Interposition Arthroplasty versus Dual Cup Mobility Prosthesis in Treatment of Trapeziometacarpal Joint Osteoarthritis: A Prospective Randomized Study.

BACKGROUND: Osteoarthritis (OA) of the trapeziometacarpal (TMC) joint is a common cause of pain and functional disability of the hand and is the second most frequent site in the hand of OA. This prospective randomized study analyses and compares the outcomes and global assessment of 2 different surgical techniques for rhizarthrosis treatment: trapeziectomy with tendon interposition arthroplasty and total joint replacement with Touch® (KeriMedical; Geneva, Switzerland) TMC prosthesis. METHODS: The enrolled patients were randomly divided into 2 groups: group A included 71 patients (75 hands) treated with tendon interposition arthroplasty, while group B included 65 patients (72 hands) treated with total joint replacement. Clinical and radiological outcomes were collected before surgery and at 1, 3, 6, 12, and 24 months of follow-up. RESULTS: Although the values of all clinical tests performed during follow-up demonstrated statistically significant improvement over preoperative ones in both groups, patients treated with prosthesis showed faster improvement, especially in tests of strength and range of motion, which showed better results than patients treated with trapeziectomy and tendon interposition arthroplasty throughout the follow-up. CONCLUSIONS: Our study suggests that joint replacement should be preferred to interposition arthroplasty as the treatment of rhizarthrosis, choosing the latter in case of prosthetic replacement complications or scaphoid-trapezium-trapezoid OA.

Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts.

Introduction The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.

Distraction Arthroplasty for Basal Thumb Osteoarthritis: 10-Year Follow-Up.

PURPOSE: Trapeziectomy has frequently been used to treat basal thumb osteoarthritis. However, complications, such as shortening of the thumb ray and reduced mobility and strength, can occur. The aim of this study was to present a 10-year follow-up of distraction arthroplasty without trapeziectomy. METHODS: Fifteen patients were followed for a mean of 121 months (range, 121-124 months). Subjective outcomes were evaluated with the Disabilities of the Arm, Shoulder, and Hand questionnaire, while the pain intensity was assessed with a Visual Analog Scale both before surgery and at the end of follow-up. Objective outcomes were obtained using the Kapandji score and an assessment of grip and pinch strength. Preoperative and final postoperative x-rays were obtained to evaluate metacarpal subsidence and progression of trapezial-metacarpal joint arthritis. RESULTS: The Visual Analog Scale score was reduced from 9.4 ± 0.5 before surgery to 2.5 ± 1 at follow-up. The mean Disabilities of the Arm, Shoulder, and Hand questionnaire score was 75.6 ± 12.6 before surgery and 16.9 ± 4 at 10 years. Hand grip strength of the operated side (26 ± 5.5 kg) achieved 95% of functionality compared to the opposite side, while key pinch strength (6.4 ± 1.6 kg) reached 93%. A Kapandji opposition score of 10 points was found in 12 patients, a score of 9 was found in 1, and a score of 8 was found in 2. CONCLUSIONS: Distraction arthroplasty of the trapeziometacarpal joint ensures good results in long-term follow-up, when performed in patients with stage I-II basal thumb osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle.

BACKGROUND: The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF. METHODS: All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures. RESULTS: The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis. CONCLUSION: This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.

Is it really necessary to perform venous anastomosis in vascularized corticoperiosteal bone flap? A randomized prospective 4-year follow-up study.

BACKGROUND: This study aims to investigate the treatment results of atrophic nonunion of the lower and upper limb with vascularized bone flaps performed with only arterial anastomosis versus the execution of flaps performed with arterial and venous anastomosis, comparing the surgical time and the healing rate of these two techniques. METHODS: 49 patients were enrolled in this study and were randomly divided into two groups: group A, the control group, consisted of 27 patients, who underwent vascularized corticoperiosteal bone flap with both arterial and venous anastomosis; group B, consisted of 22 patients, who underwent vascularized corticoperiosteal bone flap with only arterial anastomosis. The surgical time, the time to harvest the graft and the microsurgical time were evaluated. Radiological and clinical follow-ups were performed with one independent and blinded investigator to avoid bias. RESULTS: A significant reduction in the duration of the intervention in group B was found: a 13.63% reduction of the total surgical time and a 41.75% reduction of the microsurgical time. A significant difference was not found between groups A and B in bone healing time. All the patients of both groups were able to return to their daily life activities. CONCLUSIONS: Our investigation suggests that it isn't necessary to perform the venous anastomosis between the flap pedicle and the recipient area. Presumably, the venous blood flow reaches the systemic circulation through the vascular bone marrow network. Our procedure avoids venous trauma during the dissection and execution of the anastomosis and, therefore, can minimize complications such as venous thrombosis.

