Luca Dei Giudici

Epidemiology of isolated acromioclavicular joint dislocation.

Background. Acromioclavicular (AC) joint dislocation is a common shoulder problem. However, information about the basic epidemiological features of this condition is scarce. The aim of this study is to analyze the epidemiology of isolated AC dislocation in an urban population. Materials and Methods. A retrospective database search was performed to identify all patients with an AC dislocation over a 5-year period. Gender, age, affected side and traumatic mechanism were taken into account. X-rays were reviewed by two of the authors and dislocations were classified according to the Rockwoods criteria. Results. A total of 108 patients, with a mean age of 37.5 years were diagnosed with AC dislocation. 105 (97.2%) had an isolated AC dislocation, and 3 (2.8%) were associated with a clavicle fracture. The estimated incidence was 1.8 per 10000 inhabitants per year and the male-female ratio was 8.5 : 1. 50.5% of all dislocations occurred in individuals between the ages of 20 and 39 years. The most common traumatic mechanism was sport injury and the most common type of dislocation was Rockwood type III. Conclusions. Age between 20 and 39 years and male sex represent significant demographic risk factors for AC dislocation.

Homologous platelet-rich plasma for the treatment of knee osteoarthritis in selected elderly patients: an open-label, uncontrolled, pilot study.

Objective: The objective of this study was to evaluate the safety and the effect of platelet-rich plasma (PRP) intra-articular injections obtained from blood donors (homologous PRP) on elderly patients with early or moderate knee osteoarthritis (OA) who are not candidates for autologous PRP treatment. Methods: A total of 60 symptomatic patients, aged 65–86 years, affected by hematologic disorders and early or moderate knee OA, were treated with 5 ml of homologous PRP intra-articular injections every 14 days for a total of three injections. Clinical evaluations before the treatment, and after 2 and 6 months were performed by International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) and Equal Visual Analogue Scale (EQ VAS) scores. Adverse events and patient satisfaction were recorded. Results: No severe complications were noted during the treatment and the follow-up period. A statistically significant improvement from basal evaluation to the 2-month follow-up visit was observed, whereas a statistically significant worsening from the 2-month to the 6-month follow-up visit was showed. The overall worst results were observed in patients aged 80 years or over and in those affected by minor bone attrition. It was found that 90% of patients were satisfied at the 6-month evaluation. Conclusions: Homologous PRP has an excellent safety profile but offers only a short-term clinical improvement in selected elderly patients with knee OA who are not candidates for autologous PRP treatment. Increasing age and developing degeneration result in a decreased potential for homologous PRP injection therapy. Further studies are needed to confirm these findings.

The role of arthroscopy in articular fracture management: the lower limb

Abstract The management of articular fracture is always a matter of concern. While each articular fracture is different from one another, besides the classification system used and the surgical or non-surgical indication given by the specialist, main goals remain the same: anatomical reduction, stable fixation, loose body removal, and minimal invasiveness. Open procedures are the actual compromise, but unfortunately, it is not always possible to perfectly meet every treatment goal, associated lesions could pass unnoticed or delayed in treatment, and even in a best-case scenario, there could be several complications developing in the long term. In the last decades, arthroscopic joint surgery underwent an exponential evolution, expanding its application also in the trauma field with the development of arthroscopic and arthroscopically assisted reduction and internal fixation (ARIF) techniques; main advantages are an accurate diagnosis of fracture and associated soft tissue involvement, the potential for concomitant treatments, anatomical reduction, and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee, and ankle. The purpose of this paper was to provide a review of the most recent literature about arthroscopic and arthroscopically assisted reduction and internal fixation for articular and periarticular fractures of the lower limb, analyzing the results and suggesting clinical applications.

Artrhoscopic rotator cuff repair with augmentation: the V-sled technique.

