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Introduction : In the last few years, short metaphyseal-socket prosthetic humeral stems have been introduced for reverse shoulder arthroplasty (RSA). A short stem may have advantages in humeral force distribution, reducing shear stress and preserving bone stock, keeping in mind the need for possible future revision surgery. The main objective of our study was to validate the use of a short stem prosthesis in the surgical treatment of humeral fractures by comparing clinical and radiological outcomes of our studied implant with those obtained with the use of traditional long-stem implants. Methods : In this multicentric, controlled prospective study, 125 patients with proximal three- or four-fragment humerus fractures were selected and treated with RSA. A short stem was used in group A (n = 53, mean age: 75.6 ± 5.6 years old), and a long stem was used in group B (n = 72, mean age: 71.76 ± 3). Active range of motion (ROM), Constant score (CS), Quick DASH, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Visual Analog Scale (VAS) scores were collected and analyzed at 2 years mean follow-up, as well as humeral and glenoid bone resorption (sum Inoue scores and Sirveaux scores were used). Results : No statistically significant differences were observed between group A and B in ROM, Constant score (51.69 ± 15.8 vs. 53.46 ± 15.96, p > 0.05), Quick DASH (31.5 ± 21.81 vs. 28.79 ± 13.72, p = 0.85), ASES (82.53 ± 17.79 vs. 84.34 ± 15.24, p = 0.57), or the VAS (0.53 ± 1 vs. 0.56 ± 1.07, p = 0.14) at the final follow-up. No statistically significant differences were found in the radiographic parameters between the two groups. No statistically significant differences were found for the average degree of humeral and glenoid bone resorption either. Conclusions : The use of a short metaphyseal-socket stem can be considered a safe, effective, and feasible option in reverse shoulder arthroplasty for treating proximal humerus fractures. Our results are encouraging, with no statistically significant differences identified between the proposed treatment and traditional long stems.

Total knee arthroplasty (TKA) is a gold standard surgical procedure to improve pain and restore function in patients affected by moderate-to-severe severe gonarthrosis refractory to conservative treatments. Indeed, millions of these procedures are conducted yearly worldwide, with their number expected to increase in an ageing and more demanding population. Despite the progress that has been made in optimizing surgical techniques, prosthetic designs, and durability, up to 20% of patients are dissatisfied by the procedure or still report knee pain. From this perspective, the introduction of robotic TKA (R-TKA) in the late 1990s represented a valuable instrument in performing more accurate bone cuts and improving clinical outcomes. On the other hand, prolonged operative time, increased complications, and high costs of the devices slow down the diffusion of R-TKA. The advent of newer technological devices, including those using navigation systems, has made robotic surgery in the operatory room more common since the last decade. At present, many different robots are available, representing promising solutions to avoid persistent knee pain after TKA. We hereby describe their functionality, analyze potential benefits, and hint at future perspectives in this promising field.

Background: Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear., Questions/purposes: (1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?, Methods: Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only., Results: Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07)., Conclusion: In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete., Level of Evidence: Level II, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: To assess whether delaying operative fixation through the sinus tarsi approach resulted in a decreased wound complications rate or could hinder the quality of reduction in subjects with Sanders type II and III displaced intra-articular calcaneus fractures., Methods: From January 2015 to December 2019, all polytrauma patients were screened for eligibility. We divided patients into two groups: Group A, treated within 21 days after injury; Group B, treated more than 21 days after injury. Wound infections were recorded. Radiographic assessment consisted of serial radiographs and CT scans: postoperatively (T0) and at 12 weeks (T1) and at 12 months after surgery (T2). The quality of reduction of the posterior subtalar joint facet and calcaneal cuboid joint (CCJ) was classified as anatomical and non-anatomical. A post hoc power calculation was performed., Results: A total of 54 subjects were enrolled. Four wound complications (three superficial, one deep) were identified in Group A; two wound complications (one superficial one deep) were identified in Group B. According to "mean interval between trauma and surgery" and "duration of intervention", there was a significant difference between the groups ( p < 0.001). There were no significant differences between Groups A and B in terms of wound complications or quality of reduction., Conclusions: The sinus tarsi approach is a valuable approach for the surgical treatment of closed displaced intra-articular calcaneus fractures in major trauma patients who need delayed surgery. The timing of surgery did not negatively influence the quality of the reduction and the wound complication rate., Level of Evidence: level II, prospective comparative study.

Introduction  The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods  The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results  VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion  This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs., Competing Interests: Conflict of Interest The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article. Dr. Calcagni reports nonfinancial support from Sobi, nonfinancial support from Medartis, nonfinancial support from Silk Biomaterials, nonfinancial support from DyCare, outside the submitted work., (Society of Indian Hand Surgery & Microsurgeons. All rights reserved.)

Purpose: . We report a Maisonneuve case of reoperation with proximal fibula fracture, diastasis of syndesmosis and parcel posterior detachment of the third malleolus., Presentation of Cases: We report a case of 49- year old patient with a Maisonneuve fracture. The first surgery has failed with three-cortical screw rupture.  The second surgery was based on the implantation of quadricortical screw, zip tight and fibula elongation with autograph. The results were excellent despite the patient having contracted Covid-19 virus during rehabilitation., Discussion: Maisonneuve fracture is a misdiagnosed fracture. The diagnosis may be made by RX or TC of lower limb. There are many treatments provides to stabilized and reduced the ankle. We believe the gold standard is the correct realignment of syndesmosis and a strong synthesis., Conclusion: The Maisonneuve fracture accounts for 7% of all ankle fractures but misdiagnosed. We emphasize the importance of making good diagnosis of this fracture for an excellent surgical result and avoiding the chronic complications of incorrect treatment. In this case the physical rehabilitation is delayed by covid-19 infection so we suggest to carry out studies on post-operative period in orthopedic patients during this global pandemic.

Pelvic ring fractures are common in high-energy blunt trauma, especially in traffic accidents. These types of injuries have a high rate of morbidity and mortality, due to the common instability of the fractures, and the associated intrapelvic vascular and visceral complications. Computed tomography (CT) is the gold standard technique in the evaluation of pelvic trauma because it can quickly and accurately identify pelvic ring fractures, intrapelvic active bleeding, and lesions of other body systems. To properly guide the multidisciplinary management of the polytrauma patient, a classification criterion is mandatory. In this review, we decided to focus on the Young and Burgess classification, because it combines the mechanism and the stability of the fractures, helping to accurately identify injuries and related complications.

