Vincenzo Denaro

Ipsilateral free semitendinosus tendon graft with interference screw fixation for minimally invasive reconstruction of chronic tears of the Achilles tendon.

ObjectiveMinimally invasive ipsilateral semitendinosus reconstruction of large chronic tears aims to be advantageous for the patient in terms of plantar flexion recovery, anthropometric measures, fast return to daily and sport activity, is safe, with low donor site co-morbidities, low risks of wound complications and neurovascular injuries.IndicationsTendon gaps greater than 6xa0cm and in cases of revision surgery (rerupture).ContraindicationsDiabetes, vascular diseases, previous anterior cruciate ligament (ACL) reconstruction using ipsilateral semitendinosus tendon graft.Surgical techniqueThe semitendinosus tendon is harvested through an incision in the medial aspect of the popliteal fossa, and the proximal stump is exposed and mobilized through an incision performed 2xa0cm proximal and medial to the palpable tendon gap. We repeat the same steps distally, approaching the distal stump of the tendon through a 2.5xa0cm longitudinal incision made 2xa0cm distal and just anterior to the lateral margin of the distal stump. Through the distal incision, we expose the Kager’s space and the postero-superior corner of the osteotomized calcaneum. We drill a bone tunnel into the calcaneum from dorsal to plantar using a cannulated headed reamer. The semitendinosus tendon graft is passed into the proximal stump through a medial-to-lateral small incision, its two ends are moved distally, and finally it is pulled down and shuttled through the bone tunnel. The construct is fixed to the calcaneum using an interference screw.Postoperative managementImmobilization in a below the knee plaster cast with the foot in plantar flexion for 2 weeks, weight bearing on the metatarsal heads as tolerated, use elbow crutches, and keep the knee flexed. At 2 weeks, plaster removed, and rehabilitative exercises started, walker cast allowed.ResultsBetween 2008 and 2010, the procedure was performed on 28xa0consecutive patients (21xa0men and 7xa0women, median age 46xa0years). At the 2-year follow-up, average ATRS scores significantly improved (pu2009<u20090.0001) compared to average preoperative scores with good to excellent outcomes for 26 out of 28 patients (93u2009%); the maximum calf circumference also improved considerably whereby no clinical or functional relevance compared to the contralateral side observed. Of the 28 patients 16 (57u2009%) could practice sport at the same preinjury level, whereby 1 patient experienced persistent pain over the distal wound, which ameliorated after desensitization therapy.ZusammenfassungZielDie minimal-invasive ipsilaterale Semitendinosusrekonstruktion großer chronischer Rupturen hat zum Ziel, für den Chirurgen angenehm und für den Patienten vorteilhaft zu sein, und zwar in Bezug auf die Erholung der Plantarflexion, anthropometrische Parameter und eine schnelle Wiederaufnahme von Alltags- und Sportaktivitäten. Dabei ist sie sicher, geht mit geringer Komorbidität an der Entnahmestelle und einem geringen Risiko von Wundkomplikationen und Gefäß-Nerven-Verletzungen einher.IndikationenSehnendefekte von mehr als 6xa0cm und bei Revisionseingriffen (Reruptur).KontraindikationenDiabetes, Gefäßerkrankungen, vorangegangene Rekonstruktion des vorderen Kreuzbands (ACL) unter Verwendung eines ipsilateralen Semitendinosussehnentransplantats.OperationstechnikIn Bauchlage wird die Semitendinosussehne mittels einer Inzision von 2xa0cm medial über der Fossa poplitea entnommen, der proximale Stumpf dargestellt, von Narben- und fibrotischem Gewebe befreit und mittels einer Längsinzision von 3xa0cm, die 2xa0cm proximal und medial des tastbaren Sehnendefekts erfolgt, mobilisiert. Distal werden dieselben Schritte wiederholt, wobei der distale Sehnenstumpf über eine Längsinzision von 2,5xa0cm, die 2xa0cm distal und direkt anterior des Seitenrands des distalen Stumpfs erfolgt, entnommen wird. Über die distale Inzision wird der Kager-Raum dargestellt und die posterosuperiore Ecke des Kalkaneus osteotomiert. Mit einer kanülierten Kopffräse wird von dorsal nach plantar ein Knochentunnel in den Kalkaneus gebohrt. Das Semitendinosussehnentransplantat wird über eine kleine Inzision von medial nach lateral in den proximalen Stumpf eingeführt. Die beiden Enden werden nach distal und dann durch den Knochentunnel nach unten gezogen. Die Konstruktion wird mit einer Interferenzschraube am Kalkaneus befestigt.WeiterbehandlungImmobilisierung für 2xa0Wochen mit einem Unterschenkelgips und dem Fuß in Plantarflexion, mit einer Belastung der Metatarsalköpfchen je nach Verträglichkeit, Verwendung von Unterarmgehstützen und Beugehaltung des Knies. Nach 2xa0Wochen Gipsabnahme und Rehabilitationsübungen; Tragen eines Gehgipses erlaubt.ErgebnisseZwischen 2008 und 2010 wurde dieser Eingriff bei 28xa0konsekutiven Patienten (21xa0Männer, 7xa0Frauen, Durchschnittsalter 46xa0Jahre) durchgeführt. Nach 2xa0Jahren Nachbeobachtung hatte sich der durchschnittliche ATRS-Score gegenüber präoperativ signifikant verbessert, mit guten oder ausgezeichneten Ergebnissen bei 26/28 Patienten (93u2009%). Auch der maximale Wadenumfang hatte sich deutlich gebessert, dabei war der signifikante Unterschied gegenüber der kontralateralen Seite nicht klinisch oder funktionell relevant. Insgesamt 16/28xa0Patienten konnten (57u2009%) Sport auf einem Niveau wie vor der Verletzung treiben, bei 1xa0Patienten bestanden anhaltende Schmerzen über der distalen Wunde, die sich nach Desensibilisierung besserten.