The effectiveness of Kinesio Taping in improving pain and edema during early rehabilitation after Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Control Study.

BACKGROUND AND AIM: The Kinesio Taping (KT) is being increasingly applied in physical therapy and rehabilitation. The aim of this study was to evaluate the effect of KT on an early rehabilitation program, in combination with the standard protocol after ACL reconstruction (ACLR). METHODS: This study enrolled 52 male patients, aged 18 to 45 years, who underwent ACLR with doubled gracilis and semitendinosus tendon (DGST) autograft. The patients were randomized into 2 groups: Group A (the control group) which received a standard rehabilitation protocol, and Group B (the experimental group), which had the same rehabilitation protocol plus the KT application. Pain intensity, range of motion, edema, thigh circumference, Tegner-Lysholm Scale and KOOS scale were measured at the second and fourth week follow-ups. RESULTS: Patients in the experimental group showed significant results during the second week for both pain and edema reduction compared to the control group (p< 0.05). After 4 weeks of rehabilitation, pain intensity in the two groups was similar (n.s.), while edema reduction in the experimental group showed a significant result compared to the control group  (p< 0.05). Nevertheless, the other outcomes did not show significant differences. CONCLUSIONS: The application of KT after ACLR contributed to relieve pain and reduce edema in the early postoperative rehabilitation period. Other potential benefits of KT on muscle activation and strength should be investigated through a longer follow-up and a targeted test.

Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle.

Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

The Effect of Shelter-In-Place on Orthopedic Trauma Volumes in Italy During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 outbreak heavily attacked Italy, putting a strain for an extended time on the National healthcare system.  Hospitals fastly rearranged the activity to cope with the crisis. This retrospective comparative study intended to investigate the impact of the lockdown imposed in Italy, in two different periods, during the COVID-19 outbreak on acute orthopedic trauma, in order to identify significant issues for improvement and future preparation. MATERIALS AND METHODS: We obtained data on total trauma access to a single University hospital DEA (Department of Emergency and Acceptance) in Rome during two periods of the COVID-19 pandemic lockdown in Italy: from March 9th, 2020 to May 4th, 2020(Phase 1), from May 10th, 2020 to June 30th, 2020(Phase 2) and then comparing them with the analogous period in 2019. We recorded demographic data; the characteristics of the lesion, including the anatomical area, fracture, sprain, dislocation, contusion, laceration, whether the lesion site was exposed or closed, where the trauma occurred and polytrauma. We also reported the waiting time in the emergency room and the mode of transport. RESULT: The study sample was composed of 1655 patients, 894 (54%) males and 761 (46%) females. The overall number of admissions in 2019 (pre-COVID-19 period) was 995; then it was 204 during Phase 1 and increased again to 456 during Phase 2. The average age of the Phase 1 group was 51.9 ± 24.8 years, significantly higher than that of the 2019 group (41.4 ± 25.7) and Phase 2 group (42.2 ± 22.5 years) (p<0.0001). In particular, elderly patients (>=65 years) were the most commonly involved in the Phase 1 group, while in the pre-COVID-19 period and in Phase 2 they were middle-aged adults (15-44 years) (p<0.0001). The injury occurred at home in 66.2% of cases in the Phase 1 group, in 32.3% of cases in the Phase 2 group and in 32.3% of patients in the 2019 group. Concerning the injury type, in all groups, the most frequent injury was a fracture (45.1% in 2019; 62.7% in Phase 1; 50% Phase2) (p<0.0001). The most injured anatomical section during Phase 1 was the upper limb (43.1%), while in the pre-COVID-19 group and in Phase 2 group the most frequent injury location was the lower limb (48.3% and 40.8% respectively). CONCLUSION: Despite the decrease of overall acute trauma referral rates during the COVID-19 outbreak in Italy, the incidence of fractures in elderly people remained constant, indicating that not all trauma presentations would inevitably decrease during such circumstances.

Surgical Treatment of a Voluminous Median Nerve Lipofibromatous Hamartoma Involving Distal Forearm: A Case Report.