Purpose: The purpose of our study was to evaluate clinical outcomes and return to sports after medial unicompartmental knee arthroplasty (UKA) in middle-aged active patients with concomitant patella-femoral joint (PFJ) osteoarthritis at time of surgery., Methods: One-hundred and fifty-one patients who underwent medial fixed-bearing cemented UKA, between 2012 and 2015, for medial unicompartmental osteoarthritis of the knee, were retrospectively reviewed with a minimum 5-year follow-up. The mean age at surgery was 54.3 years (range 47 to 60 years). Radiological evaluation of patella-femoral joint (PFJ) osteoarthritis was performed according to Sperner classification to select a control-group (< grade III) and case-group (≥ grade III). The visual analog scale (VAS) for pain and Knee Society score (KSS) was used to evaluate preoperative and final outcomes. Physical activity level before and after the surgery was assessed by the use of UCLA score., Results: One-hundred and thirty-seven patients (89 males and 48 females) were available at last follow-up. The mean follow-up was 6.2 years (range 5.2 to 7.5 years). At last follow-up improvements of VAS and KSS scores revealed not significant correlation with PFJ osteoarthritis. The majority of patients (87.7%) returned to their sports activity after UKA surgery., Conclusions: Improved quality of life and sports activity level resulted in middle-aged, active patients after UKAs. PFJ osteoarthritis showed no significant correlation with poorer outcomes at 5-year follow-up., Level of Evidence: III, multicenter retrospective cohort study., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background and Aim: After the first Italian case of Covid-19, the Government imposed the complete closure of all areas involved by the spread of the virus to contain transmissions. There was a massive reorganization of Hospitals, a stop of all elective activities and a convertion of many hospitals in "Covid Centers''. AITOG (Associazione Italiana Traumatologia e Ortopedia Geriatrica) conducted a retrospective study on all proximal femur fractures surgeries that occurred in this period, to find out whether the pandemic and the correlated lockdown somehow changed the incidence of these events.  Methods: 10 Italian orthopedic centers were involved in the study. Considering the geographic location, three groups were created (North, Centre and South). The considered period is the Italian "Phase 1" (February 23rd - May 3rd 2020)., Results: the cohort is composed of 412 patients, 116 male and 296 female (mean age 81.1 ± 9.1 years). The same period of 2019 has been used as control group, with 558 patients, 156 male and 402 female (mean age 84.2 ± 8.0 years). In 2020 we counted 323 (78.4%) fractures occurred at home, 61 (14.8%) in retirement houses and 28 (6.8%) in different locations. We mainly treated fractures with intramedullary nails (n.237 57.5%). Among all patients we had 46 (11.1%) Covid-19 positive. The mortality rate within 30 days was of 51 patients (12.4%); 23 of these died because of complications related to Covid-19 while 31 of  these were in treatment with anticoagulant/antiaggregant., Conclusions: AITOG analysis demonstrates a decrease in surgical interventions for proximal femur fractures from 2019 to 2020, a reduction in patients mean age and an increase in trauma occurred in domestic environment. We also registered a consistent difference between the North, Center and South of the Country.

Background and Aim of the Work: In the best of our knowledge there is not yet in the literature a measurement able to assess post reduction stability of distal radius fractures., Aim: to study the relationship between our newly introduced Pacetti's line, anatomical reduction of DRFs and post-reduction stability of fractures., Methods: Patients/Participants: 230 patients (122men, 108women) who sustained a dorsally displaced distal radius fracture. Close reduction procedures attempted; below elbow cast applied., Follow-Up: Pacetti's line used on true AP and lateral view xrays after reduction and casting (T0) and at 7-14 days (T1-T2)., Main Outcome Measurements: Assessment and prediction of early displacement of DRFs., Results: The Pacetti's line intersected the lunate bone in 162 cases (70.4%) after anatomical reduction, of which 20.4% (N=33) lost anatomical reduction. Cramer's V test: significant relationship between transition of Pacetti's line through the semilunar bone and stability of anatomical reduction at T0 follow-up (p<0.001, Cramer's value=0.83). The Pacetti's line intersected the lunate bone in 119 cases (51.7%) at 7-14 days follow-up. None of patients lost anatomical reduction. Cramer's V test: significant relationship between transition of Pacetti's line through the semilunar bone and stability anatomical reduction at T1 and T2 follow-up (p<0.001, Cramer's value=0.73)., Conclusions: We strongly recommend the use of the Pacetti's line as it seems to provide reliable prediction of further fracture displacement and consequently of definitive management. The Pacetti's line seems to represent a very useful tool providing simple, feasible, efficient and reliable information on DRFs characteristics and natural course.

Background: Various conservative treatments and surgical techniques have been reported in the literature as efficient and feasible measures to treat the cubital tunnel syndrome. However, there has been no consensus on the best management of the syndrome, and uniform standardised guidelines have not yet been accepted or introduced. With our study, we present our experience on the clinical efficacies and outcomes of the surgical techniques of neurolysis alone and neurolysis associated with ulnar nerve anterior transposition at the elbow joint in patients with neuropathic symptoms due to cubital tunnel syndrome., Materials and Methods: A total of 107 patients with cubital tunnel syndrome were retrospectively enrolled, surgically treated and followed up in our study. The cohort was divided into two groups: 41 patients treated only with neurolysis of the ulnar nerve (Group 1), and 66 patients treated with neurolysis and anterior transposition (Group 2). Of the participants, 35 were women and 72 were men. The average age was 54 years. Significant comorbidities were preoperatively diagnosed in 26 patients. Conservative measures had been considered, followed by surgical management if appropriate. A pre-op electromyography was performed for all patients. All surgical procedures were performed by the same surgical team. A post-operative follow-up was carried out, and the findings were recorded. The "McGowan" and "Wilson and Krout" classifications and the DASH score were used. A satisfaction questionnaire was administered to all patients post-operatively at 2 weeks)., Results: Ulnar nerve neurolysis and anterior transposition surgery were all successfully performed. Overall complications were post-operative haematoma (8%) and wound problems (5%). In 6% there was recurrence of symptoms. In 11% there was no improvement of symptoms. Pre-op McGowan classifications for groups 1 and 2 were 0% and 0% (grade 0), 21% and 24% (grade 1), 46% and 44% (grade 2), and 33% and 34% (grade 3), respectively. The post-op McGowan classifications were 34% and 37% (grade 0), 39% and 40% (grade 1), 23% and 20% (grade 2), and 4% and 3% (grade 3), respectively. The post-op Wilson and Krout classifications were 45% and 46% (excellent), 26% and 28% (good), 19% and 15% (fair), and 10% and 11% (poor), respectively. The DASH score means for groups 1 and 2 were 14.8 and 15.2, respectively. A negative Froment's sign was present in 73.2% and 71.2%, respectively. In Group 1, the post-op satisfaction questionnaire scores were 0 for one patient, 1 for four patients, 2 for seven patients, 3 for ten patients, 4 for twelve patients and 5 for seven patients. In Group 2, the post-op satisfaction questionnaire scores were 0 for three patients, 1 for nine patients, 2 for twelve patients, 3 for fifteen patients, 4 for eighteen patients and 5 for nine patients., Conclusions: In our experience, the surgical technique to treat the cubital tunnel syndrome most efficiently and feasibly has not yet been established in terms of indications and outcomes. This is supported by the data present in the international literature. Good and similar results were obtained with neurolysis alone and neurolysis associated with anterior transposition of the ulnar nerve (in line with the international data). In conclusion, more high-quality studies of greater statistical power are needed to provide a consensus on the surgical indications and techniques to treat the cubital tunnel syndrome and to establish internationally standardised guidelines.

Aim To report clinical, functional and radiographic results of oneincision distal biceps tendon repair with Toggle Loc (Zimmer-Biomet, Warsaw, Indiana, USA) at an average 4-year follow-up and to assess posterior interosseous nerve injury complications after reconstruction. Methods We conducted a retrospective review of 58 consecutive distal biceps tendon repairs performed at our department between 2010 and 2018. Disabilities of Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) scale and elbow range of motion (ROM) were recorded at each follow-up and an ultrasound examination was also performed to assess the repaired biceps brachii tendon. Results Clinical evaluation showed good and excellent results at medium- and long-term follow-up. A temporary posterior interosseous nerve (PIN) palsy developed in four (6.81%) patients and always resolved in 8 weeks. PIN palsy prevalence is in accordance with the results of the previous studies. Conclusion Distal biceps tendon repair with Toggle Loc is an effective surgical procedure. PIN injury is a relatively rare complication after one-incision anterior repair. Our complication rate did not differ significantly from other studies that have used cortical button fixation, reported in current literature. Our results confirm that accidental injury of PIN may also happen to experienced surgeons and suggest extreme care and an appropriate surgical technique to reduce this iatrogenic risk., (Copyright© by the Medical Assotiation of Zenica-Doboj Canton.)