Numerous techniques have been described for patch positioning in rotator cuff shoulder arthroscopic surgery. These techniques seem to be difficult challenges for the majority of arthroscopic surgeons, and because of that they are called “highly demanding” techniques. Without the use of dedicated instruments and cannulas, the authors propose a V‐sled technique that seems to be more reproducible, quicker and less difficult to perform for arthroscopic shoulder surgeons. The patient is placed in the lateral position. All arthroscopic procedures are performed without the use of cannulas. The standard posterior portal is used for the glenohumeral (GH) joint arthroscopy with fluid inflowing through the scope. After an accurate evaluation of the GH space, the scope is then introduced into the subacromial space. With the use of a spinal needle, a lateral portal is performed. The great tuberosity is prepared with a bur to place two 5.5 mm triple‐loaded radiolucent anchors. In addition, two free high strength sutures are passed through the muscle, respectively. The repair is performed using two high strength sutures from each anchor. The third wire from each anchor is retrieved out of the accessories portals used for the insertion of the anchors. In addition, two free high strength sutures are passed through the muscle, and the patch sizing is done using a measuring probe introduced through the lateral portal. Next, the patch is then prepared and is introduced into the subacromial space, and then the patch is stabilized, and the free sutures are tied.

Distalization and Medialization of Tibial Tuberosity for the Treatment of Potential Patellar Instability with Patella Alta

Purpose  The aim of the study was to test the distalization and medialization of the tibial tuberosity (DMTT) for the treatment of patellar instability associated with patella alta, focusing on residual instability and pain. Methods  Twenty-four consecutive patients (26 knees) suffering from patellofemoral instability and patella alta were treated by DMTT. Two groups were identified, which differed for documented history of frank patella dislocation. The groups were named objective patellar instability (OPI) (history of dislocation) and potential patella instability (PPI) (no dislocation). Outcome was measured with visual analogue scale (VAS), Kujala score, and Tegner score. Comparison between groups was performed using Students t -test, Wilcoxon rank score, and Fishers exact test (significance at p  < 0.05). Results  At 50 ± 18 and 41 ± 18 months of follow-up, respectively, both PPI and OPI groups obtained a significant pain reduction and functional improvement. The PPI group showed a significant decrease of the subjective instability. No procedure-related complications were reported. Conclusion  This study suggests that DMTT is a viable option for PPI patients with patella alta. The outcome was comparable between PPI and OPI cases; however, decrease in subjective instability was significantly greater in PPI patients. Level of Evidence  Level III, retrospective comparative study.

Arthroscopic transphyseal anterior cruciate ligament reconstruction in adolescent athletes

Purpose To evaluate the 5-year outcome of arthroscopic transphyseal anterior cruciate ligament (ACL) reconstruction in 19 adolescent athletes. Methods 14 male and 5 female adolescent athletes aged 12 to 16 (mean, 13.9) years with Tanner stage 2 or 3 open physes underwent arthroscopic transphyseal ACL reconstruction by a single surgeon and were followed up for 5 years. Patients were evaluated using the numerical rating score (NRS) for pain, knee osteoarthritis outcome score (KOOS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale, and Lysholm Score, as well as the leg length discrepancy, femorotibial alignment, varus or valgus deformities, active and passive knee range of motion. Results At 5-year follow-up, physes were closed in all patients. The mean NRS for pain improved from 7.2 to 1.6; the KOOS improved from 55.3 to 88; the mean IKDC score improved from 34.5 to 84; the mean Tegner Activity Scale improved from 2.7 to 8.2 and was comparable with that before injury (8.4); and the mean Lysholm score improved from 36.3 to 84.6. All except 2 patients returned to their pre-injury level of sports activity after a mean of 25 weeks. The 2 exceptions had a 2+ Jerk test and a 3+ Lachman test; one of them also had positive signs for a lateral meniscal lesion. Both had sustained a second trauma not long before the 5-year follow-up. Two patients had reduced sensitivity in the anteromedial aspect of the proximal third of the tibia. One patient had leg length discrepancy of +1.5 cm owing to overgrowth response of the physis. Conclusion Transphyseal ACL reconstruction is a viable option for skeletally immature patients, with high reproducibility, a high rate of return to sport, and a low incidence of growth disturbance. Early surgery can prevent the onset of meniscal lesions and early osteoarthritis.

