from Cochrane were identified. Of 12,344 articles, the structured screening process revealed 10 eligible trials. Four different types of abductor musculature reconstruction/reinsertion were identified. Conclusions: Multiple and complex revision hip arthroplasties as well as multiple surgical procedures for proximal femur fracture fixations failures may have a great impact on proximal femur bone stock condition and soft tissue preservation requiring the use of a proximal femur megaprosthesis. In such cases, the abductor mechanism reconstruction and/or reattachment is achievable with different techniques that can be resumed in four different groups: direct suture to the prosthesis, trochanteric sleeve osteotomy, muscle-to-muscle suture, and synthetic tube augmentation suture.

Garrè Sclerosing Osteomyelitis of the Clavicle: Clinical Results after Clavicular Resection.

(1) Background: Chronic non-bacterial osteomyelitis (CNO), also known as sclerosing osteomyelitis of Garrè, is a rare inflammatory bone disease with a specific clinical picture, uncertain pathogenesis, and no consensus on an effective treatment. Most frequently affecting other long bones, CNO may rarely involve the clavicle. The aim of this study was to present the results of a series of patients affected by CNO of the clavicle treated with total and partial clavicula resection. In addition, a literature review of different types of treatment of CNO was performed. (2) Methods: We retrospectively reviewed three patients with Sclerosing Osteomyelitis of Garre' of the clavicle treated with partial resection of the clavicle (one) and with total clavicular resection (two). (3) Results: Patients (two female and one male) were an average age of 35.7 years at the time of the operation. At the 4-year follow-up, the mean active ROM was: 143° forward flexion, 133° abduction, 42° external rotation with an internal rotation of two patients at the interscapular level and one patient at the lumbosacral junction. The mean ASES score was 92/100 (range 87-100). In the literature review, after screening the abstracts and full texts for eligibility, 34 studies met the inclusion criteria. Conclusions: Partial or total clavicular resection resulted an effective treatment of CNO of the clavicle. The procedure seems to be particularly indicated after the failure of more conservative treatments.