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PURPOSE To assess whether reaction time (RT) and movement time (MT), as the two components of the total brake response time (TBRT) and brake force (BF) are different in patients with a foot joint arthrodesis in comparison to controls. METHODS The study was a comparative case series in a driving simulator under realistic driving conditions. Mobile patients without a walker, ≥6 months after surgery who were driving a car and had no neurological co-morbidity, knee or hip joint prosthesis were included in the study. The selection criteria resulted in 12 patients with right tibiotalar joint arthrodesis (TTJA) and 12 patients with another right foot joint arthrodesis (OFJA), who were compared to 17 individuals without any ankle-joint pathology. For TBRT, an empirical safe driving threshold of 700 ms was used. The outcome measures were RT, MT, TBRT, BF and McGuire score. RESULTS MT (p = 0.034) and TBRT (p = 0.026) were longer in TTJA patients in comparison with the controls. Also, more patients with TTJA than patients with OFJA and controls exceeded the safe driving threshold (p = 0.028). The outcomes in OFJA patients and in controls were comparable. The McGuire score was similar between the TTJA and OFJA patients (p = 0.26). CONCLUSIONS Significantly slower MT and TBRT, and significantly more patients exceeding the safe driving threshold, were observed after a tibiotalar-joint arthrodesis in comparison to the controls. Patients with OFJAs were not significantly different from the controls. Driving and emergency braking may be impaired after tibiotalar-joint arthrodesis.

Shoulder stiffness is a condition of painful restriction of the glenohumeral range of motion. Numerous risk factors for primary and postoperative shoulder stiffness have been described. This article summarizes the known aspects of the pathophysiology of shoulder stiffness, with special attention to elements of molecular biology and genetics, which could influence the risk of developing shoulder stiffness. Furthermore, the role of hormonal and metabolic factors, medical disorders, drugs, and of other published risk factors for primary and postoperative shoulder stiffness is reviewed and discussed. Finally, aspects related to shoulder surgery and postoperative rehabilitation protocols, which could influence the development of postoperative stiffness are presented.

The ideal graft should have a high rate of integration, a low resorption rate, and a low risk of hardware fixation complications, and it should prevent the progression of osteoarthritis secondary to instability. Glenoid bone grafting techniques are necessary for restoring glenoid width and for preventing instability recurrence, while humeral grafting is used in order to treat symptomatic engaging Hill-Sachs lesions. Coracoid transfer procedures are described along with the more recent autograft techniques by means of the corticocancellous iliac crest bone, the distal clavicle, and the allografts from fresh-frozen femoral or humeral head and from the talus. The complications related to graft resorption are a current limitation of grafting technologies. New perspectives in bone grafting technologies come from the field of the basic science in the form of growth factor-infused bioscaffolds and of engineered functional bio-scaffold ricapitulating endochondral ossification.

Periprosthetic fractures are rare with an estimated prevalence of between 5% and 29%. They can be intraoperative or postoperative and, in cases of the latter, can occur due to either a single traumatic event or secondary to massive loss of bone stock. The Mayo classification distinguishes between three types of fractures: periarticular (a), around the prosthetic stem (b), and distal to the prosthetic stem (c). Among the type B, subtypes 1 through 3 identify the bone stock quality. This classification helps the surgeon decide what type of treatment is most suitable in each case. Some patients can be treated nonoperatively, but most of the fractures usually need fixation, sometimes augmented with bone graft.

