Outpatient paediatric hand surgery: strategy in healthcare implementation and cost-efficient manner.

The increasingly cost of health care is a relevant problem as well as prolonged waiting time for admission also in emergencies. Effective cost containment measures and expenditure controls are needed to achieve and maintain clinical and organizational appropriateness. Outpatient management has proven to be the most useful method for lower-cost treatment in less severe pathologies, requiring surgery without hospitalization. The current study provided to evaluate how this model was successfully applied also to the paediatric population in hand surgery. Methods. A retrospective cohort study of 645 patients from 8 to 18 years (mean age 14.9) was performed in children treated in outpatient setting from 2015 to 2019. The direct costs were evaluated as well as the mean waiting time for surgery, comparing the data with the previous five-year period. The mean reduction in waiting time for children emergencies was 57% (from 72 to 31 h) due to the Outpatient setting into a dedicated Day-Surgery Service organizational model. The visual graphed data showed a general clear growing trend towards outpatient surgery in adults and children. The overall effect was a 29.2% of reduction in spending between expected and achieved costs, recovering resources toward the increasing technology and innovation expenditures. Outpatient paediatric hand surgery was an effective and attractive option which leaded to decreased individual and social costs, with increased clinical and organizational appropriateness. Thus, reduced delay in treatment and provided benefits for children and familiars.

Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis: satisfactory clinical outcome at 10 years.

PURPOSE: To evaluate at long-term follow-up patients undergoing a one-step procedure of debridement and BMAC seeded in situ onto a scaffold for the treatment of osteochondral lesions of the talus (OLT) in ankles affected by osteoarthritis (OA), documenting the duration of the clinical benefit and its efficacy in postponing end-stage procedures. METHODS: This series included 56 consecutive patients. Patients were evaluated preoperatively and up to a mean of 10 years of follow-up with the AOFAS score and the AOS scale, including pain and disability subscales. Furthermore, patients were asked to rate the satisfaction and failures were documented as well. RESULTS: The AOFAS score improved from 52.3 ± 14.3 to 73.5 ± 23.1 at 10 years (p < 0.0005); the AOS pain and disability subscales decreased from 70.9 ± 14.1 to 37.2 ± 32.7 and from 69.0 ± 14.8 to 34.2 ± 29.3, respectively (both p < 0.0005). The overall rate of satisfaction was 61.8 ± 41.2 and 68.6% of patients would undergo again the surgical procedure. A total of 17 failures was documented, for a failure rate of 33.3%. Older patients and those with more complex cases requiring previous or combined surgeries had lower outcomes, as well as those affected by grade 3 OA, who experienced a high failure rate of 71.4%. CONCLUSIONS: This one-step technique for the treatment of OLT in OA ankles showed to be safe and to provide a satisfactory outcome, even if patients with end stage OA presented a high revision rate at 10 years. Moreover, this procedure was effective over time, with overall good results maintained up to a long-term follow-up. However, older age, more complex cases requiring previous or combined surgeries, and advanced OA led to an overall worst outcome and a significantly higher failure rate.

Autologous Chondrocyte Implantation for Talar Osteochondral Lesions: Comparison Between 5-Year Follow-Up Magnetic Resonance Imaging Findings and 7-Year Follow-Up Clinical Results.

Autologous chondrocyte implantation (ACI) is an established surgical procedure that has provided satisfactory results. The aim of the present study was to correlate the clinical outcomes of a series of 20 patients treated by ACI at a 7-year follow-up examination with the magnetic resonance imaging (MRI) T2-mapping 5-year follow-up findings. We evaluated 20 patients using the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and the established follow-up protocol until 87.2 ± 14.5 months. MRI T2-mapping sequences were acquired at the 5-year follow-up examination. At the MRI examination (60 ± 12 months), the mean AOFAS score improved from 58.7 ± 15.7 to 83.9 ± 18.4. At the final follow-up examination at 87.2 ± 14.5 months, the AOFAS score was 90.9 ± 12.7 (p = .0005). Those patients who experienced an improvement between 5 and 7 years after surgery had a significant greater percentage of T2-map value of 35 to 45 ms (hyaline cartilage) compared with those patients who did not improve (p = .038). MRI T2 mapping was shown to be a valuable tool capable of predicting reproducible clinical outcomes after ACI even 7 years after surgery. The quality of the regenerated tissue and the degree of defect filling became statistically significant to the clinical results at the final follow-up examination.

