Deianira Luciani

Autologous chondrocyte implantation in the knee joint: open compared with arthroscopic technique. Comparison at a minimum follow-up of five years.

Autologous chondrocyte implantation is a widely used technique for treating cartilage lesions1-10. The technique, first introduced and described by Brittberg et al. in 199411, required an arthrotomy of the joint, debridement of the lesions, and the suturing of a periosteal flap to create a pocket to host the chondrocytes. Autologous chondrocyte implantation in the knee joint has provided hyaline-like repair tissue11-16, with satisfactory clinical results in 80% to 90% of patients1,7,17. Moreover, autologous chondrocyte implantation has been shown to be a valid alternative to the mosaicplasty and microfracture repair techniques used in the treatment of osteochondral lesions of the knee1,6,13,17-20. In the recent past, to simplify the autologous chondrocyte implantation surgical technique, a three-dimensional hyaluronic acid scaffold was developed to support the autologous chondrocytes13. This scaffold enables an arthroscopic implantation technique to be used21. Furthermore, the chondrocytes embedded on the hyaluronic acid scaffold tend to maintain their original phenotype22 with respect to dedifferentiation induced by the fluid medium23. Despite initial encouraging results with the use of arthroscopic autologous chondrocyte implantation in the treatment of osteochondral lesions of the knee24-26, open and arthroscopic autologous chondrocyte implantation techniques have been compared in only a few studies23,25,26, and these have included only short-term follow-up and limited and nonhomogeneous case series. The aim of this study was to compare the long-term results in two groups of patients in whom osteochondral lesions in the knee joint were treated with the two aforementioned procedures. Patients were evaluated clinically, histologically, and with magnetic resonance imaging, with a minimum five-year follow-up. Between 1997 and 2002, …

The Minimally Invasive Osteotomy “S.E.R.I.” (Simple, Effective, Rapid, Inexpensive) for Correction of Bunionette Deformity:

Background: A bunionette is a deformity of the fifth metatarsal bone with a varus deviation of the toe which can require surgical correction. Although numerous bony or soft tissue surgical procedures have been described, the ideal treatment has not yet been identified. The aim of this study was to retrospectively evaluate the results of a series of 50 consecutive feet affected by symptomatic bunionette deformity treated by S.E.R.I. (simple, effective, rapid, inexpensive) osteotomy. Materials and Methods: Between February 1998 and March 2004, 50 feet with symptomatic type II-III bunionette deformity in 32 patients (18 bilateral) underwent S.E.R.I osteotomy. The average age of the patients at the time of operation was 33 ± 13 years. The average followup was 4.8 (range, 2 to 8) years. Results: The average modified lesser toe AOFAS score increased from 62.8 ± 15.2 points preoperatively to 94 ± 6.8 points at last followup (p < 0.0005). The average fifth metatarsophalangeal (MTP) angle decreased from 16.8 ± 5.1 degrees preoperatively to 7.9 ± 3.1 degrees at final followup (p < 0.0005). The 4–5 intermetatarsal angle (I.M.A) averaged 12 ± 1.7 degrees preoperatively, while postoperatively was 6.7 ± 1.7 degrees (p < 0.0005). Complications included a skin inflammatory reaction around the Kirschner wire and 2 symptomatic plantar callosities under the fourth metatarsal heads. Conclusions: The minimally invasive osteotomy is an effective and reliable technique for the treatment of painful bunionette, and it achieved more than 90% excellent and good results with reduced surgical time and complications.

Diagnosis of Flexible Flatfoot in Children: A Systematic Clinical Approach

The goal of this study was to provide measures of symptoms and signs in a consecutive case series of children with flexible flatfoot based on a systematic clinical approach. Fifty-three children (age range, 10-14 years) previously diagnosed with flexible flatfoot were evaluated by a structured interview and clinical assessment. Most patients had foot symptoms (65.3% of feet) and functional limitation (68.3%). Symptoms included a sensation of discomfort (11.3%), such as early tiredness or difficulties during prolonged standing or walking, and pain (54%), mostly located in the plantar aspect of the foot (28.7%) and the medial hindfoot (18.8%). Body mass index was positively correlated to the presence of symptoms and their severity. Even if an enlarged footprint was present in 93.1% of feet, objective assessment evidenced the presence of heel valgus only in 83% of feet. Forefoot adduction was present in 22% of feet. Jacks test provided varus correction in only 54% of feet. Internal knee rotation was the most common associated disalignment, present in 43.6% of limbs. Symptoms were significantly correlated to knee alignment, and functional limitation was correlated to heel valgus. Standing balance on 1 leg was significantly correlated to footprint grading severity. A systematic clinical approach to assess children with flexible flatfoot should always be recommended for the correct diagnosis and the associated treatment management based on symptoms, functional limitation, and foot dysfunction. Functional assessment by specific tests should be included in the examination, as evidence exists that morphology and function are not necessarily related.

