Riccardo D'Ambrosi

All-Arthroscopic Autologous Matrix-Induced Chondrogenesis for the Treatment of Osteochondral Lesions of the Talus

Several surgical techniques have been described for the treatment of talar chondral lesions. Among them, microfracture is well established. Autologous matrix-induced chondrogenesis (AMIC), using microfracture and biomaterials, has shown promising results for the treatment of knee osteochondral lesions and has been proposed for the ankle as an open technique. We describe an all-arthroscopic AMIC technique. The benefits of an all-arthroscopic procedure include smaller incisions with less soft-tissue dissection, better visualization of the joint, and a quicker recovery compared with open surgery. The use of matrix to support cartilage regeneration promotes good-quality cartilage tissue with satisfactory long-term outcomes. Our all-arthroscopic AMIC technique uses a type I-type III porcine collagen matrix (Chondro-Gide; Geistlich Pharma, Wolhusen, Switzerland) and is characterized by 2 different arthroscopic surgical phases. First, adequate exposure is achieved through use of a Hintermann spreader (Integra LifeSciences, Plainsboro, NJ) with sufficient joint distraction and wet lesion preparation. The second surgical step is performed dry, involving matrix placement and fixation. The all-arthroscopic AMIC technique for the treatment of osteochondral lesions of the talus allows a very precise reconstruction in the case of cartilage defects and avoids the need for a more invasive operation associated with higher morbidity and a longer surgical time.

Uncemented total hip arthroplasty in patients younger than 20 years

BACKGROUND Several diseases may lead to advanced hip disease and cause disabling symptoms in adolescents. In literature there is no consensus which is the optimal surgical treatment for young adults with end-stage osteoarthritis. The purpose of this study was to assess the clinical and radiological outcomes of uncemented total hip arthroplasty for the treatment of end-stage hip arthritis in patients younger than 20 years at a minimum follow-up of ten years. METHODS We have retrospectively evaluated 24 patients who were 20 years or younger and underwent uncemented total hip arthroplasty. Minimum follow-up was 10 years. Clinical outcome was measured using the Harris Hip Score, Western Ontario McMaster, and the Short-Form 36. Hip calcification was evaluated using Brooker classification, while osteolysis was examined at the final follow-up according to the subdivision of Gruen. RESULTS The mean preoperative Harris Hip Score was 36.94 points and improved to 92.3, and the mean preoperative WOMAC score improved from 84.72 to 28.45 The Mental Component score-SF-36 improved from a preoperative mean of 26.23 points to 58.96, while the Physical Component score-SF-36 improved from a preoperative mean of 26.38-49.95. All components were stable and osseo-integrated. Radiolucent lines were not present in any hips. We noted the presence of 4 calcifications. No patient needed implant revision. The only complication was an intraoperative femoral fracture. CONCLUSION Total hip arthroplasty is a safe and reliable procedure for the treatment of end-stage arthritis in the young that provides good to excellent mid-term results.

Age-Related Outcome of Mobile-Bearing Total Ankle Replacement

The aim of this study was to investigate clinical and radiographic outcomes in patients 50 years and younger vs patients older than 50 years undergoing total ankle replacement. Seventy consecutive patients who underwent primary total ankle replacement were included in this retrospective study. Patients were assessed clinically and radiographically. There was a statistically significant difference between the 2 groups for the American Orthopaedic Foot & Ankle Society score at final follow-up. The younger group had significantly greater improvement compared with the older group. Total ankle arthroplasty is an effective treatment for young, active patients with symptomatic end-stage ankle arthritis. [Orthopedics. 2017; 40(3):e567-e573.].

Autologous Microfractured and Purified Adipose Tissue for Arthroscopic Management of Osteochondral Lesions of the Talus

In recent years, regenerative techniques have been increasingly studied and used to treat osteochondral lesions of the talus. In particular, several studies have focused their attention on mesenchymal stem cells derived from adipose tissue. Adipose-derived stem cells (ADSCs) exhibit morphological characteristics and properties similar to other mesenchymal cells, and are able to differentiate into several cellular lines. Moreover, these cells are also widely available in the subcutaneous tissue, representing 10 - 30% of the normal body weight, with a concentration of 5,000 cells per gram of tissue. In the presented technique, the first step involves harvesting ADSCs from the abdomen and a process of microfracture and purification; next, the surgical procedure is performed entirely arthroscopically, with less soft tissue dissection, better joint visualization, and a faster recovery compared with standard open procedures. Arthroscopy is characterized by a first phase in which the lesion is identified, isolated, and prepared with microperforations; the second step, performed dry, involves injection of adipose tissue at the level of the lesion. Between January 2016 and September 2016, four patients underwent arthroscopic treatment of osteochondral lesion of the talus with microfractured and purified adipose tissue. All patients reported clinical improvement six months after surgery with no reported complications. Functional scores at the latest follow-up are encouraging and confirm that the technique provides reliable pain relief and improvements in patients with osteochondral lesion of the talus.

Effect of multiple hereditary exostoses on sports activity in children

Objective The purpose of this clinical case-control study was to assess the level of sports activity in children with hereditary multiple exostoses (HME) and to compare with the degree of physical activity in children of the same age without pathology. Methods A case-control study was designed. Cases were drawn from children with HME diagnosed on the basis of clinical and radiographic evaluation with an age less then 12 years. Controls were chosen from a group of children with the same age and a negative family history for HME. All patients and controls were completed with the help of parents using the following evaluations: Tegner Activity Level Scale and University of California Los Angeles (UCLA) activity scale. Results A total of 154 individuals participated (54 cases and 100 controls). In the case groups, the mean age was 9.07; the mean number of exostoses resulted 29.51, while the mean value of UCLA and Tegner score resulted respectively 6.04 and 5.09. In the controls, the mean age was 8.88; mean UCLA and Tegner resulted respectively 7.17 and 5.64. Comparing the two groups, the only difference was between UCLA score (p = 0.0053). Moreover, comparing the results between female children affected by HME and female controls, we found a significant difference as regards UCLA score (p = 0.0045). Conclusion Children affected by HME reported lower sports activity, in particular as regards female patients. Moreover, physical activity is not correlated with any other independent factor leading different patients to a similar level of ability in performing sport. Study design Level III - Case Control Study.

