Massimiliano Mosca

State of the art review: techniques to avoid pin loosening and infection in external fixation.

Summary The purpose of this manuscript is to review techniques of optimizing the interface between the bone and pin in external fixation to minimize pin loosening and infection. Conclusions Among the different techniques to improve the bone-pin interface in external fixation, coating the pins with hydroxyapatite proved to be the most effective. In a highly loaded animal study, three pin types were compared. Type A remained uncoated, type B was coated with hydroxyapatite, and Type C was coated with titanium. Radiographic rarefaction of the bone pin tract was lower in type B pins. Extraction torque was thirteen times higher in type B pins compared to type A and two times higher compared to type C pins. Extraction torque was significantly lower compared to the corresponding insertion torque in both types A and C. In contrast, in the hydroxyapatite coated pins there was no difference between extraction and insertion torque. At sixty times magnification, bone pin contact of type B and C pins was significantly higher than type A. At 10,000 times magnification direct bone pin contact was found only in type B pins. In a clinical study the pin insertion and extraction torque forces were measured in a study of seventy-six external fixation pins in nineteen patients treated with hemicallotasis for osteoarthritis of the medial side of the knee. The patients were randomized to be treated with either standard tapered pins or tapered pins coated with hydroxyapatite. Extraction torque of the hydroxyapatite coated pins was higher than the standard ones in both cancellous and cortical bone. These studies show that in hydroxyapatite coated pins there is no deterioration of the bone-pin interface strength and there is optimal bone-pin contact. Among the various pin types coated with hydroxyapatite, the best results were obtained with the tapered pins.

Repair Potential of Matrix-Induced Bone Marrow Aspirate Concentrate and Matrix-Induced Autologous Chondrocyte Implantation for Talar Osteochondral Repair: Patterns of Some Catabolic, Inflammatory, and Pain Mediators

Objective The low regenerative potential of cartilage contributed to the development of different cell therapies aimed to improve the clinical outcome in young patients with Osteochondral Lesions of the Talus (OLT). This study is designed to assess the regenerative potential of autologous matrix-induced Bone Marrow Aspirate Concentrate (mBMAC) and matrix-induced Autologous Chondrocyte Implantation (mACI) evaluating, on a small number of osteochondral biopsies, the expression of some catabolic, inflammatory, and pain mediators. Design Twenty-two patients with OLT were analyzed in this study; 7 were treated with mACI and 15 with mBMAC. Informed consent was obtained from all the patients. Clinical assessments were performed pre-operatively and at 12, 24, and 36 months after surgery using the American Orthopedic Foot and Ankle Society (AOFAS). Histology and immunohistochemistry were used to assess cartilage repair at 24 months. Data were analyzed using non-parametric Wilcoxon-Mann-Whitney and Spearman tests. Results A remarkable improvement in AOFAS score was noticed for both treatments up to 36 months; however, patients treated with mACI reported the best AOFAS score. Various degrees of tissue remodeling were observed by histological analysis for both cell strategies. However, mBMAC treatment showed a higher expression of some fibrous and hypertrophic markers compared to mACI group. A mild positivity for nerve growth factor, as pain mediator, was noticed for both treatments.M Conclusions Our findings demonstrated the best histological and clinical results following mACI treatment since different fibrotic and hypertrophic features were evident in the mBMAC group at 24-month follow-up.

Treatment of osteochondral lesions of the talus in athletes: What is the evidence?

PURPOSE ankle injuries make up 15% of all sports injuries and osteochondral lesions of the talus (OLTs) are an increasingly frequent problem in active patients. There exist no widely shared guidelines on OLT treatment in the athletic population. The aim of this paper is to review all the existing literature evidence on the surgical treatment of OLTs in athletes, in order to determine the current state of the art in this specific population, underlining both the limits and the potential of the strategies used. METHODS a systematic review of the literature was performed focusing on the different types of surgical treatment used for OLTs in athletes. The screening process and analysis were performed separately by two independent researchers. The inclusion criteria for relevant articles were: clinical reports of any level of evidence, written in English, with no time limitation, or clinical reports describing the treatment of OLTs in the athletic population. RESULTS with the consensus of the two observers, relevant data were then extracted and collected in a single database to be analyzed for the purposes of the present manuscript. At the end of the process, 16 papers met the selection criteria. These papers report a total of 642 athletic patients with OCTs. CONCLUSIONS the ideal treatment for cartilage lesions in athletes is a controversial topic, due to the need for an early return to sports, especially in elite players; this need leads to extensive use of microfractures in this population, despite the poor quality of repair associated with this technique. None of the surgical strategies described in this paper seems to be superior to the others. LEVEL OF EVIDENCE systematic review of level IV studies, level IV.

The prospective opportunities offered by magnetic scaffolds for bone tissue engineering: a review.

