A fast, easy and reliable method for hamstrings graft size prediction in anterior cruciate ligament reconstruction.

PURPOSE: The aim of this study is to describe and validate a simple and reliable method to pre-operatively predict the size of the ACL graft in the double strand technique with autologous semitendinosus-gracilis tendons on the same MRI used for ACL rupture diagnosis. METHODS: The study included 92 patients, with a median age of 31 years (IQR 26-41 years), 73/92 (79%) of whom were males. All patients that underwent an ACL reconstruction with doubled ST + GT between 2017 and 2022 were counted in the study. RESULTS: Overall, the median predicted graft diameter from MR imaging was similar to the actual graft diameter with no significant differences (n.s.). Regarding the comparison between predicted and actual graft size, concordance was 78/92 (85%, 95% CI 76-91%), with κ = 0.797 which corresponds to a level of agreement defined as "Strong". Tendon sizes calculated on pre-operative MRI were evaluated both with intra-observer and inter-observer reliability demonstrating a statistically reproducible method. The predicted graft was then compared to the reported one with a statistically significant reliability found. CONCLUSION: This study can help the surgeons to perform a fast pre-operative planning of an ACL reconstruction for graft selection. If the planned graft with ST and GT is smaller than 8 mm, the clinician can decide to switch to a different type of graft or plan a different graft preparing technique and, therefore, reduce the risk of post-operative ligament re-rupture. The method proposed is reliable and reproducible. The major strength of the planning technique proposed is that it relies on data that are already available for the clinician before surgery, without the need of further analysis. LEVEL OF EVIDENCE: IV.

Regional migratory osteoporosis of the knee: a literature overview.

The purpose of this article is to review the clinical syndrome of regional migratory osteoporosis (RMO) of the knee and to highlight all the important aspects of diagnosis and management that can be helpful to the physician. RMO is a rare, self-limiting disease characterized by migrating arthralgia, bone marrow edema and osteoporosis. The pathogenesis of RMO remains controversial and is not yet fully elucidated. A thorough presentation of the disease is conducted with presentation of the clinical features (progressive pain and local tenderness), differential diagnosis and appropriate diagnostic criteria. The role of MRI is underlined and strategies for the treatment of RMO are presented.

Accuracy of femoral tunnel positioning in medial patellofemoral ligament reconstruction: anatomic insertion leads to better clinical outcome.

PURPOSE: The medial patello-femoral ligament (MPFL) is considered the primary restraint against patellar dislocation and its reconstruction is indicated in recurrent patellar instability. An anatomical positioning of MPFL femoral insertion is recommended to achieve satisfactory clinical outcomes and prevent osteoarthritis (OA) due to an altered kinematics. The purpose of the study was first to assess the relationship between correct femoral tunnel position and better clinical outcomes and lower patellofemoral osteoarthritis rate. Second, correlation of outcomes with factors potentially affecting the results, such as the type of graft, patellar height and trochlear dysplasia. METHODS: Fifty-three patients (58 knees) who underwent MPFL reconstruction between 2009 and 2018 by a senior knee surgeon were retrospectively evaluated. Knee radiographs were performed before surgery, 12 months later and at last follow-up to assess trochlear dysplasia, patellar height and patellofemoral OA. The tibial tuberosity-trochlear groove (TT-TG) value was measured on a CT scan. The accuracy of graft positioning was evaluated on sagittal radiographs according to Schöttle et al. Subjective outcomes were collected before surgery, at 12 months and at last follow-up using several validated scores. RESULTS: Forty-six patients (51 knees) with a mean age of 24.1 ± 7.4 years were included in the study. Mean follow-up was 8.9 ± 2.1 years. A significant improvement in all clinical scores was observed at 12 months and final follow-up. Anatomic Insertion (AI) of reconstructed MPFL was considered optimal in 33 (64.7%) and sub-optimal in 18 (35.3%) patients. Sub-optimal AI resulted in lower Kujala, IKCD and higher VAS score (p < 0.01); moreover, for every 1 mm distance in any direction from the ideal insertion, a decrease of 0.8 [95% CI (-1.4; -0.2)] in Kujala score and 0.8 [95% CI (-1.3; -0.3)] in IKDC was observed. At final follow-up, 8 patients presented patellofemoral OA Iwano grade 3 (15.7%): although that incidence did not correlate to graft positioning, the use the artificial ligament in all these cases appeared to be significant. CONCLUSION: The present study confirms the importance of an optimal anatomic femoral insertion in MPFL reconstruction, reporting a significant positive correlation between graft positioning and clinical outcome. No significant correlations were found between anatomic insertion and patello-femoral OA development. LEVEL OF EVIDENCE: IV.