Background:Tibial tuberosity anteromedialization (TTA) is a well-established treatment option for patellofemoral chondral disease that is resistant to nonoperative treatment. However, the prognostic factors of this procedure are unknown.Purpose:To analyze the prognostic factors correlated with the midterm outcomes of TTA for patellofemoral chondral disease and determine the survivorship.Study Design:Case series; Level of evidence, 4.Methods:Indications of TTA for chondral disease included skeletal maturity, age Results:From January 2003 to December 2013, among 76 eligible patients, 69 patients (78 knees, 74.4% female) were included, with a mean follow-up of 67.9 ± 34.5 months (range, 24-163 months) and a mean age at the time of surgery of 43.5 ± 16.1 years. The mean preoperative WOMAC-SF (17.8 ± 5.3) and Kujala (49.3 ± 15.6) scores significantly ( P < .001) improved after surgery (WOMAC-SF: 6.6 ± 6.9; Kujala: 74.2 ± 20.5). The patients graded their operated knee as 7.2 ± 2.1 of 10 points, on average, and stated that they would undergo the surgery again in 58 (74.4%) cases. A WOMAC-SF score of >7 points (34.6% of knees) in the multiple regression model was associated with age >45 years (odds ratio [OR], 10.4; 95% CI, 2.0-55.0) and increased femoral anteversion (OR, 7.9; 95% CI, 1.4-44.1). A Kujala score of 45 years (OR, 12.0; 95% CI, 2.6-56.2) and foot pronation (OR, 5.1; 95% CI, 1.3-20.4). Patient satisfaction of Conclusion:Overall, good outcomes and survivorship (77% at 108 months) were obtained in this case series. However, 25.6% of the patients would not undergo the surgery again. Increased age, increased femoral anteversion, foot pronation, and postoperative patellofemoral crepitus were identified as negative prognostic factors.

In the last two decades, many surgical techniques have been described for articular cartilage repair. Reliable histological scoring systems are fundamental tools to evaluate new procedures. Several histological scoring systems have been described, and these can be divided in elementary and comprehensive scores, according to the number of sub-items. The aim of this study was to test the inter- and intra-observer reliability of ten main scores used for the histological evaluation of in vivo cartilage repair. The authors tested the starting hypothesis that elementary scores would show superior intra- and inter-observer reliability compared with comprehensive scores. Fifty histological sections obtained from the trochlea of New Zealand Rabbit and stained with Safranin-O fast green were used. The histological sections were analysed by 4 observers: 2 experienced in cartilage histology and 2 inexperienced. Histological evaluations were performed at time 1 and time 2, separated by a 30-day interval. The following scores were used: Mankin, O’Driscoll, Pineda, Wakitani, Fortier, Selleres, ICRS, ICRSII, Oswestry (OsScore) and modified O’Driscoll. Intra- and inter-observer reliability were evaluated for each score. In addition, the pavement–ceiling effect and the Bland–Altman Coefficient of Repeatability were then evaluated for each sub-item of every score. Intra-observer reliability was high for all observers in every score, even though the reliability was significantly lower for non-expert observers compared with expert counterparts. In terms of Coefficient of Repeatability, some scores performed better (O’Driscoll, Modified O’Driscoll and ICRSII) than others (Fortier, Seller). Inter-observer reliability was high for all observers in every score, but significantly lower for non-expert compared with expert observers. In expert hands, all the scores showed high intra- and inter-observer reliability, independently of the complexity. Although every score has advantages and disadvantages, ICRSII, O’Driscoll and Modified O’Driscoll scores should be preferred for the evaluation of in vivo cartilage repair in animal models.

Injuries of the posteromedial corner of the knee are relatively common. These can be isolated or combined with other ligament lesions. In some cases the treatment of postero-medial corner injuries is controversial. After a brief description of the anatomy and biomechanics of the medial side of the knee, this paper reviews the indications for isolated and multiligamentous medial/posteromedial corner injuries both in the acute and in the chronic setting. In addition, the most common surgical techniques for repair and reconstruction are described in addition to outcomes based upon a review of the literature.

Minced chondral fragments are becoming popular as a source of cells for cartilage repair, as a growing interest is developing towards one-stage procedures to treat cartilage lesions. The purpose of this study is to (A) compare cell outgrowth from cartilage fragments of adult and young donors using two different types of scaffolds and (B) evaluate the influence of transforming-growth-factor-β1 (TGF-β1) and granulocyte colony-stimulating factor (G-CSF) on chondrocyte behaviour. In part (A) cartilage fragments from adult and young donors were either loaded onto an HA-derivative injectable paste scaffold or onto an HA-derivative membrane scaffold. Construct sections were then examined for cell counting after 1, 2 and 3 months. In part (B) only membrane scaffolds were prepared using cartilage fragments from young donors. Constructs were cultured either in standard growth medium or in the presence of specific growth factors, such as TGF-β1 or G-CSF or TGF-β1 + G-CSF. After 1 month, construct sections were examined for cell counting. Expression of chondrocyte markers (SOX9, CD151, CD49c) and proliferative markers (β-catenin, PCNA) was assessed using immunofluorescence techniques, both in unstimulated construct sections and in cells from unstimulated and stimulated construct cultures. Part (A): histological analysis showed age-dependent and time-dependent chondrocyte migration. A significant difference (p