Magnetic scaffolds are becoming increasingly attractive in tissue engineering, due to their ability to enhance bone tissue formation by attracting soluble factors, such as growth factors, hormones and polypeptides, directly to the implantation site, as well as their potential to improve the fixation and stability of the implant. Moreover, there is increasing evidence that the synergistic effects of magnetic scaffolds and magnetic fields can promote bone repair and regeneration. In this manuscript we review the recent innovations in bone tissue engineering that exploit magnetic biomaterials combined with static magnetic fields to enhance bone cell adhesion and proliferation, and thus bone tissue growth.

Percutaneous treatment of hallux valgus: What’s the evidence? A systematic review

Hallux and first MTP joint have a fundamental role in the transfer of the weight-bearing load during the normal ambulation. The aim of this paper is to review and analyze the available literature about the percutaneous surgical management of the hallux valgus to highlight its strengths and weakness, also comparing with other minimal invasive techniques. A systematic search of PubMed and Google Scholar databases has been performed, covering the period between 1981 and 2016. Various combinations of the keyword terms “PDO,” “hallux valgus,” “bunion,” “percutaneous,” “surgery,” “non-invasive,” “minimal invasive,” “burr,” “osteotomy,” “distal,” “linear,” “saw” have been used.Four papers, published from 2005 to 2015, fulfilled the inclusion criteria. A total of 464 hallux valgus has been treated with a properly percutaneous distal first metatarsal osteotomy. Mean AOFAS score, retrieved from the 4 studies included in our review, has been recorded. There are different aspects that the foot and ankle non-experienced surgeon has to consider about percutaneous surgery: limitation of the tools, radioexposure, lack of direct visual control of the osteotomy and higher costs and patient risk due to surgical time.

Anterior cruciate ligament revision with Achilles tendon allograft in young athletes

BACKGROUND Return to sport after revision ACL reconstruction is a controversial topic, several studies reported the results of different techniques and graft in sportsman, presenting an incredibly wide range of return to the same pre-injury activity level, from 0% to 100%. The purpose of this study was to evaluate the clinical outcomes and return to sport rate in young athletes after non anatomic double-bundle revision ACL reconstruction with Achilles allograft. HYPOTHESIS The present revision technique was effective in terms of stability, return to sport and functional outcomes. MATERIAL AND METHODS All the athletes undergone Revision ACL reconstruction with non-irradiated Achilles tendon allograft with a non-anatomical double-bundle technique were included in the study. A split Achilles tendon allograft was used to reproduce the anteromedial (AM) bundle using the over-the-top position, while the posterolateral (PL) bundle was reconstructed through a femoral tunnel located in the anatomical PL footprint. Sport activity, knee function with Lysholm score, knee laxity and re-injury or re-operations were evaluated. RESULTS Twenty-six athletes (23 males, three females) with a mean age of 23.4±3.6 years were evaluated at a mean follow-up of 6.0±1.6 years. Overall 69% of patients returned to sport both at elite (44%) or county level (56%) after a mean 6.7±1.5 (3-9 range) months. The mean Lysholm score showed a significant improvement from 64.4±8.1 at pre-operative status to 83.8±11.3 at final follow-up (P<.0001). Seven patients (30%) were rated as excellent, nine (39%) as good, five (22%) as fair and 2 (9%) as poor. Three patients (12%) experienced a further graft rupture after a mean 2.6 years, (3.5 months-48 months range) and two had >5mm side-to-side difference at KT-1000. Therefore, the overall survival rate at mean six years follow-up was 81%. CONCLUSION The ACL revision with a double-bundle technique using Achilles tendon allograft was successful in 81% of athletes at six years mean follow-up. TYPE OF STUDY AND LEVEL OF EVIDENCE Retrospective case series, level IV.

Return to Sports after Unicompartmental Knee Arthroplasty: Reality or Utopia? A 48-Month Follow-Up Prospective Study

Abstract Unicompartmental knee arthroplasty (UKA) has increased in popularity in the last years, also in younger and more active patients with great expectancies. The purpose of our study was to investigate the change in sports activities before and after medial UKA. We surveyed 53 athletic patients; all underwent cemented medial UKA, to determine not only their subjective and objective evaluation of clinical status with Hospital for Special Surgery (HSS) and visual analog score (VAS) score, but also their sporting and recreational activities at a mean follow‐up of 48 ± 6 months (range, 18‐56 months). At the last follow‐up, 48 of 53 patients were engaged in sports and recreational disciplines, resulting in a return to activity rate of 90%. No early failure and no cases of revision were reported. The frequency of activities (sessions per week) and the time session remained constant at the time of survey. The most common activities after surgery were hiking, cycling, and swimming. Several high‐impact activities, as well as skiing and football, had a significant decrease in participating patients. There were no gender‐, age‐ and body mass index (BMI)‐related differences. UKA can be considered a viable alternative in relatively young patients with high functional requirements and the correct indications, however, warning the patients about the risks of polyethylene wear and early loosening of the prosthetic components as a result of the resumption of sporting activities in high impact. Level of Evidence Prospective case series, level 4.