Complications Due to Inadequate Cervical Spinal Immobilization

Adequate immobilization of the cervical spine is an essential part of the postoperative care of the patient [1] . Orthoses are external applied devices that offer a safe way to immobilize the cervical spine, to increase fusion success, to decrease the rate of graft migration and instrumentation failure, to relieve postoperative pain, to give the patient a sense of security and comfort after surgery, and to improve the postoperative scar [2] . Historically, patients undergoing cervical spine surgery were immobilized in plaster, which was regarded as the only external immobilization device able to provide true postoperative immobilization of the cervical spine. The introduction of the internal fi xation has provided a useful tool to increase fusion rates, maintain alignment, and decrease subsidence and dislodgement of the graft. Internal fi xation acts as an internal brace, limiting motion between the graft and vertebral bodies, decreasing axial forces, reducing the tendency for graft failure. Recent decades have been characterized by great advances in material engineering, which deeply changed the bracing industry. Today, a large variety of different orthoses for the cervical spine are available, and new thermoplastic, so-called breathable, lightweight, durable, magnetic resonance imaging compatible materials are used for the production of cervical spinal orthoses. They are commonly named based on the locality of design (Philadelphia, Miami, etc.) or based on the name of their inventor (Schanz, Thomas, Guilford, etc.). This chapter does not aim to provide a detailed description of all the commercially available cervical orthoses, for which the reader should refer to other publications. We wish to highlight the need for a correct choice of the cervical orthosis in an attempt to Complications Due to Inadequate Cervical Spinal Immobilization

Megaprosthesis in Metastases of the Shoulder

The purpose of treatment for patients with skeletal metastases and pathologic fractures is a singular performance that allows for functional reconstruction. The most common surgical procedure is resection of the metastatic lesion and prosthetic reconstruction. Given the recent developments of new prosthetic implants, the metastatic disease to the proxymal humerus is more often treated surgically by the use of arthroplasty implants. The majority of patients will survive for a significant time after surgery, and hence a stable and pain-free limb should be the goal. When prosthesis implants are used, this allows for a good pain control, despite a poor functional outcome.

Spinal Metastases: Diagnosis and Management

The management of the patient affected by spinal metastases requires an integrated multidisciplinary approach. Surgery and radiotherapy being the mainstay of the treatment of these fragile patients, clinical and surgical trials are required to determine which patients will benefit most from these treatments when affected by metastatic epidural spinal cord compression. In recent years, a newer and more important role for radiotherapy is emerging for these patients; in particular, stereotactic radiosurgery is used as an adjuvant to the decompressive surgery for management of these patients.

Sudden cardiac death in young athletes with long QT syndrome: the role of genetic testing and cardiovascular screening

IntroductionnSudden cardiac death (SCD) of young athletes during competition or training is a tragic event. The long QT syndrome (LQTS) is an arrythmogenic disorder characterized by prolonged ventricular repolarization leading to torsade de pointes evident at electrocardiogram (ECG). Implantable cardioverter defibrillator is an option to revert ventricular fibrillation to sinus rhythm, although the implantation may result in denial of sports participations to the athlete. The authors reviewed the current literature on LQTS in young athletes, to clarify the role of different screening technologies to prevent SCD.nnnSources of datanA systematic review of the literature was performed applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using various combinations of the keywords: QT, syndrome, screening, young, athletes, genetic, electrocardiogram, echocardiography and prevention were used.nnnAreas of agreementnYoung athletes with LQTS are at greater risk of SCD.nnnAreas of controversynDifferent detection screening technologies, including ECG monitoring and genetic testing, are recommended, even though their role is not fully understood.nnnGrowing pointsnECG and genetic testing screening programmes could reduce the incidence of SCD, and they may positively impact on the health and safety of young athletes during sport.nnnAreas timely for developing researchnFurther studies should analyze other modalities of screening to allow early detection of cardiovascular conditions to prevent SCD in young athletes.

Inguinal Region Anatomy

Despite a high prevalence of groin pain, correct diagnosis often remains a challenge. To better understand the pathogenesis of chronic groin pain, a precise anatomical knowledge is required. The purpose of this chapter is to describe the anatomy of the inguinal region.