CASE: Lipofibromatous hamartoma (LFH) is a rare benign tumor of the peripheral nerves, which often affects upper extremity. There is no consensus regarding management of these lesions. We report a case of median nerve LFH in the volar forearm of a 24-year-old man with carpal tunnel syndrome symptoms. Clinically, the mass appeared tender to palpation, ill-defined and soft, located on the volar aspect of the left forearm. Open epineurotomy and neurolysis of the median nerve were performed with full recovery at 1 year. CONCLUSION: Surgical approach may be resolutive in patients with large masses refractory to conservative treatment.

Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions.

BACKGROUNDS: Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. MATERIALS AND METHODS: The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. RESULTS: The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. CONCLUSIONS: Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

Prevention of symptomatic neuroma in traumatic digital amputation: A RAND/UCLA appropriateness method consensus study.

INTRODUCTION: The appearance of a symptomatic neuroma following finger amputation is a devastating consequence for patient's quality of life. It could be cause of chronic neuropathic pain. The prevention of neuroma formation is a challenging effort for hand surgeons. The biological mechanisms leading to neuroma formation are mostly unknown and different preventing procedures have been tried without certain results. In this paper, a panel of Italian hand surgeons have been asked to express appropriateness about potentially preventive techniques of neuroma formation following the RAND/UCLA appropriateness protocol. METHODS: A literature review was preliminarily performed identifying the most employed methods to reduce the pathologic nerve scar. Afterwards, the selected panelists were asked to score the appropriateness of each procedure in a double scenario: in case of a sharp amputation or in a tear injury. The appropriateness was evaluated according to RAND/UCLA protocol. RESULTS: Nine Italian hand surgeons were included in the panel. Of them 5 were orthopaedic surgeons, 4 plastic surgeons. The identified appropriate procedures were: revision amputation should be done in operating room, the neurovascular bundles should be identified and is mandatory to treat surrounding soft tissues. Only in case of clean-cut amputation, it is appropriate to perform a proximal extension of the dissection, to use diathermocoagulation and coverage with local flaps. Procedures such as shortening in tension of the nerve stump, bone shortening, implantation of the nerve end in the soft tissue, treatment in the emergency room and, in both scenarios, certain results are evaluated as uncertain. DISCUSSION: In order to prevent the formation of a distal stump neuroma few methods were judged appropriate. It is mandatory to identify the neurovascular bundles and treat also the surrounding tissues, but no certain results could be obtained with local flap, bone shortening and other ancillary surgical acts. Moreover, it is not possible to guarantee the non arising of neuroma in any cases, also when every procedure has been temped. CONLUSIONS: The prevention of distal neuroma is actually a challenge, without a well known strategy due to the variability of response of nervous tissue to injury.

The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions.

OBJECTIVES: The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. MATERIALS AND METHODS: 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). RESULTS: The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05).In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). CONCLUSION: The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions.

The use of Carbon-Peek volar plate after distal radius osteotomy for Kienbock's Disease in a volleyball athlete: a case report.

Kienbock's Disease, or lunatomalacia, has uncertain etiopathogenesis, it is more common in male from 20 to 45-year-old. The Lichtman's classification is the most used by authors and it divides Kienbock's Disease in 4 stages according to radiographic parameters. In early stages could be performed a conservative treatment, but failure rate is high; various surgical techniques are available in case of failure or higher stages. We report a case of a 26-year-old female volleyball player affected by stage I Kienbock's Disease who underwent distal radius osteotomy core decompression synthesized with Carbon-Peek plate fixation. Follow-up was performed with clinical evaluation (ROM analysis, VAS score, Quick Dash Score), wrist radiographs and wrist MRI.

The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study.

Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments.

Is dual cup mobility better than hemiarthroplasty in patients with dementia and femoral neck fracture? A randomized controlled trial.

PURPOSE: Treatment of patients with dementia and hip fracture is challenging. Total hip arthroplasty (THA) with dual mobility cup (DMC) has been designed to reduce the rate of dislocation by increasing the stability of the implant. This study aimed to compare the dislocation rates of DMC THA with hemiarthroplasty (HA) in elderly patients with displaced femoral neck fracture (FNF) and a diagnosis of dementia. METHODS: All patients with a displaced FNF and dementia diagnosis were prospectively randomized to hemiarthroplasty or THA with DMC treatment during a 2-year period. Finally, the outcomes of 30 patients in the HA group were compared with those of 30 patients in the DMC THA group. Dislocation rate at a minimum follow-up of 1 year was evaluated as the primary outcome. Reoperation rate, time to surgery, surgical time, length of hospital stay, and 30-day and 1-year mortality were also evaluated. RESULTS: There was a significant difference regarding rates of dislocation in favor of THA with DMC and with regard to length of surgery (p = 0.04) in favor of bipolar HA. Dislocation occurred in five patients (16.6%) treated with bipolar HA and no one (0%) in patients treated with THA with DMC (p = 0.019). There was no difference with regard to the 30-day mortality, 1-year mortality, reoperations, and length of hospital stay between the two groups of patients. DISCUSSION: THA with DMC seems to be a safe and reliable choice to reduce the rate of dislocation at 1 year in patients with dementia and FNF without a higher risk of mortality.