Non-union in forearm fractures is an uncommon challenging clinical condition for orthopaedic surgeons. The complex anatomy and biomechanics of the upper limb make this surgery very demanding. The accurate restoration of the normal anatomy is mandatory to obtain bone healing. Infections and important bone loss further reduce the therapeutic success. The use of bone graft in atrophic non-union may significantly reduce the bone healing time with good clinical results. The aim of the study was to compare fresh-frozen bone (FFB) allograft and autograft in the treatment of forearm aseptic non-union. Inclusion criteria were patients aged between 18 to 75 years old with forearm aseptic shaft non-union treated with plating and bone grafting. The Authors retrospectively evaluated minimum 12-month follow-up with standard X-rays and clinical outcomes. All non-unions were classified according Association for the Study and Application of the Method of Ilizarov (ASAMI) classification for long bones. The sample size was divided in two groups: patients treated with FFB allograft (Allograft Group) and patients treated with iliac crest autograft (Autograft Group). The mean patient age was 33.58±16.72 (18-75) years old in Allograft Group and 33.28±17.24 (18-75) in Autograft Group. The mean follow-up was 62.6 months (±12.3, range 12-160) in Allograft Group and 64.4 (±12.4; 12-160) in Autograft Group. The mean bone union time after the surgery was 101.6 (±14.6; 82 -156) days in Allograft while 117.6 (±14.6; 90 -180) days for autograft. The Radiographic Union Score was 26.8 (±2.2; range 24.3-30) in Allograft while 26.9 (±2.8; range 24.1-30) in Autograft. A correlation between clinical and radiographic outcomes was found (Cohen κ: 0.86±0.11 in Allograft Group; Cohen κ: 0.85±0.10 in Autograft Group, p=0.051). The preoperative surgical planning is essential to apply this technique: the adequate cortical graft length is the key point to gain adequate implant stability. A meticulous surgical technique is mandatory to obtain good clinical and radiological outcomes. The study reported a good reliability of FFB allograft for large non-union bone defects. This technique may represent a feasible alternative to bone transport or amputation, as it allows the return to daily life activities. Further studies are needed to assess the long-term clinical results of this surgical procedure., (Copyright 2020 Biolife Sas. www.biolifesas.org.)

Osteoid osteoma is a benign bone lesion that accounts for approximately 10% to 12% of all benign bone tumors. More than 80% of lesions occur in patients between 5 to 25 years old; males are more commonly affected with a ratio of 3:1. The foot is rarely involved: its involvement is less than 4% in the foot and of 1.7% in the metatarsals. In this paper we discuss the case of a 27-years-old woman with a 12 months follow-up, presented with an osteoid osteoma of the proximal phalanx of the great toe that underwent an en-bloc excision of the lesion and subsequent filling with cancellous autograft from the ipsilateral calcaneus.

Introduction: Anterior cruciate ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatment are still debated, including conservative management vs. various surgical techniques. The lack of long-term reports has been highlighted in the literature., Aim: To evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis., Methods: Retrospective study. All surgeries performed by same surgeon. A total of 42 patients included. All patients had pre-operative radiological studies., Subjects: 30 males and 12 females. Average age: 12.5 years (range 11-14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000 and plain radiographs. Standardized rehabilitation protocol., Results: No instability or leg length discrepancy was recorded. Average pre-operative Tegner-Lysholm and Pedi-IKDC scores were 55 and 40, respectively, with a score of 94.8 (p < 0.05) and 94.78, respectively, at final follow-up (p < 0.05). Average post-operative (1 month) Tegner-Lysholm score: 75 (range: 62-79). Median post-operative Tegner activity: 8. Mean side-to-side (KT-1000): 1.2 mm. A total of 22 patients could go back to pre-injury sport activity, with an average rehabilitation of 7.3 months., Discussion: A significant number of cases were included in our structured standardized study and follow-up. Functional scores were excellent overall. Excellent results are testified by a final achievement of 22 patients going back to pre-injury sport activity, which is in keeping with the literature. Our experience exhibited a low complication rate and no metalwork failure. We correlate our results to the use of the Over the Top technique with lateral extra-articular tenodesis., Conclusion: The studied procedure seems to be an excellent option and an effective, feasible and safe technique when treating ruptured ACLs in skeletally immature patients.

Objectives: The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps., Materials and Methods: 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS)., Results: The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05).In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05)., Conclusion: The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions.

Aim To demonstrate validity of a bio-metallic solution in bone healing combined with the quadriceps safe approach in the treatment of nonunions of distal femur while malunions were treated by metallic solution. Methods We treated 57 patients with nonunion or malunion of distal femur at the Orthopaedics and Traumatology Department of a single orthopaedic trauma centre (Italy). A total of 57 patients were divided in two groups: the first (NU) group was composed of 35 patients affected; the second group (MU) was composed of 22 patients affected by malunion of distal femur. Criteria chosen to evaluate the two groups during a clinical and radiological followup were: the quality of life measured by the Short Form (12) Health Survey, the knee function and quality of life related to it measured by the Knee Injury and Osteoarthritis Outcome Score KOOS and the Knee Society Score, bone healing measured by modified Radiographic Union Score by X-rays during the follow-up and CT at one year after the surgery, the difference of the limbs length before and after the revision surgery, and postoperative complications. The evaluation endpoint was set at 12 months. Results There were no statistical differences between the two groups. Conclusion The role of bio-metallic solution in the treatment of nonunions and malunions is to recreate the knee anatomy and functionality compatible with a satisfactory quality of life., (Copyright© by the Medical Assotiation of Zenica-Doboj Canton.)

Purpose: To propose a geometric model to quantify the bone defect and the glenoid medialisation (in millimetres) compared to the native joint line. We also evaluated the reliability of this geometric model., Methods: Using two-dimensional CT imaging, we built a hypothetical triangle on the axial scan consisting of the following: side A, length (millimetres) of the glenoid bone; side B, average length (millimetres) of the glenoid in a healthy population; side C, the missing side; and angle α, the retroversion angle calculated using the Friedman method. The resulting triangle represents the bone defect, and its height represents the medialisation of the native joint line. To estimate inter-operator reliability, two physicians (operator 1 and operator 2) took the following measurements: angle α, side A, side C, semi-perimeter, area defect and height., Results: Forty participants (mean age ± SD 45 ± 10 years, range 26-43 years)-22 women and 18 men-participated in the study. We applied the cosine theorem (Carnot theorem) to calculate side C. After obtaining the three sides, the area of the triangle can be determined. Once the area is known, it is possible to extrapolate the height of the triangle, which corresponds to the loss of vault depth due to the bone defect. With respect to inter-operator reliability, the ICCs for all measurements were > 0.99, exhibiting a very high correlation., Conclusions: The proposed geometric model can be used to quantify the glenoid bone deficit and the glenoid medialisation compared to the native joint line, which can be used to improve surgical treatment.

