Functional and radiographic outcomes of hallux valgus correction by mini-invasive surgery with Reverdin-Isham and Akin percutaneous osteotomies: a longitudinal prospective study with a 48-month follow-up.

BACKGROUND: Minimally invasive surgery (MIS) represents one of the most innovative surgical treatments of hallux valgus (HV). However, long-term outcomes still remain a matter of discussion within the orthopaedic community. The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy, following exostosectomy and lateral release. METHODS: Eighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed preoperatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Patient satisfaction and complications were recorded. Computer-assisted measurement of antero-posterior radiographs was taken preoperatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA) and the tibial sesamoid position. Also, the bridging bone/callus formation was evaluated at the different radiographic follow-ups, while the articular surface congruency and the metatarsal index were calculated only preoperatively and at the last follow-up. Patient satisfaction was assessed using the visual analogue score (VAS). Statistical analysis was carried out using the paired t test. Statistical significance was set at p < 0.05. RESULTS: The mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The post-operative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°, HVA 12.50°, DMAA 4.72° and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3 (3.75%). The complete healing of the osteotomies was achieved in all series at 3-month follow-up. However, the results obtained in the correction of the severe HV deformities were less encouraging. CONCLUSIONS: Minimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy, in combination with previous exostosectomy and subsequent lateral soft-tissue release, is a safe, effective and reliable procedure for correction of mild-to-moderate HV. However, it requires a long learning curve because of the inherent difficulty of the mixed different surgical procedures. TRIAL REGISTRATION: ClinicalTrials.gov PRS Protocol Registration and Results System: NCT02886221.

Minimally Invasive Surgery for Tibiotalocalcaneal Arthrodesis Using a Retrograde Intramedullary Nail: Preliminary Results of an Innovative Modified Technique.

The aim of the present longitudinal prospective study was to evaluate the clinical, functional, and radiologic outcomes and patient satisfaction of those who had undergone minimally invasive surgery (MIS) for tibiotalocalcaneal arthrodesis with an intramedullary nail. The 28 patients, who had consecutively undergone surgery with the MIS technique, were evaluated clinically and radiographically at 1, 2, 3, and 6 months after surgery and at last follow-up examination. For the clinical evaluation, the American Orthopaedic Foot and Ankle Society scale and visual analog scale for the foot and ankle were used in the preoperative and final follow-up examinations. The patients rated their satisfaction on a scale from 0 to 10. The mean score obtained with the American Orthopaedic Foot and Ankle Society scale was 68.28 ± 5.02 (range 58 to 74) points and with the visual analog scale for the foot and ankle was 70.76 ± 7.72 (range 58 to 82) points, with a mean follow-up of 25.07 ± 6.32 (range 6 to 40) months. The clinical improvement was statistically significant with both types of evaluation (p ≤ .05), comparing the preoperative and follow-up periods. Fusion was achieved in all patients, with a mean fusion time of 14.85 ± 4.12 (range 8 to 56) weeks. The alignment of the ankle and foot was optimal in 27 of 28 patients (96.42%), and patient satisfaction was rated as 6.71 ± 1.37 (range 5 to 10) points. Finally, the use of MIS for tibiotalocalcaneal arthrodesis with intramedullary nail results in fusion of the articulation with a low complication rate.

Endolog technique for correction of hallux valgus: a prospective study of 30 patients with 4-year follow-up.

BACKGROUND: Hallux valgus (HV) is a complex deformity of the forefoot altering the kinematics of walking. Many different treatment alternatives exist for the correction of hallux valgus, but to date, none has been shown to be more effective than any other. The rate of complications following hallux valgus surgery is variable and has been reported as ranging from 1 to 55 % in the scientific literature. The purpose of this preliminary prospective study was to evaluate the result of the Endolog device, an innovative titanium endomedullary nail, for the treatment of HV. METHODS: Thirty patients with mild-to-severe HV were treated with the Endolog device. Clinical evaluation was assessed preoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery with a final follow-up at 4 years, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Computer-assisted measurement of weight-bearing antero-posterior radiographs was taken preoperatively and postoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery. Non-weight-bearing radiographs were taken before the patients were discharged. The radiological parameters measured included the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tibial sesamoid position. Statistical analysis was carried out using the paired t test (p < 0.05). RESULTS: The mean AOFAS score was 93.98 points at the 48-month follow-up. The postoperative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections for each angular value at the last follow-up were as follows: IMA 5.95°; HVA 16.81°; DMAA 10.70°; and tibial sesamoid 1.36°. CONCLUSION: The Endolog is a safe and effective technique for the correction of HV deformity, to relieve pain and to preserve joint movement.

