Keller's arthroplasty for hallux rigidus: A systematic review.

BACKGROUND: Several surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique's suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus. METHODS: Selected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications. RESULTS: Seventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%). CONCLUSION: Despite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients' selection.

Post-operative management after total ankle arthroplasty: A systematic review of the literature.

BACKGROUND: Currently, there is no consensus on the most appropriate post-operative management for patients undergoing total ankle arthroplasty. The aim of this study is therefore to offer a systematic review of the pertaining literature to identify current post-operative protocols and describe possible differences. METHODS: A systematic review to identify recent studies concerning the post-operative management after total ankle arthroplasty was conducted. Five topics were analyzed: length of hospital stay, type and duration of immobilization, weight-bearing management, post-operative pharmacological therapies, adopted rehabilitation scheme. RESULTS: Eighty-four studies met the inclusion criteria and were included in the review process. Most of the papers appear to have conflicting opinions with no consensus and homogeneous protocols. CONCLUSION: Due to various methodological limitations, it is not possible to provide sufficiently supported evidence-based recommendations, and it is therefore difficult to determine the superiority of one post-operative protocol over the others after total ankle arthroplasty.

Unicompartmental knee arthroplasty has higher revisions than total knee arthroplasty at long term follow-up: a registry study on 6453 prostheses.

PURPOSE: The purpose of this study is to analyse long-term unicompartmental knee arthroplasty (UKA) focusing on survivorship, causes of failure and revision strategy. METHODS: This study is a retrospective analysis of data from a regional arthroplasty registry for cases performed between 2000 and 2017. A total of 6453 UKAs were identified and the following information was analysed: demographic data, diagnosis leading to primary implant, survivorship, complication rate, causes of failure, revision strategies. UKA registry data were compared with total knee arthroplasty (TKA) registry data of 54,012 prostheses, which were implanted in the same time period. RESULTS: 6453 UKAs were included in the study: the vast majority of them (84.4%) were implanted due to primary osteoarthritis followed by deformity (7.1%) and necrosis of the condyle (5.1%). When compared to TKA, UKA showed lower perioperative complication rate (0.3% compared to 0.6%) but higher revision rate (18.2% at 15 years, compared to 6.2% for TKA). No correlation was found between diagnosis leading to primary implant and prosthesis survival. The most frequent cause of failure was total aseptic loosening (37.4%), followed by pain without loosening (19.8%). Of the 620 UKAs requiring revision, 485 were revised with a TKA and 61 of them required a re-revision; on the other hand, of the 35 cases where another UKA was implanted, 16 required a re-revision. CONCLUSION: UKA is associated with fewer perioperative complications but higher revision rates when compared to TKA. Its survivorship is not affected by the diagnosis leading to primary implant. Revision surgery of a failed UKA should be performed implanting a TKA, which is associated with a lower re-revision rate when compared to another UKA. LEVEL OF EVIDENCE: Level 3, therapeutic study.

A new ligament-compatible patient-specific 3D-printed implant and instrumentation for total ankle arthroplasty: from biomechanical studies to clinical cases.

BACKGROUND: Computer navigation and patient-specific instrumentation for total ankle arthroplasty have still to demonstrate their theoretical ability to improve implant positioning and functional outcomes. The purpose of this paper is to present a new and complete total ankle arthroplasty customization process for severe posttraumatic ankle joint arthritis, consisting of patient-specific 3D-printed implant and instrumentation, starting from a ligament-compatible design. CASE PRESENTATION: The new customization process was proposed in a 57-year-old male patient and involved image analysis, joint modeling, prosthesis design, patient-specific implant and instrumentation development, relevant prototyping, manufacturing, and implantation. Images obtained from a CT scan were processed for a 3D model of the ankle, and the BOX ankle prosthesis (MatOrtho, UK) geometries were customized to best fit the model. Virtual in silico, i.e., at the computer, implantation was performed to optimize positioning of these components. Corresponding patient-specific cutting guides for bone preparation were designed. The obtained models were printed in ABS by additive manufacturing for a final check. Once the planning procedure was approved, the models were sent to final state-of-the-art additive manufacturing (the metal components using cobalt-chromium-molybdenum powders, and the guides using polyamide). The custom-made prosthesis was then implanted using the cutting guides. The design, manufacturing, and implantation procedures were completed successfully and consistently, and final dimensions and location for the implant corresponded with the preoperative plan. Immediate post-op X-rays showed good implant positioning and alignment. After 4 months, clinical scores and functional abilities were excellent. Gait analysis showed satisfactory joint moment at the ankle complex and muscle activation timing within normality. CONCLUSIONS: The complete customization process for total ankle arthroplasty provided accurate and reliable implant positioning, with satisfactory short-term clinical outcomes. However, further studies are needed to confirm the potential benefits of this complete customization process. LEVEL OF EVIDENCE: 5.

