Unusual soft tissue metastases in a patient with chondrosarcoma: a case report.

Chondrosarcoma (CS) is the second most frequent primary malignant bone tumour, characterized by production of non-osteoid cartilage matrix. Up to more than 30% of patients with CS present distant metastases, and the lungs represent the preferred site. Hence, CS soft tissue metastases and superficial cutaneous lesions are extremely rare. We report the case of a female who developed unusual multiple soft tissue CS metastases. This patient underwent left hindquarter amputation for recurrent grade 3 chondrosarcoma of the femoral neck with extension to the pelvis approximately 4 years after internal fixation with an intramedullary nail for pathological fracture of left proximal femur and subsequent total proximal femoral endoprosthetic replacement for grade 1-2 chondrosarcoma. In the following years, she underwent metastasectomy for several grade 2 pulmonary metastatic chondrosarcomas. More than 14 years after the amputation, she presented with multiple unusual superficial cutaneous lesions, and a whole-body magnetic resonance imaging demonstrated multiple soft tissue foci of metastatic disease. The histology of multiple soft tissue lesions excised confirmed metastatic chondrosarcoma. Then, she underwent marginal excision of further multifocal soft tissue metastatic high-grade chondrosarcoma. Unlike the poor survival from the onset of these metastases in the other cases reported in the literature, our patient is still alive 2 years after the first multiple soft tissue excision of metastatic chondrosarcoma, and approximately 20 years after the diagnosis of chondrosarcoma. Soft tissue CS metastases are a rare entity with few cases described in literature. This study aims to make the reader aware of this lesser-known CS manifestation.

Femorotibial angle on short knee radiographs fails to accurately predict the lower limb mechanical alignment. A systematic review and meta-analysis on different femorotibial angle definitions and short knee radiograph types.

Introduction: Hip-knee-ankle angle (HKA) on Full Limb Radiographs (FLRs) is the gold standard for coronal knee alignment assessment. Despite the widespread utilization of the more convenient femorotibial angle (FTA) on either antero-posterior (AP) or postero-anterior (PA) short knee radiographs (SKRs), its definition and correlation with HKA remains controversial. This review is the first to systematically investigate FTA-HKA correlation and the effect of different FTA methods and SKRs. Methods: Systematic literature search (Pubmed, Scopus, Cochrane Library) followed PRISMA guidelines, to evaluate studies examining the FTA-HKA correlation. Meta-analyses compared the 3 most common FTA methods, knee center determination method and SKR types. Results: 17 studies (2597 patients, 3234 knees) were included. The strongest correlation with HKA (r = 0.78) was found for FTA Method 1 (angle formed by lines drawn from the midpoint of tibial spines to points 10 cm above and below the joint line). No significant differences were observed when grouping the FTA methods by knee center assessment (Group I, r = 0.78; Group II, r = 0.77). AP SKRs showed a trend towards stronger FTA-HKA correlation compared to PA SKRs, in both Method 1 (r = 0.79 vs 0.75) and Method 3 (r = 0.80 vs 0.66). Conclusion: Irrespective of its definition or type of SKR used, FTA lacks reliable accuracy in predicting the HKA in most knees. FLRs should be used whenever precise estimation of the patient's alignment is necessary. Caution is warranted in interpreting studies investigating knee alignment or knee arthroplasty outcomes based on FTA.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis.

BACKGROUND: Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion. MATERIALS AND METHODS: The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis). RESULTS: The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias. DISCUSSION: Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand. LEVEL OF EVIDENCE: Level-IV.

An unusual cystic presentation of pelvic skeletal Ewing sarcoma: a case series.