Systematic review of bone marrow stimulation for osteochondral lesion of talus - evaluation for level and quality of clinical studies.

AIM: To clarify the quality of the studies indicating lesion size and/or containment as prognostic indicators of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLT). METHODS: Two reviewers searched the PubMed/MEDLINE and EMBASE databases using specific terms on March 2015 in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Predetermined variables were extracted for all the included studies. Level of evidence (LOE) was determined using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was evaluated using the Modified Coleman Methodology Score. RESULTS: This review included 22 studies. Overall, 21 of the 22 (95.5%) included studies were level IV or level III evidences. The remaining study was a level II evidence. MQOE analysis revealed 14 of the 22 (63.6%) included studies having fair quality, 7 (31.8%) studies having poor quality and only 1 study having excellent quality. CONCLUSION: The evidence supporting the use of lesion size and containment as prognostic indicators of BMS for OLTs has been shown to be of low quality.

Return to Sports After Bone Marrow-Derived Cell Transplantation for Osteochondral Lesions of the Talus.

OBJECTIVE: Arthroscopic "one-step" technique based on bone marrow-derived cell transplantation (BMDCT) have achieved good results in repairing osteochondral lesions of the talus (OLT), overcoming important drawbacks of older techniques. It may be particularly adequate for the treatment of athletes in order to permit a safe and stable return to sports. The aim of this study was to report the results at 48 months of a series of athletes and the factors influencing the return to sports. DESIGN: Case series. A total of 140 athletes underwent a "one-step" BMDCT repair of OLT. All the patients had the cells harvested from the iliac crest, condensed and loaded on a scaffold, and then implanted. Patients were evaluated clinically by the American Orthopaedic Foot and Ankle Society (AOFAS) scores and Halasi score. RESULTS: AOFAS score improved from 58.7 ± 13.5 preoperatively to 90.6 ± 8.6 (P < 0.005) at 24 months, and to 90.9 ± 10.7 at 48 months. Halasi score was 6.88 ± 1.8 preinjury, 4.08 ± 1.7 preoperatively, and 5.56 ± 2.0 at final follow-up. At the final follow-up, all the patients (beside 1 failure and 3 lost) were able to return to activity and 72.8% were able to resume sports at preinjury level. CONCLUSIONS: "One-step" BMDCT repair of OLT had good clinical results that was durable over time in athletes, permitting a return to sports at preinjury level in the majority of patients. The preoperative presence of impingement and articular degeneration were the main negative prognostic factors.

Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review.

BACKGROUND: The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm2 in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs. PURPOSE: To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs. STUDY DESIGN: Systematic review. METHODS: A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes. RESULTS: Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm2 in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm2, while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm2. The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies. CONCLUSION: An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm2 in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

"One-step" bone marrow-derived cells transplantation and joint debridement for osteochondral lesions of the talus in ankle osteoarthritis: clinical and radiological outcomes at 36 months.

INTRODUCTION: Ankle osteoarthritis (OA) is a challenging pathology, often requiring surgical treatments. In young patients, joint sparing, biologic procedures would be desirable. Recently, a few reports have described the efficacy of bone marrow stem cells in OA. Considering the good outcomes of one-step bone marrow derived cells transplantation (BMDCT) for osteochondral lesions of the talus (OLT), we applied this procedure for OLT in concomitant ankle OA. MATERIALS AND METHODS: 56 patients, with a mean age of 35.6 years (range 16­50), who suffered from OLT and ankle OA, were treated using BMDCT. All patients were clinically checked using AOFAS score, in the pre-operative setting until the final follow-up of 36 months. Weight-bearing radiographs and MRI evaluation using Mocart score were performed, preoperatively and postoperatively. RESULTS: The whole clinical outcome had a remarkable improvement at 12 months, a further amelioration at 24 months and a lowering trend at 36 months (77.8 ± 18.3). Early OA had better outcomes. 16 patients required another treatment and they were considered failures. Clinical outcome significantly correlates with OA degree, BMI, associate procedures. Radiographs were in line with clinical results. MRI evaluation showed signs of osteochondral repair. CONCLUSIONS: BMDCT showed encouraging clinical and radiological outcomes at short-term follow-up. This procedure should be applied in young and selected patients, excluding severe ankle degeneration, where the results are critical. Longer follow-ups and larger case series are needed to confirm these results and if this treatment could be effective in postponing end-stage procedures. LEVEL OF EVIDENCE: IV.