How to prevent dislocation after revision total hip arthroplasty: a systematic review of the risk factors and a focus on treatment options.

BACKGROUND: Dislocation represents the most common complication after revision total hip arthroplasty (rTHA). Understanding risk factors for dislocation has a great clinical relevance for every hip surgeon in order to consider all surgical options for effective planning. The aim of this systematic review was to answer two main questions-(1) what are the risk factors for instability after rTHA? and (2) what are the best preoperative assessments and surgical options to avoid dislocation after rTHA? MATERIALS AND METHODS: Scientific databases were accessed to identify papers dealing with prevention and treatment of dislocation after rTHA. We performed a search using the keywords 'revision hip arthroplasty' and 'dislocation', 'instability', 'outcome', 'failure', 'treatment'. After removal of duplicates and exclusion of works published in different languages, 33 articles were reviewed completely. RESULTS: Risk factors were analysed in order to establish the most relevant and evidence-based treatments available in the current literature. CONCLUSIONS: The risk of dislocation after rTHA can be reduced using some precautions inferred from the literature. The use of a larger femoral and acetabular component, elevated rim liner and dual mobility implants can significantly reduce the risk of dislocation after rTHA. However, care must be taken regarding patient-related risk factors since these cannot be addressed and modified. Hence, a complete evaluation of risk factors should be performed for each patient and procedure before starting rTHA.

Modified minimally invasive direct anterior approach through a bikini incision for total hip arthroplasty: technique and results in young female patients.

Direct anterior approach for THA has gained popularity over the last years. However, concerns have been raised regarding the cosmetic, related to the incision that does not respect the Langer's skin tension line and may produce hypertrophic scars. The aim of this study was to analyze the preliminary results in 22 young female patients undergoing THA through a minimally invasive direct anterior approach using a modified oblique bikini incision. Clinical evaluations showed an improvement of WOMAC, UCLA and Harris Hip Score at 5-month follow-up. The technique ensured proper implant positioning and showed advantages in terms of complications, transfusion rates, hospital length of stay and functional recovery. From the aesthetic point of view, the expected cosmetic results were obtained. Minimally invasive direct anterior approach using a modified oblique bikini incision represent a viable option for THA, combining both the advantages of a minimal invasive procedure with a better aesthetic appearance.

Direct vertebral rotation and differently shaped dual rod translation technique in adolescent idiopathic scoliosis.

Direct vertebral rotation (DVR) is widely used to correct the axial deformity in adolescent idiopathic scoliosis (AIS). Indirect rotation techniques may help DVR in order to improve outcome. Vertebral translation technique combined with the use of two differently shaped rods resulted effective in reducing the rib hump deformity. The aim of this study is to describe the technique and evaluate the efficacy of combined DVR and vertebral translation technique on axial deformity correction. Mean follow-up was 2.7 years. Cobb angle, kyphosis angle, apical vertebrae axial rotation angle, SRS-22 questionnaire of 30 AIS patients treated with combined DVR and differently shaped dual rods translation technique were collected and compared preoperatively and postoperatively. At the last follow-up no screw pull-out, nonunion or loss of correction were recorded. The combination of DVR and differently shaped dual rods translation technique in AIS can provide good three-dimensional correction and improvement of patient's quality of life.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period.

