Raffaele Garofalo

Grade I and II acromioclavicular dislocations: results of conservative treatment

The purpose of this study was to assess the results of acute grade I and II acromioclavicular (AC) joint sprains treated by conservative measures. Between 1993 and 1997, 37 consecutive patients were treated conservatively for AC joint sprains, grade I and II in the Tossy classification. Of these patients, 4 were excluded (three lost to follow-up and one sustained a further AC injury), leaving a series of 33 patients. Among them, in 9 (27%), chronic AC joint pathology that required subsequent surgery developed at a mean of 26 months after injury. The remaining 24 were reviewed clinically and radiologically at a mean of 6.3 years (range, 4-8 years) after injury. At the latest follow-up, 17 of the 33 patients (52%) remained asymptomatic. Of the 24 patients reviewed, 7 complained of activity-related pain. Eight patients presented with residual anteroposterior instability. Tenderness at the AC joint as well as a positive cross-body test was observed in 12 patients. The mean Constant score at follow-up was 82 points. The x-ray films showed degenerative changes in 13 patients, ossification of the coracoclavicular ligaments in 2, an association of degenerative changes with ossification of the coracoclavicular ligaments in 3, and distal clavicular osteolysis in 3. Only 4 cases had no radiographic changes after this kind of AC injury. On the basis of these results, we conclude that the severity of the consequences after grade I and II AC sprains is underestimated.

Arthroscopic Bankart Suture-Anchor Repair Radiological and Clinical Outcome at Minimum 10 Years of Follow-up

Background There are not many reports in the literature about the long-term outcomes in terms of recurrence and degenerative changes after arthroscopic capsulolabral reconstruction for anterior shoulder instability. Purpose The aim of this study was to evaluate long-term follow-up (minimum 10 years) of arthroscopic suture-anchor repair for traumatic unidirectional anterior instability, with special emphasis on the radiological evidence of arthritis and clinical outcome. Study Design Case series; Level of evidence, 4. Methods Forty-two patients (43 shoulders) treated at our institute from 1995 to 1997 were included in the study. Thirty patients (31 shoulders) were available for clinical and radiological examination (71%). The mean follow-up was 10.9 years (range, 9.8-14.3 years). Patients were evaluated preoperatively and after surgery using the University of California, Los Angeles (UCLA), Simple Shoulder Test (SST), and Rowe score. Patient satisfaction was determined by asking the patients if they would do this operation again. Radiological outcome was used to evaluate the incidence and grade of arthritis according to the Samilson-Prieto classification. Results At the final follow-up examination, 5 patients (16%) reported an atraumatic recurrent instability, while 2 recurrences (7%) occurred after a major injury. Three of the 7 recurrences occurred 6 years after surgery. All of the patients in the recurrence group except 1 were contact or overhead athletes. Twenty-six patients were satisfied (84%) with the outcome. The SST showed an improvement of shoulder function in 23 cases, the UCLA score improved from 21.8 to 32.1, and the Rowe score showed excellent or good results in 77.3% of cases. Twenty-two patients (71%) were able to return to their preoperative sports level. Radiographic findings showed 9 cases with mild arthritis (29%) and 3 cases with moderate arthritis (10%). Conclusion The recurrence rate deteriorated with time. Involvement in contact sports and overhead activities appears to be a risk factor for recurrence of instability, although this could not be proved statistically with the numbers available, whereas age, gender, and number of preoperative dislocations did not reveal any correlation with recurrence. Degenerative changes of the glenohumeral joint were noted but had no significant effect on the clinical outcomes.

Anatomic anterior cruciate ligament reconstruction: the two-incision technique

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction technique.

Arthroscopic Stabilization of the Shoulder in Adolescent Athletes Participating in Overhead or Contact Sports

PURPOSE To investigate the outcome of arthroscopic capsular repair for shoulder instability in an active adolescent population participating in overhead or contact sports. METHODS We identified 67 patients (aged 13 to 18 years) with post-traumatic recurrent shoulder instability for inclusion in the study from our computer database. Of these patients, 65 (96%) were available for clinical review. There were 44 male and 21 female patients, with a mean age of 16 years at the time of surgery. All patients participated in overhead or contact sports at a competitive level. Arthroscopic capsulolabral repair was performed after at least 6 months of failed nonoperative treatment. The mean follow-up was 63 months. Shoulder range of motion and functional outcomes were measured preoperatively and postoperatively with Single Assessment Numeric Evaluation (SANE), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores. Furthermore, type of sport, time until surgery, and number of dislocations were analyzed from our database to find any correlation with the recurrence rate. RESULTS At final follow-up, the mean SANE score was 87.23% (range, 30% to 100%) (preoperative mean, 46.15% [range, 20% to 50%]); the mean Rowe score was 85 (range, 30 to 100) (preoperative mean, 35.9 [range, 30 to 50]); and the mean ASES score was 84.12 (range, 30 to 100) (preoperative mean, 36.92 [range, 30 to 48]). The mean forward flexion and external rotation with the arm at 90° abduction did not change from preoperative values; 81% of the patients returned to their preinjury level of sport, and the rate of failure was 21%. The recurrence rate was not related to the postoperative scores (P = .556 for SANE score, P = .753 for Rowe score, and P = .478 for ASES score), the number of preoperative episodes of instability (P = .59), or the time from the first instability episode to the time of surgery (P = .43). There was a statistically significant relation (P = .0021) between recurrence and the type of sport practiced. Recurrence rate was related to the type of sport practiced. CONCLUSIONS Arthroscopic stabilization is a reasonable surgical option even in an adolescent population performing sports activities. However, it must be emphasized to the patients and their relatives that the recurrence rate that could be expected after an arthroscopic procedure is higher than in the adult population. LEVEL OF EVIDENCE Level IV, therapeutic case series.

