Matteo Romagnoli

Alignments and clinical results in conventional and navigated total knee arthroplasty.

In this prospective, randomized, controlled study, we compared the performance of conventional and navigated total knee arthroplasties. Component alignment was measured in 60 patients operated on using navigation and in 60 patients operated on using the conventional technique. The groups then were divided into a subpopulation to measure alignments of the distal femoral cuts in the three anatomic planes, the proximal tibial cut in the frontal and sagittal planes, and the resulting lower limb mechanical axis in the frontal plane. Postoperative weightbearing long-view radiographs were evaluated as were clinical results using three standard questionnaires at 28 months followup. The intraoperative measurements (mean ± standard deviation) at the resection planes showed navigated surgeries result in more accurate alignments than conventional surgeries for the femur: in the frontal plane, 0.1° ± 0.9° and 0.7° ± 1.6° valgus, respectively; in the sagittal plane, 1.1° ± 1.8° and 2.8° ± 2.0° flexion; and in the transversal plane, 0.1° ± 1.2° and 0.9° ± 1.7° internal rotation. The navigated technique also reduced the number of cases with final mechanical axes greater than 3° from 20.0% to 1.7%. Postoperative radiographs showed better component alignment using navigation, particularly at the femur. However, clinical scoring systems showed this radiographic improvement did not necessarily result in a better clinical outcome at short-term followup.Level of Evidence: Level I, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

Percutaneous and minimally invasive techniques of achilles tendon repair

Despite the controversy regarding the best treatment for an acute Achilles tendon rupture, percutaneous and minimally invasive techniques seem to offer good results in terms of low risks of rerupture and complications with satisfactory clinical and functional outcomes. A comparison between a percutaneous surgical technique and a minimally invasive one has not been reported in the literature. We consecutively evaluated 12 patients who had a modified Ma and Griffith percutaneous Achilles tendon repair and 12 patients who had a minimally invasive technique. The same semifunctional rehabilitation protocol was used after surgery in both groups. At a minimum followup of 24 months (mean, 33 months; range, 24-42 months), we observed no reruptures or major complications in either group. Both groups had similarly high values for the American Orthopaedic Foot and Ankle Society score. The two techniques allowed equivalent time for return to work and sports. In the group of patients treated with the modified Ma and Griffith suture only, the mean loss of calf circumference in the injured leg was greater, compared with the contralateral leg. The two groups were isokinetically similar. In this study, the percutaneous and minimally invasive techniques of repair of the Achilles tendon yielded essentially identical clinical and functional outcomes.Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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 …

A biomechanical and histological analysis of standard versus hydroxyapatite-coated pins for external fixation

This sheep study was designed to make a comparative evaluation of two external fixation pin types each with and without hydroxyapatite (HA) coating. The two pins had different taper, pitch, and self drilling capabilities. Twenty Orthofix standard, self-tapping pins (group A), 20 Orthofix HA-coated, self-tapping pins (group B), 20 X-caliber, self-drilling, self-tapping pins (group C), and 20 X-caliber HA-coated, self-drilling, self-tapping pins (group D) were selected. Four pins were implanted in the right femurs of 20 adult sheep that were euthanized at 6 weeks. Mean pin insertion torque was 2745 +/- 822 Nmm in group A, 2726 +/- 784 Nmm in group B, 2818 +/- 552 Nmm in group C, and 2657 +/- 732 Nmm in group D (ns). Mean pin extraction torque was 1567 +/- 541 Nmm in group A, 2524 +/- 838 Nmm in group B, 1650 +/- 650 Nmm in group C, and 2517 +/- 726 Nmm in group D. HA-coated pins (group B and D) had a significantly greater mean pin extraction torque compared to similar uncoated pins (group A and C) (p < 0.0005). Histological analysis showed good osteointegration of the two coated pin types. This study shows that HA-coating is more important for optimal pin fixation than the particular combination of design parameters used in each pin type.

Early Clinical Results of the BOX Ankle Replacement Are Satisfactory: A Multicenter Feasibility Study of 158 Ankles

A new design for a 3-part ankle replacement was developed in an effort to achieve compatibility with the naturally occurring ligaments of the ankle by allowing certain fibers to remain isometric during passive motion. In order to test the design concept clinically, 158 prostheses were implanted in 156 patients within a 9-center trial and were followed up for a mean of 17 (range 6 to 48) months. The mean age at the time of surgery was 60.5 (range 29.7 to 82.5) years. Outcome measures included the American Orthopaedic Foot & Ankle Surgery hindfoot-ankle score and range of motion measured on lateral radiographs of the ankle. The preoperative American Orthopaedic Foot & Ankle Surgery score of 36.3 rose to 74.6, 78.6, 76.4, and 79.0, respectively, at 12, 24, 36, and 48 months. A significant correlation between meniscal bearing movement on the tibial component (mean 3.3 mm; range 2 to 11 mm) and range of flexion at the replaced ankle (mean 26.5°; range 14° to 53°) was observed in radiograms at extreme flexions. Two (1.3%) revisions in the second and third postoperative years necessitated component removal (neither were for implant failure), and 7 (4.4%) further secondary operations were required. The results of this investigation demonstrated that non-anatomic-shaped talar and tibial components, with a fully conforming interposed meniscal bearing, can provide safety and efficacy in the short term, although a longer follow-up period is required to more thoroughly evaluate this ankle implant.

