Angelo Del Buono

Arthroscopic-Assisted Broström-Gould for Chronic Ankle Instability A Long-Term Follow-up

Background: Lateral ankle sprains account for 85% of ankle lesions. Hypothesis: Combined open and arthroscopic procedures could improve the diagnosis and management of intra-articular lesions and allow surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex. Study Design: Case series; Level of evidence, 4. Methods: Forty consecutive patients underwent ankle arthroscopy for recurrent (2 or more episodes) lateral ankle instability unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was confirmed at imaging (plain radiographs and magnetic resonance imaging [MRI]) and arthroscopic assessment. All patients underwent arthroscopic Broström-Gould repair for management of lateral ankle instability; secondary lesions were also managed. Postoperatively, the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to assess the functional status; clinical examination and conventional radiographs were performed in all patients. Results: Thirty-eight patients were reviewed at an average postoperative follow-up of 9.8 years. The mean AOFAS score was 90 (range, 44-100) at the last follow-up. No significantly different outcomes were found in patients who had undergone microfractures for management of grade III to IV cartilage lesions compared with patients with no cartilage lesions. Postoperative AOFAS scores were graded as excellent and good in almost all patients (94.7%). Concerning failure rate, 2 patients (5.3%) reported a low AOFAS score: one patient underwent soft tissue removal for anterior impingement, and one received simultaneous medial ankle instability repair. Conclusion: The arthroscopic Broström-Gould–assisted technique could be a viable alternative to the gold-standard Broström-Gould procedure for anatomic repair of chronic lateral ankle instability and management of intra-articular lesions. Prospective randomized controlled trials are needed.

Acute muscle strain injuries: a proposed new classification system

PurposeTo better define and classify acute muscle strain injuries.MethodsHistorically, acute muscle strains have been classified as grade I, II and III. This system does not accurately reflect the anatomy of the injury and has not been shown to reliably predict prognosis and time for return to sport.ResultsWe describe an imaging (magnetic resonance or ultrasound) nomenclature, which considers the anatomical site, pattern and severity of the lesion in the acute stage. By site of injury, we define muscular injuries as proximal, middle and distal. Anatomically, based on the various muscular structures involved, we distinguish intramuscular, myofascial, myofascial/perifascial and musculotendinous injuries.ConclusionsThis classification system must be applied to a variety of muscle architectures and locations to determine its utility; additional studies are therefore needed prior to its general acceptance.Level of evidenceV.

Metalloproteases and rotator cuff disease

The molecular changes occurring in rotator cuff tears are still unknown, but much attention has been paid to better understand the role of matrix metalloproteinases (MMP) in the development of tendinopathy. These are potent enzymes that, once activated, can completely degrade all components of the connective tissue, modify the extracellular matrix (ECM), and mediatethe development of painful tendinopathy and tendon rupture. To control the local activity of activated proteinases, the same cells produce tissue inhibitors of metalloproteinases (TIMP) that bind to the enzymes and prevent degradation. The balance between the activities of MMPs and TIMPs regulates tendon remodeling, whereas an imbalance produces a collagen dis-regulation and disturbances intendons. ADAMs (a disintegrin and metalloproteinase) are cell membrane-linked enzymes with proteolytic and cell signaling functions. ADAMTSs (ADAM with thrombospondin motifs) are secreted into the circulation, and constitute a heterogenous family of proteases with both anabolic and catabolic functions. Biologic modulation of endogenous MMP activity to basal levels may reduce pathologic tissue degradation and favorably influence healing after rotator cuff repair. Further studies are needed to better define the mechanism of action, and whether these new strategies are safe and effective in larger models.