Good clinical results using a modified kinematic alignment technique with a cruciate sacrificing medially stabilised total knee arthroplasty.

BACKGROUND: This study aims to evaluate the clinical and radiological outcomes of a modified technique of Kinematically Aligned Total Knee Arthroplasty (KA TKA) using a cruciate sacrificing (CS) medially stabilised prosthesis at a minimum 24-months follow-up. METHODS: 59 patients with a varus HKA angle who underwent a TKA from May, 2016 to April, 2017 were retrospectively enrolled. Radiological and clinical evaluations were assessed after 40 days, 6 months and at a minimum follow-up of 24 months. Long leg standing X-rays were performed pre-operatively and the Hip-Knee-Ankle (HKA) angle, the mechanical Lateral Distal Femoral Angle (mLDFA), the mechanical Medial Proximal Tibial Angle (mMPTA) and the Knee Joint Line Obliquity Angle (KJLOA) were analysed. At a minimum follow-up of 24 months, the patients were evaluated subjectively based on the Western Ontario and McMaster Universities Osteoarthritis Index Score (WOMAC) and the Oxford Knee Score (OKS). The post-operative range of motion (ROM) was measured. To reduce flexion instability, an original technique was used, with more posterior positioning of the femoral component, called the "virtuous mistake". Results were compared to the data reported in the literature in patients treated with standard kinematic alignment (KA) technique. RESULTS: No difference was found between the mean pre-operative and post-operative angles regarding mLDFA (p value = 0.410) and mMTPA (p value = 0.242). A difference of 0.8° in HKA angle between males and females was found, with more varus results in males. At a minimum follow-up of 24 months, the WOMAC was 87 (SD 4.3), the OKS was 41 (SD 2.4), and the flexion was 124°, which was similar to the data reported in literature with standard KA. There were not any cases of aseptic failures. CONCLUSIONS: The modified KA TKA surgical technique proposed in this study can achieve good clinical results at minimum 24 months of follow-up, reproducing accurately native mLDFA and mMPTA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Autologous chondrocyte transplantation in the treatment of thumb CMC joint osteoarthritis.

