Gianluca Grandi

Surgical Treatment of Osteochondral Lesions of the Talus in Young Active Patients

C artilage is a smooth, highly specialized tissue that coats the surface of the joint. Although it is only a few millimeters thick, it has exceptional stiffness to compression and resilience and is able to distribute loads1. It is susceptible to injury and is limited in regenerative capability2. The biological function of cartilage is to permit articular movement while minimizing surface friction, to absorb loads in the weight-bearing joints, and to reduce the stress on the subchondral bone. Figs. 1-A and 1-B Histological appearance of hyaline cartilage. Fig. 1-A After staining with safranin O (×30). Fig. 1-B After staining with alcian blue (×100). Hyaline (articular) cartilage consists of 70% water; 15% collagens (primarily type II); and 15% proteoglycans (in particular, aggrecan), noncollagen proteins, lipids, and inorganic material. Chondrocytes, the only cell type in this tissue, sit within the matrix of proteoglycans and collagen, which give the cartilage its compressive and tensile properties3 (Figs. 1-A and 1-B). Osteochondral lesions of the talus are defects of the cartilaginous surface and underlying subchondral bone of the talar dome4. The etiology of osteochondral lesions of the talus can be divided into primary and secondary. Primary osteochondral lesions of the talus represent chronic diseases of the subchondral bone, most likely due to a deficiency of the vascular supply. More rarely, they are described as associated with endocrine disorders and genetic abnormalities4. Primary osteochondral lesions were formerly described as osteochondritis dissecans5. Secondary osteochondral lesions of the talus most likely occur as a result of ankle injuries (ankle sprain or fracture), chronic instability, axial defects of the lower leg, or dysbaric osteonecrosis6,7. Because joint cartilage has a poor reparative capability, osteochondral lesions of the talus rarely heal spontaneously. More frequently, patients with osteochondral lesions of …

What's new in surgical options for hallux rigidus?

The term hallux rigidus is used to describe a condition characterized by pain and a reduction in the range of motion, especially dorsiflexion, at the first metatarsophalangeal joint1-3. According to the etiology, hallux rigidus can be classified as primary (hallux limitus) or secondary (Table I)1,2,4-8. View this table: TABLE I Etiology of Secondary Hallux Rigidus ### Functional Consequences With normal locomotion, the amount of hallux dorsiflexion during propulsion must approximate 65° to 75°9. With hallux rigidus, dorsiflexion of the first metatarsophalangeal joint is restricted9. As a consequence, during the propulsive phase of gait, functional limitation and pain lead to an internal rotation of the forefoot, reducing push-off and creating transfer metatarsalgia (Fig. 1)9,10. Fig. 1 During the propulsive phase of gait, the hallux is unable to dorsiflex adequately. As a consequence, the foot internally rotates, reducing push-off and causing transfer metatarsalgia of the lesser metatarsals. ### Indications for Surgery The indication for surgery is pain combined with degenerative changes of the first metatarsophalangeal joint. Because there is no correlation between reduction of dorsiflexion and radiographic findings in hallux rigidus, we believe that the most useful parameter for the choice of a specific surgical technique is the extent of arthritis of the metatarsophalangeal joint as seen radiographically with use of a classification system described by Coughlin and Shurnas11 and modified by us (Table II) (Fig. 2). View this table: TABLE II Classification of Arthritis of the Metatarsophalangeal Joint Associated with Hallux Rigidus Fig. 2 Radiographic classification of hallux rigidus. (See Table II for a description of the grades.) ### Patient Factors The surgical strategy has to be planned according to the arthritis classification and must include consideration of other patient factors (Table III). The goal of surgery is to relieve pain, improve function, reduce the progression of arthritis, and correct any …

The Treatment of Severe Posttraumatic Arthritis of the Ankle Joint

Posttraumatic ankle arthritis consists of a progressive alteration of the hyaline cartilage, sclerosis of the subchondral bone, and osteophyte and loose-body formation as a result of an ankle injury. It may develop after nonoperative or surgical repair of an ankle injury in the form of cartilage damage, lateral malleolus malunion with shortening and valgus deformity, tibial plafond disruption and cartilage damage, malunion or necrosis of the talus, or joint instability1-5. The aim of the current study was to present our treatment guidelines for severe posttraumatic stage-2 or 3 ankle arthritis6 on the basis of the results for a series of 190 patients. One hundred and ninety patients ranging from seventeen to seventy years of age who had stage-2 or 3 posttraumatic ankle arthritis (Table I) were managed between 1994 and 2004. View this table: TABLE I Ankle Arthritis Classification System Surgical strategies were decided according to the stage of arthritis, the age of the patient, the quality of joint alignment, and the range of motion of the adjacent foot joints (the midtarsal, Lisfranc, and subtalar joints) according to the algorithm described in Table II. View this table: TABLE II Decision-Making Algorithm All patients were examined clinically and radiographically, and the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating score7 was calculated both preoperatively and at the time of follow-up. The AOFAS score was graded as excellent (80 to 100), good (70 to 79), fair (60 to 69), or poor (≤59). Patients who were managed with allograft were also studied with computed tomography and magnetic resonance imaging. A cartilage biopsy was performed during hardware removal at 1.5 years of follow-up. ### Surgical Strategies #### Stage-2 Arthritis with Preserved Ankle Anatomy: Arthroscopic Debridement and Ankle Arthrodiastasis (Fig. 1) Twelve patients ranging from twenty-one to forty-eight years of age were managed with arthroscopic debridement and arthrodiastasis with an external fixator8. Standard arthroscopic approaches were used, and debridement of degenerated cartilage …

Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy a review of thirty-nine cases

### Definition Idiopathic cavus foot (ICF) is a complex deformity that can be morphologically defined as a dorsiflexed and varus hindfoot, a plantar flexed forefoot, and subsequent elevation of the plantar arch frequently associated with claw deformity of the toes 1 ( Fig. 1 ). In addition, ICF can be also functionally defined as a foot in a persistent or prevalent state of supination 2. Fig. 1: The typical morphologic appearance of a cavus foot. ### Etiology The etiology of ICF is yet unknown. However, ICF should be considered to be a deformity caused by a neurologic disorder that we are not able to diagnose. Although an accurate neurologic (clinical and electrophysiological) evaluation can identify the cause of cavus foot deformity in some patients 3,4, Lelievre maintained that ICF is caused by a neurologic disorder in which the only symptom is the cavus foot 5. ### Pathogenesis The exact pathogenesis of ICF is not yet clear. Ombredanne and Mathieu 6 described the normal foot as a structure in which the balance of muscles (intrinsic and extrinsic), soft tissues, and bones maintains the normal anatomy and function ( Fig. 2 ). When this balance is disturbed because of a prevalence of the invertor muscles, the foot becomes deformed. The most widely accepted theory maintains that the first metatarsal bone is plantar flexed because of an imbalance between a strong peroneus longus muscle and a weak tibialis anterior 7 ( Fig. 3 ). Fig. 2: Mechanical model of the foot in which the balance of muscles, soft tissues, and bones maintains the normal anatomy and function. (Modified from: Ombredanne L, Mathieu P. Traite de chirurgie orthopedique. Paris: Masson; 1937.) Fig. 3: When the balance is disturbed because of weakness of the tibialis anterior muscle, the foot becomes deformed as a whole, producing a cavus deformity. (Modified from: Ombredanne L, …

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.

Surgical treatment of neck hyperextension in duchenne muscular dystrophy by posterior interspinous fusion

Study Design. Seven patients affected by Duchenne muscular dystrophy with neck hyperextension or poor head control in extension have undergone surgery consisting of posterior cervical interspinous fusion. Objective. To report the results of surgical treatment of neck hyperextension executed simultaneously with the correction of the thoracolumbar scoliosis. Summary of Background Data. A severely progressive deformity of the spine in patients affected by DMD can involve also the cervical spine presenting a rigid neck hyperextension or poor head control in extension, forcing the patients to assume awkward compensating postures in order to look straight ahead, worsening significantly their quality of life. Methods. The procedure consisted of a posterior approach to the cervical spine, correction of the hyperextension by releasing the fibrotic muscles and ligaments, and stabilization with bone grafts driven into the interspinous spaces, to achieve solid fusion. Results. No surgical complications were observed, and fusion was achieved in all patients. The mean angle between C2–C7 decreased from an average of 29.8° (7°–56°) before surgery, to an average of 18.5° (6°–30°) at 1 year of follow-up. Range of motion between C1–C2 was preserved. Conclusions. Surgical treatment of neck hyperextension in these patients contributes to a better sitting position, to an easier nursing, to a better appearance.

Surgical treatment of unstable intertrochanteric fractures by bipolar hip replacement or total hip replacement in elderly osteoporotic patients

A retrospective study was conducted to assess the complications, clinical and functional outcomes at 5 years of follow-up of a series of elderly osteoporotic patients with an unstable intertrochanteric fracture treated by bipolar or total hip replacement. Fifty-four patients with an A2 intertrochanteric osteoporotic fracture were identified between 1996 and 2000. The average age of the patients was 81 years (SD=5). The follow-up time was 5 years. Patients received a bipolar or total hip replacement. During follow-up, we analyzed postoperative complications, mortality rate, functional results using the Harris hip score, time to return to normal activities, and radiographic evidence of healing. One patient died intraoperatively; two patients died on the third and eighth postoperative days and seven patients died within 1 year. Twenty-five patients were living at the 5-year follow-up. Harris hip score at 1 month was 64±8 (mean±SD); at 3 months, 75±5; at 1 year, 76±5; and at 5 years, 76±9. Weight-bearing was permitted immediately after surgery, as tolerated. Time to return to normal daily activities was 27±5 days. No loosening or infection of the implants were observed. In elderly osteoporotic patients with an unstable intertrochanteric fracture, bipolar or total hip replacement in association with reduction of the greater trochanter is a valid alternative to the standard treatment of internal fixation. This surgical technique permits a more rapid recovery with immediate weight-bearing, and a maintenance of a good level of function, with little risk of mechanical failure.