Anatomical and CT angiographic study of superior gluteal neurovascular pedicle: implications for hip surgery.

PURPOSE: To identify the site of incision with the lowest risk of injury of the superior gluteal neurovascular pedicle in the total hip arthroplasty with Hardinge's direct lateral approach. METHODS: Eight fresh donated bodies were dissected and the branches of the superior gluteal nerve (SGN) and superior gluteal artery (SGA) were dissected. The distance between the SGA and the apex of greater trochanter (GT) was also evaluated in vivo in 29 patients by CT angiography. RESULTS: We observed 12 spray pattern and 4 transverse neural trunk pattern of the SGN. In all cases the nerve runs inferiorly to the artery, with a mean distance of 0.5 cm. At the CT angiography the average distance between the main branch of SGA and the GT was 5.2 cm, indicating a mean distance of 4.7 cm from the SGN to the GT. Terminal branches of SGA are found until 2.7 cm from GT. CONCLUSIONS: This study analyzed the relationships between superior gluteal neurovascular pedicle and the GT in vivo (considering also the muscular tone), showing that during direct lateral access a safe area of 4.7 cm exists from the GT to the SGN and of 3.5 cm to its lower rami.

Prospective study of three surgical procedures for long head biceps tendinopathy associated with rotator cuff tears.

PURPOSE: simple tenotomy in the treatment of long head biceps (LHB) lesion offers good results, as well as tenotomy/tenodesis. MATERIALS AND METHODS: we prospectively evaluated 252 patients, divided into 3 groups, treated with rotator cuff repair associated with LHB tenotomy or 2 different types of tenodesis in cases where there had been a partial lesion of the LHB or instability of the bicipital groove. We ascertained whether there was residual pain and the presence of the "Popeye sign" in the post-operative stage. RESULTS: patients who underwent tenotomy alone achieved an improvement on the Visual Analogue Scale (VAS), Simple Shoulder Test (SST) and modified UCLA shoulder rating compared to patients who underwent LHB tenodesis. A positive Popeye sign is poorly perceived by patients. CONCLUSION: we considered the LHB tenotomy as treatment of choice for the rotator cuff surgical repair when there was an evident LHB lesion.

Clinical review of patients subjected to mini-Mumford arthroscopy.

PURPOSE: assessment of the clinical efficacy of isolated arthroscopic mini-Mumford surgery, associated with shoulder surgery in patients with degenerative disease of the acromioclavicular joint. MATERIALS AND METHODS: 52 patients (group A) underwent isolated arthroscopic mini-Mumford and 84 (group B) additional arthroscopic surgery of rotator cuff and/or long head of biceps. They were evaluated clinically using Visual Analogue Scale (VAS), Simple Shoulder Test (SST) and Modified UCLA shoulder rating, pre- and post-operatively after a mean period of 18.1 months. RESULTS: the results obtained in groups A and B overlap. DISCUSSION: arthroscopic mini-Mumford is a simple, low-risk procedure, which has proved effective in treating degenerative disease of the acromioclavicular joint, both in isolation and in association with reconstruction of the rotator cuff and/or biceps long head tenotomy.

Hypermobility of the first ray in ballet dancer.

Hypermobility of the first ray, which is caused by an instability of the first metatarsocuneiform joint, is one of the factors that induces hallux valgus and can be caused by technical mistakes in ballet practice. Correlation between ballet practice and hypermobility of the first ray. Using a modified Klaue device, mobility of the first metatarsocuneiform joint was measured (hypermobility ≥ 10mm) in both dorsal and dorso-medial directions in 264 feet in 2 groups of people: ballet dancers (non professional) and a control group of non-dancers. 45° mobility is statistically higher than dorsal mobility, and mobility in the ballet dancer group is higher than in the control group, but there is no correlation between hours of ballet and en-pointe shoe practice, and hypermobility of the first ray. First ray hypermobility, and even hallux valgus, in ballet practice is related to anatomical-hereditary factors and to incorrect technical execution.