Degenerative thumb carpometacarpal (CMC) joint osteoarthritis is a common disease in women starting at 40-50 years of age. Nevertheless, synovitis and initial cartilage damage start earlier, and then degenerative arthritis develops leading to joint narrowing with progressive exposure of subchondral bone, subluxation, osteophyte formation and joint deformity that can impact the surrounding joints. The aim of this study was to evaluate the outcome of patients treated with autologous chondrocyte transplantation at the thumb CMC joint at early stages. A prospective study on 10 cases of thumb CMC osteoarthritis in 8 patients was done. The thumbs were stage Eaton II (2 cases) and III (8 cases) and were treated by CMC arthroplasty with the implant of autologous chondrocytes by an open or arthroscopic technique. Two patients were treated bilaterally. Preoperatively all patients had persistent pain resistant to various kinds of nonoperative treatments for at least 1 year. Mean preoperative pinch strength was 3.7 Kg pain on VAS was 8, DASH was 55. All patients had limited abduction and flexion at the end range. Ethics committee approval was obtained for this study. Fragments of 3-4 mm of cartilage were harvested by arthroscopy or by an open technique from the wrist or elbow joint. Cartilage cells were sent to the laboratory to be grown on a collagenous biphasic matrix (MACI/Novocart®). After 3 weeks, the chondrocyte augmented scaffold was ready to be implanted in the thumb CMC joint, or frozen for a second operation later. All patients were females aged 42-67 years (mean 52 years). The dominant hand was treated in 6 cases. In 7 cases, the patients were operated with an open technique and in three cases by arthroscopy. Partial trapezium resection and dorsoradial ligament reconstruction was added to stabilize the CMC joint in most cases. Patients were seen in person at 1, 3, and 6, months, 1 year, 2 years, and 5 years after the initial surgery. Patients (nine thumbs) were then reviewed at a mean follow up 8 years (range 4.4-11 years); pain on VAS, Mayo, DASH and PRWE scores were evaluated at follow-up. One patient was lost to follow-up after 2 years. Of those nine hands, seven had an excellent result according to Mayo score, one had a good result. One thumb CMC joint was still painful and was reoperated and converted to arthroplasty after 4.4 years. All patients regained full range of motion. Mean pinch strength increased to 6.25 ± 1.3 Kg, mean DASH score was 7.3 ± 6.7; pain on VAS was 1.0 ± 1.5; these data were statistically significant compared to preoperative values (p < 0.01). Grip strength also increased in all cases, but this was not statistically significant. PRWE was 7.7 ± 6.4. No complications occurred postoperatively. The results obtained are encouraging since the implanted cartilage has lasted a mean of 8 years and up to 11 years. Biological tissue engineering techniques are being developed and could be a new solution to restore normal cartilage in young patients to postpone more aggressive surgical procedures until an older age. In cases of CMC joint instability, a ligament stabilization procedure was added to avoid subsequent damage to the implanted neocartilage. A longer follow-up and a greater number of cases are necessary to definitively establish the usefulness of this procedure, which has the advantage of being completely biological but the disadvantage of being costly.

Direct anterior approach and dual mobility cup: the "head-first" reduction technique: a technical note and early case series.

PURPOSE: Less invasive direct anterior approach (DAA) and dual mobility cup (DMC) are increasingly adopted in practice over the last decade. Their use aims to reduce, as much as possible, soft tissue dissection and dislocation rate. This study aims to present a novel surgical technique to reduce a DMC prosthesis during a DAA easily. METHODS: A mildly modified version of the direct anterior approach is proposed. When leg lengths, stability, impingement, and tension have been checked, the trial stem is disassembled in situ, dislocated, and removed, leaving the space to exchange the trial double mobility head with the definitive one. When the definitive stem is inserted, the surgeon guides and helps the assistant to match the trunnion in the double mobility head. As soon as the components are matched, the traction is released, and the unit is impacted by an alternation of axial traction and release. RESULTS: Of 164 patients who underwent primary total hip arthroplasty (December 2016-May 2017) by a single surgeon, a double mobility cup through DAA and the "head-first" technique was performed in 26 patients (15.8%). The mean operative time was 130 min (85-220 min; SD 34.28). No significant complications occurred during the mean follow-up of 23.6 months. CONCLUSIONS: Specific difficulties can be anticipated when pairing dual mobility cup and direct anterior approach. The "head-first" technique is a useful technique in reducing the possible difficulties related to the reduction of double mobility cup through a less invasive direct anterior approach.

Reliability of anterior medial collateral ligament plication of the elbow.

PURPOSE: The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series. METHODS: Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner. RESULTS: In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35-74.5] points; postoperative median OES was 17 [15.5-31.5] points; postoperative median MEPI was 65 [57.5-72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities. CONCLUSIONS: The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension. CLINICAL RELEVANCE: The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

It's time to change perspective! New diagnostic tools for lateral elbow pain.