One-step techniques are a promising approach for cartilage repair. This study introduces a simple chondrocyte culturefree approach with autologous cartilage fragments loaded onto a mixed scaffold composed of high molecular weight hyaluronic acid derivative felt (Hyaff-11), injectable human fibrin glue (Tisseel) and autologous platelet-rich plasma (PRP). Nanoindentation of goat samples showed mechanical properties close to native goat-trochelarcartilage

Femoral interference screw divergence is a potential pitfall associated with ACL reconstruction through transtibial tunnel technique, as angles greater than 15 jeopardize graft fixation. Our mathematical model theorizes the proper degrees of knee flexion during femoral screw insertion and the correct screwdriver position to obtain a minimal divergence of the screw in the femoral tunnel. The cadaveric study confirms our method

The diagnosis and the prompt treatment of early osteoarthritis (OA) represent vital steps for delaying the onset and progression of fully blown OA, which is the most common form of arthritis, involving more than 10 % of the world’s population older than 60 years of age. Nonsurgical treatments such as physiotherapy, anti-inflammatory medications, and other disease-modifying drugs all have modest and short-lasting effect. In this context, the biological approaches have recently gained more and more attention. Growth factors, blood derivatives, such as platelet concentrates, and mesenchymal adult stem cells, either expanded or freshly isolated, are advocated amongst the most promising tool for the treatment of OA, especially in the early phases. Primarily targeted towards focal cartilage defects, these biological agents have indeed recently showed promising results to relieve pain and reduce inflammation in patients with more advanced OA as well, with the final aim to halt the progression of the disease and the need for joint replacement. However, despite of a number of satisfactory in vitro and pre-clinical studies, the evidences are still limited to support their clinical efficacy in OA setting.

Revision total knee arthroplasty (TKA) is the treatment of choice in patients with periprosthetic joint infection. It may be performed in either a single stage or two stages. In the latter option, between stages, an antibiotic-loaded spacer may be used to maintain a certain amount of joint stability and mobility after the infected implant is removed, adding an intra-articular concentration of antibiotics. There are two types of antibiotic-loaded cement spacers: static and dynamic. Static spacers basically create a temporary arthrodesis with antibiotic-loaded cement and usually are handmade within the surgical field. Dynamic spacers can be created intraoperatively by using different tools or may be prepackaged by the manufacturer; they allow range of motion between stages. In this article, the authors review the indications, surgical techniques, and results for static and dynamic spacers in two-stage revision TKA.

Purpose: athletes affected by shoulder instability cannot be judged solely according to the criteria used for non-athletes. In order to improve the assessment of shoulder instability surgery outcomes, the SPORTS score was tested in a cohort of athletes. Methods: ninety-eight athletes at an average follow-up of 4.6 years (range 1-9.2) after open or arthroscopic surgery for recurrent anterior shoulder instability were included in this study. The patients were asked to complete the SPORTS score questionnaire twice, with an interval of 2-3 weeks between the two assessments. The Bland-Altman method and the intra-class correlation coefficient were used to measure reliability. Criterion validity was assessed by calculating the Spearman correlation coefficient between the SPORTS score and the Western Ontario Shoulder Instability Index (WOSI) score, the Rowe score, the Oxford Shoulder Instability Score (OSIS), and the Subjective Shoulder Value (SSV). Results: the SPORTS score showed excellent test-retest reliability. The systematic error between the first and the second assessment was 0.3 points (95% upper limit of agreement = 2.3 points). The criterion validity was found to be strong for the SPORTS score, which correlated best with the SSV and the “sport, recreation, and work” component of the WOSI score. The SPORTS score had an acceptable floor effect (8%). The ceiling effect was 46%, which was better than the ceiling effects seen with the Rowe, OSIS and WOSI scores. Conclusions: this study suggests that the SPORTS score is a valid score in the assessment of athletes after surgery for shoulder instability and that it adds important information to the currently available scores. Level of evidence: Level III, diagnostic study of nonconsecutive patients.

