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Background:  The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF., Methods:  All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures., Results:  The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m 2 , and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis., Conclusion:  This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones., Competing Interests: A.F. is consultant for Arthrex. A.C. received instructional grant from Arthrex. The other authors declare that they have no competing interests., (Thieme. All rights reserved.)

Background: Osteoarthritis (OA) of the trapeziometacarpal (TMC) joint is a common cause of pain and functional disability of the hand and is the second most frequent site in the hand of OA. This prospective randomized study analyses and compares the outcomes and global assessment of 2 different surgical techniques for rhizarthrosis treatment: trapeziectomy with tendon interposition arthroplasty and total joint replacement with Touch® (KeriMedical; Geneva, Switzerland) TMC prosthesis., Methods: The enrolled patients were randomly divided into 2 groups: group A included 71 patients (75 hands) treated with tendon interposition arthroplasty, while group B included 65 patients (72 hands) treated with total joint replacement. Clinical and radiological outcomes were collected before surgery and at 1, 3, 6, 12, and 24 months of follow-up., Results: Although the values of all clinical tests performed during follow-up demonstrated statistically significant improvement over preoperative ones in both groups, patients treated with prosthesis showed faster improvement, especially in tests of strength and range of motion, which showed better results than patients treated with trapeziectomy and tendon interposition arthroplasty throughout the follow-up., Conclusions: Our study suggests that joint replacement should be preferred to interposition arthroplasty as the treatment of rhizarthrosis, choosing the latter in case of prosthetic replacement complications or scaphoid-trapezium-trapezoid OA.

Background: This study aims to investigate the treatment results of atrophic nonunion of the lower and upper limb with vascularized bone flaps performed with only arterial anastomosis versus the execution of flaps performed with arterial and venous anastomosis, comparing the surgical time and the healing rate of these two techniques., Methods: 49 patients were enrolled in this study and were randomly divided into two groups: group A, the control group, consisted of 27 patients, who underwent vascularized corticoperiosteal bone flap with both arterial and venous anastomosis; group B, consisted of 22 patients, who underwent vascularized corticoperiosteal bone flap with only arterial anastomosis. The surgical time, the time to harvest the graft and the microsurgical time were evaluated. Radiological and clinical follow-ups were performed with one independent and blinded investigator to avoid bias., Results: A significant reduction in the duration of the intervention in group B was found: a 13.63% reduction of the total surgical time and a 41.75% reduction of the microsurgical time. A significant difference was not found between groups A and B in bone healing time. All the patients of both groups were able to return to their daily life activities., Conclusions: Our investigation suggests that it isn't necessary to perform the venous anastomosis between the flap pedicle and the recipient area. Presumably, the venous blood flow reaches the systemic circulation through the vascular bone marrow network. Our procedure avoids venous trauma during the dissection and execution of the anastomosis and, therefore, can minimize complications such as venous thrombosis., Competing Interests: Declaration of Conflict of Interest The Authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The injury rate in professional soccer players may be influenced by match frequency., Purpose: To assess how changes in match frequency that occurred because of coronavirus disease 2019 (COVID-19) influenced training and match injuries in the Italian Serie A league., Study Design: Descriptive epidemiology study ., Methods: Three phases in the Serie A league, each 41 days long, were evaluated: phase A was the beginning of the 2019-2020 season; phase B was a period after the COVID-19 lockdown was lifted, when the remaining matches of the season were played with greater frequency; and phase C was the beginning of the 2020-2021 season. All male professional soccer players who were injured during the 3 phases were included. Player age, height, position, injury history, and return to play (RTP) were retrieved from a publicly available website. Training- and match-related injuries during each of the 3 phases were collected and compared. Moreover, match injuries that occurred after the lockdown phase (phase B), in which there were 12 days designated for playing matches ("match-days"), were compared with injuries in the first 12 match-days of phases A and C., Results: When comparing 41-day periods, we observed the injury burden (per 1000 exposure-hours) was significantly lower in phase B (278.99 days absent) than in phase A (425.4 days absent; P < .05) and phase C (484.76 days absent; P < .05). A longer mean RTP period was recorded in phase A than in phase B (44.6 vs 23.1 days; P < .05). Regarding 12-match day periods (81 days in phase A, 41 days in phase B, and 89 days in phase C), there was a significantly higher match injury rate (0.56 vs 0.39 injuries/1000 exposure-hours; P < .05) and incidence (11.8% vs 9.3%; P < .05) in phase B than in phase A and a longer mean RTP period in phase A than in phase B (41.8 vs 23.1 days; P < .05). Finally, the rate and incidence of training-related injuries were significantly higher in phase B (4.6 injuries/1000 exposure-hours and 6.5, respectively) than in phase A (1.41 injuries/1000 exposure-hours and 2.04, respectively) ( P < .05)., Conclusion: Both training- and match-related injuries were greater during the abbreviated period after the COVID-19 lockdown. These may be linked to the greater match frequency of that period., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

Backgrounds:  Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap., Materials and Methods:  The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications., Results:  The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients., Conclusions:  Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing., Competing Interests: All Authors have nothing to declare concerning the content of this manuscript., (Thieme. All rights reserved.)

Case: Lipofibromatous hamartoma (LFH) is a rare benign tumor of the peripheral nerves, which often affects upper extremity. There is no consensus regarding management of these lesions. We report a case of median nerve LFH in the volar forearm of a 24-year-old man with carpal tunnel syndrome symptoms. Clinically, the mass appeared tender to palpation, ill-defined and soft, located on the volar aspect of the left forearm. Open epineurotomy and neurolysis of the median nerve were performed with full recovery at 1 year., Conclusion: Surgical approach may be resolutive in patients with large masses refractory to conservative treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B462)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The combined left atrial appendage closure (LAAC) and cryoenergy pulmonary vein isolation (PVI) procedure has been proven safe and effective in managing stroke in patients with nonvalvular atrial fibrillation (AF), although most data refer to procedures performed using radiofrequency as the main energy source., Objective: The purpose of this study was to evaluate long-term follow-up of patients with AF undergoing concomitant LAAC and cryoenergy PVI., Methods: Patients undergoing LAAC and cryoballoon PVI at our institution were enrolled. At 3, 6, and 24 months from the index procedure, we determined the atrial arrhythmia recurrence rate, the extent of LAAC, and the rate of cerebrovascular/bleeding events., Results: Forty-nine patients (mean age 69 ± 8 years; 32/49 (67%) men; CHA 2 DS 2 -VASc score 2.8 ± 1.2; HAS-BLED score 3 ± 1) with a guideline-recommended LAAC indication were included. Acute PVI and complete LAAC were achieved in 100% of patients. All patients completed at least 24 months of follow-up. At 8 weeks and 6 months, complete or satisfactory (<5 mm leak) LAAC rates were achieved in 40 (82%) and 9 (18%) and in 42 (86%) and 7 (14%) of patients, respectively. The overall freedom from atrial arrhythmia rate at 24 months was 29 (60%), and 45 (92%) of patients were off antithrombotic drugs. The observed annualized stroke and bleeding rates were 1% and 2%, respectively, a 71% and 60% risk reduction in comparison to event rates predicted from CHA 2 DS 2 -VASc and HAS-BLED scores., Conclusion: Concomitant cryoballoon ablation and LAAC procedures appear safe and effective at long-term follow-up, with high antithrombotic drug withdrawal rates at 24 months., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)