PURPOSE: The presence of intra-articular findings that may complement the extra-articular pathology in lateral epicondilytis has been suggested, and a role for minor instability of the elbow as part of the causative process of this disease has been postulated. This study was designed to describe two new clinical tests, aimed at detecting intra-articular pathology in patients affected by recalcitrant lateral epicondylitis and investigate their diagnostic performance. METHODS: Ten patients suffering of atraumatic lateral elbow pain unresponsive to conservative treatment were considered in this study. Two clinical tests were developed and administrated prior to arthroscopy: Supination and Antero-Lateral pain Test (SALT); Posterior Elbow Pain by Palpation-Extension of the Radiocapitellar joint (PEPPER). Sensitivity, specificity, predictive values and accuracy of SALT and PEPPER as diagnostic tests for seven intra-articular findings were calculated. RESULTS: In 90% of the patients, at least one test was positive. All patients with signs of lateral ligamentous patholaxity or intra-articular abnormal findings had a positive response to at least one of the two tests. SALT proved to have a high sensitivity but a low specificity and is accurate in detecting the presence of intra-articular abnormal findings, especially synovitis. PEPPER test was sensible, specific and accurate in the detection of radial head chondropathy. CONCLUSIONS: Two new diagnostic tests (SALT and PEPPER) were specifically designed to evoke pain from intra-articular structures. These tests could be a valid support in the diagnostic algorithm of recalcitrant lateral elbow pain. Positive findings may be indicative of a minor instability of the lateral elbow condition. LEVEL OF EVIDENCE: Diagnostic study, development of diagnostic criteria on basis of consecutive patients, level II.

Different culture conditions affect the growth of human tendon stem/progenitor cells (TSPCs) within a mixed tendon cells (TCs) population.

BACKGROUND: Tendon resident cells (TCs) are a mixed population made of terminally differentiated tenocytes and tendon stem/progenitor cells (TSPCs). Since the enrichment of progenitors proportion could enhance the effectiveness of treatments based on these cell populations, the interest on the effect of culture conditions on the TSPCs is growing. In this study the clonal selection and the culture in presence or absence of basic fibroblast growth factor (bFGF) were used to assess their influences on the stemness properties and phenotype specific features of tendon cells. METHODS: Cells cultured with the different methods were analyzed in terms of clonogenic and differentiation abilities, stem and tendon specific genes expression and immunophenotype at passage 2 and passage 4. RESULTS: The clonal selection allowed to isolate cells with a higher multi-differentiation potential, but at the same time a lower proliferation rate in comparison to the whole population. Moreover, the clones express a higher amounts of stemness marker OCT4 and tendon specific transcription factor Scleraxis (SCX) mRNA, but a lower level of decorin (DCN). On the other hand, the number of cells obtained by clonal selection was extremely low and most of the clones were unable to reach a high number of passages in cultures. The presence of bFGF influences TCs morphology, enhance their proliferation rate and reduce their clonogenic ability. Interestingly, the expression of CD54, a known mesenchymal stem cell marker, is reduced in presence of bFGF at early passages. Nevertheless, bFGF does not affect the chondrogenic and osteogenic potential of TCs and the expression of tendon specific markers, while it was able to downregulate the OCT4 expression. CONCLUSION: This study showed that clonal selection enhance progenitors content in TCs populations, but the extremely low number of cells produced with this method could represent an insurmountable obstacle to its application in clinical approaches. We observed that the addition of bFGF to the culture medium promotes the maintenance of a higher number of differentiated cells, reducing the proportion of progenitors within the whole population. Overall our findings demonstrated the importance of the use of specific culture protocols to obtain tendon cells for possible clinical applications.

Risk factors for post-operative shoulder stiffness: are there new candidates?