Purpose: Some authors consider preservation of the subscapularis tendon as one of the most important elements for a successful long-term outcome in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation. The purpose of this study was to evaluate whether vertical tenotomy of the subscapularis tendon might affect internal rotation strength recovery in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation., Methods: Ninety-six patients were retrospectively followed up at a mean of 72.5 months. They underwent clinical evaluation, Rowe and Walch-Duplay scoring scales, the Visual Analog Scale (VAS), and dynamometric measurements (side-to-side) of internal and external rotation, forward elevation, and abduction. All patients were athletes: 25% were practising risk-free sports, 44% contact sports, 14.5% sports with cocking of the arm, and 14.5% high-risk sports activities., Results: Five (5.2%) recurrences were registered, and all patients returned to pre-operative sports activity. The Rowe score was 98.12, the Walch-Duplay score 92.25, and the VAS score 0.1. Dynamometric assessment showed no significant differences (side-to-side) in internal rotation (p = 0.34), external rotation (p = 0.9), flexion (p = 0.7), and abduction (p = 0.7). Dominant arms showed better results than non-dominant arms (p < 0.01)., Conclusion: Complete tenotomy of the subscapularis tendon does not seem to negatively affect internal rotation strength recovery or external rotation movement in athletes.

Background and aim o the work In the recent last years there was a diffusion of new radiolucent plates for the treatment of distal radius fractures. The aim of our study is to evaluate the clinical and radiological outcomes at 12-month-follow-up for the treatment of distal radius fracture with the new triangular CarboFix "Piccolo" Distal Radius Plate. Methods All consecutive patients aged from 18 or over, who were treated for unstable distal radius fracture with a volar CarboFix "Piccolo" Distal Radius Plate with triangular design between September 2015 and May 2016, have been included in the study. From the original 28 patients, 6 patients were lost to the follow up or did not meet the inclusion criteria and 22 were available for the study.  The 22 patients were prospectively reviewed with dynamometric,radiographic and clinical evaluations (ROM, VAS, Quick DASH). Results The mean follow-up was 15.7 months. All fractures healed, and radiographic union was observed at an average of 5 weeks. All patients have recovery of R.O.M. comparable to the contralateral at the final follow up; with no significant difference (p>0.05) as regards extension, flexion, ulnar deviation, radial deviation, supination and pronation comparing to the unaffected arm. At final follow-up, no patients had a statistically significant difference (p>0.05) of grip strength, comparing to the contralateral side. The mean Quick DASH was 9.3 and the mean VAS score was 2.3. Conclusion The most important finding of the present study was that the triangular CarboFix "Piccolo" Distal Radius Plate showed good clinical and radiological results in the treatment of distal radial fractures. These results are comparable to those achieved with conventional plates.

Introduction: Over the last 20 years, the incidence of pediatric diaphyseal femoral fractures was increased, due to changes in the children's daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, involvement of the soft tissues, and concomitance with other injuries., Materials and Methods: From 2000 to 2015, 38 pediatric patients with diaphyseal femoral fractures were surgically treated and enrolled in the study. The average age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN) and the other 16 with external axial fixators. Comparing the two groups, radiographic images were taken to assess the fracture reduction and consolidation., Results: The average follow-up was 14 months. The average time needed to remove the TEN nails was 5 months; while 2.5 months was the time to remove the external fixator. At the final follow-up, there were no differences between two groups in term of significant rotation defects, angulation, growth, and/or nonunion., Conclusions: This study showed that TENS and external fixation have similar results in term of fracture healing and complication, even if patients treated with TENS are more satisfied.

Background: Intertrochanteric fractures are of great interest worldwide and are the most frequently operated fractures. Intramedullary nailing is commonly used in the treatment of intertrochanteric fractures. The purpose of this study is to assess the necessity of using the distal blocking screw in 31-A1 and 31-A2 fractures, classified according to the Orthopaedic Trauma Association classification system (AO/OTA)., Methods: This is a prospective study of 143 consecutive patients (mean age 85.01 years, mean final follow-up 14.1 months) surgically treated with the same intramedullary nail. In 75 cases, the distal locking screw was not used. Parameters evaluated during follow-up were: blood loss, transfusion requirements, surgery duration, and fluoroscopy time. Harris Hip Score and Barthel Activity Daily Living were used for the clinical evaluation. Radiographic Union Score For Hip (RUSH score) and Tip apex distance (TAD) were measured for radiologic evaluation., Results: The group treated without locking screw showed significantly shorter surgical duration time (31.9 vs. 47.2 min), a decrease in blood loss (variation Hb - 1.06 vs. - 1.97), and reduced X-rays exposure time (25.4 vs. 31.6 s). No significant differences were observed in the postoperative period and in the radiographic and clinical scores., Conclusion: This study demonstrates that in intertrochanteric 31-A1 and 31-A2 stable fractures, the absence of distal locking screw does not compromise bone healing and prevents several clinical complications.

Introduction: The elbow interposition arthroplasty is a very common procedure performed mainly on active young patients who need great functionality and for whom total joint replacement is contraindicated and arthrodesis is noncompliant. We are going to demonstrate a case of a 34-year-old male suffering from malunion of the distal humerus, elbow stiffness, and manifest signs of arthrosis of the dominant limb, treated with the IA Grika technique at a 5-year follow-up., Patients and Methods: The chosen criteria to evaluate the injured side and the uninjured side during the clinical and radiological follow-up were the objective function and related quality of life, measured by the Mayo Elbow Performance Score (MEPS), and postoperative complications. To assess flexion and supination forces and elbow muscular strength, a hydraulic dynamometer was used., Results: At a 5-year follow-up, the results were excellent as during the first year., Conclusions: The Grika technique is a valid and feasible option in the treatment of elbow injuries.

Purpose: To evaluate the effect of progressive lesions of the anterior cruciate ligament (ACL) and anterolateral ligament (ALL) on anterior tibial translation (ATT) as evaluated through the Lachman test and internal tibial rotation (ITR) during a dynamic pivot-shift test in a cadaveric model., Methods: A total of 7 specimens were tested using a navigation system (2.2 OrthoPilot ACL navigation system). The anterior stability of the knee was measured through the Lachman test and dynamic rotational stability was measured through the pivot-shift test in 3 different conditions: intact knee; ACL-deficient knee; and finally, ACL- and ALL-deficient knee. The resulting measurements from the navigation system recorded the real-time changes in both translation and internal rotation during the Lachman and pivot-shift maneuvers., Results: Mean ATT was 7.57 ± 0.53 mm in the intact knee, 14 ± 2.44 mm in the ACL-deficient knee, and 14 ± 2.44 mm in the ACL- and ALL-deficient knee. Mean ITR during the pivot-shift test was 10.14° ± 2.26° in the intact knee, 12.14° ± 2.19° in the ACL-deficient knee, and 18.86° ± 2.73° in the ACL- and ALL-deficient knee. There was a statistically significant difference in static ATT between the intact and ACL-deficient knees (P = .039) but no difference through the addition of an ALL lesion (P = .068). For dynamic rotational control testing, there was no significant difference in ATT between groups but a significant difference in ITR was found (F = 25.17, P = .00034)., Conclusions: During the pivot-shift test, a combined lesion of the ACL and ALL has a significant effect on ITR whereas an isolated lesion of the ACL has no effect on either ATT or ITR. During the Lachman test, an isolated lesion of the ACL has a significant effect on ATT but an additional lesion of the ALL does not affect ATT., Clinical Relevance: Dynamic rotational control as tested by the pivot-shift test is greatly influenced by a combined lesion of the ACL and ALL. In clinical cases of a pivot shift, addressing the anterolateral structures may be considered., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Open reduction and internal fixation is the standard treatment for displaced ankle fractures. However, the presence of comorbidities such as diabetes mellitus and body mass index (BMI) are associated with poor bone quality, and these factors may predict the development of postoperative complications. The study aim was to assess the role of diabetes mellitus and BMI in wound healing in patients younger than 65 years who were surgically treated for malleoli fractures., Methods: Ninety patients, aged from 18 to 65 years old, with surgically treated ankle fracture, were retrospectively enrolled. Patients were classified in two groups: patient with diabetes and patients without diabetes (insulin-dependent and noninsulin dependent). All patients were assessed for wound complications, Visual Analogue Scale and Foot and Ankle Disability Index (FADI) were assessed for all patients. Logistic regression was used to identify the risk of wound complications after surgery using the following factors as explanatory variables: age, gender, duration of surgery, BMI, hypercholesterolemia, smoking history, diabetes mellitus, and high blood pressure., Results: In total, 38.9% of patients showed wound complications. Of them, 17.1% were nondiabetics and 82.9% were diabetics. We observed a significant association between DM and wound complications after surgery (P = .005). Logistic regression analysis revealed that DM (P < .001) and BMI (P = .03) were associated with wound complications. The odds of having a postoperative wound complication were increased 0.16 times in the presence of diabetes and 1.14 times for increasing BMI., Conclusion: This study showed that diabetes mellitus and higher BMI delay the wound healing and increase the complication rate in young adult patients with surgically treated bimalleolar fractures., (Copyright © 2017 John Wiley & Sons, Ltd.)