High tibial osteotomy (HTO) is a common and widely accepted procedure in orthopaedic surgery. Although the improvements of partial and total knee arthroplasty (TKA), HTO remains a good option in some patients. Everybody agree in saying that in this surgery, in order to obtain satisfactory results, it is mandatory to have an appropriate patient selection and precise surgical planning. In this chapter we describe the advantage and the disadvantage of this procedure and the results compared to other techniques.

Background:Medial opening wedge high tibial osteotomy (OWHTO) is a widely accepted procedure for the treatment of medial compartment arthritis of the knee. Compared with closing wedge HTO, however, the outcomes of OWHTO reported in the literature are incomplete.Purpose:To identify the positive and negative prognostic factors related to the outcomes of OWHTO through an evaluation of midterm study results and survivorship analysis.Study Design:Case series; Level of evidence, 4.Methods:From January 2001 to December 2009, a total of 141 consecutive OWHTOs were performed in 123 patients. Only patients with symptomatic medial knee overload/arthritis were included. The patients were evaluated preoperatively and at every follow-up visit with (1) the Knee Society score, (2) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, (3) another self-evaluation scale, (4) long-leg radiographs, and (5) plain radiographs. Preoperative, intraoperative, and postoperative variables were investigated to find an association with the outcomes.Results:Of the 123 patients, 15 were lost to follow-up, and 24 were excluded from the study, leaving 84 patients (99 OWHTOs) for the present study. The mean age of the patients at the time of surgery was 54.5 ± 9.2 years. The mean follow-up was 51.5 ± 23.8 months. The Knee Society and WOMAC scores significantly improved after surgery ( P < .001). The variables significantly related to a poor outcome were (1) age >56 years ( P = .008) and (2) postoperative knee flexion Conclusion:With correct indications, OWHTO is a reliable procedure for medial knee arthritis/overload. The outcomes reported are similar to those from other studies, although the variables related to outcomes are slightly different.

To evaluate granulocyte colony-stimulating factor (G-CSF) efficacy in accelerating bone regeneration following opening-wedge high tibial valgus osteotomy for genu varum. A phase II trial was conducted for evaluating the preoperative administration of G-CSF given at 10 μg/kg/day for 3 consecutive days with an additional half-dose 4 h before the opening-wedge high tibial valgus osteotomy. Overall, 12 patients (Group A) received G-CSF treatment, and the subsequent 12 patients (Group B) underwent surgery without G-CSF. The osteotomy gap was filled by a bone graft substitute. Bone marrow cell (BMC) mobilization was monitored by CD34+ve cell and clonogenic progenitor cell analysis. All patients underwent a clinical (Lysholm Knee Scale and SF-36) and radiographic evaluation preoperatively, as well as at given intervals postsurgery. All patients completed the treatment program without major side effects; G-CSF was well tolerated. BMC mobilization occurred in all Group A patients, with median peak values of circulating CD34+ve cells of 110/μL (range 29–256). Circulating clonogenic progenitors paralleled CD34+ve cell levels. A significant improvement in Lysholm Knee Scale was recorded at follow-up in Group A compared to Group B. At the radiographic evaluation, there was a significant increase in osseointegration at the bone-graft junction in Group A at 1, 2, 3 and 6 months postsurgery compared to Group B. The computerized tomography scan of the grafted area at 2 months postsurgery showed no significant difference in the quality of the newly formed bone between the two Groups. Although the limited number of patients does not allow firm conclusions, the study suggests that G-CSF can be safely administered preoperatively in subjects undergoing opening-wedge high tibial valgus osteotomy; in addition, the clinical, radiographic and CT monitoring indicate that G-CSF and/or mobilized BMCs may hasten bone graft substitute osseointegration. I.