Ewing sarcoma (ES) is the second most common primary malignant bone tumour in children and adolescents. About 14.5% of primary malignancies develop in pelvic bones, where they typically have worse prognoses than extremity or acral sarcomas. It usually presents with aggressive features on radiology scans, but may also present with different radiological characteristics. In this series, we describe rare appearances of pelvic skeletal Ewing sarcoma, with large extraosseous cystic component on imaging, defined by the presence of fluid-filled spaces in the extraosseous tumour lesion, which distinguishes it from the solid nature of conventional ES. We report 3 cases of cystic presentation of ES, with imaging features supporting diagnosis of a primary malignant bone tumour arising from the superior pubic ramus with associated massive intrapelvic solid and cystic mass. CT-guided biopsy provided diagnosis of ES, with large intrapelvic soft tissue and cystic component. These patients underwent neo-adjuvant chemotherapy and proton beam therapy with significant reduction in size of the solid components, while the cystic components remained relatively unchanged. Two patients underwent surgical resection of the tumour (navigated P3 internal hemipelvectomy and hemipelvis P2/P3 resection, respectively), and one patient died while on treatment. In both who underwent surgery, histology showed ES with margins clear and more than 99% of treatment-induced necrosis. To the authors' knowledge, this unusual presentation of pelvic ES is described for the first time in the literature as a case series, with particular reference to atypical extraosseous cystic changes, along with the clinical and radiological characteristics, and their treatment.

Intraoperative Cone-Beam Computed Tomography Navigation Versus 2-Dimensional Fluoroscopy in Single-Level Lumbar Spinal Fusion: A Comparative Analysis.

OBJECTIVE: Several studies have advocated for the higher accuracy of transpedicular screw placement under cone-beam computed tomography (CBCT) compared to conventional 2-dimensional (2D) fluoroscopy. The superiority of navigation systems in perioperative and postoperative outcomes remains a topic of debate. This study aimed to compare operative time, screw placement time and accuracy, total radiation dose, perioperative and postoperative outcomes in patients who underwent transpedicular screw fixation for degenerative lumbar spondylolisthesis (DLS) using intraoperative CBCT navigation versus 2D fluoroscopy. METHODS: A retrospective analysis was conducted on patients affected by single-level DLS who underwent posterior lumbar instrumentation with transpedicular screw fixation using surgical CBCT navigation (NV group) or 2D fluoroscopy-assisted freehand technique (FH group). Demographics, screw placement time and accuracy, operative time, total radiation dose, intraoperative blood loss, screw revision rate, complications, and length of stay (LOS) were assessed. RESULTS: The study included a total of 30 patients (NV group: n = 15; FH group: n = 15). The mean screw placement time, operative time, and LOS were significantly reduced in the NV group compared to the FH group (p < 0.05). The total radiation dose was significantly higher in the NV group (p < 0.0001). No significant difference was found in terms of blood loss and postoperative complications. CONCLUSION: This study suggests that intraoperative CBCT-navigated single-level lumbar transpedicular screw fixation is superior in terms of mean screw placement time, operative time, and LOS compared to 2D fluoroscopy, despite a higher intraoperative radiation exposure.

Arthroscopic microfracture and associated techniques in the treatment of osteochondral lesions of the talus: A systematic review and metanalysis.

BACKGROUND: Osteochondral lesions of the talus are common in patients suffering even minor trauma; timely diagnosis and treatment can prevent the development of early osteoarthritis. The objectives of this systematic review and meta-analysis were to evaluate the effects of additional procedures on arthroscopic ankle microperforations for osteochondral lesions. METHODS: A systematic literature search was conducted using PubMed-Medline, Cochrane Central, and Google Scholar to select clinical studies analyzing the efficacy of platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow concentrate (BMC) procedures. Ten articles following PRISMA guidelines with a total of 464 patients were included in this review. Quality assessment using MINORS was performed, and all studies demonstrated high quality. RESULTS: The results of the systematic review showed benefits in all patients undergoing infiltrative therapy with PRP, hyaluronic acid, and BMC. The best results in terms of AOFAS score and VAS scale were found in patients undergoing PRP injection. The meta-analysis showed improvements in pain relief and return to daily activities in patients undergoing arthroscopic microperforations and PRP, although not reporting statistically significant results (p = 0.42). CONCLUSION: All treatment strategies reported better scores compared to the control groups. Among the various treatments analyzed, the addition of PRP appears to be the most valuable probably for the larger population receiving this treatment, showing excellent outcomes in pain reduction, clinical outcomes, and return to daily activities. LEVEL OF EVIDENCE: II.

Interventional treatments for low back pain due to sacroiliac joint dysfunction: a systematic review of the literature.

