Filippo Familiari

Midterm Results and Complications After Minimally Invasive Distal Metatarsal Osteotomy for Treatment of Hallux Valgus

Background: Minimally invasive distal metatarsal osteotomy (MIDMO) is a common technique used to correct the hallux valgus deformity, but controversy remains regarding the expected outcomes of this surgery. Methods: Seventy-two patients (85 feet) suffering from hallux valgus underwent MIDMO with a modified Bösch technique. Patients were prospectively evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, and the AOFAS recovery rate was calculated. Before surgery and at follow-up, the hallux valgus (HVA), intermetatarsal (IMA), and distal metatarsal articular (DMAA) angles were measured, and the severity of disease was categorized according to the preoperative HVA. The tibial sesamoid position and articular congruence were evaluated. Postoperative complications were noted. Results: After an average follow-up of 73.3 ± 38.1 months, the total AOFAS score improved from 47.6 ± 13.3 to 87.3 ± 11.5 (P < .001). The HVA decreased from 34.7 ± 8.2 to 14.8 ± 7.8 degrees, the IMA from 14.7 ± 4 to 6.6 ± 3.6 degrees, and the DMAA from 20.9 ± 9.8 to 9 ± 6.6 degrees (P < .001 for all). Postoperative improvement in AOFAS was inversely related to the preoperative severity of disease (P < .001, β = –.378). Sixteen (18.8%) deformity recurrences were noted, 9 of which were observed in patients with preoperative HVA more than 40 degrees. Worse preoperative congruence of the metatarsophalangeal joint and tibial sesamoid position correlated with a higher rate of recurrence of the disease after surgery (P = .001, β = –.353 and P < .001, β = .427, respectively). Conclusions: Satisfactory clinical and radiological results can be expected after MIDMO, but caution should be exercised when using this technique because of the likelihood of possible complications (29.4% overall complication rate). Predictors of surgical outcomes can be used to select the best candidates for this surgery. Level of Evidence: Level IV, case series.

Meniscal Transplants and Scaffolds: A Systematic Review of the Literature

The reported incidence of meniscal tears is approximately 61 per 100,000. In instances where preservation of the native meniscus is no longer a feasible option, meniscal allograft transplantation (MAT) and implants or scaffolds may be considered. The goal of this review was to compare the success and failure rates of two techniques, MAT and meniscal scaffolds, and make an inference which treatment is more preferable at the present time and future. Studies that met inclusion criteria were assessed for technique used, type of transplant used, number of procedures included in the study, mean age of patients, mean follow-up time, number of failures, failure rate, and reported reoperation rate. Fifteen studies for the MAT group and 7 studies for the meniscal scaffold group were identified. In this selection of studies, the average failure rate in the MAT group was 18.7% and average reoperation rate was 31.3%. The average failure rate in the meniscal scaffold group was 5.6%, and average reoperation rate was 6.9%. It appears that although MAT is associated with high reoperation and failure rates, the limited number of studies on both MAT and scaffolds and mainly short-term results of scaffold studies make it difficult to make an objective comparison.

Arthroscopic Partial Repair of Irreparable, Massive Rotator Cuff Tears

Several treatment options for chronic, massive rotator cuff tears exist, and they include debridement with possible biceps tenotomy or tenodesis, open or arthroscopic partial repair, muscle or tendon transfer, superior capsule reconstruction, synthetic patch augmentation, and reverse total shoulder arthroplasty. The aim of this technique article is to describe our preferred surgical option for irreparable, massive rotator cuff tears with an irreparable supraspinatus, a reparable infraspinatus, and an intact or reparable subscapularis tendon.

Clinical Outcomes and Failure Rates of Osteochondral Allograft Transplantation in the Knee: A Systematic Review:

Background: Cartilage lesions are a significant cause of morbidity and impaired knee function; however, cartilage repair procedures have failed to reproduce native cartilage to date. Thus, osteochondral allograft (OCA) transplantation represents a 1-step procedure to repair large chondral defects without the donor site morbidity of osteochondral autograft transplantation. Purpose: To perform a systematic review of clinical outcomes and failure rates after OCA transplantation in the knee at a minimum mean 2 years’ follow-up. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA transplantation in the knee joint was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1980 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCAs for the treatment of chondral defects in the knee joint, English language, mean follow-up of 2 years and minimum follow-up of 18 months, minimum study size of 20 patients, and human studies. The methodological quality of each study was assessed using a modified version of the Coleman methodology score. Results: The systematic search identified 19 studies with a total of 1036 patients. The mean 5-year survival rate across the studies included in this review was 86.7% (range, 64.1%-100.0%), while the mean 10-year survival rate was 78.7% (range, 39.0%-93.0%). The mean survival rate was 72.8% at 15 years (range, 55.8%-84.0%) and 67.5% at 20 years (range, 66.0%-69.0%). The weighted mean patient age was 31.5 years (range, 10-82 years), and the weighted mean follow-up was 8.7 years (range, 2-32 years). The following outcome measures showed significant improvement from preoperatively to postoperatively: d’Aubigné-Postel, International Knee Documentation Committee, Knee Society function, and Lysholm scores. The weighted mean reoperation rate was 30.2% (range, 0%-63%). The weighted mean failure rate was 18.2% (range, 0%-31%). Of note, revision cases, patellar lesions, and bipolar lesions demonstrated worse survival rates. Conclusion: Improved patient-reported outcomes can be expected after OCA transplantation, with a survival rate of 78.7% at 10 years. Revision cases, patellar lesions, and bipolar lesions were associated with worse survival rates; therefore, utilization of the most appropriate index cartilage restoration procedure and proper patient selection are key to improving results.

