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 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.

Early surgical treatment of first-time anterior glenohumeral dislocation in a young, active population is superior to conservative management at long-term follow-up.

PURPOSE: To compare the long-term effectiveness of non-operative treatment with immediate arthroscopic surgical stabilization in young, active patients after first-time anterior glenohumeral dislocation. MATERIALS AND METHODS: Consecutive patients aged 15-25 years who suffered primary traumatic anterior glenohumeral dislocation were enrolled in this prospective, non-randomized investigation. In total, 160 patients were enrolled-64 opted for surgical stabilization (group A), while 96 opted for conservative treatment (group B). At final follow-up of over 6.5 years, 60 patients in group A (96.7% males, age 22.8 ± 3.2) and 70 patients in group B (90.0% males, age 20.8 ± 2.9) were evaluated with physical examination, patient-reported outcome measures (PROMs), and radiological studies. Recurrence and return to sport (RTS) data were collected, and variables were compared between groups. RESULTS: Recurrence rate in group A was 13.3% at mean latency of 3.3 ± 1.9 years, compared to 71.4% at mean latency of 2.1 ± 1.5 years in group B (P < 0.001 for both recurrence rate and latency). In group A, 70.0% of patients RTS at the pre-injury level, versus 41.4% of patients in group B (P < 0.001). Patients in group A scored significantly higher on all PROMs (all P < 0.001) and had significantly less osteoarthritis (P = 0.004), when compared to group B. CONCLUSION: Acute surgical stabilization of first-time anterior shoulder dislocation in young, active patients is more effective than conservative treatment at long-term follow up, based on lower recurrence rate, better RTS, and higher patient-perceived improvement.

The Waterfall Fascia Lata Interposition Arthroplasty "Grika Technique" as Treatment of Posttraumatic Osteoarthritis of the Elbow in a High-Demand Adult Patient: Validity and Reliability.

INTRODUCTION: The elbow interposition arthroplasty is a very common procedure performed mainly on active young patients who need great functionality and for whom total joint replacement is contraindicated and arthrodesis is noncompliant. We are going to demonstrate a case of a 34-year-old male suffering from malunion of the distal humerus, elbow stiffness, and manifest signs of arthrosis of the dominant limb, treated with the IA Grika technique at a 5-year follow-up. PATIENTS AND METHODS: The chosen criteria to evaluate the injured side and the uninjured side during the clinical and radiological follow-up were the objective function and related quality of life, measured by the Mayo Elbow Performance Score (MEPS), and postoperative complications. To assess flexion and supination forces and elbow muscular strength, a hydraulic dynamometer was used. RESULTS: At a 5-year follow-up, the results were excellent as during the first year. CONCLUSIONS: The Grika technique is a valid and feasible option in the treatment of elbow injuries.

TEN versus external fixator in the management of pediatric diaphyseal femoral fractures: evaluation of the outcomes.

INTRODUCTION: Over the last 20 years, the incidence of pediatric diaphyseal femoral fractures was increased, due to changes in the children's daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, involvement of the soft tissues, and concomitance with other injuries. MATERIALS AND METHODS: From 2000 to 2015, 38 pediatric patients with diaphyseal femoral fractures were surgically treated and enrolled in the study. The average age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN) and the other 16 with external axial fixators. Comparing the two groups, radiographic images were taken to assess the fracture reduction and consolidation. RESULTS: The average follow-up was 14 months. The average time needed to remove the TEN nails was 5 months; while 2.5 months was the time to remove the external fixator. At the final follow-up, there were no differences between two groups in term of significant rotation defects, angulation, growth, and/or nonunion. CONCLUSIONS: This study showed that TENS and external fixation have similar results in term of fracture healing and complication, even if patients treated with TENS are more satisfied.

Comparison between locked and unlocked intramedullary nails in intertrochanteric fractures.