PURPOSE: This systematic review aimed to report the current evidence in the literature about the efficacy of interventional treatments in the management of low back pain (LBP) due to sacroiliac joint dysfunction. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, EMBASE, Scopus, CINAHL, Cochrane Library, and CENTRAL bibliographic databases were searched. The search was performed from October to December 2021, and articles from the inception of the database to December 2021 were searched. RESULTS: Fourteen studies were included for qualitative synthesis. Five studies used the traditional radiofrequency approach (tRF), five studies used cooled radiofrequency approach (cRF), one study used botulinum toxin (BT), two studies used steroid injection, triamcinolone (TA) and local anesthetics injections, and one study used pulsed radiofrequency (PRF) denervation. Two studies used sham as a comparator. CONCLUSIONS: Cooled radiofrequency seems to be the most effective treatment in improving pain and functionality, while intra-articular injections are helpful only as diagnostic tools. However, due to the lack of high-quality studies, it was not possible to draw significant conclusions.

No differences in terms of complications, readmissions, reoperations, and patient-reported outcomes in simultaneous bilateral versus staged bilateral total knee arthroplasty in selected patients.

BACKGROUND: The safety and the clinical success of simultaneous bilateral total knee arthroplasty (BTKA) is controversial. The aim of this study was to compare complications and patient-reported outcomes following simultaneous BTKA (simBTKA) versus staged BKTA (staBTKA) in patients affected by bilateral symptomatic end-stage knee osteoarthritis (OA). METHODS: Data from patients who underwent simBTKA or staBTKA at a single institution from January 2017 to December 2020, with a minimum 1-year follow up period were retrospectively collected. Differences in terms of complications and clinical success were compared among the simBTKA and staBTKA patient groups. Alpha was set at 0.05. RESULTS: A total of 173 patients were included in this study. The results revealed no statistically significant differences between the two groups in terms of mortality, revision rate, readmission rate, local and systemic complications and patient-reported outcomes. SimBTKA group had a shorter operating room time (96 (73-119) vs. 195 (159-227); P < 0.0001), and length of hospital stay (4 (3-5) vs. 7 (6-9); P < 0.0001) compared with the staBTKA group. CONCLUSIONS: SimBTKA performed in a selected patient population at a high-volume center can be considered comparable to staBTKA in terms of safety, postoperative complications, 30-day readmissions and patient satisfaction. Consequently, reduced operating room time and hospital stay renders simBTKA a cost-effective and advantageous option, not only for patients, but also for healthcare institutes. Furthermore, the current study also highlights the importance of correct patient selection based on clinical preoperative characteristics.

Machine learning can predict anterior elevation after reverse total shoulder arthroplasty: A new tool for daily outpatient clinic?

The aim of the present study was to individuate and compare specific machine learning algorithms that could predict postoperative anterior elevation score after reverse shoulder arthroplasty surgery at different time points. Data from 105 patients who underwent reverse shoulder arthroplasty at the same institute have been collected with the purpose of generating algorithms which could predict the target. Twenty-eight features were extracted and applied to two different machine learning techniques: Linear regression and support vector regression (SVR). These two techniques were also compared in order to define to most faithfully predictive. Using the extracted features, the SVR algorithm resulted in a mean absolute error (MAE) of 11.6° and a classification accuracy (PCC) of 0.88 on the test-set. Linear regression, instead, resulted in a MAE of 13.0° and a PCC of 0.85 on the test-set. Our machine learning study demonstrates that machine learning could provide high predictive algorithms for anterior elevation after reverse shoulder arthroplasty. The differential analysis between the utilized techniques showed higher accuracy in prediction for the support vector regression. Level of Evidence III: Retrospective cohort comparison; Computer Modeling.

Restricted kinematic alignment is clinically non-inferior to mechanical alignment in the short and mid-term: A systematic review.