This study proposes a single-step therapeutic approach for osteochondral defects using autologous cartilage fragments loaded onto a scaffold composed of a hyaluronic acid (HA) derivative, human fibrin glue (FG) and autologous platelet-rich-plasma (PRP), in a rabbit model. The aim is to demonstrate the in vitro outgrowth of chondrocytes from cartilage fragments and the in vivo formation of a functional repair tissue. In vitro: minced articular cartilage was loaded onto two different types of scaffold (paste or membrane) according to two different HA preparations (injectable HA-derivative or HA-derivative felt). In vivo: trochlear osteochondral defects were created in 50 adult rabbits, which were then assigned to 5 different treatment groups: cartilage fragments loaded onto membrane scaffolds with FG (Group 1) or without FG (Group 2); membrane scaffolds alone with FG (Group 3) or without FG (Group 4); empty defects (Group 5). Membrane scaffolds were used “in vivo” for simpler preparation and better adhesive properties. Repair processes were evaluated histologically and by immunohistochemistry at 1, 3, and 6 months. An in vitro time-dependent cell outgrowth from cartilage fragments was observed with both types of scaffolds. At 6 months, in vivo, cartilage fragment-loaded scaffolds induced significantly better repair tissue than the scaffold alone using histological scoring. Repair in Group 2 was superior to that in any of the control groups (p

The aim of this anatomic descriptive cadaver study is to evaluate the entrance points of cross-pins and the possible chondral damages, using a two cross-pin femoral fixation device via anteromedial portal, during anterior cruciate ligament (ACL) reconstruction. Twenty fresh-frozen cadaver knees (12 cadavers) were tested. We employed the Rigidfix Cross Pin device (Mitek, Norwood, MA), designed to use two biodegradable pins (PLA, length 42 mm, diameter 2.7 mm). Instead of PLA pins, we used color coded metallic pins. Femoral tunnel drilling and cross-pin guide insertions were performed through the anteromedial portal. We gave three positions to the cross-pin guide: 0 degrees , 45 degrees and 90 degrees slope, referring to the horizontal plane. Per each position, we inserted two metallic pins. We recorded and subdivided the pin holes, in three different groups: Group A (0 degrees ); B (45 degrees ); C (90 degrees of slope). Then a wide dissection has been implemented. Group A: 6 knees (30%) had two pins inside the cartilage of the lateral femoral condyle; 10 knees (50%) had one pin inside the cartilage; and 4 knees (20%) had both pins out of the cartilage. Group B: 7 knees (35%) had two pins inside the cartilage; 12 knees (60%) had one pin inside the cartilage; and one knee (5%) had both pins out of the cartilage. Group C: 7 knees (35%) had two pins inside the cartilage; and 13 knees (65%) had one pin inside the cartilage. The risk of chondral injury, using this technique, is high: from 80% (group A) to 100% (Group C) to have at least one pin inside the cartilage. The use of Rigidfix via AM portal is not recommended for routine ACL reconstruction.

We present a new technique for arthroscopic-assisted fluoroscopic treatment of external tibial plateau fractures (Schatzker type I, II, III), using custom-made instrumentation. The instrument includes 4 basic elements: 2 cutting guides, a hollow trephine cutter with a saw-toothed tip, and a bone plunger. The lateral plateau is restored from the opposite side. An anteromedial rectangular cortical window in the proximal diaphysis of the tibia is created using the cutting guides. To achieve the reduction, the hollow trephine cutter is introduced into the opening created. The bone plunger is inserted into the hollow trephine cutter until resistance is felt. At this point the cancellous bone is compacted by applying force onto the plunger with the hammer so as to obtain a strong compact bone carrot. The plunger then pushes it under the depressed area, filling it out and pushing it upward, creating an indirect reduction. The arthroscopy comes into play estimating the precise anatomic reduction of the articular surface of the tibia. No graft is necessary and cannulated lag screws fix and strengthen the reduction. This new technique is reproducible, easy, less invasive than others, and ensures a stable cartilage and subchondral support without the need for grafts.