Purpose: To evaluate and compare the effect of preconditioning according to intraoperative workflow on the elongation behavior of single-side and fully knotted all-inside anterior cruciate ligament (ACL) reconstruction configurations in a biomechanical in vitro study., Methods: Four full construct all-inside ACL reconstruction groups (n = 8 per group) were tested using porcine tibias and bovine tendons. Groups included both an all-inside configuration with one- (group 1) and both-side knotted adjustable loop-length devices (group 2), without and with performing intraoperative preconditioning (group 1-intraoperative preconditioned [IPC], group 2-IPC). Adjustable loop-length devices for control groups were knotted according to test configurations. Intraoperative preconditioning specimens were further precycled for 10 times at 0.5 Hz and manually retensioned before knotting. All groups underwent dynamic cycling in position and force control mode each for 1,000 cycles at 0.75 Hz according to in vitro loading parameters replicating the in vivo ACL environment. Finally, a load-to-failure test at 50 mm/min was performed., Results: Intraoperative preconditioning increases initial graft tension for single- (242 ± 22 N vs 174 ± 13 N; P < .0001) and both-side knotted configurations (225 ± 15 N vs 159 ± 10 N; P < .0001) compared with controls and allows maintained graft tension at higher levels until reaching the end of position-controlled cyclic loading. Furthermore, dynamic elongation is reduced for one- (1.93 ± 0.28 vs 0.76 ± 0.12; P < .0001) and both-side knotted (1.84 ± 0.20 vs 0.96 ± 0.32; P < .0001) configurations by 61% and 47%, respectively. No intergroup (group 1 vs group 2 and group 1-IPC vs group 2-IPC) statistically significant differences could be found between one- and both-side knotted configurations., Conclusions: All-inside ACL reconstruction with preconditioning according to intraoperative workflow leads to a statistically significant improved mechanical behavior and may allow for optimizing initial graft tension and elongation for all-inside ACL reconstruction to reduce knee laxity. A single-side knotted configuration achieves similar stabilization strength to fully knotted constructs., Clinical Relevance: Graft insertion until tunnel docking increases the intratunnel graft portion that may optimize graft incorporation. Eliminating a suture knot stack may improve intraoperative workflow and reduce postoperative knot irritation., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: The treatment of the sacroiliac joint (SIJ) vertical instability is a matter of current discussions and remains controversial. The aim of our study is the evaluation of the surgical management of SIJ vertical instability involving the use of cannulated screws introduced under CT guidance and local anesthesia., Materials and Methods: In the set time frame of 7 years, 96 poly-trauma patients with Tile's type C fracture of the pelvis with vertical instability of the SIJ were treated. The average distance between the two stumps was 73.4 mm (range: 43-100 mm). All patients were treated with anterior stabilization and subsequent stabilization with cannulated screws (Asnis ® Stryker ® 6 mm, an average length of 70 mm; range from 55 to 85 mm) of the sacroiliac fracture. The clinical and radiological follow-up was performed with follow-up plain radiograph and Majeed score (from 1 to 60 months after injury)., Results: The consolidation of pelvic fractures was obtained after an average of 63 days. The average Majeed score was as follows: 96 points at 1 month, 84 points at 3 months, 62 points at 6 months, 44 points at 12 months, 42 points at 24 months, 32 points at 36 months, 28 points at 48 months and 28 points at 60 months. Complications were as follows: not fatal deep vein thrombosis in five cases, skin infection at the entry point of the screws in six cases, screw breakage in one case and loosening of the screws in one case. Radiological evidence of fracture consolidation was achieved on average at 63 days. Forty-seven patients managed to get back to their pre-trauma employment at the end of the convalescence period., Conclusions: Our results suggest that the stabilization of SI Tile type C fracture/dislocations with CT-guided percutaneous cannulated screws is a valid and feasible management option and associated with a low complication rate., (© The Authors, published by EDP Sciences, 2018.)

Purpose: The purpose of this study was to correlate the bone block graft position, its dimension, its reabsorption and its integration with clinical outcome in patients operated on for recurrent anterior shoulder instability., Methods: Twenty-four patients affected by recurrent anterior shoulder dislocation and operated on using the Latarjet procedure were enrolled in this study. At 6 and 24 months, patients were evaluated with the following scales: ROWE, WOSI, Oxford instability score, UCLA, DASH and Constant score. Patients underwent two postoperative CT scans: immediately after surgery (T0) and at 24 months post-op (T1)., Results: At 24 months, none of the 24 patients reported further episodes of dislocation. Clinically at the final follow-up, we found excellent results in all the evaluation scales. Mean reduction in bone graft from T0 to T1 was 42% of the overall volume; similarly reduction in the overall surface was 29.3%; decrease in length, width and depth was, respectively, 3.4, 2.2 and 1.0 mm; all these parameters decreased significantly (p < 0.05). No correlations were found between radiological parameters and clinical and functional outcomes., Conclusions: The results confirm that a lack of integration or a significant reabsorption of the graft is present in the Latarjet procedure, but they do not significantly affect the clinical and functional results.

Background and Purpose: Medial condyle corticoperiosteal flap is an emerging option for the treatment of upper limb non-infected nonunions. The hypothesis of our study is that corticoperiosteal flap could be an effective and safe procedure for the treatment of upper limb non-infected nonunions, evaluating radiographic and clinical outcome., Methods: We enrolled 14 patients who underwent vascularized medial femoral condyle corticoperiosteal free flaps from January 2011 to December 2014. All patients were clinically evaluated (VAS, DASH) before surgery and at 6 and 12 months post surgery. The radiographic evaluation was performed every 30 days until the complete healing and at 12-month follow-up. We also recorded the range of motion pre and post surgery at the donor site., Results: All nonunion sites healed primarily at an average time period of 5.2 months ±1. Preoperative DASH score was 70 ± 15.6; at 6 month follow-up was 21.51 ± 10.63; at 12 month follow-up 18.0 ± 9.9. Preoperative VAS was 7.05 ± 2; at 6-month follow-up was 2.1 ± 2; at 12-month follow-up was 1.8 ± 1.16. Statistical analysis showed a significant difference (p <0.001) about the preoperative and the postoperative VAS and DASH evaluation both at 6 and 12-month follow-up, but we did not record any statistical difference between the 6-month and 12-month follow-up. At the donor site, the mean VAS score was 2 ± 2.1 at seven days post operatively. All patients restore the full ROM at 7 days post surgery., Conclusions: Vascularized medial condyle corticoperiosteal free flap represents an effective and safe procedure for the treatment of upper limb nonunions., (© 2017 Elsevier Ltd. All rights reserved.)

