Vitantonio Digennaro

Alignment Deviation Between Bone Resection and Final Implant Positioning in Computer-Navigated Total Knee Arthroplasty

BACKGROUND Computer-navigated total knee arthroplasty is aimed at improving accuracy in the positioning of prosthetic components and realigning the lower limb. The optimal position and orientation of the bone resection planes are targeted by the navigation system, but, after these are obtained, additional manual surgical actions, which may considerably affect final component alignment, are necessary for implantation. The aim of this study was to measure the alignment deviation caused by standard impaction of the tibial and femoral components following bone resections with use of navigation control. METHODS Ninety-one primary total knee arthroplasties were performed with an image-free knee navigation system. The alignment of the tibial and femoral bone resections was measured in three planes during surgery by the instrumented probe of the system. The alignment measure was repeated after final tibial and femoral component implantation with cement. The alignment deviations between the two measures were considered the positioning error associated with the final manual implantation of the components. RESULTS The alignment deviations between the bone resections and the subsequent implant placement were >1 degrees in the frontal plane of the femur and in the frontal and sagittal planes of the tibia in 20%, 11%, and 33% of the patients, respectively. The deviations were >2 degrees in 4%, 3%, and 9% of the patients, respectively. Deviations as large as 3 degrees were found at the tibia in the sagittal plane (the posterior slope). CONCLUSIONS Positioning of the femoral and tibial components in total knee arthroplasty, which mainly involves cementation and impaction of the final components, can introduce a considerable error in alignment, regardless of how accurately the resection planes are made. After computer-navigated total knee arthroplasty, it would be useful therefore to check the alignment of the prosthetic component carefully before the cement hardens.

The Minimally Invasive Osteotomy “S.E.R.I.” (Simple, Effective, Rapid, Inexpensive) for Correction of Bunionette Deformity:

Background: A bunionette is a deformity of the fifth metatarsal bone with a varus deviation of the toe which can require surgical correction. Although numerous bony or soft tissue surgical procedures have been described, the ideal treatment has not yet been identified. The aim of this study was to retrospectively evaluate the results of a series of 50 consecutive feet affected by symptomatic bunionette deformity treated by S.E.R.I. (simple, effective, rapid, inexpensive) osteotomy. Materials and Methods: Between February 1998 and March 2004, 50 feet with symptomatic type II-III bunionette deformity in 32 patients (18 bilateral) underwent S.E.R.I osteotomy. The average age of the patients at the time of operation was 33 ± 13 years. The average followup was 4.8 (range, 2 to 8) years. Results: The average modified lesser toe AOFAS score increased from 62.8 ± 15.2 points preoperatively to 94 ± 6.8 points at last followup (p < 0.0005). The average fifth metatarsophalangeal (MTP) angle decreased from 16.8 ± 5.1 degrees preoperatively to 7.9 ± 3.1 degrees at final followup (p < 0.0005). The 4–5 intermetatarsal angle (I.M.A) averaged 12 ± 1.7 degrees preoperatively, while postoperatively was 6.7 ± 1.7 degrees (p < 0.0005). Complications included a skin inflammatory reaction around the Kirschner wire and 2 symptomatic plantar callosities under the fourth metatarsal heads. Conclusions: The minimally invasive osteotomy is an effective and reliable technique for the treatment of painful bunionette, and it achieved more than 90% excellent and good results with reduced surgical time and complications.

Fixation of Winged Scapula in Facioscapulohumeral Muscular Dystrophy

Objective: To verify if stabilizing the scapulothoracic joint without arthrodesis could lead to functional improvement of shoulder range of motion and clinical improvement of winged scapula, we incorporated four additional patients into our previous analysis to determine if the results obtained were long lasting, and to compare this fixation with the other techniques described in the literature, balancing the benefits with the complications. Design: A retrospective study. Participants: Thirteen patients with bilateral winged scapula affected by facioscapulohumeral muscular dystrophy. Nine of these patients had been analyzed in our previous study. Methods: Patients were operated on by bilateral fixing of the scapula to the rib cage using metal wires without arthrodesis (scapulopexy). Results: All patients experienced improvement in active range of motion of the shoulder and all of them had clinical improvement with complete resolution of the winged scapula. In all twenty-six surgical interventions of scapulopexy, a stable and long-lasting fixation of the scapula to the rib cage was achieved.The complications strictly associated to the surgical technique encountered were one pneumothorax, which was resolved spontaneously, and one wire breakage without trauma. Average follow-up was 10 years (range, 3 to 18 years). Conclusion: The scapulopexy used in this extended series of patients consisted of repositioning the scapula and fixing it to four ribs by using metal wires without performing arthrodesis.This technique has a low rate of complications, is reproducible, safe and effective, resulting in clinical and functional improvement.

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.

