Francesco Sadile

Core decompression versus other joint preserving treatments for osteonecrosis of the femoral head: a meta-analysis

INTRODUCTION Osteonecrosis of femoral head (ONFH) leads to hip osteoarthritis (HOA); among joint preserving treatments (JPT), the role of core decompression (CD) is still debated. We assessed the efficacy of CD compared with all other JPT in delaying the natural osteonecrosis evolution to HOA. SOURCES OF DATA Following the PRISMA checklist, the Medline and Scopus databases were searched. Fifteen- to 70-year-old subjects with ONFH with a minimum follow-up of 24 months were considered. The outcomes evaluated were patient clinical status, radiographic progression and total hip arthroplasty (THA) or further surgery (FS) need. Risk ratio (RR) was calculated for every outcome reported. RCT, CCT and prospective studies were included. AREAS OF AGREEMENT A total of 12 studies (776 patients) met the inclusion criteria. Clinical outcome (RR = 1.14; 95% CI 0.58-2.32; P = 0.05), radiographic progression (RR = 1.64; 95% CI 1.14-2.35; P = 0.05) and the need for THA/FS (RR = 1.52; 95% CI 0.95-2.45; P = 0.05) suggested a slight superiority of other JPT compared with CD. AREAS OF CONTROVERSY High heterogeneity of the primary investigations was the main limitation of our study. GROWING POINTS The efficacy and effectiveness of core decompression for ONFH are, at best, no better than other joint preserving strategies. The more recent scientific evidence seems to suggest that such procedure is less successful than other joint preserving strategies. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies are needed to identify the best therapeutic approach to the ONFH.

Southwick osteotomy in stable slipped capital femoral epiphysis: A long-term outcome study

OBJECTIVES Moderate to severe chronic stable slipped capital femoral epiphysis (SCFE) produce permanent irregularities in the femoral head and acetabulum. We report a single centre long-term outcome study of Southwicks procedure for the management of moderate or severe stable chronic SCFE with irregularity of the femoral head. METHODS In the period from January 1978 to January 1990, 20 patients (16 girls, 4 boys; mean age 13 years; range 11 to 15 years) underwent 22 Southwick osteotomies for chronic stable SCFE with closure or partial closure of the growth plate and a slip between 30 degrees and 70 degrees . All osteotomies were performed by the same surgeon. Patients were followed-up for an average of 22 years (range 16 to 28 years). RESULTS External rotation deformity was corrected, and the Trendelenburg sign was hardly observable in any of the patients from six months of surgery. Radiographically, all patients showed full consolidation of the osteotomy within two months of surgery. There was no further epiphyseal slipping. We did not encounter any infection or avascular necrosis. Only one patient developed chondrolysis, which resolved fully in eight months. At the latest follow-up, no limb length discrepancy was seen in 18 patients, while two patients had a mean of 0.8 cm shortening. Eight patients (36.4%) showed radiographic evidence for degenerative joint disease, but none were symptomatic. CONCLUSION The management of chronic stable (moderate to severe) SCFE by Southwicks osteotomy is safe, but technically demanding. It affords good predictable outcome with a low complication rate.

Treatment of the trapeziometacarpal osteoarthritis by arthroplasty with a pyrocarbon implant

PurposeTrapeziometacarpal (TM) osteoarthritis is the most common type of arthritis of the hand. To date, among surgical alternatives proposed, no one type has been proven superior to others. In this prospective study we evaluated the efficacy of treating arthroplasty with a latest-generation pyrocarbon implant (Pyrocardan).MethodsThirty-six patients with TM arthritis were treated using Pyrocardan implant arthroplasty. Results were evaluated through thumb radial and palmar abduction assessment, key pinch strength evaluation, thumb opposition assessment according to Kapandji classification, the visual analogue scale, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Patient’s Satisfaction Index.ResultsThere was substantial pain reduction and a satisfying increase in range of motion and strength (p < 0.01) and improvement in DASH score (p < 0.01). Average Patient’s Satisfaction Index was 8 out of 10.ConclusionsTM arthroplasty with Pyrocardan implantation is a suitable option in treating Eaton-Littler grade II or III TM osteoarthritis.

Italian experience on use of E.S.W. therapy for avascular necrosis of femoral head

Osteonecrosis (avascular necrosis) of the femoral head is a clinical disease due to a severe bone vascular alteration associated with intense pain and loss of joint function, with an incidence of 0.1% and unknown aetiology. Many classifications exist to describe it and in the final stages the patient will need a total hip arthroplasty. In the early stages, ESWT has given excellent responses.
 The Neapolitan school studied more than 600 patients who had very good results in I and II stages of Ficat and Arlet Classification, with an improve of outcomes in VAS and HSS scores. Moreover it has shown a complete restoration of the signal intensity of the femoral head in MRI.

Percutaneous intralesional brushing of cystic lesions of bone: a technical improvement of diagnostic cytology

A modified bronchial brush is presented as a new cytologic method to improve the value of fineneedle aspiration biopsy in the diagnosis of cystic lesions of bone. Four female and six male patients ranging in age from 10 to 44 years were studied. In all cases intralesional brushing was percutaneously performed under fluoroscopic control with local anesthesia. Fine-needle aspiration biopsy preceded intralesional brushing and was performed as described elsewhere. The brush was driven into the walls and septa of an osteolytic lesion through a 14-G needle; material obtained was fixed and processed for cytological and/or histological examinations.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy. METHODS Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated. RESULTS Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous. CONCLUSIONS The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Efficacy of betamethasone valerate medicated plaster on painful chronic elbow tendinopathy: A double-blind, randomized, placebo-controlled trial

OBJECTIVE to investigate the efficacy and safety of a medicated plaster containing betamethasone valerate (BMV) 2.25 mg in patients with chronic elbow tendinopathy. METHODS randomized, double-blind, placebo-controlled study with assignment 2:2:1:1 to BMV medicated plaster applied daily for 12 hours, daily for 24 hours or matched placebo. 62 patients aged ≥18 years with chronic lateral elbow tendinopathy were randomized. The primary efficacy variable was pain reduction (VAS) at day 28. Secondary objectives included summed pain intensity differences (SPID), overall treatment efficacy and tolerability. RESULTS mean reduction in VAS pain score at day 28 was greater in both BMV medicated plaster groups, -39.35±27.69 mm for BMV12-h and -36.91±32.50 mm for BMV24-h, than with placebo, -20.20±27.32 mm. Considering the adjusted mean decreases, there was a statistically significant difference between BMV12-h and placebo (p=0.0110). Global pain relief (SPID) and overall treatment efficacy were significantly better with BMV. BMV and placebo plasters had similar local tolerability and there were few treatment-related adverse events. CONCLUSIONS BMV plaster was significantly more effective than placebo at reducing pain in patients with chronic elbow tendinopathies. The BMV plaster was safe and well tolerated.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

Background: Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data. Methods: We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated. Results: At a mean of 25.6 months’ follow-up, VAS-pain (P < .001), SF-36 PCS (P = .039), and SF-36 MCS (P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament. Conclusions: Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description. Level of Evidence: Level IV, therapeutic study, case series.

The role of arthroereisis of the subtalar joint for flatfoot in children and adults

Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults. It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome. Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols. Sinus tarsi pain is the most frequent complication, often requiring removal of the implant. To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear. Cite this article: EFORT Open Rev 2017;2:438–446. DOI: 10.1302/2058-5241.2.170009