BACKGROUND: Intertrochanteric fractures are of great interest worldwide and are the most frequently operated fractures. Intramedullary nailing is commonly used in the treatment of intertrochanteric fractures. The purpose of this study is to assess the necessity of using the distal blocking screw in 31-A1 and 31-A2 fractures, classified according to the Orthopaedic Trauma Association classification system (AO/OTA). METHODS: This is a prospective study of 143 consecutive patients (mean age 85.01 years, mean final follow-up 14.1 months) surgically treated with the same intramedullary nail. In 75 cases, the distal locking screw was not used. Parameters evaluated during follow-up were: blood loss, transfusion requirements, surgery duration, and fluoroscopy time. Harris Hip Score and Barthel Activity Daily Living were used for the clinical evaluation. Radiographic Union Score For Hip (RUSH score) and Tip apex distance (TAD) were measured for radiologic evaluation. RESULTS: The group treated without locking screw showed significantly shorter surgical duration time (31.9 vs. 47.2 min), a decrease in blood loss (variation Hb - 1.06 vs. - 1.97), and reduced X-rays exposure time (25.4 vs. 31.6 s). No significant differences were observed in the postoperative period and in the radiographic and clinical scores. CONCLUSION: This study demonstrates that in intertrochanteric 31-A1 and 31-A2 stable fractures, the absence of distal locking screw does not compromise bone healing and prevents several clinical complications.

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.

The treatment of long bones nonunions of upper limb with microsurgical cortico-periosteal free flap.

BACKGROUND AND PURPOSE: Medial condyle corticoperiosteal flap is an emerging option for the treatment of upper limb non-infected nonunions. The hypothesis of our study is that corticoperiosteal flap could be an effective and safe procedure for the treatment of upper limb non-infected nonunions, evaluating radiographic and clinical outcome. METHODS: We enrolled 14 patients who underwent vascularized medial femoral condyle corticoperiosteal free flaps from January 2011 to December 2014. All patients were clinically evaluated (VAS, DASH) before surgery and at 6 and 12 months post surgery. The radiographic evaluation was performed every 30 days until the complete healing and at 12-month follow-up. We also recorded the range of motion pre and post surgery at the donor site. RESULTS: All nonunion sites healed primarily at an average time period of 5.2 months ±1. Preoperative DASH score was 70 ± 15.6; at 6 month follow-up was 21.51 ± 10.63; at 12 month follow-up 18.0 ± 9.9. Preoperative VAS was 7.05 ± 2; at 6-month follow-up was 2.1 ± 2; at 12-month follow-up was 1.8 ± 1.16. Statistical analysis showed a significant difference (p <0.001) about the preoperative and the postoperative VAS and DASH evaluation both at 6 and 12-month follow-up, but we did not record any statistical difference between the 6-month and 12-month follow-up. At the donor site, the mean VAS score was 2 ± 2.1 at seven days post operatively. All patients restore the full ROM at 7 days post surgery. CONCLUSIONS: Vascularized medial condyle corticoperiosteal free flap represents an effective and safe procedure for the treatment of upper limb nonunions.

The influence of playing surface on injury risk in italian elite rugby players.

BACKGROUND: There is a growing interest in the use of artificial turf surfaces in rugby. In particular, artificial surfaces may be an useful means of increasing participation in the sport by allowing greater usage of a given pitch, especially in regions where natural turf pitches are difficult to maintain. METHODS: The incidence of site, nature, cause, and severity of training and match injuries was prospectively recorded in two professional teams (one equipped with World Rugby certified third generation artificial turf and the other with natural grass over the 2014-2015 season). RESULTS: A total of 23,840 minutes of exposure was displayed for the whole sample, 1,440 minutes during matches and 22,400 during training sessions. We recorded 37 (48%) traumatic injuries and 39 (52%) overuse injuries. For traumatic injuries, we did not find significant differences in the overall risk injury between grass and artificial turf considering match exposure and training sessions. For overuse injuries, there were significant differences in the overall risk injury between grass and artificial turf considering match exposure (p=0.03) and training sessions (p=0.02). CONCLUSION: In elite Italian rugby players, artificial turf seems to be safe in regards to traumatic injury while it seems to be a risk factor for overuse injuries. LEVEL OF EVIDENCE: II.