The aim of this study was to document the incidence of postoperative shoulder stiffness (SS) after arthroscopic rotator cuff repair and evaluate the role of risk factors for its development. Seventy-five consecutive patients that underwent arthroscopic rotator cuff repair were included. The incidence of postoperative SS was prospectively investigated and the presence of 20 potential risk factors was documented retrospectively. The incidence of post-operative SS was 10.4%. All patients were women, and sex was significantly associated to pathology development (p=0.0067). The presence of gastroesophageal diseases was found to be significantly associated with post-operative SS development (p=0.0046). A significant association between the occurrence of post-operative SS and the presence of gastroesophageal diseases was identified. This finding, not yet reported in literature, deserves further investigation. The incidence of postoperative SS fell among previously reported ranges, with females significantly more affected than men.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis.

PURPOSE: The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques. MATERIALS AND METHODS: A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated. RESULTS: Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis. CONCLUSIONS: The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient. LEVEL OF EVIDENCE: III.

Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear.

BACKGROUND AND PURPOSE: Irreparable rotator cuff tears are a common cause of pain in adult population, requiring in many cases a surgical treatment. Possible alternatives are debridement, partial repair, muscle transfers and joint replacement. We evaluated two groups of patients with irreparable rotator cuff tear treated surgically: one group received an arthroscopic-assisted latissimus dorsi tendon transfer (LDTT), and the other an arthroscopic rotator cuff partial repair. Aim of our study was to compare clinical results and quality of life in two groups of patients with massive irreparable rotator cuff tear: one receiving an arthroscopic LDTT and the other receiving an arthroscopic rotator cuff partial repair. METHODS: Forty patients were assigned to two groups: 20 patients to group TT treated with LDTT and 20 patients to group PR treated with a partial repair. The average follow-up duration was 2.8 years (1-5, SD 3). Pre- and postoperative modified UCLA shoulder score, ROM, measurement of the strength and the rotator cuff quality of life (RC-QOL) were used to asses the outcome. RESULTS: LDTT showed significative improvements when compared to partial repair in UCLA score results, strength and RC-QOL questionnaire. No differences were found between the groups in pain relief. CONCLUSION: Both techniques are effective in reducing patients' symptoms. We believe that in younger, high-demanding patients with no or mild osteoarthritis, the LDTT represents a valid treatment option with better modified UCLA score improvement and strength at our follow-up.

Why menisci show higher healing rate when repaired during ACL reconstruction? Growth factors release can be the explanation.

PURPOSE: Healing rate of meniscus repair is higher when the suture is associated with anterior cruciate ligament reconstruction. A possible explanation can be a different pattern of release of growth factors between anterior cruciate ligament reconstruction and isolated meniscus surgery. Hypothesis of this study is that the concentrations of bFGF, TGF-ß and platelet-derived growth factor (PDGF) in joint fluid, immediately after single-bundle anterior cruciate ligament reconstruction and arthroscopic partial meniscectomy, can be different. METHODS: Twenty consecutive patients underwent partial medial meniscectomy and twenty consecutive patients underwent single-bundle anterior cruciate ligament reconstruction with hamstring grafts were enrolled in the study. Thirty minutes after the end of the surgical procedure, a sample of joint fluid, as well of venous blood, was collected from all the patients. Concentrations of growth factors were determined by enzyme-linked immunosorbent assay. RESULTS: The peripheral blood concentration of TGF-ß, bFGF and PDGF was comparable between partial meniscectomy and anterior cruciate ligament reconstruction groups. No differences between the two surgical techniques were also found in term of TGF-ß and bFGF joint fluid concentration, whereas joint PDGF concentration of anterior cruciate ligament reconstruction patients was significantly higher than the one found in partial meniscectomy patients. CONCLUSIONS: A significant growth factors release was detected in the knee joint during arthroscopic surgery. PDGF concentration was significantly higher in anterior cruciate ligament reconstructed knee than in the meniscectomy group. PDGF can play an important role enhancing the healing response of meniscus suture and can be one of the biological reasons of the higher meniscal healing rate in anterior cruciate ligament reconstructed knee.

Optimal glenoid component inclination in reverse shoulder arthroplasty. How to improve implant stability.