The SERI Distal Metatarsal Osteotomy and Scarf Osteotomy Provide Similar Correction of Hallux Valgus

BackgroundIdeal surgical treatment for hallux valgus is still controversial. A traditional distal metatarsal osteotomy with rigid fixation (Scarf procedure) and a more minimally invasive approach to a distal metatarsal osteotomy, termed SERI (Simple, Effective, Rapid, Inexpensive), have proven successful with short-term followup. However, no data are available directly comparing the two procedures.Questions/PurposesWe performed a prospective randomized trial to determine which technique (SERI or Scarf) was associated with (1) better functional outcomes, (2) better radiographic correction, and (3) fewer complications at 2 and 7 years followup.MethodsTwenty patients, 53 ± 11 years of age, with bilateral hallux valgus, clinically and radiographically similar, underwent bilateral surgery with Scarf on one side and SERI on the other, at random. Clinical (AOFAS score) and radiographic assessments were considered before surgery, and at 7 years followup.ResultsSERI and Scarf techniques provided correction of the hallux valgus angle, intermetatarsal angle, and distal metatarsal angle in the range of normal. Both led to similar clinically important improvements in the AOFAS. No differences were observed between the groups. All osteotomies healed, and two patients who underwent the Scarf procedure required hardware removal. Reduction of ROM with respect to preoperative was observed in three patients for SERI and three patients for Scarf procedures.ConclusionsScarf and SERI techniques resulted in effective correction of hallux valgus with similar outcomes, however the SERI technique required a shorter skin incision, less surgical time, less expensive fixation device, and was without residual pain attributable to hardware.Level of EvidenceLevel II, prospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Partial ACL tears augmented with distally inserted hamstring tendons and over-the-top fixation: An MRI evaluation

This study evaluated the mid-term MRI appearance of partial ACL tear augmentation with quadrupled distally inserted hamstrings, while preserving the intact ACL bundle. Twenty-eight patients with ACL partial tear underwent augmentation. After 15-40 months follow-up, patients were evaluated clinically and by MRI. The mean IKDC score at follow-up was 93.8. Twenty-five patients were rated as excellent, three as fair. The mean tibial tunnel section area decreased by 27%. A correlation was noted between the clinical and MRI results: the graft was not visible or continuous with high intensity areas and the mean decrease in the tunnel section area was 3% in the three cases rated as fair. The graft appeared continuous and low intensity and the reduction in tibial tunnel section area was 30% in the cases with excellent clinical results. The residual part of the ACL was still recognizable in 79% of cases. The tibial hamstring attachment appeared normal in 93% of cases. In conclusion, excellent results correlated with a decrease in tunnel size and normal graft appearances on MRI. The poor results showed that the graft was not visible or not continuous, with high intensity areas and intra-ligamentous cystic formation within the tunnel. MRI scanning is useful in evaluating hamstring ACL grafts after reconstruction.

Atypical femoral fractures.

Bisphosphonates (BPs) represent the most widely used therapy for osteoporosis. Recently, a relationship between long-term treatment with BPs and a subset of atypical femoral fractures (AFFs) from below the lesser trochanter to the sovracondilar line has been described. Many etiopathogenetic theories have been invoked to explain AFFs: reduced bone turnover and increased osteoblast bone apposition with accumulation of microdamage and decreased bone toughness with subsequent increased risk of micro-cracks and duration fractures, collagen fiber cross-linking and vascularization impairment. Based on published studies, a task force of the American Society for Bone and Mineral Research has redacted the diagnostic criteria of AFFs by classifying them according to their major and minor criteria. The treatment for displaced AFFs is osteosynthesis, but there is a lack of evidence for undisplaced AFFs and the duration of fracture treatment. BPs have a proven efficacy in osteoporotic fracture reduction as well as in the treatment of other bone diseases caused by the downregulation of osteoclast activity. BPs have an excellent benefit-to-risk ratio; however, minor adverse events, such as AFFs, occur in a variable percentage of patients treated over a long period of time.

Viscosupplementation for grade II osteoarthritis of the ankle: a prospective study at 18 months’ follow-up

BackgroundViscosupplementation, with hyaluronan derivates injected into the intra-space of osteoarthritic joints, is now widely used for the treatment of knee osteoarthritis. This study evaluates the results in terms of pain and disability of intra-articular injections of hyaluronan derivates into the ankle joint in patients suffering from grade II primary or secondary osteoarthritis of the ankle.MethodsTwenty-one patients with a painful ankle and radiographic evidence of grade II osteoarthritis had three weekly intra-articular injections of 2 ml of hylan G-F 20 (10 mg/ml) into the ankle joint. The primary clinical outcome measurement was the ankle osteoarthritis score (AOS) at the baseline, and at 6, 12 and 18 months.ResultsSignificant improvement of the AOS from baseline was seen after 6 months (p=0.0001). This improvement was maintained over time with no further changes at 12- and 18-month follow-ups. Regarding pain, the AOS improved over time from the baseline to the 18-month follow up and became statistically significant at the 12- and 18-month follow-ups (p<0.05).