Isolated Anterior Talofibular Ligament Broström Repair for Chronic Lateral Ankle Instability 9-Year Follow-up

Background: Lateral ankle sprains may result in pain and disability in the short term, decreased sport activity and early retirement from sports in the mid term, and secondary injuries and development of early osteoarthritis to the ankle in the long term. Hypothesis: This combined approach to chronic lateral instability and intra-articular lesions of the ankle is safe and in the long term maintains mechanical stability, functional ability, and a good level of sport activity. Study Design: Case series; Level of evidence, 4. Methods: We present the long-term outcomes of 42 athletes who underwent ankle arthroscopy and anterior talofibular Broström repair for management of chronic lateral ankle instability. We assessed in all patients preoperative and postoperative anterior drawer test and side-to-side differences, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Kaikkonen grading scales. Patients were asked about return to sport and level of activity. Patients were also assessed for development of degenerative changes to the ankle, and preoperative versus postoperative findings were compared. Results: Thirty-eight patients were reviewed at an average of 8.7 years (range, 5-13 years) after surgery; 4 patients were lost to follow-up. At the last follow-up, patients were significantly improved for ankle laxity, AOFAS scores, and Kaikkonen scales. The mean AOFAS score improved from 51 (range, 32-71) to 90 (range, 67-100), and the mean Kaikkonen score improved from 45 (range, 30-70) to 90 (range, 65-100). According to outcome criteria set preoperatively, there were 8 failures by the AOFAS score and 9 by the Kaikkonen score. Twenty-two (58%) patients practiced sport at the preinjury level, 6 (16%) had changed to lower levels but were still active in less demanding sports (cycling and tennis), and 10 (26%) had abandoned active sport participation although they still were physically active. Six of these patients did not feel safe with their ankle because of the occurrence of new episodes of ankle instability. Of the 27 patients who had no evidence of degenerative changes preoperatively, 8 patients (30%) had radiographic signs of degenerative changes (5 grade I and 3 grade II) of the ankle; 4 of the 11 patients (11%) with preexisting grade I changes remained unchanged, and 7 patients (18%) had progressed to grade II. No correlation was found between osteoarthritis and status of sport activity (P = .72). Conclusion: Combined Broström repair and ankle arthroscopy are safe and allow most patients to return to preinjury daily and sport activities.

Femoroacetabular impingement syndrome management: arthroscopy or open surgery?

PurposeThis review explores the scientific evidence for clinical, functional and imaging outcomes after surgical management of Femoroacetabular Impingement (FAI) syndrome, and assesses the methodological quality of the published literature reporting this issue.MethodsThe medical literature databases of Pubmed, Medline, Ovid, Google Scholar and Embase were searched for articles published in English, Spanish, French and Italian, using a combination of the keywords ‘femoro-acetabular impingement syndrome’, ‘postoperative outcomes’, ‘open surgery’, and ‘arthroscopic management’. To address three main questions, we extracted data on demographic features, operative techniques, postoperative rehabilitation regimens, imaging features, pre and postoperative hip scores. Complications and conversion to arthroplasty were also investigated.ResultsThirty-one studies published have reported clinical, functional and imaging outcomes after open and arthroscopic management of FAI syndrome. The modified Coleman methodology score (CMS) averaged 56.2 (range, 30–81). From extracted data, it was shown that arthroscopy, open surgery and arthroscopic surgery followed by mini open surgery are comparable for functional results, biomechanics, and return to sport. Progression of OA and conversion to hip arthroplasty are dependent on preoperative status of cartilage and osteoarthritis and type of management. Debridement and osteoplasty provide better results than debridement only. Significantly improved outcomes have been recorded in patients undergoing labral refixation than resection. The Coleman methodology score showed great heterogeneity in terms of study design and outcome assessment, and generally low methodological quality.ConclusionAlthough open and minimally invasive procedures allow athletes to return to professional sports activity, they are contraindicated in patients with severe osteoarthritis and cartilage degeneration.

Management of the greater trochanteric pain syndrome: a systematic review

INTRODUCTION Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter. SOURCE OF DATA We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected. AREAS OF AGREEMENT Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months. AREAS OF CONTROVERSY Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS. GROWING POINTS Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported. AREAS TIMELY FOR DEVELOPING RESEARCH Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS. CONCLUSION The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

Remplissage Repair—New Frontiers in the Prevention of Recurrent Shoulder Instability A 2-Year Follow-up Comparative Study