PURPOSE: The purpose of this study is to demonstrate that inferior inclination of the glenosphere is a protecting factor from joint dislocation in reverse total shoulder replacement. The hypothesis is that an average of 10° of inferior inclination of the glenoid component would determine a significant inferior rate of dislocation as compared to neutral inclination. METHODS: A retrospective case (dislocation)-control (stability of the implant) study was performed. Inclusion criteria were the homogeneity of the prosthetic model and availability of pre- and postoperative imaging of the shoulder, including antero-posterior and axillary X-ray views. Glenoid and glenosphere inclination were calculated according to standardized methods. Difference in between the angles determined the inferior tilt. RESULTS: Thirty-three cases fit the inclusion criteria. Glenoid and glenosphere inclination measured, respectively, 74.1° and 83.5°. The average tilt of the glenosphere measured 9.4°. The average tilt in stable patients was 10.2°. Tilt in patients with atraumatic dislocation measured, respectively, -6.9° (superior tilt) and 2.4°, while it was 8.3° for the patient with traumatic instability. The association between the tilt of glenosphere and atraumatic dislocation was significant. CONCLUSIONS: A 10° inferior tilt of the glenoid component in reverse shoulder arthroplasty is associated with a reduced risk of dislocation when compared to neutral tilt.

Complications related to fracture treatment in HIV patients: a case report.

We present the case report of a 40-year-old woman who was HIV-positive in Highly Active Anti-Retroviral Therapy (HAART) and affected by femural pertrochanteric fracture, which was treated by endomedullary nailing. Two years after the surgical operation, the woman developed an aseptic symptomatic osteolysis around the implant. Hardware removal was resolutive. Aseptic and septic hardware mobilization, hardware removal, and implant decision in HIV patients with pertrochanteric fractures is discussed. The authors suggest close follow-up and prompt hardware removal, as soon as X-rays demonstrate healing signs, in HIV patients with fracture fixation, if general condition allows.

Functional repair in massive immobile rotator cuff tears leads to satisfactory quality of living: results at 3-year follow-up.

PURPOSE: The aim of this retrospective study was to report clinical results of a selective population undergone to arthroscopic functional repair of massive, contracted, immobile rotator cuff tears. METHODS: From 2005 to 2009, 311 patients with rotator cuff tears were treated at our institution. Of them, 26 shoulders in 25 patients with a mean age of 64 years that presented a massive, contracted immobile tear repaired using an interval slide technique, were included in this study. RESULTS: The mean postoperative follow-up period was 39 months (range 19-70 months). The mean postoperative disabilities of the arm, shoulder and hand (DASH) score and simple shoulder test (SST) score were, respectively, 20.91 and 8.8 (range DASH: 0.83-59.1; range SST: 2-12). Based on single assessment numeric evaluation score, the outcome of surgery was satisfactory with a mean of 76 % (range 0-100 %). The residual level of pain was low, as reported by a final mean visual analog scale score of 1.8 (range 0-8). The mean postoperative range of motion was 157.5° in forward elevation (range 90°-180°) and 55.3° in extra rotation (range 0°-90°). Eleven patients reached mid-back, in 7, the lower back and in 8 cases, upper back. CONCLUSION: Arthroscopic functional repair could be considered an appropriate treatment option in case of massive, contracted and immobile cuff tears. This treatment can provide improvement in pain and function that positively affects patients' quality of life without precluding other, more invasive, eventually consequent solutions.

[Trends in prevalence of continuous positive airway pressure treatment for adults from 2006 to 2010]. / Évolution de 2006 à 2010 du nombre d'adultes traités par pression positive continue.

