Cesare Faldini

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review

PurposeInfrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting.MethodsThe available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords “Saphenous” and “Infrapatellar branch” in combination with “Anterior cruciate ligament”, “arthroscopy” and “hamstrings”, supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles.ResultsFive articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance.ConclusionAlthough the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice.Level of evidence Systematic review, Level II.

Effect of different postoperative flexion regimes on the outcomes of total knee arthroplasty: randomized controlled trial

Purpose A consistent limb position strategy could be an attractive and easier alternative to reduce blood loss and increase range of motion following total knee arthroplasty. The aim of this study was to understand the proper amount of flexion required to improve functional outcomes with limited patients’ discomfort.MethodsEighty-five patients undergoing total knee arthroplasty were randomly assigned to receive mild (30° of knee flexion) or high-flexion protocol (70° of knee flexion), 48xa0h after surgery. The same daily rehabilitation scheme was followed. Total blood loss, hidden blood loss, haemoglobin and haematocrit levels, fixed flexion deformity, range of motion and limb circumference at the superior patellar pole were evaluated preoperatively and 7xa0days after surgery.ResultsDemographics, blood parameters and preoperative range of motion did not show any significant difference between the two groups. No complications were recorded in both groups. High-flexion group had greater rate of dropout due to excessive patients’ discomfort. A significantly lower Hb at day 1 was found in the high-flexion group. No differences were recorded regarding the remaining parameters.ConclusionNo significant differences were found between the high-flexion and mild-flexion protocols; however, mild-flexion protocol was better tolerated by patients. We therefore recommend a 30° flexion protocol to be routinely used 48xa0h postoperatively after total knee arthroplasty. This is an easy strategy to improve functional outcomes, which is a fundamental issue considering the steady increase in knee prostheses utilization.Level of evidenceRandomized controlled trial, Level II.

Surgical tricks for open lumbar discectomy.

Herniated disc syndrome in the lumbar spine is the consequence of the conflict between a spinal root or cauda equina and a fragment of nucleus pulposus migrated through the annulus fibrosus. Patients usually complain of pain or paraesthesia travelling down to the lower extremity in the corresponding dermatome. In the majority of cases symptoms and radiographic signs regress with conservative measures [1]. However, many patients experience persistent symptoms or severe rapid pain progression with sensitive and motor deficits due to the rapid compression of one or more spinal roots. Lumbar discectomy is usually indicated after 6–12 weeks of conservative treatment if pain remains intractable or in case of severe sensitive or motor deficits [2, 3].

Osteogenic commitment and differentiation of human mesenchymal stem cells by low-intensity pulsed ultrasound stimulation.

Low‐intensity pulsed ultrasound (LIPUS) as an adjuvant therapy in in vitro and in vivo bone engineering has proven to be extremely useful. The present study aimed at investigating the effect of 30u2009mW/cm2 LIPUS stimulation on commercially available human mesenchymal stem cells (hMSCs) cultured in basal or osteogenic medium at different experimental time points (7, 14, 21 days). The hypothesis was that LIPUS would improve the osteogenic differentiation of hMSC and guarantying the maintenance of osteogenic committed fraction, as demonstrated by cell vitality and proteomic analysis. LIPUS stimulation (a) regulated the balance between osteoblast commitment and differentiation by specific networks (activations of RhoA/ROCK signaling and upregulation of Ribosome constituent/Protein metabolic process, Glycolysis/Gluconeogenesis, RNA metabolic process/Splicing and Tubulins); (b) allowed the maintenance of a few percentage of osteoblast precursors (21 days CD73+/CD90+: 6%; OCT‐3/4+/NANOG+/SOX2+: 10%); (c) induced the activation of osteogenic specific pathways shown by gene expression (early: ALPL, COL1A1, late: RUNX2, BGLAP, MAPK1/6) and related protein release (COL1a1, OPN, OC), in particular in the presence of osteogenic soluble factors able to mimic bone microenvironment. To summarize, LIPUS might be able to improve the osteogenic commitment of hMSCs in vitro, and, at the same time, enhance their osteogenic differentiation.

Anterior Approach in Total Hip Replacement

In total hip replacement, the anterior approach is intermuscular and internervous and allows the surgeon to reach the capsule without muscle detachment. Advantages include faster recovery and excellent functional outcome as well as reduced postoperative pain and hospital stay. Experienced surgeons currently performing total hip replacement should be aware of all of the difficulties associated with this procedure as well as all of the tricks to overcome the most challenging steps in order to reduce complications during the learning curve. The authors present the most crucial steps in total hip replacement through the anterior approach and describe the potential pitfalls and solutions. [Orthopedics. 2017; 40(3):e553-e556.].