Treatment of Ankle Osteoarthritis with Total Ankle Replacement Through a Lateral Transfibular Approach

Total ankle replacement (TAR) is a valid option for the treatment of ankle osteoarthritis. The traditional surgical approach for TAR is the anterior approach. Recently, the lateral transfibular approach to the ankle has gained popularity since a new TAR implant was designed to be performed via this approach that results in an ideal visualization of the center of rotation of the ankle and curved resections that allow for sparing bone cuts. The aim of the present paper is to present our preoperative, operative, and postoperative protocols for the treatment of the osteoarthritis of the ankle with TAR via lateral approach. We present our preoperative clinical and radiographic protocol. In addition, we describe our surgical technique with some technical tips. Finally, we report our follow-up schedule that includes the collection of clinical, functional, and radiographic data. The results of this procedure are encouraging: TAR through a lateral transfibular approach provides reliable pain relief and improvements in functional outcomes in patients with ankle osteoarthritis.

Survival Analysis after Core Decompression in Association with Platelet-Rich Plasma, Mesenchymal Stem Cells, and Synthetic Bone Graft in Patients with Osteonecrosis of the Femoral Head

Purpose  The aim of this study was to report the rate of survivorship in patients with osteonecrosis of the femoral head treated with core decompression in association with mesenchymal stem cells (MSCs) implantation, platelet-rich plasma (PRP) injection, and synthetic bone graft. Methods  We evaluated 24 hips in 16 patients, according to Ficat classification, treated by core decompression, injection of PRP and MSCs, and backfilling of the core tract with synthetic bone graft. Survivorship was estimated using Kaplan–Meier curves. Results  The survivorship of core decompression in association with the procedure is 50% at 75 months of follow-up. The survival rate was 80% for patients in early stage and 28.6% for patients in advanced stage at 75 months. When we compared Kaplan–Meier survival curves of patients in stage III + IV and patients in stage I + II, we noticed that the survival functions are statistically different ( p  < 0.05, log-rank test), particularly in stage I + II where we had a greater surviving core decompression, in comparison to patients in stage III + IV. Conclusion  This technique is safe and good preliminary results were obtained in patients with early stages of the disease with no reported complications. Level of Evidence  Level IV, therapeutic case series.

Clinical Outcomes and Return to Sports in Patients with Chronic Achilles Tendon Rupture after Minimally Invasive Reconstruction with Semitendinosus Tendon Graft Transfer

Objective  The purpose of the study is to evaluate the clinical results and return to sports in patients undergoing reconstruction of the Achilles tendon after minimally invasive reconstruction with semitendinosus tendon graft transfer. Methods  Eight patients underwent surgical reconstruction with a minimally invasive technique and tendon graft augmentation with ipsilateral semitendinosus tendon for chronic Achilles tendon rupture (more than 30 days after the injury and a gap of >6 cm). Patients were evaluated at a minimum follow-up of 24 months after the surgery through the American Orthopaedic Foot and Ankle Society (AOFAS), the Achilles Tendon Total Rupture Scores (ATRS), the Endurance test, the calf circumference of the operated limb, and the contralateral and the eventual return to sports activity performed before the trauma. Results  The mean age at surgery was 50.5 years. Five men and three women underwent the surgery. The average AOFAS was 92, mean Endurance test was 28.1, and the average ATRS was 87. All patients returned to their daily activities, and six out of eight patients have returned to sports activities prior to the accident (two football players, three runners, one tennis player) at a mean of 7.0 (range: 6.7–7.2) months after the surgery. No patient reported complications or reruptures. Conclusion  Our study confirms encouraging results for the treatment of Achilles tendon rupture with a minimally invasive technique with semitendinosus graft augmentation. The technique can be considered safe and allows patients to return to their sports activity. Level of Evidence  Level IV, therapeutic case series.

Total Hip Arthroplasty in an Inveterate Femoral Neck Fracture in a Patient with Congenital Insensitivity to Pain with Anhidrosis

Congenital insensitivity to pain with anhidrosis (CIPA) is an extremely rare disorder characterized by autonomic and sensory nerves malfunction with insensitivity to both deep and superficial painful stimuli, inability to sweat and produce tears, and mild to moderate mental retardation with self-mutilating behavior. Related consequences of inveterate musculoskeletal injuries represent a major issue for these patients, since pain cannot act as a protection mechanism. For the same reason, the patients are at risk during postoperative rehabilitation, which should be taken into account when selecting an orthopaedic implant. To our knowledge, only one case of total hip arthroplasty has been reported in the literature to date. A 21-year-old Caucasian male patient affected with CIPA arrived at our attention complaining about a functional limitation of the left hip. No history of trauma was reported. The X-rays showed an inveterate femoral neck fracture with a severe necrosis and resorption of the femoral head. We decided to perform a total hip arthroplasty with a cemented stem and a cemented dual mobility cup. The postoperative course and rehabilitation were satisfactory, with excellent clinical results, measured with the Harris Hip Score at 1 year.