SHOCK WAVES IN THE TREATMENT OF STRESS FRACTURES

In soccer players, lower extremity stress fractures are common injuries and are the result of repetitive use damage that exceeds the intrinsic ability of the bone to repair itself. They may be treated conservatively but this may cause long-term complications, such as delayed union, muscle atrophy and chronic pain. Stress fractures that fail to respond to this management require surgical treatment, which is also not without risks and complications. Extracorporeal shock wave therapy (ESWT) has been used successfully on fracture complications, such as delayed union and nonunion. As such, we want to examine ESWT in the management of stress fractures. In this article, we present a retrospective study of 10 athletes affected by chronic stress fractures of the fifth metatarsus and tibia that received three to four sessions of low-middle energy ESWT. At the follow-up (8 wk on average), the clinical and radiography results were excellent and enabled all players to gradually return to sports activities. These reports show that ESWT is a noninvasive and effective treatment for resistant stress fractures in soccer players.

Arthroscopic transosseous (anchorless) rotator cuff repair

The traditional open transosseous rotator cuff repair gives excellent results for the fixation of tendon to bone and has represented the gold standard for rotator cuff surgery with excellent long-term results. In the last few years, different arthroscopic techniques using suture anchors have been developed to increase the tendon–bone contact area in an attempt to reconstitute a more anatomic configuration of the rotator cuff footprint while providing a better environment for tendon healing. However, the anchor-based techniques have still not replicated the traditional open transosseous repair. A surgical technique that allows surgeons to perform a standardized arthroscopic transosseous (anchor free) repair of rotator cuff tears using a new disposable device is described. With this system, it is possible to perform a transosseous technique in a reproducible fashion. This novel technique combines the clinical advantages of minimally invasive arthroscopic surgery and the biomechanical advantages of open transosseous procedures. Level of evidence V.

Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement

The purpose of this paper is to discuss the post-traumatic overload syndrome of the os trigonum as a possible cause of posterior ankle impingement and hindfoot pain. We have reviewed 19 athletes who were referred to our foot unit between 1995 and 2001 because of posterior ankle pain, and in whom a post-traumatic overload syndrome of os trigonum was diagnosed. All these patients were followed up over a period of 2 years. In 11 cases a chronic repetitive movements in forced plantar flexion was found. In the other eight cases the pain appeared to persist after a standard treatment of an ankle sprain in inversion plantar flexion. The diagnosis was based on clinical history, physical examination and X-rays that revealed a non-fused os trigonum. The confirmation of diagnosis was carried-out injecting local anaesthetic under fluoroscopic control. In all cases a corticosteroid injection as first line treatment was performed. In 6 cases a second injection was necessary to alleviate pain because incomplete recovery with the first injection. Three cases (16%) were recalcitrant to this treatment and in these three cases a surgical excision of the os trigonum was carried out. Our conclusion is that after some chronic athletic activity or an acute ankle sprain the os trigonum, if present, may undergo mechanical overload, remain undisrupted and become painful. Treatment by corticosteroid injection often resolves the problem.

Chondral print on humeral head: an indirect sign of long head biceps tendon instability

Long head biceps (LHB) tendon pathologies are becoming increasingly recognized causes of shoulder pain in the published literature. Instability of LHB presenting as dislocation or subluxation has been recently recognized as a possible cause of disabling pain or discomfort of the shoulder. A clinical diagnosis of LHB instability is very difficult and often confounding because of association with other shoulder pathologies. However, an early diagnosis of LHB instability is important in order to prevent the evolution of lesions of the biceps pulley until an internal anterosuperior impingement of the shoulder (ASI) and subscapular tear occur. The advent of arthroscopy contributed to enhance understandings. The goal of this article is to describe an arthroscopic sign, the chondral print on the humeral head, associated with a LHB instability, that when present can be very useful to help the surgeon to make the diagnosis of unstable LHB tendon.

Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years.

We describe the use of cable fixation and acute total hip replacement for acetabular fracture in the elderly. 12 patients with acetabular fractures, having a mean age of 79 (65-93) years, were treated with cable fixation and acute total hip arthroplasty. 8 were T-shaped fractures and 4 associated fractures of the posterior column and posterior wall. 1 patient died 5 months after surgery and the remaining 11 were followed for 2 years. All patients had a good clinical outcome. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This surgical technique provides good primary fixation, stabilizes complex acetabular fractures in elderly patients with osteoporotic bone and permits early postoperative mobilization.

Role of metalloproteinases in rotator cuff tear.

The role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPS) in the pathophysiology of rotator cuff tears has not been established yet. Recent advances empathize about the role of MMPs and TIMPS in extracellular matrix (ECM) remodeling and degradation in rotator cuff tears pathogenesis and healing after surgical repair. An increase in MMPs synthesis and the resulting MMPs mediated alterations in the ECM of tendons have been implicated in the etiopathogenesis of tendinopathy, and there is an increase in the expression of MMPs and a decrease in TIMP messenger ribonucleic acid expression in tenocytes from degenerative or ruptured tendons. Importantly, MMPs are amenable to inhibition by cheap, safe, and widely available drugs such as the tetracycline antibiotics and bisphosphonates. A better understanding of relationship and activity of these molecules could provide better strategies to optimize outcomes of rotator cuff therapy.