Patient-perceived outcomes after subtalar arthroereisis with bioabsorbable implants for flexible flatfoot in growing age: a 4-year follow-up study

AbstractPurposeResults of subtalar arthroereisis in flexible flatfoot have been mainly reported in the literature using clinical or radiographical findings. However, the aim of this study is to evaluate the patient-perceived quality of life using self-reported questionnaires after subtalar arthroereisis using a bioabsorbable implant.nMethodsItalian modified FFI and the SEFAS scores were submitted to a consecutive series of 173 patients who underwent surgical treatment for flatfoot deformity using a bioabsorbable endo-orthotic implant. Postoperative complication rates were assessed. Time needed to resume normal sports activities was recorded.nResultsMean population age was 11.2xa0years with slight variability between males and females. At a mean follow-up of 4xa0years, arthroereisis with bioabsorbable implants showed excellent results for the perception of the quality of life with an average result for FFI score of 4.5 and an average SEFAS score of 47.19. Time needed to resume sport activities was 4.7xa0months ±xa00.2 with almost no difference between the groups. Four patients needed a second procedure for implant removal.nConclusionArthroereisis using a bioabsorbable implant offers good results in terms of satisfaction and quality of life with a negligible rate of failures and patient complaints based on self-reported questionnaires. The patient reported high degrees of satisfaction, and their quality of life was not compromised at all by the procedure.

METHODS FOR THE CHARACTERIZATION OF THE LONG-TERM MECHANICAL PERFORMANCE OF CEMENTS FOR VERTEBROPLASTY AND KYPHOPLASTY: CRITICAL REVIEW AND SUGGESTIONS FOR TEST METHODS

There is a growing interest towards bone cements for use in vertebroplasty and kyphoplasty, as such spine procedures are becoming more and more common. Such cements feature different compositions, including both traditional acrylic cements and resorbable and bioactive materials. Due to the different compositions and intended use, the mechanical requirements of cements for spinal applications differ from those of traditional cements used in joint replacement. Because of the great clinical implications, it is very important to assess their long-term mechanical competence in terms of fatigue strength and creep. This paper aims at offering a critical overview of the methods currently adopted for such mechanical tests. The existing international standards and guidelines and the literature were searched for publications relevant to fatigue and creep of cements for vertebroplasty and kyphoplasty. While standard methods are available for traditional bone cements in general, no standard indicates specific methods ...

Outcomes of total hip replacement in limbs affected by poliomyelitis

Introduction The outcomes of total hip replacement in patients suffering from residual poliomyelitis are poorly covered in the literature. In this retrospective study we posed the question of whether total hip replacement performed for degenerative hip diseases in limbs with residual poliomyelitis could determine satisfactory mid-term clinical and radiographic results, with a reasonable complication rate. Methods A retrospective study was carried out to assess the results of 14 total hip replacements performed on 14 patients with residual poliomyelitis on the involved limb from June 1999 to September 2011. Average age at the time of surgery was 51 years (range 26-66 years). Mean duration of follow-up was 92 months (range 52-156 months). Surgery was performed through a direct lateral approach on all hips. All but one were cementless implants. Results 2 implants failed, 1 due to traumatic acetabular fracture 6 days after surgery, and 1 due to aseptic cup loosening 13 years after surgery. Surgery was uneventful in all patients except 1 (7%), who experienced a transient sensory sciatic nerve palsy. At the latest follow up Harris Hip Score was 83.3 (range 72-91) with a marked improvement when compared to preoperative score (average 52, range 32-78). No dislocations had occurred. Conclusions Total hip replacement can be considered a feasible option for hip osteoarthritis in patients with limbs affected by residual poliomyelitis. Longer follow-up studies are needed to assess the effectiveness of unconstrained total hip replacement in polio patients.

Prenatal Diagnosis of Clubfoot: A Review of Current Available Methodology

Abstract Background: Clubfoot is one of the most common congenital limb deformities. Prenatal diagnosis of the condition is essential as it can help treat the malformation as early as possible. We reviewed the recent available literature concerning the current methods for prenatal diagnosis of clubfoot. Methods: The following databases were searched from 1966 to 2015: PubMed, OVID, Cochrane, CINAHL, Google scholar and Embase. Results: Out of a total number of 197 retrieved articles, after abstract or title page evaluation, 158 articles not matching the inclusion criteria were excluded. The full text versions of the remaining 39 articles were obtained, and their reference lists screened, with the addition of another 5 full-text articles. Conclusions: Currently, ultrasonography is considered the most reliable method of prenatal diagnosis of clubfoot. Ultrasonographic diagnosis of clubfoot appears more likely between the 18th and the 24th week of pregnancy. Alternative imaging is not indicated. There is no agreement whether to propose foetal karyotyping when isolated clubfoot is diagnosed by prenatal ultrasonography. Early detection of clubfoot should prompt a careful surveillance during pregnancy in order to detect any possible additional abnormalities and, if any of these are detected, invasive testing should be offered.

Single level anterior cervical discectomy and interbody fusion

Degenerative disorder of cervical intervertebral disc is a common cause of neck and upper limb pain. There are several reported surgical techniques available for decompression and stabilization of the interested segment in order to treat the degenerative disorder of cervical disc [1]. Anterior cervical discectomy and interbody fusion (ACDIF) for a single level can be performed in different ways to provide good stability and restoring sagittal segmental alignment [2]; however, the rationale for the choice between different techniques remains unclear [1, 3]. The aim of this video case presentation is to show the surgical technique of ACDIF using stand-alone polyetheretherketone (PEEK) cage.