Main surgical approaches to the hip have been modified during last decades, in an effort to reduce invasiveness of the surgical procedure and allow a faster rehabilitation. Direct anterior approach is the only approach, which does not require muscle detachment, thus theoretically leading to reduced post-operative pain and allows earlier recovery. The aim of this study was to report a comparison between patients operated with direct anterior approach and postero-lateral approach in terms of immediate post-operative and in-hospital records. Pain, operative time, intra- and post-operative complications, blood loss, hospitalization, motor component of the Functional Independence Measure (M-FIM), timed up and go (TUG) test were measured between the two groups and compared. Direct anterior approach showed better results in M-FIM, TUG, hospitalization and blood loss, without any significant difference for intra- and post-operative complications between the 2 groups. This study shows that early post-operative recovery is influenced by the chosen approach. Direct anterior approach showed better outcomes when compared to postero-lateral approach, limited to hospitalization, blood loss, and functional scores. Further comparisons are needed to evaluate direct anterior approach to maintain advantages over postero-lateral approach on longer follow-up period.

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review.

PURPOSE: Infrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting. METHODS: The available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords "Saphenous" and "Infrapatellar branch" in combination with "Anterior cruciate ligament", "arthroscopy" and "hamstrings", supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles. RESULTS: Five articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance. CONCLUSION: Although the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice. LEVEL OF EVIDENCE: Systematic review, Level II.

TGF-ß1 differentially modulates the collagen VI α5 and α6 chains in human tendon cultures.

Collagen VI is a microfibrillar collagen with a potential regulatory role in tendon repair mechanism. We studied the expression of collagen VI α5 and α6 chains in normal human tendon fibroblast cultures, both under basal condition and in response to TGF-ß1, a potent regulator of tendon healing. Under basal condition, we found that the α5 chain was expressed, although to a lesser extent with respect to the α3 chain; in contrast, the α6 chain was absent. The treatment with TGFß1 induced an opposite effect on the expression of the α5 and α6 chains; in fact, while the α5 chain was dramatically reduced, the α6 chain was induced and released in the culture medium. These data indicate that collagen VI α5 and α6 chains are differentially involved in tendon matrix homeostasis. The α6 chain may represent a new potential biomarker for monitoring TGFß1-related events in tendon, as healing and fibrotic scar formation.

Surgical treatment of insertional Achilles tendinopathy: a systematic review.

Insertional Achilles tendinopathy is a frequent cause of pain and performance impairment of the ankle. It is more common in runners, but may also affect general population. Conservative treatment is the gold standard in the early phases but 10% to 30% of patients require surgery. The aim of this study is to review the current literature in order to evaluate current surgical strategies for Insertional Achilles tendinopathy and to analyze the effectiveness of the available techniques. We performed a systematic review of the literature, to identify studies reporting clinical outcome after surgical treatment for Insertional Achilles tendinopathy in any population group with at least 6 months follow-up. The quality of the articles included was evaluated by the Coleman Methodology Score and correlated with the reported outcome and year of publication. We identified 16 studies reporting on 465 surgically treated Insertional Achilles tendinopathy with a mean follow-up of 29.8 months. Average age at the time of surgery was 53 years. Two different categories of surgical treatment were distinct: debridement alone or debridement with augmentation in case of excessive tendon loss. Results were excellent or good in 89.6% of cases and fair or poor in 10.4%. Average complications rate was 18.3%, with 15.7% of minor and 2.6% of major complications with no difference in the two groups. Negative correlation was found between Coleman Methodology Score and the reported outcome and positive correlation was found between Coleman Methodology Score and year of publication. Good or excellent outcome can be expected after surgical treatment for Insertional Achilles tendinopathy whatever the adopted procedure, but there is no specific evidence regarding which surgical technique provides a better outcome or a lower rate of complications. Research with higher levels of evidence and methodology that is more rigorous are needed in order to evaluate the optimal surgical strategy for patients with IAT.

Isolate acetabular cup revision through the direct anterior hip approach: surgical technique, early experience and review of the literature.