New Trends in Anterior Cruciate Ligament Reconstruction: A Systematic Review of National Surveys of the Last 5 Years

The purpose of this study was to analyze national surveys of orthopaedic surgeons on anterior cruciate ligament (ACL) reconstruction to determine their preferences related to the preferred graft, femoral tunnel positioning, fixation and tensioning methods, antibiotic and anti-thromboembolic prophylaxis, and use of tourniquet and drains. A systematic search of PubMed, Web of Science, and Cochrane Library was performed. Inclusion criteria were surveys of ACL reconstruction trends and preferences published in the past 5 years (2011-2016), involving members of national societies of orthopaedics. Information regarding survey modalities, population surveyed, graft choice both in the general or in the athletic population, surgical technique, fixation, use of antibiotic, tourniquet, drains, and anti-thromboembolic prophylaxis was extracted. Eight national surveys were included from Europe (three), North or Latin America (three), and Asia (two). Overall, 7,420 questionnaires were sent, and 1,495 participants completed the survey (response rate ranging from 16 to 76.6%). All surveys reported the hamstring tendon (HT) autograft as the preferred graft, ranging from 45 to 89% of the surveyed population, followed by bone-patellar tendon-bone (BPTB) graft (2-41%) and allograft (2-17%). Only two surveys focusing on graft choice in athletic population underlined how in high-demand sportive population the graft choices changes in favor of BPTB. Single-bundle reconstruction was the preferred surgical technique in the four surveys that investigated this issue. Five surveys were in favor of anteromedial (AM) portal and two in favor of trans-tibial technique. Suspension devices for femoral fixation were the preferred choice in all but one survey, while interference screws were the preferred method for tibial fixation. The two surveys that investigated graft tensioning were in favor of manual tensioning. The use of tourniquet, antibiotics, drains, and anti-thromboembolic prophylaxis were vaguely reported. A trend toward the preference of HT autograft was registered in all the surveys; however, sport participation has been highlighted as an important variable for increased use of BPTB. Single-bundle reconstruction with AM portal technique and suspension femoral fixation and screws fixation for the tibia seem the preferred solution. Other variables such as tensioning, antibiotic, anti-thromboembolic prophylaxis, tourniquet use, and drains were investigated scarcely among the surveys; therefore, no clear trends could be delineated. This is a Level V, systematic review of expert opinion study.

Postarthroscopy Osteonecrosis of the Knee: Current Concepts

Knee osteonecrosis is a severe disease rapidly leading to end-stage osteoarthritis, which was classified into three categories: spontaneous, secondary, and postarthroscopy. To understand postarthroscopy osteonecrosis of the knee, all the three types of knee osteonecrosis have to be deepened. This article reviewed spontaneous and secondary osteonecroses of the knee, with special focus upon postarthroscopy osteonecrosis, which is a rare form, affecting patients operated for arthroscopic knee surgery, most commonly for meniscectomy. Due to its rarity, patients and surgeons are often unprepared for this complication. A correct diagnosis is essential for appropriate treatment, and also to determine if a preexisting osteonecrosis was present, avoiding medicolegal sequelae, although many authors agree that osteonecrosis (both spontaneous and postarthroscopy) represent unpreventable and unpredictable conditions. In spontaneous osteonecrosis, the treatment is defined according to the size and the degree of the lesion, whereas in postarthroscopy osteonecrosis, the size of the lesion has no prognostic value, and therefore, the choice of the correct treatment is based more on the timing of the diagnosis. A diagnostic and therapeutic algorithm was outlined on the basis of the actual knowledge.

Ankle and foot: Chronic instability

Ankle sprain is a common sports-related injury that predominantly occurs in skeletally mature patients with a lower incidence in children and adolescents. Recurrence of acute twisting episodes may lead to chronic ankle instability, which is distinguished into mechanical and functional. Mechanical ankle instability (MAI) is characterized by an abnormal ankle mobility, assessed clinically using manual stress application via the anterior drawer and the talar tilt tests. Functional ankle instability (FAI) was firstly described as a subjective feeling of the ankle giving way during either physical activity or during common activities of daily living. More than 80 different surgical procedures have been described in literature for managing chronic ankle instability. Anatomic reconstruction should be the primary choice for the surgical treatment of chronic ankle instability in young patient and more widely in athletes. Some studies are available addressing non-anatomic reconstruction in youngers and reporting satisfactory results, even if the need of bony tunnels in a growing epiphysis, alteration in ankle biomechanics and the high frequency of restricted subtalar motion are major drawbacks of non-anatomic reconstruction.