Degenerative lumbar scoliosis: features and surgical treatment

Degenerative lumbar scoliosis is a de novo deformity of the spine occurring after the fourth or fifth decade of life in patients with no history of scoliosis in the growing age. We evaluated complications and functional and radiographic outcomes of twelve patients with degenerative lumbar scoliosis, treated by spinal decompression associated with posterolateral and/or interbody fusion. Mean lumbar scoliosis angle was 18° (SD=4°) and mean age at surgery was 57 years (SD=6 years). Average follow–up was 3.5 years. Surgical treatment consisted in decompression of one or more roots, associated with stabilization with pedicle screws and posterolateral fusion. To correct the deformity, the collapse of the disc was corrected by implanting a cage in the anterior interbody cage. Clinical symptoms and functional tolerance for daily activities improved after surgery. Radiographic evaluation showed a reduction in the deformity on the frontal and sagittal planes. There were no infections, evidence of pseudoarthrosis, instrumentrelated failures or re–operations in this series. In patients with persisting pain caused by degenerative scoliosis associated with spinal stenosis, in whom conservative treatment has failed, spinal decompression and segmented fusion with instrumentation represents a valid treatment option.

What happens to the elbow joint after fractured radial head excision? Clinical and radiographic study at a mean 15-yearfollow-up

Comminuted fractures of the radial head can be treated by radial head excision, open reduction and internal fixation, or radial head replacement. The aim of this study was to evaluate the long-term clinical and radiographic results of 22 patients with an isolated Mason type III fracture of the radial head treated by radial head excision. Mean age at the time of surgery was 36 years and average follow-up was 15 years. Overall outcome at the last follow-up was scored as excellent, good, fair or poor, considering elbow and wrist pain, valgus deformity, elbow and forearm range of motion, and elbow radiographic osteoarthritic changes. At follow-up mean pain score on VAS was was 1, average increase in elbow valgus deformity was 8°, mean flexion of the elbow was 138°, pronation of the forearm averaged 78°, and supination averaged 85°. Degenerative changes were scored as grade 0 in 4 patients, grade 1 in 14 patients, and grade 2 in 4 patients. The overall outcome was excellent in 18 patients and good in 4 patients. When a comminuted radial head fracture is not associated with elbow dislocation or ligamentous injuries, resection of the radial head is a valid surgical option because it is a simple and rapid technique, it has a low learning curve, and it has a high rate of excellent clinical and radiographic long-term results.

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated

Complex tibial plateau fractures are a challenge in trauma surgery. In these fractures it is necessary to anatomically reduce the articular part of the fracture and to obtain stable fixation. The aim of this study is to review the results of a surgical technique consisting of fluoroscopic closed reduction and combined percutaneous internal and external fixation. Thirty-two complex tibial plateau fractures in 32 patients were included. Twenty-one fractures were closed, 4 were open Gustilo grade I, 3 were Gustilo grade II and 4 were Gustilo grade III. The mean age was 37.8 years (range 21–64 years). Surgery was performed with patients in transcalcaneal traction and the knee flexed at 30° was used. Through a 1-cm incision centred over the tibial metaphysis of the tibia, a 3.2-mm hole was drilled in the antero-medial tibial aspect. The tibial plateau fracture fragments were elevated using either 1 or 2 curved Kirschner wires under fluoroscopy to control the reduction. Then the fragments were fixed with 2 cannulated AO screws inserted through small incisions into the medial aspect of the tibial plateau. Knee rehabilitation started postoperatively. Weight bearing started after 8–12 weeks depending upon the radiographic appearance. All external fixators were removed in outpatient facilities. All patients were clinically and radiographically evaluated at a mean follow-up of 48 months (range 38–57 months). Clinical results were evaluated according to the Knee Society clinical score. Average healing time was 24 weeks (range 18–29 weeks). In 1 patient a non-union occurred. This patient was treated with open reduction and plate fixation. In 2 patients a varus knee deformity occurred and a surgical correction was performed. There were no surgical complications. Mean knee range of motion was 105° (range 75–125°) and mean Knee Society clinical score was 89. Twenty-five results were scored as excellent, 4 good, 2 fair and 1 poor. Using this technique there is limited soft tissue damage and virtually no periosteum damage to the fracture fragments. However anatomical reconstruction of the joint can be obtained. Furthermore knee rehabilitation can be started immediately after surgery. We think that these factors were responsible for the optimal clinical long-term results.