INTRODUCTION: The aim of this study was to evaluate the evolution from 2006 to 2010 of the prevalence of continuous positive airway pressure treatment for the beneficiaries of two regional health care insurance funds (17 and 43). METHODS: One million forty-eight thousand four hundred and thirty beneficiary-years were analyzed from 2006 to 2010. The prevalence of continuous positive airway pressure treatment was tested with regard to the effect of the year of delivery. A logit regression was used to adjust for potentially confounding differences in age and gender, which were included as covariates. The prevalence of alternative treatments and of controls of reimbursement benefits implemented by the funds are evaluated too during the same period. RESULTS: Continuous positive airway pressure treatment annual prevalence was 6.34/1000. A significant annual increase of prevalence from 2006 to 2008 was followed by a slowing of the rate of growth starting from 2008. In the same time for fund 43, obesity surgery rose from 41.85/100,000 to 55.44/100,000 and mandibular osteotomy surgery rose from 0.97/100,000 to 4.78/100,000. For fund 17 mandibular advancement devices rose from 10.72/100,000 to 21,08/100,000. The two funds started a reinforced inspections of reimbursement benefits for continuous positive airway pressure treatment in 2008. CONCLUSIONS: The dynamics of continuous positive airway pressure treatment have to be considered in the context of policies introduced and trends in the application of alternative treatments in each fund.

Risk factors for recurrence after Bankart repair a systematic review.

PURPOSE: Arthroscopic Bankart repair of anterior shoulder instability is a common practice in orthopedics. The aim of this study was to evaluate pre-operative risks factors associated with recurrent instability and to delineate possible indications for revision surgery. METHODS: A systematic review was performed including the following keywords: arthroscopy, Bankart repair, anterior shoulder instability, recurrence of instability, suture anchors and treatment outcome. Studies eligible for inclusion in the review were clinical trials published in the last 10 years investigating patients with anterior shoulder instability managed by an arthroscopic repair technique with suture anchors. The studies had to report data about recurrence of instability and investigational parameters (risk factors) that influenced the results referred to the rate of recurrence. Twenty-four articles were identified that met the inclusion criteria and underwent further review. Data from these studies were collected, and the risk of treatment failure was statistically recalculated. An estimate of the overall recurrence rate was obtained by pooling data about failure from the trials. RESULTS: The rate of recurrent instability at 10 years of follow-up ranged from 3.4 to 35 %. Epidemiological parameters significantly associated with the recurrence of instability were age below 22 years old, male gender, the number of preoperative dislocations and participation in competitive sports. Surgical parameters significantly associated with recurrence of instability were repair with fewer than three anchors and the use of knotless anchors. The patho-anatomical factors significantly associated with recurrences were substantial associated glenoid or humeral head bone loss and the presence of anterior labroligamentous periosteal sleeve avulsion. CONCLUSIONS: Knowledge of risk factors for post-operative outcomes allows surgeons to provide appropriate preoperative counselling to patients and support more realistic expectations. An accurate analysis of causes of failure should enable the correct revision strategy to be adopted. LEVEL OF EVIDENCE: II.

Complications associated with arthroscopic rotator cuff repair: a literature review.

The aim of this literature review was to report complications associated with arthroscopic rotator cuff repair (RCR). A computerized search of articles published between 200 and 2009 was performed using MEDLINE and PubMed. We included clinical studies (Level 1-4): (a) investigating patients with rotator cuff tears, managed by a completely arthroscopic RCR technique; (b) reported data about complications. Data about arthroscopic-assisted techniques were excluded. Articles that meet criteria inclusion were analytically examined. Complications were classified into general complications and specific complications related to arthroscopic RCR. We found 414 complications in 2,890 patients; most of them were specific complications related to arthroscopic RCR. Re-rupture was the most frequently encountered complication: re-tear rate ranged between 11.4 and 94%. Stiffness and hardware-related complications were observed in 74 and 12 patients, respectively. Eleven less common complications were also reported: 5 neurovascular, 3 septic, 2 thromboembolic events, and 1 anesthesiological complication. This review stated that arthroscopic RCR is a low-risk surgical procedure. Anatomical failure of the repair is the most common complication encountered in the literature.