Objective: The best treatment for moderately displaced radial head fractures (Mason type II) still remains controversial. In cases of isolated fractures, there is no evidence that a fragment displacement of ≥ 2 mm gives poor results in conservatively treated fractures., Patients and Methods: We retrospectively reviewed 52 patients (31M, 21F) affected by an isolated Mason type II fracture, treated with a long arm cast for two weeks between 2008 and 2013. All patients had practiced sports before being injured. They were all either bicyclists, or baseball, boxers, basketball, rugby, tennis or football players. The mean follow-up was 36 months. Elbow and forearm range of motion were measured. The Mayo Elbow Performance Score, the Broberg and Morrey rating system and the Disabilities of the Arm, Shoulder and Hand Score (DASH score) were analyzed. Follow-up radiographs were examined for evidence of consolidation, late displacement, early arthritis and non-unions., Results: Flexion was slightly impaired in the injured limb when compared to the uninjured limb (137°± 6° versus 139°±5°) as were extension (-3°±6° versus 1°±4°, p < 0.05), supination (86°±6° versus 88°±3°), pronation (87°±4° versus 88°±6°) and valgus deviation (10°±4° versus 8°±3°, p < 0.05). 40 patients had no elbow complaints; 9 patients experienced occasional pain, 2 a mild instability of the elbow, and 4 a mild loss of grip strength. The DASH score was excellent in 48 patients (92.31%). In only 6 cases (11.53%) degenerative changes were greater in formerly injured elbows than in uninjured elbows. All patients returned to their previous sports activities., Conclusions: Isolated Mason type II fractures can have a good or excellent mid-term functional outcome even when treated conservatively.

Background: In recent years, the type of surgical treatment for Achilles tendon rupture has been the subject of controversial debate. This biomechanical study evaluates for the first time in literature the ultimate failure load (UFL) of interlocking horizontal mattress (IHM) suture as compared with Kakiuchi suture in Achilles tendon rupture. The hypothesis is that IHM suture can be performed also for Achilles tendon rupture and ensures higher resistance compared with the traditional Kakiuchi suture., Materials and Methods: Twenty fresh bovine Achilles tendons were obtained. Ten preparations were randomly assigned to each of two different groups: group A (10 specimens) sutured by IHM technique, and group B (10 specimens) sutured by Kakiuchi technique. Each construct was mounted and fixed on a tensile testing machine. Static preconditioning of 50 N was applied for 5 min as initial tensioning to stabilize the mechanical properties of the graft, then a load to failure test was performed at crosshead speed of 500 mm/min., Results: Ten specimens were tested for each group. The mean UFL was 228.6 ± 98.6 N in the IHM suture group and 96.57 ± 80.1 N in the Kakiuchi suture group. Statistical analysis showed a significant difference (p < 0.05) with better UFL in the IHM group. In both groups, the failure mode registered in each specimen was suture breakage (rupture of suture thread)., Conclusions: IHM suture achieved better UFL compared with Kakiuchi suture in an animal model of Achilles tendon repair. These results seem to support IHM as a valid option in Achilles tendon rupture.

Background: To compare in an animal model the biomechanical properties of four coupled fixation devices currently used in ACL reconstruction. Three out of four devices used a full tibial tunnel with an interference screw, while the other one system used a tibial socket and an adjustable loop suspension device. The null hypothesis is that there are no biomechanical differences between all the techniques tested., Methods: Thirty two femur-graft-tibia complexes were mounted on a tensile machine using bovine digital extensor tendons, porcine knees and four different fixation device combinations: After a preconditioning with a tensile load of 90N for five minutes, 1000cycles between 0 and 150N were applied to the complex before the final pulled to failure. Stiffness and strength were evaluated at the final pullout, as was the displacement (slippage) at one, 100, 500, and 1000cycles., Results: The multiple mean comparison led to a significant difference for the case of stiffness, with worse results in group C compared to group A (p=0.037). Conversely, no differences were found in UFL and slippage between all groups (p>0.05)., Conclusion: All the tested systems demonstrated in an animal model sufficient properties for a safe postoperative rehabilitation both for strength and for stiffness and slippage under cyclic loading., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: (1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score., Methods: From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value., Results: The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears., Conclusions: The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy., Level of Evidence: Comparative case series, Level IV.

Background: There are different techniques for drilling the femoral tunnel in the anterior cruciate ligament reconstruction (ACLR), but their influence in the bone tunnel enlargement in unknown. The purpose of this study was to compare two different surgical techniques for evaluating femoral tunnel enlargement in ACLR. The hypothesis was that tunnel placement using the outside-in technique leads to less tunnel enlargement compared to the transtibial technique., Methods: Forty-four patients treated for ACLR between March 2013 and March 2014 were prospectively enrolled in this study. According to the surgical technique, subjects were assigned to Group A (Out-in) or Group B (Transtibial). All patients underwent CT examination in order to evaluate the femoral tunnel enlargement at four different levels. Moreover, all patients were evaluated with the Lachman test and pivot shift test, and the KT1000 arthrometer was used to measure the anterior laxity of the knee. A subjective evaluation was performed using the 2000 International Knee Documentation Committee Subjective Knee score, Lysholm knee score and Tegner activity scale. All patients were assessed after 24 months of follow-up., Results: At the final follow-up, there were statistically significant differences (p < 0.05) in femoral tunnel enlargement between the two groups at all four femoral levels in favor of the out-in group. No statistical significant differences were found in the objective and subjective clinical outcomes between the two groups (p > 0.05)., Conclusions: In ACLR with a suspension system, the outside-in technique leads to less enlargement of the femoral tunnel lower than the transtibial technique.