Anterosuperior labral tear without biceps anchor involvement: a subtle isolated cause of a painful shoulder.

PURPOSE: The purposes of this study were to determine common clinical symptoms related to an anterosuperior labral tear without biceps anchor involvement and to establish the outcome of arthroscopic management of this injury. METHODS: In our database of arthroscopic procedures we identified 23 patients with an isolated anterosuperior labral tear. The mean age at the time of surgery was 38.3 ± 6.8 years (range, 18 to 59 years). The preoperative clinical diagnosis varied, but an anterosuperior labral isolated lesion was not detected before surgery. The diagnosis of anterosuperior labral tear was made arthroscopically, and the lesion was fixed with a suture anchor technique, by use of 1 single bioabsorbable anchor. Patients were reviewed after a minimum of 2.5 years of follow-up. Clinical outcome was evaluated with the Rowe score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. RESULTS: History, clinical examination, and preoperative imaging usually failed to indicate the presence of an isolated anterosuperior labral tear as the cause of shoulder pain in our patients. Repair of the labral lesions yielded good to excellent results with normalization of the range of motion and a significant improvement in shoulder scores (Rowe, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale). CONCLUSIONS: Isolated tears of the anterosuperior labrum represent a subtle cause of shoulder pain and dysfunction. The lesion is very difficult to diagnose clinically. Arthroscopic repair is a reliable procedure providing a good outcome in terms of pain relief, patient satisfaction, and shoulder scores. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Surgical anatomy of the axillary nerve and its implication in the transdeltoid approaches to the shoulder.

BACKGROUND: Traumatic and iatrogenic injuries of the axillary nerve (AN) are frequent in clinical practice; nevertheless, its anatomy and its relationships with the transdeltoid approaches to the shoulder are not well documented. MATERIALS AND METHODS: Anatomic study was performed on 16 shoulders of unembalmed cadavers. A proximal humeral internal locking system (PHILOS) plate was placed to simulate the osteosynthesis of a fracture of humeral surgical neck. The relationships between the plate and the nerve were evaluated. Selective dissection of all the nerve branches inside the deltoid muscle was performed. RESULTS: The mean distance between the point where the AN entered into the deltoid muscle and the humeral head was 5.0 cm, and it was 6.8 cm from the acromion. The mean distance between the origins of the anterior and posterior branches of the axillary nerve was 5.4 cm. The mean diameter of the AN was 0.57 cm, the anterior branch diameter was 0.40 cm, of posterior branch diameter was 0.33 cm, and the teres minor branch diameter was 0.24 cm. The application of the PHILOS plate demonstrated that in 100% of cases, the 2 distal holes of the plate of those dedicated to the humeral head coincided with the passage of AN. DISCUSSION: The different patterns of nerve branches inside the deltoid muscle show that the "safe zone" during transdeltoid approaches is the anterior region of the deltoid muscle for a maximum of 6.7 cm from the acromion. In addition, the insertion of the 2 distal screws of those dedicated to humeral head of the plate should be avoided.

Bone transport using the Ilizarov method: a review of complications in 100 consecutive cases.

We present the results of treatment of 100 patients (72 men, 28 women) by the Ilizarov method of bone transport using circular (55) and monolateral external fixators (45). A total of 26 femurs (18 monolateral, 8 circular) and 74 tibias (49 circular, 25 monolateral) was examined. There were no significant differences between the circular fixator and the monolateral fixator with regard to treatment time, complications in the treated bone segments or compliance with the presence of the fixator. The main complications (pseudoarthrosis at bone contact points after transport, insufficient ossification of lengthened bone, knee stiffness) were resolved with further treatment for all patients with the exception of one case which continued with repeated infections. The circular fixator allows for deformity corrections during bone transport but the monolateral fixator is tolerated better by patients, especially in those with femoral defects.

PHN for treatment of proximal humerus fractures: evaluation of 80 cases.

This paper analyses 80 cases of displaced proximal humerus fractures, with two or three fragments, treated by PHN nailing. The hold of the spiral blade was effective, and is particularly recommended for fractures with two fragments according to Neer's classification. The results, analysed with Constant's score and radiographic checkups, were satisfactory. Nearly all our patients (76 out of 80) had a mean age of 75 years and a total Constant score of 78.48. Only four (mean age 42.5 years) had a Constant score of 86. Shoulder articulation was good and only a few complications occurred.