Arthroscopic management of articular and peri-articular fractures of the upper limb

The management of articular fractures is always a matter of concern. Each articular fracture is different from the other, whatever the classification system used and the surgical or non-surgical indications employed by the surgeon. The main goals remain anatomical reduction, stable fixation, loose body removal and minimal invasiveness. Open procedures are a compromise. Unfortunately, it is not always possible to meet every treatment goal perfectly, since associated lesions can pass unnoticed or delay treatment, and even in a ‘best-case’ scenario there can be complications in the long term. In the last few decades, arthroscopic joint surgery has undergone an exponential evolution, expanding its application in the trauma field with the development of arthroscopic and arthroscopically-assisted reduction and internal fixation (ARIF) techniques. The main advantages are an accurate diagnosis of the fracture and associated soft-tissue involvement, the potential for concomitant treatments, anatomical reduction and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee and ankle. The purpose of this paper is to provide a review of the most recent literature concerning arthroscopic and arthroscopically-assisted reduction and internal fixation for articular and peri-articular fractures of the upper limb, to analyse the results and suggest the best clinical applications. ARIF is an approach with excellent results in treating upper-limb articular and peri-articular fractures; it can be used in every joint and allows treatment of both the bony structure and soft-tissues. Post-operative outcomes are generally good or excellent. While under some circumstances ARIF is better than a conventional approach, the results are still beneficial due to the consistent range of movement recovery and shorter rehabilitation time. The main limitation of this technique is the steep learning curve, but investing in ARIF reduces intra-operative morbidity, surgical errors, operative times and costs. Cite this article: Dei Giudici L, Faini A, Garro L, Tucciarone A, Gigante A. Arthroscopic management of articular and peri-articular fractures of the upper limb. EFORT Open Rev 2016;1:325-331. DOI: 10.1302/2058-5241.1.160016.

How to Manage Failed Rotator Cuff Repair: Biologic Augmentation

Failure of a rotator cuff repair complicates up to 94% of the cases, and revision surgery is often required. Initial good results seem to decrease after 2 years from surgeries; therefore new techniques that could enhance the repair are being developed in order to decrease the retear rate. The procedures that add a biological enhancement, directly or indirectly, fall under the term of biological augmentation. Several types of grafts are currently available, including autografts, xenografts, allografts, and synthetic grafts, each with different advantages and disadvantages, obtaining various degrees of improvement compared to standard repairs. Bioengineering allowed the addition of special molecules and cells to those scaffolds, enhancing the intrinsic biological potentiality and modulating the healing response of the host, with interesting findings. Clinical, functional, imaging, and laboratory data suggest that patch augmentation for rotator cuff repair is a safe procedure that constantly enhances the mechanical strength, resulting in a repair tissue that is healthier and stronger. Application of growth factors and mesenchymal stem cells from different origins, instead, has yet to be applied in human studies, but in vitro and animal experimentations suggest that it will be soon possible to obtain a repaired tendon that is completely similar to the native tissue.

Isolated Subscapularis Tendon Tear in a Skeletally Immature Soccer Player

Subscapularis injury in adolescents, usually associated to an avulsion fracture of the lesser humeral tuberosity, accounts for less than 2% of all fractures of the proximal humerus. Isolated tears of the subscapularis tendon without a history of dislocation and associated avulsion fractures are an even rarer occurrence, and treatment is controversial. This article describes a rare case of a 12-year-old suffering from an isolated subscapularis tear and discusses its management. The patient was evaluated at presentation, and at 1 to 2.5 months after he underwent a cuff tear arthroscopic repair with a single “all suture” anchor loaded with two wires, active/passive range of motion (A/PROM), Constant–Murley score, and American Shoulder and Elbow Surgeons (ASES) score were noted. Patient reported an excellent outcome, recovered the whole ROM, was pain free, and returned to the previous level of activity. Isolated avulsion of the subscapularis tendon requires a high index of suspicion for a proper diagnosis as early treatment is required for a good recovery. Arthroscopy reserves more advantages in proper hands, restoring the previous levels of function and activity. An increase in attention for this condition is mandatory in a society where many adolescents are getting more and more active in high levels of sport activities.