Introduction: The aim of our study is to compare the clinical and radiological outcomes of the treatment of distal fibular fracture with the traditional stainless steel or the new radiolucent CFR-PEEK plates. The hypothesis is that there are no differences in clinical and radiological outcomes at the final follow-up between the two fixation devices., Methods: All consecutive patients aged from 18 or over, who had undergone operative treatment for malleolar fracture between 2013 and 2014, have been included in the study. 87 were available for the study. The patients were assigned to group A (47 patients, radiolucent plate group) and group B (41 patients, stainless steal plate group). At 6, 12 and 24 months all patients were prospectively reviewed with radiographic and clinical evaluations (OMAS scale, AOFAS, VAS, ROM)., Results: The groups were homogenous with regard to age, gender, BMI, dominance and disease duration. The mean follow-up was 23+/-2 months. The mean waiting time to operation was 2.94days (SD 2.74) (range 0.2-6.8). Statistical analysis showed no difference (p>0.05) about the VAS, OMAS, AOFAS and ROM evaluation at 6, 12 and 24 month follow-up between two groups. Radiographic evaluation showed no difference between two groups at all the follow-up with similar results obtained with the two fixation devices., Discussion: Our results showed a substantial equivalence of the two fixation devices at 6, 12 and 24 month of clinical and radiographic follow-up. Fixation of the lateral malleolus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. These results are comparable to those achieved with conventional plates., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to compare rehabilitation protocol and operative treatment in a population of patients with a diagnosis of small to medium rotator cuff tears (≤3 cm), the null hypothesis being that there would been no difference in terms of clinical outcomes and patient's satisfaction between the rehabilitation protocol and the surgical treatment., Methods: Patients with small to medium supraspinatus tears were retrospectively enrolled in this study and divided in 2 groups: arthroscopic repair (group A, 20 patients) and reinstated (group B, 18 patients). At a mean follow-up of 18 months, both groups underwent clinical (Constant, QuickDash, VAS), dynamometric and ultrasonographic evaluation., Results: In both groups a significant clinical improvement was registered compared to baseline. However, surgical treatment yielded better results in Constant (p=0.004), Quick-Dash (p=0.0012), VAS (p=0.048) and strength evaluation (p=0.0014). In group A the re-tear rate was 10%, while in group B only 11% of increased tear size was registered., Conclusion: At a short term follow-up, the surgical treatment of small to medium supraspinatus tears yielded better clinical outcomes compared to the rehabilitation protocol, with better strength outcomes and 10% re-tear rate. Nevertheless, physiotherapy still offers acceptable results and could be a valuable option in patients not undergoing surgery., Level of Evidence: III., Competing Interests: Conflict of interest The Author has no financial or personal relationships with other people or organizations that could inappropriately influence their work.

Background: To evaluate the reliability of the Iliotibial band compared to gracilis tendon as a graft to be used in anterolateral ligament reconstruction., Methods: Gracilis tendon and a strip of Iliotibial band compared were harvested from 8 fresh human cadaveric knees. The gracilis tendon was prepared to obtain a graft of 10cm in length (Group 1). Iliotibial band compared was prepared to obtain a graft of 10cm in length and 0.5cm in width from the middle portion (Group 2). All the specimens were fixed on a servo hydraulic tensile machine with dedicated cryo-clamp. The loading protocol, used to compare the previously published results of ultimate failure load and Stiffness of the anterolateral ligament (Group 3), included a cyclic preconditioning between 10 and 25N at 0.1Hz for 10cycles and then a load to failure test at 20mm/min., Findings: Gracilis tendon showed higher Ultimante Failure Load and stiffness when compared to a strip of Iliotibial band. Gracilis tendon and a strip of Iliotibial band compared showed higher Ultimante Failure Load and stiffness when compared with native anterolateral ligament as reported by Kennedy., Interpretation: Both grafts tested in the present studies are suitable for an anatomical anterolateral ligament reconstruction., (Copyright © 2017. Published by Elsevier Ltd.)

Our hypothesis is that there are no difference in the injury incidence on artificial turf and natural grass. During the 2011/2012 season, we recorded injuries which occurred to two Italian stadiums equipped with third-generation artificial turf during 36 games (391 players). Data were compared with the injuries which occurred in the same season in two stadiums equipped with natural grass (372 players). We recorded 43 injuries during the playing time (16.7 per 1000 h). About 23 (18.1 per 1000 h) injuries occurred on artificial turf, while 20 (15.2 per 1000 h) on the natural grass with no statistical differences P > 0.05. We recorded 10 (7.87 per 1000 h) contact and 13 (10.23 per 1000 h) non-contact injuries on artificial turf, while 5 (3.8 per 1000 h) contact and 15 (11.4 per 1000 h) non-contact injuries on natural grass P > 0.05. The overall relative risk was 1.15; 95% CI: 0.64-2.07). Our study demonstrates a substantial equivalence in injury risk on natural grass and artificial turf in elite professional soccer athletes during official matches., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The all-inside graft-link technique for anterior cruciate ligament reconstruction is performed with two cortical suspension devices with adjustable loops on both femur and tibia. This technique requires meticulous graft preparation. The aim of this study was to biomechanically test three different graft configurations resulting from differences in initial graft length., Materials and Methods: Thirty bovine digital extensor tendons were arranged in three different ways: "half-quadrupled", "tripled" and "quadrupled". The final graft length was 65-75 mm. The specimens were fixed vertical to the loading axis of a tensile testing machine. After a static pre-conditioning of 50 N for 5 min, a load to failure test was performed and data regarding the ultimate failure load (UFL), the stiffness and mode of failure were recorded., Results: The evaluation of UFL showed a significant differences between group means as determined by one-way analysis of variance (F = 21.92, p = 0.002). Post hoc comparisons showed a significantly better UFL of "tripled" (p = 0.007) and "quadrupled" preparations (p = 0.014) compared to the "half-quadrupled" configuration, with no significant differences between "tripled" and "quadrupled" grafts (p = 0.061). No significant differences were found when evaluating the stiffness between the groups. Failure occurred by tendon slippage across the suture in all specimens., Conclusion: The "quadrupled" tendon achieved the best UFL, with even the "tripled" configuration having sufficient biomechanical characteristics to withstand the loads experienced during early rehabilitation. For this reason, with a total semitendinosus length of less than 260 mm it could be better to "triple" instead of "half-quadruple" it to achieve better performance of the graft.

Background: The aim of this study was to compare bone femoral tunnel enlargement in patients who underwent anterior cruciate ligament (ACL) transtibial reconstruction using an adjustable-loop length suspensory fixation device and a fixed-loop length suspensory fixation device., Methods: All patients treated for ACL reconstruction with an ipsilateral hamstring between March 2013 and March 2014 were evaluated. Subjects were assigned to Group A (TightRope™ (TR) femoral fixation) or Group B (EndoButton® (EB) femoral fixation). All patients were evaluated with the Lachman test, pivot-shift test, 2000 International Knee Documentation Committee (IKDC) knee examination and KT1000 arthrometer. The subjective evaluation was performed using the 2000 IKDC Subjective Knee score, the Lysholm knee score, and the Tegner activity scale. CT examination was performed to evaluate femoral tunnel enlargement at four different levels. All patients were assessed at a 12month follow-up visit. Power analysis was performed a priori in accordance with the femoral tunnel enlargement values from the CT scans. Differences with P-values of ≤0.05 were considered to be statistically significant., Results: The groups were homogenous at baseline with regard to age, gender, BMI, dominance and disease duration. At the final follow-up, no statistically significant differences (P>0.05) were found according to subjective and objective clinical outcome measures. According to the femoral tunnel enlargement, no statistically significant difference was found between the two groups (P>0.05)., Conclusion: In transtibial ACL reconstruction, the use of a fixed or adjustable-loop length device products, on the femoral side, led to similar clinical and radiological results., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Rotator cuff tears are closely related with muscle atrophy and fatty infiltration and both affect healing after surgical treatment. The aim of this study was to compare surgical versus conservative management of medium-to-large reparable rotator cuff tears., Methods: Forty-one patients with clinical and radiological (MRI) diagnosis of medium-to-large rotator cuff tears were retrospectively identified and divided into two groups: Group A, arthroscopic repair; Group B, conservative treatment. At follow-up (T1) all patients underwent a new clinical (VAS, SST, Constant and Relative Constant Scale) and radiological evaluation (MRI)., Results: When comparing the two groups at T1 (mean follow-up: Group A, 50 months; Group B, 61 months), we registered better results in Group A in the SST (p < 0.05), the VAS score (p < 0.01), the Constant and the Relative Constant Scale (p < 0.05). Radiological evaluation did not show a significant increase of fatty infiltration (p = 0.16) in Group A (no progression in 15 out of 17 patients -82.3%-, and an increase in 2 out of 17 patients -11.7%-), while in Group B a significant increase was detected (p < 0.01) in all patients; in regard to muscle atrophy, no cases of progression were detected in Group A (4 out of 17 patients -23.5%- showed an increased post-operative supraspinatus trophysm), while a significant worsening (p < 0.05) was found in Group B. In Group B a significant worsening of tendon retraction (p < 0.01) and of tear size (p = 0.01) was also detected., Conclusions: Surgical treatment of complete rotator cuff tears seems to decrease the irreversible changes that involve muscle belly., (Copyright © 2016 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose: Our hypothesis was that the Achilles tendon healing process after surgical treatment would be promoted by PRP with a faster return to sports activities., Methods: Thirty patients with Achilles tendon rupture and surgically treated with a combined mini-open and percutaneous technique were prospectively enroled in the study. Patients were alternately case-by-case assigned to Group A (control group; 15 patients) or Group B (study group; 15 patients). In Group B, PRP was locally infiltrated both during surgery and 14 days after surgery. Patients in both groups were followed up at 1, 3, 6 and 24 months post-operatively via physical examination, VAS, FAOS and VISA-A scales; ultrasonography (US) and MRI were also conducted at one and 6 months; at the 6-month follow-up, isokinetic and jumping capacity tests were also performed., Results: The VAS, FAOS and VISA-A scale showed no difference between the two groups at 1, 3, 6 and 24 months post-operatively. Isokinetic evaluation showed no differences at both angular speeds. Jumping evaluation showed no difference at 6 months. Also US evaluation showed no differences. MRI data analysis before administration of gadolinium did not reveal significant differences between the two groups. Moreover, after intravenous injection of gadolinium, patients in Group B showed signal enhancement in 30 % of patients compared to 80 % in Group A at 6 months, as indirect evidence of better tendon remodelling (P < 0.05)., Conclusions: A substantial equivalence in structural and functional results in Achilles tendon ruptures surgically treated with and without addition of PRP is shown by present study. Clinical results, morphological features and jumping capability were similar in both groups. The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results., Level of Evidence: IV.