Custom-Made Total Talonavicular Replacement in a Professional Rock Climber.

Professional athletes are often eager to resume sporting activities at preinjury levels. When facing the challenge of restoring joint function after a complex articular fracture, innovative solutions must be explored. We describe the results of what we believe to be the first custom-made talonavicular prosthesis implanted in a professional rock climber who had developed post-traumatic ankle and talonavicular arthritis as sequelae of a complex talar and navicular fracture. Using computed tomography scan reconstruction of the contralateral healthy ankle and direct metal laser sintering, a custom-made talonavicular prosthesis was obtained and implanted using an anteromedial approach. The patient was clinically and radiographically evaluated every 6 months after surgery for 30 months. A 3-dimensional videofluoroscopic analysis was performed to assess the range of motion about the prosthesis. At the last follow-up visit, the functional scores were excellent (Tegner activity scale score of 9 of 10), and he had completely resumed his sporting activity. The American Orthopaedic Foot and Ankle Society score had increased from 36 to 81 points, and no signs of radiolucency were observed on the radiographs. The 3-dimensional videofluoroscopic analysis showed 15° of dorsiflexion and 4° of plantar flexion at the ankle. A customized solution is an option when the patient's expectations are not likely to be met by standard treatment, such as arthrodesis. A custom-made talonavicular prosthesis can be an effective solution for complex ankle injury sequelae in patients demanding high functionality.

Regenerative treatment in osteochondral lesions of the talus: autologous chondrocyte implantation versus one-step bone marrow derived cells transplantation.

PURPOSE: Osteochondral lesions of the talus (OLT) usually require surgical treatment. Regenerative techniques for hyaline cartilage restoration, like autologous chondrocytes implantation (ACI) or bone marrow derived cells transplantation (BMDCT), should be preferred. The aim of this work is comparing two clusters with OLT, treated with ACI or BMDCT. METHODS: Eighty patients were treated with regenerative techniques, 40 with ACI and 40 with BMDCT. The two groups were homogenous regarding age, lesion size and depth, previous surgeries, etiology of the lesion, subchondral bone graft, final follow-up and pre-operative AOFAS score. The two procedures were performed arthroscopically. The scaffold was a hyaluronic acid membrane in all the cases, loaded with previously cultured chondrocytes (ACI) or with bone marrow concentrated cells, harvested in the same surgical session (BMDCT). All the patients were clinically and radiologically evaluated, using MRI Mocart score and T2 mapping sequence. RESULTS: Clinical results were similar in both groups at 48 months. No statistically significant influence was reported after evaluation of all the pre-operative parameters. The rate of return to sport activity showed slightly better results for BMDCT than ACI. MRI Mocart score was similar in both groups. MRI T2 mapping evaluation highlighted a higher presence of hyaline like values in the BMDCT group, and lower incidence of fibrocartilage as well. CONCLUSIONS: To date, ACI and BMDCT showed to be effective regenerative techniques for the treatment of OLT. BMDCT could be preferred over ACI for the single step procedure, patients' discomfort and lower costs.

Bone marrow-derived cells and biophysical stimulation for talar osteochondral lesions: a randomized controlled study.

BACKGROUND: Osteochondral lesions of the talus (OLT) frequently occur after ankle sprains in young patients participating in sports activities. These injuries may lead to chronic pain, joint swelling, and finally osteoarthritis, therefore, surgical repair is frequently needed. A collagen scaffold seeded with bone marrow-derived cells (BMDCs) harvested from patient's iliac crest and implanted into the OLT through a single arthroscopic procedure has been recently proposed as an effective treatment option. Nevertheless, BMDCs, embedded in an inflammatory environment, tend to differentiate toward a fibroblast phenotype with a consequential loss of mechanical characteristics. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been shown to promote anabolic chondrocyte activity, stimulate proteoglycan synthesis, and reduce the release of the most relevant pro-inflammatory cytokines. The aim of this randomized controlled trial was to evaluate the effects of PEMFs on clinical outcome in patients who underwent BMDCs transplantation for OLT. METHODS: Thirty patients affected by grade III and IV Outerbridge OLT underwent BMDCs transplantation. After surgery, patients were randomly assigned to either experimental group (PEMFs 4 hours per day for 60 days starting within 3 days after operation) or control group. Clinical outcome was evaluated with (American Orthopaedic Foot and Ankle Society) AOFAS score, Visual Analog Scale (VAS), and Short Form-36 (SF-36). RESULTS: Significantly higher AOFAS score was recorded in the experimental group both at 6 or 12 months follow-up. At 60 days and 6 and 12 months follow-up, significant lower pain was observed in the experimental group. No significant difference was found in SF-36 between groups. CONCLUSION: A superior clinical outcome was found in the experimental group with more than 10 points higher AOFAS score at final follow-up. Biophysical stimulation started soon after surgery aided patient recovery leading to pain control and a better clinical outcome with these improvements lasting more than 1 year after surgery. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Partial ACL tears: anatomic reconstruction versus nonanatomic augmentation surgery.