Comparison between carbon-peek plate and conventional stainless steal plate in ankle fractures. A prospective study of two years follow up.

INTRODUCTION: The aim of our study is to compare the clinical and radiological outcomes of the treatment of distal fibular fracture with the traditional stainless steel or the new radiolucent CFR-PEEK plates. The hypothesis is that there are no differences in clinical and radiological outcomes at the final follow-up between the two fixation devices. METHODS: All consecutive patients aged from 18 or over, who had undergone operative treatment for malleolar fracture between 2013 and 2014, have been included in the study. 87 were available for the study. The patients were assigned to group A (47 patients, radiolucent plate group) and group B (41 patients, stainless steal plate group). At 6, 12 and 24 months all patients were prospectively reviewed with radiographic and clinical evaluations (OMAS scale, AOFAS, VAS, ROM). RESULTS: The groups were homogenous with regard to age, gender, BMI, dominance and disease duration. The mean follow-up was 23+/-2 months. The mean waiting time to operation was 2.94days (SD 2.74) (range 0.2-6.8). Statistical analysis showed no difference (p>0.05) about the VAS, OMAS, AOFAS and ROM evaluation at 6, 12 and 24 month follow-up between two groups. Radiographic evaluation showed no difference between two groups at all the follow-up with similar results obtained with the two fixation devices. DISCUSSION: Our results showed a substantial equivalence of the two fixation devices at 6, 12 and 24 month of clinical and radiographic follow-up. Fixation of the lateral malleolus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. These results are comparable to those achieved with conventional plates.

Can the outside-in half-tunnel technique reduce femoral tunnel widening in anterior cruciate ligament reconstruction? A CT study.

BACKGROUND: There are different techniques for drilling the femoral tunnel in the anterior cruciate ligament reconstruction (ACLR), but their influence in the bone tunnel enlargement in unknown. The purpose of this study was to compare two different surgical techniques for evaluating femoral tunnel enlargement in ACLR. The hypothesis was that tunnel placement using the outside-in technique leads to less tunnel enlargement compared to the transtibial technique. METHODS: Forty-four patients treated for ACLR between March 2013 and March 2014 were prospectively enrolled in this study. According to the surgical technique, subjects were assigned to Group A (Out-in) or Group B (Transtibial). All patients underwent CT examination in order to evaluate the femoral tunnel enlargement at four different levels. Moreover, all patients were evaluated with the Lachman test and pivot shift test, and the KT1000 arthrometer was used to measure the anterior laxity of the knee. A subjective evaluation was performed using the 2000 International Knee Documentation Committee Subjective Knee score, Lysholm knee score and Tegner activity scale. All patients were assessed after 24 months of follow-up. RESULTS: At the final follow-up, there were statistically significant differences (p < 0.05) in femoral tunnel enlargement between the two groups at all four femoral levels in favor of the out-in group. No statistical significant differences were found in the objective and subjective clinical outcomes between the two groups (p > 0.05). CONCLUSIONS: In ACLR with a suspension system, the outside-in technique leads to less enlargement of the femoral tunnel lower than the transtibial technique.

Can platelet-rich plasma have a role in Achilles tendon surgical repair?