Background: The management of acute Rockwood type III acromioclavicular joint (ACJ) dislocation remains controversial, and the debate about whether patients should be conservatively or surgically treated continues. This study aims to compare conservative and surgical treatment of acute type III ACJ injuries in active sport participants (<35 years of age) by analysing clinical and radiological results after a minimum of 24 months follow-up., Methods: The records of 72 patients with acute type III ACJ dislocations who were treated from January 2006 to December 2011 were retrospectively evaluated. Patients were categorised into two groups. group A included 25 patients treated conservatively, and group B included 30 patients treated surgically with the TightRope™ system. Seventeen patients were lost to follow-up. All patients were evaluated at final follow-up with these clinical scores: Constant, University of California Los Angeles scale (UCLA), American Shoulder and Elbow Surgeons Scale (ASES) and Acromioclavicular Joint Instability (ACJI) and with a subjective evaluation of the patient satisfaction, aesthetic results and shoulder function. The distance between the acromion and clavicle and between the coracoid process and clavicle were evaluated radiographically and compared with preoperative values. Δ, the difference in mm between the distance at the final follow-up and at T0 in the injured shoulder, and α, the side-to-side difference in mm at follow-up, were calculated. Heterotopic ossification and postoperative osteolysis were evaluated in both groups., Results: There were no major intraoperative complications in the surgical group. The subjective parameters significantly differed between the two groups. Constant, ASES and UCLA scores were similar in both groups (P > 0.05), whereas ACJI results favoured the surgical group (group A, 72.4; group B, 87.9; P < 0.05). All measurements of radiographic evaluation were significantly reduced in the surgical group compared with the conservative group. In group A, we detected calcifications in 30% of patients; in group B we detected two cases of moderate osteolysis and calcifications in 70% of patients., Conclusion: Although better subjective and radiographic results were achieved in surgically treated patients, traditional objective scores did not show significant differences between the two groups. Our results cannot support routine use of surgery to treat type III ACJ dislocations.

Introduction: in this study we report the functional results of 36 professional athletes treated with a combined percutaneous and mini-open technique., Methods: patients were evaluated with Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A), the objective 100-points Hannover scale and the Ergo-jump Bosco System device., Results: at a mean 28- month follow-up no re-rupture cases were observed. Six patients had minor complications. The Ergo-jump Bosco System device showed no significant differences in the side-to-side evaluation in regard to strength (-0.94%) and elasticity (+2.44%), while a significant post-operative loss was detected in the endurance trials (-6.78%). The Hannover scale showed an average score of 94.5, while the VISA-A had an average of 93.1. Thirty-one patients resumed their pre-operative sports activity level within five months from surgery., Conclusions: our results showed that the combined mini-open and percutaneous repair is an effective treatment for professional athletes, with satisfactory clinical and functional results, lack of major complications and a quick return to professional sports activity.

This article presents a 46-year-old man with bilateral atraumatic quadriceps rupture that occurred while he was descending stairs. The patient underwent surgery the day after the accident. In the left knee, quadriceps reinsertion was performed using a conventional technique. In the right knee, platelet-rich plasma (PRP), both in its liquid and semisolid patterns, was added intraoperatively. Ultrasonography and magnetic resonance imaging evaluations were performed 1, 6, and 24 months postoperatively. At 6 and 24 months postoperatively, clinical and functional evaluations also were performed. Clinical examination showed no differences between the knees, and functional scores were the same for both knees. Ultrasonographic evaluation showed bilateral persistent tendon thickening and gross echotexture abnormalities, with no side-to-side differences. Magnetic resonance imaging showed signals of vascularized granulation tissue in both knees, which was more evident in the right (PRP) knee at 1 month postoperatively, along with a better signal of scar tissue in the right knee at 6 and 24 months postoperatively. The use of PRP yielded no better clinical or functional results than the lack of its use. However, a more intense and significant reparative healing process occurred where the PRP was used, thus suggesting a more rapid completion of the healing process, although this effect seems to remain only a radiographic finding with no clinical correlation., (Copyright 2013, SLACK Incorporated.)

Background: Despite technical advances in rotator cuff surgery, recurrent or persistent defects in the repaired tendon continue to occur. The improved strength of sutures and suture anchors has shown that the most common site of failure is the suture-tendon interface. The purpose of this study was to compare two different types of repair under both cyclic and load-to-failure conditions. The hypothesis is that the use of a fixation system with knotless anchor and taped suture results in better biomechanical performance, under both cyclic and load-to-failure conditions., Methods: Thirty bovine shoulder specimens were randomly assigned to two group tests: the Swivelock 5-mm anchor with Fibertape (Group A) and the Bio-Corkscrew 5 mm with Fiberwire (Group B). We simulated the reconstruction of a rotator cuff tear with a single-row technique, performing a tenodesis with types A and B fixation. Each specimen underwent cyclic testing from 5 to 30 N for 30 cycles, followed by load-to-failure testing, in order to calculate the ultimate failure load (UFL)., Results: Load-to-failure tests revealed a significantly higher UFL in Group A than in Group B. Wire fixing failed at the anchor loop whereas tape fixing failed at the sutures, suture-tendon interface, and anchors. Cyclic testing revealed no significantly greater slippage between the two groups. Stiffness values were not statistically significantly different. In all cases, tendons remained intact until the end of the cyclic testing., Conclusions: The tape structure is biomechanically stronger than the wire structure.