Abstract 4773 Introduction. Bone substitutes are widely used to improve bone repair in orthopaedic surgical procedures. Osseointegration is a slow process that takes place both at bone-implant interface and inside the tridimensional structure. The process might benefit from the addition of bone marrow-derived cells (BMC). In order to exploit this possible effects, a study protocol has been designed including preoperative BMC mobilization induced by granulocyte-colony stimulating factor (G-CSF). Aim of the study was to verify feasibility, safety and efficacy of BMC-mobilization in patients undergoing high tibial valgus osteotomy (HTVO). Patients and Methods. Overall, 24 patients undergoing medial open wedge HTVO to treat genu varum were enrolled in a prospective phase II trial. The osteotomy gap was filled by hydroxyapatite and tricalciumphosphate bone graft substitute. Two consecutive cohorts of 12 patients were assigned to receive (GROUP A) or not receive (GROUP B) a daily dose of 10 μ g/kg of G-CSF for 3 consecutive days, with an additional dose 4 hours before surgery. BMC mobilization was monitored by White Blood Cell (WBC) count and flow cytometry analysis of circulating CD34+ cells. All patients underwent a clinical (Lysholm Score and SF-36) and X-ray evaluation preoperatively, and at 1, 3 and 6 months after surgery. Anteroposterior standard radiographs were analysed to compare bone structure of the osteotomy areas. The percentage of integration at the interface between host bone and bone substitute (“host bone-substitute interface”) was estimated by 2 blinded observers. A computed tomography (CT) evaluation of the host bone-substitute interface was performed at 2 months. The osseointegration at the host bone-substitute interface was estimated through a semiquantitative score by 2 blinded observers and through a measure of bone density. Results. Patients of Groups A and B were well balanced in terms of age and clinical presentation. All patients of both groups completed the study. The most common adverse events among patients assigned to G-CSF were mild to moderate bone pain and muscle discomfort, well controlled by oral analgesics. There were no severe adverse events in both Group A and B, all patients are presently alive and well. Mobilization of CD34+ve cells occurred in all patients receiving G-CSF: mean preoperative WBC and CD34+ values were 39,09 × 103/μ l (21,57-51,11) and 131,58/ƒnμ l (29.1 - 404) in Group A, and 6,77 (2,8-12-06) and 7,67/μ l (5,4-12) in Group B, respectively. At the post-surgery clinical evaluation, patients of Group A experienced pain and a slight impairment in overall performance at 1 month assessment, whereas they displayed a slight increase in overall performance at 3 and 6 months compared to Group B. Semi-quantitative radiographic evaluation revealed a higher rate of bone substitute osseointegration in Group A than in Group B at 1, 3 and 6 months post-surgery. Also semiquantitative CT evaluation at 2 months showed an overall improved osseointegration at the host bone-substitute interface in Group A patients. Bone density was measured at the host bone-substitute interface by the Hounsfield score: Group A patients scored lower values at the upper interface compared to Group B, accordingly with advanced stage bone remodelling. The differences between Group A and B on assessment of host bone-substitute interface reached a statistical significance (p< 0,05). Bone mineral density at the host bone-substitute interface as measured with DEXA (Dual-energy X-ray absorptiometry), was lower, although without statistical significance, in Group A than in Group B, again suggesting a more advanced stage of bone remodelling in the treated group compared to controls. Conclusions. G-CSF administration given to induce pre-operative mobilization of bone marrow-derived cells: i. is feasible and safe in patients undergoing orthopaedic surgery; ii. allows the peripheral blood circulation of high numbers of CD34+ve cells; iii. may hasten bone graft substitute integration as suggested by both clinical and radiographical and CT evaluations. The enhanced osseointegration might be the result of a direct activity of G-CSF or of a cellular effect mediated by either hematopoietic or endothelial progenitors mobilized by G-CSF or by the combination of all these factors. Disclosures: No relevant conflicts of interest to declare.

Background The aim of the study was to evaluate the quality of life (QoL) in patients affected by osteoarthritis (OA) secondary to congenital hip dysplasia (CHD) and treated by hip arthroplasty. Methods We prospectively treated 40 patients admitted to our hospital between 2001 and 2006. Each patient was asked to answer to two questionnaires: WOMAC and MOS SF-36. Patients were evaluated four months before surgery and once they had achieved postoperative rehabilitation. Pre- and postoperative results were analyzed and compared with the international literature on patients affected by OA and also with a healthy population. Results Pre- and post-operative results: WOMAC: pain 14.06–0.84; stiffness 4.26–0.52; function 42.68–5.39. SF-36: physical function 18.55–84.52; role physical 28.33–87.10; body pain 23.26–83.39; general health 55.19–81.74; vitality 32.74–72.10; social function 43.55–84.66; role emotional 68.82–93.55; mental health 48.77–79.35. All results were statistically significant. Conclusions The study reports an important QoL improvement in patients affected by arthritis secondary to CHD that underwent hip surgery, and underlines differences with respect to primary OA. QoL evaluation cannot replace either clinical and instrumental evaluation or the physician’s experience, but it can give weight to the patient’s expectations, and may be considered an efficient test for medical and surgical treatments.