Functional performance of a total ankle replacement: thorough assessment by combining gait and fluoroscopic analyses

BACKGROUND A thorough assessment of patients after total ankle replacement during activity of daily living can provide complete evidence of restored function in the overall lower limbs and replaced ankle. This study analyzes how far a possible restoration of physiological mobility in the replaced ankle can also improve the function of the whole locomotor apparatus. METHODS Twenty patients implanted with an original three-part ankle prosthesis were analyzed 12 months after surgery during stair climbing and descending. Standard gait analysis and motion tracking of the components by three-dimensional fluoroscopic analysis were performed on the same day using an established protocol and technique, respectively. FINDINGS Nearly physiological ankle kinematic, kinetic and electromyography patterns were observed in the contralateral side in both motor activities, whereas these patterns were observed only during stair climbing in the operated side. Particularly, the mean ranges of flexion at the replaced ankle were 13° and 17° during stair climbing and descending, respectively. Corresponding 2.1 and 3.1mm antero/posterior meniscal-to-tibial translations were correlated with flexion between the two metal components (p<0.05). In addition, a larger tibiotalar flexion revealed by fluoroscopic analysis resulted in a physiological hip and knee moment. INTERPRETATION The local and global functional performances of these patients were satisfactory, especially during stair climbing. These might be associated to the recovery of physiological kinematics at the replaced ankle, as also shown by the consistent antero/posterior motion of the meniscal bearing, according to the original concepts of this ankle replacement design.

Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction?: a meta-analysis of 32 studies

Aims Our aim was to perform a meta‐analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. Materials and Methods A search was performed of Medline and Pubmed using the terms “Anterior Cruciate Ligament” and “ACL” combined with “revision”, “re‐operation” and “failure”. Only studies that reported the outcome at a minimum follow‐up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone‐patellar tendon‐bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. Results A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow‐up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow‐up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT‐1000/2000 (MEDmetric Corporation) and the rates of complications and re‐operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. Conclusion Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post‐operative laxity and rates of complications and re‐operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft.

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.

Bioabsorbable Calcaneo-Stop Implant for the Treatment of Flexible Flatfoot: A Retrospective Cohort Study at a Minimum Follow-Up of 4 Years

ABSTRACT Arthroereisis of the subtalar joint is a common surgical technique in Europe for the management of flexible flatfoot in the pediatric population. In most cases, it is performed using a calcaneo‐stop metallic screw. Despite the good clinical results, screw removal is always advised after 2 to 3 years. The use of a bioabsorbable screw might overcome the need for a second operation to remove a nonabsorbable device. We report the results of a biodegradable calcaneo‐stop screw at a minimum of 4 years of follow‐up. Eighty‐eight procedures were performed on 44 children. All patients were clinically and radiologically evaluated preoperatively and at a minimum 4‐year follow‐up period. Patient satisfaction and plantar collapse using Viladots classification were recorded. Mearys talus–first metatarsal angle and talocalcaneal angle were measured on radiographs preoperatively and at the last follow‐up visit. The presence of the device at the last follow‐up examination was assessed by magnetic resonance imaging. The mean follow‐up duration was 56 months. Of the 44 patients, 33 (75%) reported excellent clinical outcomes, 9 (20.5%) good outcomes, and 2 (4.5%) poor. Foot print improvement was registered for all patients. The mean Mearys talus–first metatarsal angle had improved from 160.6° ± 7.7° preoperatively to 170.6° ± 6.5° at the last follow‐up visit (p < .001). The talocalcaneal angle had decreased from 39.9° ± 5.2° preoperatively to 29.4° ± 4° at the last follow‐up examination (p < .001). At the 4‐year follow‐up point, the implant could be seen to have almost completely biodegraded on magnetic resonance imaging. Two screw breakages occurred. The bioabsorbable calcaneo‐stop screw seems to be an effective solution for flexible flatfoot in pediatric patients. Also, owing to its biodegradable composition, the need of a second operation for implant removal will not always be necessary. &NA; Level of Clinical Evidence: 4