Suspension arthroplasty versus interposition arthroplasty in the treatment of trapeziometacarpal osteoarthritis: a clinical and magnetic resonance imaging study.

INTRODUCTION: Biological arthroplasties are the most used surgical techniques, for the treatment of trapeziometacarpal osteoarthritis; all of them provide the reconstruction of trapeziometacarpal joint by a tendon graft. The aim of the study is to compare two surgical techniques: interposition arthroplasty and suspension arthroplasty at 12-month follow-up in order to evaluate the clinical and radiographic results. METHODS: Sixty-seven patients surgically treated for basal thumb osteoarthritis were divided into two groups: 36 patients, (8 M; 27 F) (39 hands), treated with interposition arthroplasty are included in group A and 31 patients, (6 M; 25 F) (34 hands), treated with suspension are included in group B. Both groups were radiographically evaluated with X-ray and MRI at 12 months and clinically evaluated with DASH score, VAS, Grind test, hand grip tests, Kapandji test and ROM before surgery and at final follow-up. RESULTS: At final follow-up about Kapandji test, in group A, 31 hands (79.4%) presented Kapandji score of 10 and eight hands (20.6%), a Kapandji score of 8. In group B, six hands (17.6%) reported a Kapandji score of 8 and 28 patients (82.4%), a Kapandji score of 10 (p < 0.05). Regarding the radial abduction, patients of group A recovered on average 79.5° of abduction and in group B recovered on average 78°. About DASH score and VAS score, group B shows better results. Mean decalage was 2.3 mm in group A and 0 mm in group B. Jamar dynamometer shows statistically better results for group B in all tests (hand grip test, pulp pinch and key pinch test). CONCLUSIONS: Suspension arthroplasty seems to guarantee better outcomes in terms of pain reduction, clinical score and recovery of grip strength. Moreover, it seem to be associated with better results at MRI like absence of I ray decalage and minor scaphoid subchondral oedema at final follow-up.

The unhappy triad of the knee re-revisited.

AIM OF THE STUDY: To describe the surgical findings of the anterolateral complex in patients with the "unhappy triad" lesion of the knee. METHOD: One hundred and twenty-five consecutive patients presenting with acute anterior cruciate ligament (ACL) tears were selected for this study. Only cases, evaluated with a valgus stress test under fluoroscopy, with a medial opening more than 5 mm of the medial collateral ligament (MCL) were included in the study (11 patients). For the included cases, open MCL surgical repair was performed only in cases with a valgus stress test more than 10 mm as revealed by fluoroscopy (3 patients). All included cases (11 patients) underwent ACL reconstruction and exploration of the anterolateral complex that was then assessed, photographed, classified, and eventually repaired. RESULTS: At clinical evaluation under anaesthesia, all patients presented a positive Lachman test and a pivot shift test graded as ++ in four cases and +++ in five cases, not valuable in two cases. At surgical exploration, the anterolateral complex was involved in all cases (11 patients): one case demonstrated a type I injury, eight cases a type II injury, two cases a type III injury, and no patient with a type IV injury (Segond's fracture). All anterolateral complex lesions were repaired by direct suture and re-tensioning. DISCUSSION: On the basis of a recent analysis performed by other authors, we could speculate that injuries of ACL and anterolateral compartment occur in the very early phase of the injury when the knee is forced into internal rotation. The MRI evidence of bone bruising in the lateral compartment in most cases of the present series support the hypothesis of an internal rotation torque. CONCLUSIONS: The unhappy triad of injuries to the knee is actually a tetrad involving not just the ACL, MCL, and medial/lateral meniscus but also involved the anterolateral complex.

The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures.