Partial ACL Tears: Anatomic Reconstruction Versus Nonanatomic Augmentation Surgery

Treatment of partial anterior cruciate ligament (ACL) tears requires ACL remnant preservation. The goal of this study was to compare the outcome of anatomic reconstruction of the torn bundle with nonanatomic augmentation using the over-the-top femoral route. Fifty-two athletes (mean age, 23.3 years) with partial ACL lesions underwent anatomic reconstruction (n=26) or nonanatomic augmentation (n=26). Intraoperative damage of the healthy bundle that required a standard ACL reconstruction occurred in 2 patients in the anatomic reconstruction group. International Knee Documentation Committee (IKDC) score, Tegner score, and arthrometer evaluation were used pre-operatively and at follow-up for up to 5 years postoperatively. One failure occurred in the anatomic reconstruction group. Mean IKDC subjective score at follow-up was 88.2 ± 5.7 in the anatomic reconstruction group and 90.2 ± 4.7 in the nonanatomic augmentation group. According to the IKDC objective score at final follow-up, 96% of knees in the nonanatomic augmentation group were normal vs 87.5% in the anatomic reconstruction group. No significative differences were observed between the 2 groups at final follow-up. Anteromedial bundle reconstruction showed significantly lower IKDC subjective and objective scores and higher residual instability values as evaluated with the arthrometer compared with posterolateral bundle reconstruction (P=.017). The surgical treatment of ACL partial tears is demanding. Adapted portals, perfect control of the tunnel drilling process, and intercondylar space management are required in anatomic reconstruction. The nonanatomic augmentation technique is simpler, providing excellent durable results over time with a lower complication rate. Anteromedial bundle reconstruction is associated with a poorer outcome, especially when performed with anatomic reconstruction.

Fixation of Winged Scapula in Facioscapulohumeral Muscular Dystrophy

Objective: To verify if stabilizing the scapulothoracic joint without arthrodesis could lead to functional improvement of shoulder range of motion and clinical improvement of winged scapula, we incorporated four additional patients into our previous analysis to determine if the results obtained were long lasting, and to compare this fixation with the other techniques described in the literature, balancing the benefits with the complications. Design: A retrospective study. Participants: Thirteen patients with bilateral winged scapula affected by facioscapulohumeral muscular dystrophy. Nine of these patients had been analyzed in our previous study. Methods: Patients were operated on by bilateral fixing of the scapula to the rib cage using metal wires without arthrodesis (scapulopexy). Results: All patients experienced improvement in active range of motion of the shoulder and all of them had clinical improvement with complete resolution of the winged scapula. In all twenty-six surgical interventions of scapulopexy, a stable and long-lasting fixation of the scapula to the rib cage was achieved.The complications strictly associated to the surgical technique encountered were one pneumothorax, which was resolved spontaneously, and one wire breakage without trauma. Average follow-up was 10 years (range, 3 to 18 years). Conclusion: The scapulopexy used in this extended series of patients consisted of repositioning the scapula and fixing it to four ribs by using metal wires without performing arthrodesis.This technique has a low rate of complications, is reproducible, safe and effective, resulting in clinical and functional improvement.

Electromagnetic bone growth stimulation in patients with femoral neck fractures treated with screws: prospective randomized double-blind study

BackgroundTo determine the effect of pulsed electro-magnetic fields (PEMF) on time to healing, onset of osteonecrosis of the femoral head and pain in patients with intracapsular femoral neck fracture. MethodsSeventy-seven patients had their fracture fixed with cannulated screws. After surgery, patients were randomized to receive either an active or placebo PEMF stimulator and were instructed to use it for at least 8 h per day for 90 days. Patient compliance was monitored by a clock inside the stimulator. The active stimulators generated PEMF at 75 Hz, 1.3 m/s impulse length, 2 mTesla peak magnetic field. Fracture healing and onset of osteonecrosis were evaluated on radiographs obtained 30, 60 and 90 days and then at 6, 12 and 24 months after surgery. During the first three visits pain was assessed by a visual analog scale (VAS). ResultsFracture healing was achieved in 94% of active compliant patients compared with 69% of the placebo group. The percentage of osteonecrosis was higher in the placebo group but does not reach statistical significance (37% vs. 49%). Pain assessment with the VAS evidenced significantly lower levels in the compliant active group compared with the placebo group at all visits. No differences were observed between patients who were noncompliant with the PEMF protocol and the placebo group. ConclusionsThis study shows that stimulation with PEMF accelerates fracture healing and reduces pain, leading to a better quality of life in patients suffering femoral neck fractures.