Background: An engaging Hill-Sachs lesion is a defect of the humeral head, large enough to cause locking of the humeral head against the anterior corner of the glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation. Hypothesis: When Bankart lesions are associated with engaging Hill-Sachs defects, simultaneous Bankart repair and remplissage provide lower recurrence rates than does Bankart repair alone. Study Design: Cohort study; Level of evidence, 3. Methods: Fifty patients (36 men, 14 women) with combined engaging Hill-Sachs and Bankart lesions were evaluated, before and after arthroscopic management, at a minimum follow-up of 2 years. After imaging and arthroscopic assessment, 25 patients underwent remplissage and Bankart repair, and 25 patients received Bankart repair alone. Patients were evaluated using the UCLA, Constant, and Rowe scores, and range of motion was measured using a goniometer. Postoperatively, all patients underwent magnetic resonance imaging to assess the status of healing of the anterior labrum and whether the tenodesis of the infraspinatus covered the Hill-Sachs defect. Results: At the last appointment, active forward elevation, external rotation beside the body, internal rotation, and all administered scores were significantly improved compared with baseline assessment, with no statistically significant intergroup differences. A new posttraumatic dislocation occurred in 5 patients, all from the Bankart-only group (20%). Conclusion: Remplissage is a safe, relatively short procedure that allows the surgeon to address large humeral defects with a low postoperative recurrence rate. Humeral head large defects predispose to recurrent instability of the shoulder and deserve surgical management.

Glenohumeral osteoarthritis after arthroscopic Bankart repair for anterior instability.

Background Few data on shoulder arthropathy in patients undergoing arthroscopic repair for glenohumeral instability are available. Hypothesis Arthroscopic stabilization of Bankart lesions does not prevent the development of postoperative glenohumeral osteoarthritis. Study Design Case series; Level of evidence, 4. Methods Clinical (Rowe and Constant scores) and radiographic preoperative and postoperative data from 60 patients who underwent arthroscopic Bankart repair were compared. Osteoarthritis was graded preoperatively and postoperatively with the Buscayret classification grading system. The average age at surgery was 27.6 years, and follow-up averaged 8.0 years. Results The postoperative incidence of osteoarthritis in patients with no preoperative degenerative changes was 21.8% (12 of 55 patients). The incidence of degenerative joint disease of the glenohumeral joint showed evidence of a statistically significant association with older age at first dislocation and at surgery, increased length of time from the first episode to surgery, increased number of preoperative dislocations, increased length of time from the initial dislocation until surgery, increased number of anchors used at surgery, and more degenerated labrum at surgery. A higher number of preoperative dislocations, a greater length of follow-up, and reduced external rotation in abduction influenced Rowe and Constant scores. Conclusion The number of anchors used and the state of the labrum are the most important factors associated with a higher risk of radiographic degenerative changes. Longer follow-up investigations are needed to draw meaningful conclusions.

Platelet plasma rich products in musculoskeletal medicine: any evidence?

Platelet reach plasma (PRP) is considered to accelerate muscle and tendon healing and allow early return to elite competition, and it is often recommend as best practice for management of musculoskeletal injuries. Even though several growth factors abundant in PRPs have been extensively studied in tissue regeneration, the key factors are yet unknown. Given our rudimentary knowledge of the mechanism of action of the PRPs, it is challenging to use this technology to promote early healing, and produce improved and accelerated functional recovery. We prompt researchers to undertake appropriately powered level I studies with adequate and relevant outcome measures and clinically appropriate follow up.

Percutaneous repair of acute ruptures of the tendo Achillis

Minimally invasive repair of acute traumatic ruptures of the tendo Achillis may produce lower complications compared to open repair. Twenty-three active patients underwent percutaneous repair of an acute rupture of the tendo Achillis. Post-operatively, the ATRS score was administered to assess the functional status. The maximum calf circumference, isometric plantar flexion strength of the gastrocsoleus muscle complex, ankle dorsiflexion, and return to sport activity were assessed in all patients at an average post-operative follow-up of 25.7 months. At the last follow-up, the mean Achilles tendon total rupture score (ATRS) score was 84 (range: 53-99). Ankle dorsiflexion and maximum calf circumference on the operated limb were not significantly different compared to the uninjured side. The isometric strength on the operated limb was significantly lower (P=0.04) compared to the contralateral side. Of the 21 (90%) patients participating in sports activities, 16 (80%) had returned to their pre-operative sport, 2 changed to lower activity, and 1 increased his performance. This percutaneous technique provides satisfactory outcome in terms of strength and return to pre-operative level of sport activity.