Direct anterior approach to the hip allows perfect exposure of the acetabulum and an easy proximal and medial extension that makes it eligible for isolate acetabular cup revision although it is seldom used and there are only few published studies. On 23 consecutive acetabular revision (16 cases Paprosky grade 1 or 2, 5 cases 3A, 1 case 3B and 1 case 4) at an average 28-month follow up, we did not record failures or major complications. Early complications included prolonged wound healing in 4 cases and transient femoral cutaneous nerve palsy in 2 cases, the mean postoperative Harris Hip Score was 82.2 with 82.5% of excellent and good results. Our results are consistent with those reported in the literature with similar techniques. The direct anterior approach has shown excellent results for isolated cup revision, though is probably better suited for surgeons that have some experience with the same approach for primary cases.

Simultaneous double rod and en-bloc direct vertebral rotation technique for correction of main thoracic adolescent idiopathic scoliosis: retrospective analysis of 14 cases.

Adolescent idiopathic scoliosis (AIS) is a triplanar deformity associated with rib hump, especially when a principle thoracic curve is present. The aim of this study is to evaluate the results of AIS correction retrospectively, using simultaneous double rod derotation manoeuvre technique followed by en-bloc direct vertebral rotation (DVR). Fourteen patients were included in this study. Coronal and sagittal thoracic Cobb angle, global coronal balance, sagittal balance, rib hump prominence, Scoliosis Research Society outcome instrument score (SRS-22) and Walter Reed visual assessment scale (WR-VAS) values were recorded pre- and postoperatively and evaluated. Results were evaluated at a mean follow-up of 2 years. Good to excellent radiographic and clinical results were obtained in all patients. No major perioperative complications occurred. This technique has proved to be effective for surgical correction of the deformity in Lenke type 1 AIS with good clinical and radiological results and low rate of complications.

Is a minimally invasive anterior approach effective in old patients? A pilot study.

Minimally invasive approach to the hip is a blood preserving surgery, with rapid rehabilitation, and low dislocation rate. Intuitively, these characteristics render this approach extremely suitable in the elderly patient. The aim of this study was to analyze the early clinical and radiographic results in the first 30 consecutive patients above 70 years of age undergoing THR through a minimally invasive anterior approach. Clinical evaluations showed an improvement of the Harris Hip Score and WOMAC score after surgery. Radiographic assessment showed cup orientation averaging 47° (range 40°–59°) and no valgus stem aligned. Allogeneic blood transfusion was required in only 6 patients (19.8%). One patient experienced an intraoperative fracture of the greater trochanter. No early implant dislocation was observed in the study population. In conclusion we advise a minimally invasive anterior approach for THR in older patients when a careful patient selection has been done.

Defective collagen VI α6 chain expression in the skeletal muscle of patients with collagen VI-related myopathies.

Collagen VI is a non-fibrillar collagen present in the extracellular matrix (ECM) as a complex polymer; the mainly expressed form is composed of α1, α2 and α3 chains; mutations in genes encoding these chains cause myopathies known as Ullrich congenital muscular dystrophy (UCMD), Bethlem myopathy (BM) and myosclerosis myopathy (MM). The collagen VI α6 chain is a recently identified component of the ECM of the human skeletal muscle. Here we report that the α6 chain was dramatically reduced in skeletal muscle and muscle cell cultures of genetically characterized UCMD, BM and MM patients, independently of the clinical phenotype, the gene involved and the effect of the mutation on the expression of the "classical" α1α2α3 heterotrimer. By contrast, the collagen VI α6 chain was normally expressed or increased in the muscle of patients affected by other forms of muscular dystrophy, the overexpression matching with areas of increased fibrosis. In vitro treatment with TGF-ß1, a potent collagen inducer, promoted the collagen VI α6 chain deposition in the ECM of normal muscle cells, whereas, in cultures derived from collagen VI-related myopathy patients, the collagen VI α6 chain failed to develop a network outside the cells and accumulated in the endoplasmic reticulum. The defect of the α6 chain points to a contribution to the pathogenesis of collagen VI-related disorders.

Under 2$ hand anesthesia? Our first 800 cases with Wide-Awake Local Anesthesia No Tourniquet (WALANT) in hand surgery.