Open Repair of Quadriceps Tendon With Suture Anchors and Semitendinosus Tendon Allograft Augmentation

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Italian consensus statement for the use of allografts in ACL reconstructive surgery

PurposeGraft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the “Allografts for Anterior Cruciate Ligament Reconstruction” consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making.MethodsIn March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members.ResultsA different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients.ConclusionsResults of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R.Level of evidenceIV, consensus of experts.

Use and Effectiveness of the Cadaver-Lab in Orthopaedic and Traumatology Education: An Italian Survey

Purpose  The purpose of this study is to provide basic information on the availability and current use of cadaver laboratories in the education of orthopaedic residents and trainees and to determine the interest for the implementation of this type of training. Methods  All Orthopaedic residents and trainees who attended a cadaver laboratory organized by SIGASCOT (Italian Society of the Knee, Arthroscopy, Sports Traumatology, Cartilage and Orthopaedic Technology) between 2013 and 2016 were asked to complete a survey on the availability and current use of cadaver laboratories in the education of Orthopaedic residents and trainees. The survey was sent via e-mail to 102 Orthopaedic residents and trainees. All data were analyzed and all responses are presented as counts, percentages, or means. Results  Thirty-eight (37.2%) Orthopaedics and traumatology residents and trainees completed the survey and were included in this analysis. Eighteen trainees (18/38; 44.3%) attended a cadaver laboratory focused on lower limb surgery, whereas 20 (20/38; 52.7%) on upper limb surgery. Twenty participants (55.7%) perceived skills laboratory sessions as extremely beneficial to the understanding and becoming familiar with the normal surgical anatomy; moreover, 16 (45.7%) participants considered the cadaver laboratory extremely beneficial to the understanding of a specific surgical technique and very beneficial (44.4%) to become confident with arthroscopic or other specific surgical instruments. Over 60% of participants perceived cadaver laboratory to be very to extremely beneficial to increase confidence and speed in the operating room (OR), and more than a half of them considered skills laboratory sessions to be extremely beneficial to increase participation and decrease the occurrence of damages in the real surgical activity. Conclusion  Orthopaedic residents and trainees found the addition of a cadaver laboratory for teaching surgical skills a significant benefit to both their overall education and surgical skills training. Level of Evidence  Level IV, survey study.

Effects of Notchplasty on Anterior Cruciate Ligament Reconstruction: A Systematic Review

Purpose  Notchplasty is a complementary surgical procedure often performed during anterior cruciate ligament reconstruction (ACLR) with the aim to widen the intercondylar notch and to avoid graft impingement. The aim of this review was to analyze the current literature evidence concerning the effects of notchplasty on clinical outcome after primary ACLR. Methods  Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE were used to search English language studies, from January 1990 to July 2015, concerning the effects of the notchplasty on ACLR, using the following keywords: “ACL” OR “anterior cruciate ligament” OR “ACL reconstruction” OR “anterior cruciate ligament reconstruction” AND “notch” OR “notchplasty” OR “intercondylar notch”. Randomized and nonrandomized trials, case series, technical notes, biomechanical studies and radiological study were included. Results  At the final screening 16 studies were included. Despite widely used, the usefulness of notchplasty during ACLR remains unclear. Some concerns emerged regarding potential harmful effects of notchplasty, mostly related to the knee biomechanics and postoperative blood loss. Notchplasty can be useful in the treatment of arthrofibrosis and in presence of bony spurs of the notch both in primary and revision surgery. However, the level of evidence of available literature is poor and there is a strong need for randomized controlled trials investigating the role of notchplasty on ACLR. Conclusion  We suggest being aware of potential complications following notchplasty during ACLR before deciding to perform notchplasty in primary ACLR, reserving it for the surgical management of arthrofibrosis, treatment of notch osteophytosis and revision ACLR. Level of Evidence  Level IV, systematic review of level II-IV studies.

All-Arthroscopic Treatment of Intra- and Extra-Articular Localized Villonodular Synovitis of Knee

Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferative neoplastic condition affecting synovial-lined anatomic spaces. PVNS is characterized by hypertrophy of a synovial membrane by villous, nodular, and villonodular proliferation, with pigmentation secondary to hemosiderin deposition. The two forms of PVNS that have been described are diffuse (DPVNS) and localized (LPVNS). The knee is the most commonly involved anatomic location, followed by hip, ankle, shoulder, and elbow. Diagnosis of PVNS is not always obvious clinically. Various imaging modalities are often necessary to exclude other conditions and narrow the diagnosis. Magnetic resonance imaging has become the modality of choice for diagnosing PVNS. We present a case of intra-articular LPVNS with an extra-articular extension through the posterior capsule that has been successfully removed in an all-arthroscopic fashion.