Historical review of carpal tunnel syndrome.

The first description of median nerve compression in the carpal tunnel goes back to 1854, but it was only a century later that the term "carpal tunnel syndrome" (CTS) appeared in print. Until then, patients with symptoms, which we now know were due to CTS, were sometimes diagnosed as having acroparaesthesia, and at other times compression of the motor branch of the median nerve or the brachial plexus. The first description of an operation to open the carpal tunnel goes back to 1933, but only with Brain and Phalen was idiopathic CTS defined from both clinical and anatomopathological viewpoints. Since 1960, CTS has become the most frequently diagnosed of peripheral compression-induced neuropathies. The last part of this paper reports the latest theories giving an aetiological explanation of cases of CTS until now considered to be idiopathic.

The expansions of the pectoral girdle muscles onto the brachial fascia: morphological aspects and spatial disposition.

BACKGROUND/AIMS: The aim of this study was to analyse the relationships between the expansions of the pectoral girdle muscles, i.e. pectoralis major, latissimus dorsi and deltoid, and the brachial fascia. METHODS: Thirty shoulder specimens from 15 unembalmed adult cadavers were studied by dissection and in vivo radiological studies were performed in 20 patients using magnetic resonance (MR) imaging. RESULTS: The clavicular part of the pectoralis major muscle sent a fibrous expansion onto the anterior portion of the brachial fascia, its costal part onto the medial portion and medial intermuscular septum. The latissimus dorsi muscle showed a triangular fibrous expansion onto the posterior portion of the brachial fascia. The posterior part of the deltoid muscle inserted muscular fibres directly onto the posterior portion of the brachial fascia, its lateral part onto the lateral portion and the lateral intermuscular septum. In MR images, the brachial fascia appeared as a low-signal-intensity sinuous line of connective tissue, sharply delineated in T(1)-weighted sequences. CONCLUSION: The expansions of the pectoral girdle muscles onto the brachial fascia were present in all the subjects and showed a quite constant course with a specific spatial organization. During the various movements of the arm, these expansions stretch selective portions of the brachial fascia, with possible activation of specific patterns of fascial proprioceptors.

Histological characteristics of the deep fascia of the upper limb.

Post-mortem specimens taken from the antebrachial and brachial fasciae of 20 upper limbs were studied by histological and immunohistochemical staining in order to evaluate collagen fibre bundle arrangement, the presence of elastic fibres, and the density of innervation in deep muscular fascia. The study demonstrated that the fasciae are formed of numerous layers of undulating collagen fibre bundles. In each layer, the bundles are parallel to each other, whereas adjacent layers show different orientations. Each layer is separated from the adjacent one by a thin layer of adipose tissue, like plywood. Many elastic fibres and a variety of both free and encapsulated nerve endings, especially Ruffini and Pacini corpuscles, are also present, suggesting a proprioceptive capacity of the deep fascia. Thanks to the undulating collagen fibre bundles and elastic fibres, the fasciae can adapt to stretching, but this is only possible within certain limits, beyond which nerve terminations are activated by stretching. This mechanism allows a sort of "gate control" on the normal activation of intrafascial receptors. The capacity of the various collagen layers to slide over each other may be altered in cases of over-use syndrome, trauma or surgery. In such cases, the amortising mechanism of the fascia on the nervous terminations is lost, causing incorrect paradoxical activation of nerve receptors within the fascia, resulting in the propagation of a nociceptive signal even in situations of normal physiological stretch. At the same time, the layered collagen fibres allow transmission of tension according to the various lines of force. This structure of the muscular fascia guarantees perceptive and directional continuity along a particular myokinetic chain, acting like a transmission belt between two adjacent joints and also between synergic muscle groups.

Efficacy of platelet gel in reconstructive bone surgery.

Autologous platelet concentrate and cryoprecipitate, mixed to obtain a gel, have been successful in various operations, primarily oral and maxillofacial surgery. This study assessed the use of platelet gel in 19 patients undergoing 22 reconstructive bone surgical procedures. After a median follow-up of 12.9 months, improved osteoblastic reaction and reconstruction of physiologic bone structure was observed in all patients with no adverse reactions. These findings confirm the osteoinductive property of platelet gel in reconstructive bone surgery.