BACKGROUND: In recent years, kinematic alignment (KA) is becoming a valid alternative to mechanical alignment (MA) in total knee arthroplasty (TKA). However, to avoid early failures, the restricted kinematic alignment (rKA) approach has been developed to restore native knee kinematics without reproducing extreme knee phenotype. This systematic review aims to evaluate clinical and radiological outcomes between rKA and MA for TKA. METHODS: A systematic literature search was conducted following PRISMA guidelines on Pubmed, Scopus and Cochrane Library. The following search string was adopted: (((restricted kinematic) AND (mechanical)) AND (alignment)) AND (knee). We included studies that analyzed rKA versus MA in terms of clinical outcomes and complications with a minimum of 6 months of follow up. The following rKA- and MA-related data were evaluated: patient-reported outcome scores (PROMs), radiographic analysis of lower limb alignment, and complications. Criteria from the Methodological Index for Non-Randomized Studies were used to assess the methodological quality of the articles. RESULTS: This systematic review included seven clinical studies with a total of 892 knees (471 for MA group and 421 for rKA group, respectively). Overall, post-operative PROMs were similar between rKA and MA. Moreover, rKA reached better results regarding Forgotten Joint Score and post-operative patient satisfaction. Finally, no higher complication rate was observed with the rKA approach. CONCLUSION: The rKA aims to restore native knee kinematics, avoiding extreme deformities. Clinical outcomes are not inferior or even better for rKA compared with MA, without increasing the risk of short-middle-term implant failure. However, there is a high heterogeneity regarding the 'restricted' protocols used.

Allograft Prosthesis Composite (APC) for Proximal Humeral Bone Loss: Outcomes and Perspectives.

(1) Background: Allograft prosthetic composite (APC) represents one of the techniques used for reconstruction in large proximal humeral bone deficits. The present systematic review aimed at summarizing the state of the art of the technique and analyzing its outcomes. (2) Methods: The PRISMA guidelines were followed to perform this systematic review. A systematic electronic search was performed using PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. All the studies analyzing the rates of allograft prosthesis composite were pooled, and the data were extracted and analyzed. (3) Results: A total of 10 studies were eligible for inclusion in this systematic review for a total of 239 patients. The rate of patient satisfaction with surgery was reported in 7 studies with a mean of 86.4% ± 13.64. The mean constant score was 45.7 ± 3.51, the mean ASES score was 63.58 ± 8.37, and the mean SST was 4.6 ± 1.04. The mean revision rate observed was 10.32% ± 3.63 and the mean implant survival was 83.66% ± 14.98. (4) Conclusions: Based on the currently available data, allograft prosthesis composite represents a valuable option for the reconstruction of proximal humeral deficits. All studies analyzed showed the favorable impact of this surgical technique on clinical outcomes and patient satisfaction.

MicroRNA expression changes in the development of rotator cuff tendon injuries.

Traumatic or degenerative rotator cuff (RC) tendon injuries are a leading cause of persistent shoulder pain and reduction of mobility with associated disability and dysfunction, which require each year more than 250,000 surgical repairs in the United States. MicroRNAs (miRNAs) are small noncoding RNAs, that in the posttranscriptional phase lead to the development and function of tissues. The aim of this review was to identify miRNA expression changes in patients with RC pathologies and to determine their relevance as a potential novel diagnostic and potentially therapeutic tool for RC disorders. Various miRNAs seemed to be key regulators in the muscle architecture, determining several modifications in muscle atrophy, skeletal muscle mechanical adaptation, lipid accumulation, and fibrosis in the presence of RC tears. The search was executed using PubMed, Medline, Scopus, and Cochrane Central. We included studies written in English that evaluated the role of miRNA in diagnosis, physiopathology, and potential therapeutic application of RC tendon injuries. We included 11 studies in this review. Many miRNAs emerged as key regulators in the pathogenesis of RC tears, inflammation, and muscle fatty degeneration. In fact, they are involved in the regulation of myogenesis, inflammatory cytokines, metalloproteases expression, muscle adaptation, adipogenesis, fibrogenic factors, and extracellular matrix synthesis. The gene expression may be altered in the pathological processes of tendon lesions. Therefore, the knowledge of all the gene mechanisms underlying RC tendinopathy should be achieved with future diagnostic and clinical studies.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis.

PURPOSE: Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA. METHODS: A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants. RESULTS: Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61). CONCLUSION: Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Unicompartmental knee arthroplasty (UKA) for primary spontaneous osteonecrosis of the knee (SONK): a systematic review.