INTRODUCTION: The Wide-Awake-Local-Anesthesia-No-Tourniquet (WALANT) technique is being used progressively more and more in hand surgery as it avoids tourniquet-related complications and saves money. MATERIALS AND METHODS: In the present study, we analyzed our cases of carpal tunnel syndrome or trigger finger operated upon with this technique from January 1, 2018 to December 31, 2022. RESULTS: We obtained 822 cases (426 carpal tunnel syndrome, 396 trigger finger) with an overall anesthesiologic efficacy (no need of additional anesthetic) of 97.8%. Patients were satisfied or very satisfied with the anesthetic choice in 99.8% of cases. CONCLUSIONS: We believe WALANT to be a safe and effective technique that every hand surgeon should have in his/her repertoire.

First Metatarsal Headphones-Like Lesion: A Case of Unreducible Sesamoid Complex Dislocation.

CASE: A 34-year-old woman sustained a direct trauma to the left hallux during a fall. Radiographs showed a dorsal dislocation of the first metatarsophalangeal joint and a wide separation of sesamoid complex. Closed reduction was tried: postreduction radiographs displayed reduction of first metatarsophalangeal joint and a complete sesamoid complex dislocation. The patient was scheduled for surgery. Through a medial approach, open reduction together with plantar structures release and repair were performed. Functional and radiographic outcomes were satisfactory at the last follow-up. CONCLUSION: In case of a "headphones-like lesion" surgery is required, together with plantar structures repair.

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

BACKGROUND: Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury. MATERIALS AND METHODS: The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles. RESULTS: Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance. CONCLUSIONS: In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

Injective Treatments for Sacroiliac Joint Pain: A Systematic Review and Meta-analysis.

Background: The most effective injective treatment approach for sacroiliac joint (SIJ) pain remains unclear. Aim of this study was to quantify the safety and effectiveness of the available injective strategies to address SIJ pain. Methods: A systematic review and meta-analysis of the literature was conducted on PubMed, Scopus, and Embase databases from inception until January 2023. Inclusion criteria were studies written in English, comparative and non-comparative studies regardless of the minimum follow-up, and case series on SIJ injections. Safety and efficacy of the different injection therapies for the SIJ were quantified. A meta-analysis was conducted on the available data of the documented injective therapies. The "Checklist for Measuring Quality" by Downs and Black was used to assess the risk of bias and the quality of papers. Results: The literature search retrieved 43 papers (2431 patients): 16 retrospective case series, 2 retrospective comparative studies, 17 prospective case series, 3 prospective comparative studies, and 5 randomized controlled trials. Of the selected studies, 63% examined the effect of steroid injections, 16% of PRP injections, while 21% reported other heterogeneous treatments. The failure rate was 26% in steroid injections and 14% in PRP injections. The meta-analysis showed a statistically significant reduction in pain with the VAS score for both steroids and PRP: steroids improvement at mid-term 3.4 points (p < 0.05), at long-term 3.0 (p < 0.05), PRP improvement at mid-term 2.2 (p = 0.007), at long-term 2.3 points of the VAS pain scale (p = 0.02). Conclusions: Steroids are the most documented injective approach, with studies showing an overall safety and effectiveness. Still, the high number of failures underlined by some studies suggest the need for alternative procedures. Early PRP data showed promise, but the limitations of the current literature do not allow to clearly define the most suitable injective approach, and further studies are needed to identify the best injective treatment for SIJ patients.

Incidental dural tears do not affect the overall patients' reported outcome of spine surgery at long-term follow-up: results of a systematic review.

To conduct a systematic review of the literature in order to establish if there is an overall adverse effect of accidental durotomy on the long-term patients' reported outcome after elective spine surgery. A systematic literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about pre- and postoperative clinical outcomes of patients with accidental durotomy and patients without were extracted and analysed. After screening, eleven studies were included with a total of 80,541 patients. About 4112 of these patients (5.10%) had incidental dural tear. When comparing patients with dural tear to patients without, 9/11 authors found no patients' reported differences at last follow-up. One author found a slightly worse VAS back pain in dural tear patients, and another author found inferior SF-36 and ODI scores in dural tear patients (both below minimal clinically important difference). Accidental dural tear did not have a significant adverse effect on clinical outcome of elective spine surgery. More studies are needed to better demonstrate this result.