PURPOSE: Our hypothesis was that the Achilles tendon healing process after surgical treatment would be promoted by PRP with a faster return to sports activities. METHODS: Thirty patients with Achilles tendon rupture and surgically treated with a combined mini-open and percutaneous technique were prospectively enroled in the study. Patients were alternately case-by-case assigned to Group A (control group; 15 patients) or Group B (study group; 15 patients). In Group B, PRP was locally infiltrated both during surgery and 14 days after surgery. Patients in both groups were followed up at 1, 3, 6 and 24 months post-operatively via physical examination, VAS, FAOS and VISA-A scales; ultrasonography (US) and MRI were also conducted at one and 6 months; at the 6-month follow-up, isokinetic and jumping capacity tests were also performed. RESULTS: The VAS, FAOS and VISA-A scale showed no difference between the two groups at 1, 3, 6 and 24 months post-operatively. Isokinetic evaluation showed no differences at both angular speeds. Jumping evaluation showed no difference at 6 months. Also US evaluation showed no differences. MRI data analysis before administration of gadolinium did not reveal significant differences between the two groups. Moreover, after intravenous injection of gadolinium, patients in Group B showed signal enhancement in 30 % of patients compared to 80 % in Group A at 6 months, as indirect evidence of better tendon remodelling (P < 0.05). CONCLUSIONS: A substantial equivalence in structural and functional results in Achilles tendon ruptures surgically treated with and without addition of PRP is shown by present study. Clinical results, morphological features and jumping capability were similar in both groups. The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results. LEVEL OF EVIDENCE: IV.

Acromioclavicular third degree dislocation: surgical treatment in acute cases.

BACKGROUND: The management of acute Rockwood type III acromioclavicular joint (ACJ) dislocation remains controversial, and the debate about whether patients should be conservatively or surgically treated continues. This study aims to compare conservative and surgical treatment of acute type III ACJ injuries in active sport participants (<35 years of age) by analysing clinical and radiological results after a minimum of 24 months follow-up. METHODS: The records of 72 patients with acute type III ACJ dislocations who were treated from January 2006 to December 2011 were retrospectively evaluated. Patients were categorised into two groups. group A included 25 patients treated conservatively, and group B included 30 patients treated surgically with the TightRope™ system. Seventeen patients were lost to follow-up. All patients were evaluated at final follow-up with these clinical scores: Constant, University of California Los Angeles scale (UCLA), American Shoulder and Elbow Surgeons Scale (ASES) and Acromioclavicular Joint Instability (ACJI) and with a subjective evaluation of the patient satisfaction, aesthetic results and shoulder function. The distance between the acromion and clavicle and between the coracoid process and clavicle were evaluated radiographically and compared with preoperative values. Δ, the difference in mm between the distance at the final follow-up and at T0 in the injured shoulder, and α, the side-to-side difference in mm at follow-up, were calculated. Heterotopic ossification and postoperative osteolysis were evaluated in both groups. RESULTS: There were no major intraoperative complications in the surgical group. The subjective parameters significantly differed between the two groups. Constant, ASES and UCLA scores were similar in both groups (P > 0.05), whereas ACJI results favoured the surgical group (group A, 72.4; group B, 87.9; P < 0.05). All measurements of radiographic evaluation were significantly reduced in the surgical group compared with the conservative group. In group A, we detected calcifications in 30% of patients; in group B we detected two cases of moderate osteolysis and calcifications in 70% of patients. CONCLUSION: Although better subjective and radiographic results were achieved in surgically treated patients, traditional objective scores did not show significant differences between the two groups. Our results cannot support routine use of surgery to treat type III ACJ dislocations.

Functional evaluation of professional athletes treated with a mini-open technique for achilles tendon rupture.

INTRODUCTION: in this study we report the functional results of 36 professional athletes treated with a combined percutaneous and mini-open technique. METHODS: patients were evaluated with Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the objective 100-points Hannover scale and the Ergo-jump Bosco System device. RESULTS: at a mean 28- month follow-up no re-rupture cases were observed. Six patients had minor complications. The Ergo-jump Bosco System device showed no significant differences in the side-to-side evaluation in regard to strength (-0.94%) and elasticity (+2.44%), while a significant post-operative loss was detected in the endurance trials (-6.78%). The Hannover scale showed an average score of 94.5, while the VISA-A had an average of 93.1. Thirty-one patients resumed their pre-operative sports activity level within five months from surgery. CONCLUSIONS: our results showed that the combined mini-open and percutaneous repair is an effective treatment for professional athletes, with satisfactory clinical and functional results, lack of major complications and a quick return to professional sports activity.