Degenerative lumbar scoliosis: features and surgical treatment

Degenerative lumbar scoliosis is a de novo deformity of the spine occurring after the fourth or fifth decade of life in patients with no history of scoliosis in the growing age. We evaluated complications and functional and radiographic outcomes of twelve patients with degenerative lumbar scoliosis, treated by spinal decompression associated with posterolateral and/or interbody fusion. Mean lumbar scoliosis angle was 18° (SD=4°) and mean age at surgery was 57 years (SD=6 years). Average follow–up was 3.5 years. Surgical treatment consisted in decompression of one or more roots, associated with stabilization with pedicle screws and posterolateral fusion. To correct the deformity, the collapse of the disc was corrected by implanting a cage in the anterior interbody cage. Clinical symptoms and functional tolerance for daily activities improved after surgery. Radiographic evaluation showed a reduction in the deformity on the frontal and sagittal planes. There were no infections, evidence of pseudoarthrosis, instrumentrelated failures or re–operations in this series. In patients with persisting pain caused by degenerative scoliosis associated with spinal stenosis, in whom conservative treatment has failed, spinal decompression and segmented fusion with instrumentation represents a valid treatment option.

What happens to the elbow joint after fractured radial head excision? Clinical and radiographic study at a mean 15-yearfollow-up

Comminuted fractures of the radial head can be treated by radial head excision, open reduction and internal fixation, or radial head replacement. The aim of this study was to evaluate the long-term clinical and radiographic results of 22 patients with an isolated Mason type III fracture of the radial head treated by radial head excision. Mean age at the time of surgery was 36 years and average follow-up was 15 years. Overall outcome at the last follow-up was scored as excellent, good, fair or poor, considering elbow and wrist pain, valgus deformity, elbow and forearm range of motion, and elbow radiographic osteoarthritic changes. At follow-up mean pain score on VAS was was 1, average increase in elbow valgus deformity was 8°, mean flexion of the elbow was 138°, pronation of the forearm averaged 78°, and supination averaged 85°. Degenerative changes were scored as grade 0 in 4 patients, grade 1 in 14 patients, and grade 2 in 4 patients. The overall outcome was excellent in 18 patients and good in 4 patients. When a comminuted radial head fracture is not associated with elbow dislocation or ligamentous injuries, resection of the radial head is a valid surgical option because it is a simple and rapid technique, it has a low learning curve, and it has a high rate of excellent clinical and radiographic long-term results.

The Impact of Bone Deformity on Osteoarthritic Varus Knee Correctability

BACKGROUND Bone deformities in the varus osteoarthritic knee may influence soft-tissue balancing and therefore knee correctability. The hypothesis of the present study was that the grade of coronal plane knee deformity may influence directly knee correctability along the entire range of motion from 0° to 90°. Tibial and femoral epiphyseal bone deformities were also analyzed to determine which kind had the greater impact on knee correctability. METHODS A coronal plane deformity radiographic assessment and an intraoperative correctability assessment using computer-assisted surgery were performed on 118 varus osteoarthritic knees undergoing total knee arthroplasty. Knees were divided into groups taking into account the kind of bone deformity (tibial, femoral, and combined). RESULTS A significant inverse correlation was found between coronal plane deformity and knee correctability at every 10 degrees of flexion. Correlation was strong at 0° and progressively got weaker at further flexion angles. According to literature, knees with a varus deformity >10° were rarely correctable in full extension, but often correctable in flexion, whereas knees with varus deformity >15° showed to be almost never correctable. Combined deformity group had a significantly lower rate of correctability along the entire range of motion. CONCLUSION The severity of varus knee malalignment always influenced knee correctability with the knee in full extension, in further flexion (20°-60°), correctability was mildly affected. Isolated tibial epiphyseal deformity and combined epiphyseal deformity have the greatest impact on knee correctability.

Surgical treatment of metastatic lesion of the spine. A review of 51 consecutive cases operated

Metastatic lesions of the spine have recently become a debated topic in orthopaedics, because more and more patients survive long enough to require surgical treatment. The aim of this study is to review a series of 51 patients affected by metastatic lesions of the spine. Fifty-one patients affected by metastatic lesions of the spine were treated between 1987 and 2000. In 5 cases the cervical spine was involved, in 27 the thoracic and in 19 the lumbar spine. Surgery was planned according to the following labelling factors: type of malignancy, life expectancy, neurological involvement, pain, site of lesion, lesion extension and spine stability. Surgical treatment consisted of: minimally invasive cord decompression in 3 cases, posterior stabilization in 21, posterior stabilization and cord decompression in 13 cases, anterior resection and reconstruction of anterior column associated or not at posterior stabilization in 14 cases. Two patients died due to complications related to surgery. At the last available follow-up of 4 (±2.5) years, 29 patients had excellent results, 16 had good results, 2 fair and 2 poor results. One fair and 1 poor result had recurrence of the metastatic lesions of the spine and needed another operation. We believe that surgical treatment of metastatic lesion of the spine has a positive cost/benefit ratio for the patients condition; in fact most of our patients had improvement of quality of life. The labelling factors of each lesion have to be carefully studied together with the oncologist to decide the correct surgical option because unsatisfactory results could be sometimes related to incorrect evaluation of the evolution of the neoplasm.