BACKGROUND: Open reduction and internal fixation is the standard treatment for displaced ankle fractures. However, the presence of comorbidities such as diabetes mellitus and body mass index (BMI) are associated with poor bone quality, and these factors may predict the development of postoperative complications. The study aim was to assess the role of diabetes mellitus and BMI in wound healing in patients younger than 65 years who were surgically treated for malleoli fractures. METHODS: Ninety patients, aged from 18 to 65 years old, with surgically treated ankle fracture, were retrospectively enrolled. Patients were classified in two groups: patient with diabetes and patients without diabetes (insulin-dependent and noninsulin dependent). All patients were assessed for wound complications, Visual Analogue Scale and Foot and Ankle Disability Index (FADI) were assessed for all patients. Logistic regression was used to identify the risk of wound complications after surgery using the following factors as explanatory variables: age, gender, duration of surgery, BMI, hypercholesterolemia, smoking history, diabetes mellitus, and high blood pressure. RESULTS: In total, 38.9% of patients showed wound complications. Of them, 17.1% were nondiabetics and 82.9% were diabetics. We observed a significant association between DM and wound complications after surgery (P = .005). Logistic regression analysis revealed that DM (P < .001) and BMI (P = .03) were associated with wound complications. The odds of having a postoperative wound complication were increased 0.16 times in the presence of diabetes and 1.14 times for increasing BMI. CONCLUSION: This study showed that diabetes mellitus and higher BMI delay the wound healing and increase the complication rate in young adult patients with surgically treated bimalleolar fractures.

Preliminary experience with triangular CarboFix "Piccolo" Distal Radius Plate in wrist fractures. Clinical and radiological results.

Background and aim o the work In the recent last years there was a diffusion of new radiolucent plates for the treatment of distal radius fractures. The aim of our study is to evaluate the clinical and radiological outcomes at 12-month-follow-up for the treatment of distal radius fracture with the new triangular CarboFix "Piccolo" Distal Radius Plate. Methods All consecutive patients aged from 18 or over, who were treated for unstable distal radius fracture with a volar CarboFix "Piccolo" Distal Radius Plate with triangular design between September 2015 and May 2016, have been included in the study. From the original 28 patients, 6 patients were lost to the follow up or did not meet the inclusion criteria and 22 were available for the study.  The 22 patients were prospectively reviewed with dynamometric,radiographic and clinical evaluations (ROM, VAS, Quick DASH). Results The mean follow-up was 15.7 months. All fractures healed, and radiographic union was observed at an average of 5 weeks. All patients have recovery of R.O.M. comparable to the contralateral at the final follow up; with no significant difference (p>0.05) as regards extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm. At final follow-up, no patients had a statistically significant difference (p>0.05) of grip strength, comparing to the contralateral side. The mean Quick DASH was 9.3 and the mean VAS score was 2.3. Conclusion The most important finding of the present study was that the triangular CarboFix "Piccolo" Distal Radius Plate showed good clinical and radiological results in the treatment of distal radial fractures. These results are comparable to those achieved with conventional plates.

Comparison between Carbon-Peek volar locking plates and titanium volar locking plates in the treatment of distal radius fractures.

INTRODUCTION: Unstable intra articular fractures of distal radius are frequently being managed with open reduction and internal fixation. Volar locking plate based on polyetheretherketon (PEEK) polymer has developed lately as an alternative to conventional metallic devices. The advantage of this kind of plates include the lack of metal allergies, radiolucency, low artefacts on MRI or imaging scans and the high resistance associated to loading forces. The aim of this study was to evaluate the clinical and radiological results using a new Carbon-PEEK volar locking plate compared with titanium volar locking plates for the treatment of distal radius fractures. METHODS AND MATERIAL: Thirty patients were included in this study. They all underwent traumatic intra-articular distal radius fractures and were surgically treated with volar locking plates. The patients were randomly divided in two groups: In Group A (15 patients) the fracture was stabilized with a CarboFix volar locking plate whereas in group B (15 patients) with an Acu-Lock Volar Distal Radius Plate. Range of motion (ROM), grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score and X-rays were evaluated. The mean follow up was 12 months. RESULTS: Analysis of Wrist ROM revealed that there was no statistical significant difference (p > 0.05) in regards to extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm and between Group A and Group B. The mean score on the DASH was 15.3 in Group A and 13.2 in Group B (p > 0.05). Patients were able to return to their normal activities of daily living at an average of 4 weeks post-op in both Groups. Overall, the mean VAS score was 3.6 There were no statistically significant differences (p > 0.05) on X-Rays examination between two Groups in regards to alignment and fracture healing. CONCLUSIONS: Volar locking plates represent the most common procedure for the treatment of displaced distal radius fractures. In our series Carbon-peek volar locking plates seems to be analogue to titanium volar locking plates in terms of radiographic parameters and functional outcome.