Introduction: The role of unicompartmental knee arthroplasty (UKA) in spontaneous osteonecrosis of the knee (SONK) is still controversial. Materials and methods: We performed a systematic review to evaluate all available current literature on UKA in the setting of SONK. A comprehensive electronic research was performed using the PubMed, Embase, Web of Science, and Cochrane databases with keywords related to SONK and knee arthroplasty. Studies were selected with predetermined inclusion criteria: 1) studies that specifically assessed SONK treated with UKA; 2) studies reporting implant survival rate and global clinical outcomes; 3) studies with a minimum follow up of 1 year. We excluded articles not written in English, articles that did not differentiate between primary and secondary osteonecrosis and articles published before 2000. Results: The overall research process produced 19 studies. We extrapolated data of a total of 717 unicompartimental knee arthroplasty procedures (1,39% lateral UKA, 98,61% medial UKA). Extracted data include years of follow-up, patient demographics, laterality of lesion, radiological findings, unicompartimental knee arthroplasty implants, reason of revision, revision rate, maximum knee flexion, knee clinical outcomes score, and Kaplan-Meier survival curves. The data collected show that UKA had acceptable survival rates as well as revision rates and good clinical outcomes both in the short- and long-term. Conclusion: UKA is an optimal treatment choice for primary SONK when correctly indicated in a carefully selected subset of patients, with no significant difference compared to osteoarthritis. Attention must be paid to distinguish the primary from secondary SONK, as the latter could lead to worse outcomes.

Meniscal extrusion: risk factors and diagnostic tools to predict early osteoarthritis.

Meniscal extrusion (ME) is strongly correlated with cartilage wear and osteoarthritis (OA), be-cause of the altered kinematic and the decreased contact area between the tibia and femur. The aim of this narrative review is to analyze the process of ME, focusing on the possible causes, and to evaluate the correlation between ME and knee OA, in order to provide early diagnosis and treatments. Studies written in English that analyzed the causes of ME, provided indications re-garding diagnosis and treatment, and evaluated the relation between ME and early OA were in-cluded. Injuries, degeneration of the meniscal substance and meniscus root tears are associated with significantly increased ME. An extruded meniscus could be a manifestation of other pa-thologies such as disruption of coronary ligaments, cartilage loss, knee malalignment, ligament injuries, or OA. ME is strongly associated with osteoarthritis features, particularly with bone marrow lesion and cartilage damage. Magnetic resonance imaging represents the gold standard for the detection of ME. The severity of the medial meniscus extrusion may also affect healing af-ter repair, and meniscus extrusion is not completely reduced by meniscus posterior root tear re-pair. In this study, we proved that ME represents an important risk factor for early knee OA. We provided alternative theories of ME, such as meniscal fibers injury first and "dynamic extrusion of the menisci". The phenomenon of aging has been described as a new concept in the etiology of ME. Finally, we stated all the main techniques and characteristics of the diagnostic process, as well as the current knowledge in the therapeutic field.

The role of patient surgical positioning on hip arthroplasty component placement and clinical outcomes: a systematic re-view and meta-analysis.

Total Hip Arthroplasty (THA) may be performed through various approaches; however, depending on the surgical position of the patient, the superiority of lateral or supine position is still debated. The aim of this systematic review and meta-analysis was to compare the supine versus lateral position in THA in terms of intraoperative and postoperative outcomes and component placement. The systematic literature search was performed by the use of Cochrane Central, Pub-Med-Medline, and Google Scholar in order to select studies that evaluated clinical outcomes and the outliers of cup alignment for inclination and anteversion between supine and lateral position for hip arthroplasty. Finally, 9 articles were included in this review. The meta-analysis showed no significant differences between the two groups for clinical outcomes, unless for blood loss and VAS (respectively p = 0.05 and p = 0.004 in favour of lateral decubitus). Regarding the number of outliers, the supine decubitus showed significant differences only for the cup anteversion (p = 0.01). However, more prospective studies with a longer follow-up that analyze both clinical and radiological parameters are needed to assess the superiority of supine or lateral patient position for total hip arthroplasty.

Dual-mobility total hip arthroplasty in patients younger than 55 years old: a systematic review.