Talar osteochondral size influences outcome after bone marrow stimulation: a systematic review

Importance No accepted definition of lesion size exists to treat osteochondral defects (OCD) of talus with bone marrow stimulation. Objective The aim of this study is to establish a relationship between the clinical outcomes and size of OCD lesion to identify the area or diameter best suited to be treated with arthroscopic bone marrow stimulation. Evidence review A search was conducted of level I through IV studies from January 2000 to August 2017, to identify studies reporting on talus OCDs treated with bone marrow stimulation. 21 articles were identified. The overall quality of evidence was fair. Findings 21 articles were included in which 1303 ankles with OCD of talus were evaluated. Patients were assessed at a median follow-up period of 38.1 months, ranging from 6.3 to 217 months. Considering a cut-off of an area <1.5u2009cm2 or with a diameter ≤1.5u2009cm, the mean postoperative AOFAS (American Orthopaedic Foot and Ankle Society) value was 89.1±3u2009and 84.65±2.7,u2009respectively (p=0.016). Conclusions and relevance Despite the current lack of high-level evidence, our results suggest that bone marrow stimulation techniques provide an effective and reliable means to treat small to mid-sized OCD. Arthroscopic bone marrow stimulation for isolated osteochondral lesions of the talus is a safe and effective procedure that provides good clinical outcomes for lesions with an area less than 1.5u2009cm2 or with a diameter less than 1.5u2009cm. The attempt to find a new cut-off value to identify more precisely good outcome lesions was unsuccessful. However, the long-term benefits of bone marrow stimulation techniques should be tested in larger cohort of patients with longer term evaluations. Level of evidence Systematic review, level III.

Shoulder Anterior Instability

Anterior glenohumeral instability is a common injury among athletes, with a higher incidence compared to the general population, especially among contact athletes. n n nAnterior dislocations account for about 95 % of instances, while posterior and inferior represent together less than 5 %. n n nThe most common lesion following an anterior traumatic dislocation is the Bankart lesion, in which the anteroinferior capsulolabral complex is torn away from the glenoid rim. This injury can also come with a bony fragment from the anteroinferior edge of the glenoid. n n nThe treatment of anterior shoulder instability is a heavily debated issue. A lot of factors enter in the decision-making process: age and level of activity of the patient, the kind of sport and the role of the athlete (overhead/thrower vs nonoverhead/nonthrower), the type of lesion (soft tissue or soft tissue and bony lesion), number of dislocations, and timing with respect to sport season. n n nImmobilization, physical therapy, and bracing, with a delayed return to activity, are the basis of nonoperative management. n n nNearly 90 % of shoulder stabilization surgeries are arthroscopically performed, while a significant decline in the incidence of open Bankart repair has been observed in the United States.

Reverse total shoulder arthroplasty: research models

PURPOSEnthe past decade has seen a considerable increase in the use of research models to study reverse total shoulder arthroplasty (RTSA). Nevertheless, none of these models has been shown to completely reflect real in vivo conditions.nnnMETHODSnwe performed a systematic review of the literature matching the following key words: reverse total shoulder arthroplasty or reverse total shoulder replacement or reverse total shoulder prosthesis and research models or biomechanical models or physical simulators or virtual simulators. The following databases were screened: Medline, Google Scholar, EMBASE, CINAHIL and Ovid. We identified and included all articles reporting research models of any kind, such as physical or virtual simulators, in which RTSA and the glenohumeral joint were reproduced.nnnRESULTSncomputer models and cadaveric models are the most commonly used, and they were shown to be reliable in simulating in vivo conditions. Bone substitute models have been used in a few studies. Mechanical testing machines provided useful information on stability factors in RTSA.nnnCONCLUSIONnbecause of the limitations of each individual model, additional research is required to develop a research model of RTSA that may reduce the limitations of those presently available, and increase the reproducibility of this technique in the clinical setting.

Complications Related to Posterior Approach

The posterior approach through a midline longitudinal incision provides the most direct access to the posterior elements of the cervical spine. Through this approach, the posterior elements of the cervical spine can be removed, and access to the posterior aspect of the spinal cord and nerve roots from the occiput to C7 can be obtained. The posterior approach to the cervical spine allows excellent exposure to perform several surgical techniques, with or without internal fi xation. It can also be a useful rostral extension of a longer posterior thoracic spinal approach [1] . The posterior elements of the cervical spine play an important role in the stabilization of the cervical spine. Indeed, their removal in patients undergoing wide laminectomies (i.e., for the management of pathologies such as the spondylotic myelopathy, or extraor intra-medullary tumors) may cause subluxation, or severe kyphotic angulation of the spine (i.e., swan neck), causing increased compression of the neural elements and worsening of neurological defi cits [1] . In some patients, if necessary, with careful retraction and protection of the neural structures, it is possible to expose the anterior side of the spinal canal (actually the lateral side of the posterior wall of the vertebral body and the intervertebral disk space), the pedicles, and the posterior portion of the root canals. With this approach, however, the surgeon should not expect to be able to reach the central region of the posterior vertebral bodies [1] . This would involve particularly diffi cult (if not impossible) retraction or displacement of neural structures, which might produce severe neurological damage [2] . Complications Related to Posterior Approach