Treatment of partial anterior cruciate ligament (ACL) tears requires ACL remnant preservation. The goal of this study was to compare the outcome of anatomic reconstruction of the torn bundle with nonanatomic augmentation using the over-the-top femoral route. Fifty-two athletes (mean age, 23.3 years) with partial ACL lesions underwent anatomic reconstruction (n=26) or nonanatomic augmentation (n=26). Intraoperative damage of the healthy bundle that required a standard ACL reconstruction occurred in 2 patients in the anatomic reconstruction group. International Knee Documentation Committee (IKDC) score, Tegner score, and arthrometer evaluation were used pre-operatively and at follow-up for up to 5 years postoperatively. One failure occurred in the anatomic reconstruction group. Mean IKDC subjective score at follow-up was 88.2 ± 5.7 in the anatomic reconstruction group and 90.2 ± 4.7 in the nonanatomic augmentation group. According to the IKDC objective score at final follow-up, 96% of knees in the nonanatomic augmentation group were normal vs 87.5% in the anatomic reconstruction group. No significative differences were observed between the 2 groups at final follow-up. Anteromedial bundle reconstruction showed significantly lower IKDC subjective and objective scores and higher residual instability values as evaluated with the arthrometer compared with posterolateral bundle reconstruction (P=.017). The surgical treatment of ACL partial tears is demanding. Adapted portals, perfect control of the tunnel drilling process, and intercondylar space management are required in anatomic reconstruction. The nonanatomic augmentation technique is simpler, providing excellent durable results over time with a lower complication rate. Anteromedial bundle reconstruction is associated with a poorer outcome, especially when performed with anatomic reconstruction.

One-step repair in talar osteochondral lesions: 4-year clinical results and t2-mapping capability in outcome prediction.

BACKGROUND: A recent one-step arthroscopic technique based on bone marrow-derived cell transplantation has achieved good results in repairing osteochondral lesions of the talus (OLTs), overcoming some of the drawbacks of older techniques. PURPOSE: To report the results after 4 years of a series of patients who underwent a one-step repair of osteochondral lesions of the talar dome, as well as the capability of magnetic resonance imaging (MRI) using a T2-mapping sequence to predict the clinical outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-nine patients (age [mean ± SD], 28.08 ± 9.51 y) underwent a one-step repair of OLTs. Patients were evaluated clinically by American Orthopaedic Foot and Ankle Society (AOFAS) scores and radiographs and underwent MRI preoperatively and during postoperative follow-ups at predetermined times. In all patients, the cells were harvested from the iliac crest, concentrated, and loaded on a scaffold that was implanted arthroscopically. RESULTS: The overall AOFAS score (mean ± SD) improved from 63.73 ± 14.13 preoperatively to 82.19 ± 17.04 at 48 ± 6.1 months (P < .0005), with best results at the 24-month follow-up. A significant decrease in the clinical score was observed between 24 and 36 months postoperatively (P = .001) and between 24 and 48 months (P < .005). The T2-mapping analysis showed regenerated tissue with T2 values of 35 to 45 milliseconds, similar to hyaline cartilage, in a mean of 78% ± 16% of the repaired lesion area. The time between the occurrence of trauma and surgery was found to negatively affect the clinical outcome at the latest follow-up; patient's age and lesion size influenced the early clinical results but did not affect the outcome at final follow-up. The stability of clinical results over time and the percentage of tissue with values similar to hyaline cartilage evidenced by MRI T2 mapping showed a tendency to correlate at the last follow-up (r = 0.497, P = .06). CONCLUSION: One-step repair of OLTs had good clinical results that were durable over time, even though there was a slight decrease in AOFAS score at the latest follow-up. The quality of the regenerated tissue detected by MRI T2 mapping directly correlated with the clinical results.