Total hip arthroplasty (THA) is regarded as one of the most successful and cost-effective orthopedic procedures. However, THA is a surgical procedure with potential intraoperative and postoperative risks. Dislocation is one of the common postoperative complications and remains one of the main indications for THA revision. The purpose of this systematic review was to evaluate the role and the outcomes of dual-mobility implant to prevent dislocation in patients younger than < 55 years in primary THA. In this systematic review, we included observational, prospective, and retrospective studies that evaluated the outcome and the complications of the dual-mobility cup in < 55-year-old patients. After applying exclusion criteria (femoral neck fractures or THA revision, case series, reviews, and meta-analyses), ten articles were included in the study. The overall number of participants in all the studies was 1530. The mean age of the participants was 50 years. The mean follow-up was 11.7 years. A total of 46 patients (2.7%) reported intraprosthetic dislocations, in which the polyethylene liner dissociates from the femoral head, while 4.8% of revision was due to aseptic loosening. The mean revision rate at twelve years was 11%. The mean value of Harris Hip Score increased from 50.9 pre-operatively to 91.6 after surgery. Dual mobility is a valid option for young patients with extended survivorship and low rates of instability and dislocation after primary THA.

Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVES: The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS). METHODS: Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups. RESULTS: The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS. CONCLUSIONS: Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.

Early return to activity of daily living after total hip arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Total hip arthroplasty (THA) is an orthopaedic procedure that improves the quality of life in patients suffering from hip pain related to osteoarthritis, fractures, and avascular osteonecrosis of the femoral head. Different surgical approaches can be used for THA leading to different recovery times. Because of the lowering medium age of people undergoing THA, it is important to focus on the earlier return of physiological activity after surgery. AIM: To evaluate the best approach for THA in terms of earlier return to activity. METHOD: Studies comparing the postoperative outcomes in patients who underwent THA through different approaches were analysed focusing on patients' self-reported outcomes, ADL score and UCLA activity score with a short follow-up. RESULTS: A total of 1990 articles were identified in the search, and 14 met the inclusion criteria. The Review Manager software version 5.4 was used to conduct a meta-analysis to compare the direct anterior (DAA) and posterior (PA) approaches, which are the most adopted approaches. An earlier return to walk without aids and to independent ADLs were reported with DAA, but without statistical significance (respectively p = 0.06 and p = 0.10). The time to return to drive was similar among the 2 groups (p = 0.88). The return to work was faster with PA, but no statistical significance was reported (p = 0.47). CONCLUSIONS: Further studies are needed with a larger number of patients, that present homogeneous outcomes, follow-ups and rehabilitation programmes, and that compare similar surgical approaches to assess the early return to activity of daily living after THA.

Modular versus monoblock stem in revision total hip arthroplasty: a systematic review and meta-analysis.

Background: Total hip arthroplasty (THA) is estimated to grow in the following decades with a consequent increase of THA revisions (rTHA). This systematic review and meta-analysis aims to compare modular and monoblock stem in rTHA surgery, focusing on clinical and radiological outcomes and complication rates. Methods: A literature search was performed using the following search strategy: ((Modular stem) OR (monolithic stem)) AND (hip review) on PubMed, Scopus, and Cochrane. Randomized controlled trials (RCTs) and observational studies (OS) compared clinical and radiological outcomes, and complication rates for monoblock and modular revision femoral stem were included. The risk of bias was assessed through the Methodological Index for Non-Randomized Studies (MINORS) score. The Review Manager (RevMan) software was used for the meta-analysis. The rate of complications was assessed using odds ratio (OR) with 95% confidence intervals (CIs). Results: The authors included 11 OS and one RCT with 3,671 participants (mean age: 68.4 years old). The mean follow-up was 46.9 months. There was no prevalence of subsidence for one type of stem. Mean subsidence was from 0.92 to 10 mm for modular stem and from 1 to 15 mm for monoblock stem. Postoperative Harris Hip Score (HHS) showed better results with modular stems without statistical significance [mean difference (MD) =1.32; 95% CI: -1.62 to 4.27; P=0.38]. No statistically significant difference was found for dislocations (OR =2.48; 95% CI: 0.67 to 9.14; P=0.17), infections (OR =1.07; 95% CI: 0.51 to 2.23; P=0.86), intraoperative fractures (OR =1.62; 95% CI: 0.42 to 6.21; P=0.48), and postoperative fractures (OR =1.60; 95% CI: 0.55 to 4.64; P=0.39). Conclusions: Modular and monoblock stems show comparable and satisfactory clinical and radiological outcomes for rTHA. Both stems are valid and effective options for managing femoral bone deficit in hip revision surgery. The main limitation of this study is the small number and low quality of enclosed studies that compared the two stems. Moreover, the modular stem is usually used for more complex cases with lower quality femoral bone stock.