Flexor Tendon Pulley Injuries: A Systematic Review of the Literature and Current Treatment Options

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non - rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

Closed flexor pulley injuries: A literature review and current practice

Background

Closed flexor pulley injuries are a clinical entity of great interest in hand surgery, and these lesions could be observed mainly in rock-climbing athletes.

Objective

An extensive literature search of PubMed, SCOPUS, Cochrane Library, and Web of Sciences databases on closed finger pulley rupture, related treatments, and outcomes were performed. All relevant information was used in this literature review.

Conclusions

Many athletes are potentially exposed to these uncommon injuries. Therefore, these lesions require careful examination and a high index of suspicion to confirm the diagnosis and identify the degree of soft tissue injury, particularly in patients not involved in sporting activities. The data summarized in this literature review demonstrated that according to Schöffl's classification, conservative treatment should be indicated for low-grade injuries (grade 1 or 2), whereas surgical treatment should be performed in patients with more severe acute injuries (grade 4). Grade 3 flexor pulley injuries lie in a grey area where conservative and surgical treatment may give good clinical and return-to-sport patient results.

Microfragmented Adipose Tissue (M-FATS) for Improved Healing of Surgically Repaired Achilles Tendon Tears: A Preliminary Study

INTRODUCTION

Tendon healing is a complicated process that results in inferior structural and functional properties when compared with healthy tendon; the purpose of this study was to assess the effects of the adjunct of microfragmented adipose tissue (M-FATS) after the suture of a series of Achilles tendons.

METHODS

After complete Achilles tendon tear, 8 patients underwent open suture repair in conjunction with perilesional application of a preparation of M-FATS rich in mesenchymal stem cells. Results were compared with a similar group of patients treated with conventional open suture. Outcomes were evaluated based on range of motion, functional recovery, and complications according to the American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Disability Index (FADI). Achilles tendons were examined by ultrasound (US) at 3 months.

RESULTS

The AOFAS and FADI scores showed no differences between the 2 groups. US evaluation showed quicker tendon remodeling in the M-FATS group. Adverse events were not documented for both procedures.

CONCLUSIONS

The combined application of derived M-FATS for tendon rupture is safe and presents new possibilities for enhanced healing.

LEVELS OF EVIDENCE

Level IIIb: Case control study.

Acute Rockwood type III ACJ dislocation: Conservative vs surgical approach. A systematic review and meta-analysis of current concepts in literature

BACKGROUND

The most appropriate approach, surgical or conservative, for acute Rockwood type III acromioclavicular joint (ACJ) dislocation is still under debate. In literature, similar results have been reported with both treatments. This review aims to analyze the operative and conservative outcomes of acute Rockwood type III ACJ dislocation to guide orthopedics in daily practice.

MATERIAL/METHODS

A systematic review and meta-analysis were performed according to PRISMA guidelines. A PICOS template was developed. Four databases (Pubmed, Scopus, Embase, and Medline) were searched, and eligible articles were evaluated according to the Levels of Evidence. The methodological quality of the articles was assessed through the ROBINS-I and the RoB-2. This review was registered in PROSPERO.

RESULTS

Five studies were included, with 73 and 110 patients treated with conservative and surgical approaches, respectively. Three outcomes, Constant Score (CS), coracoclavicular distance (CCD), and acromioclavicular distance (ACD) were analyzed. Only the acromioclavicular distance was statistically significant in the surgical group over the conservative one (p < 0.05); instead, the other two outcomes demonstrated no statistical difference between the two groups.

CONCLUSIONS

This study demonstrated statistically significant superiority of the mean ACD score in the radiological follow-up of the surgical group compared to the conservative one. A tendency for better radiological and clinical results, mean CCD and CS scores, respectively, although non statically significant, was reported in the surgical group. High-quality randomized controlled clinical trials should help determine the most appropriate treatment for acute Rockwood type III ACJ dislocations.

UNSTABLE LESIONS OF THE FOREARM: TERMINOLOGY, EVALUATIVE SCORE AND SYNOPTIC TABLE

The term "unstable lesions of the forearm" (ULF) was born to more easily describe how a partial or complete instability of the forearm unit might occur due to a traumatic loss of the transverse or longitudinal connection between the radius and ulna. For such an alteration to occur, at least two of the three main osteoligamentous locks (proximal, middle and distal) must be interrupted, often in association with a radial and/or ulnar fracture. Examining the historical patterns (Monteggia, Galeazzi, Essex-Lopresti and criss-cross lesions) and variants described in the literature, out of a total of 586 recorded interventions for forearm trauma, two elbow teams and one wrist team selected 75 cases of ULF. The aim was to describe the instability depending on its clinical and radiographic features, together with the anatomopathological evolution of the lesions based on the time of diagnosis and treatment. The clinical results, evaluated using a new score (FIPS) the Forearm Italian Performance, revealed a correlation between earlier diagnosis and treatment and a better score. The authors suggest a synoptic table that describes 1) the type of instability (proximal transverse, distal transverse, longitudinal and transverse, proximal and distal transverse), 2) classic patterns and variants with characteristic lesions and evolution over time (acute, chronic dynamic, chronic static) and 3) the three forearm constraints and segmental involvement of radius and/or ulna using an alphanumeric classification. Finally, some generic surgical suggestions are proposed.

Heterotopic ossification in primary total hip arthroplasty: risk factor analysis

BACKGROUND

Aim is to identify if age, sex, type of posterolateral approach (mini vs standard), surgical time and time from surgery to drainage removal were independent risk factors for heterotopic ossifications after total hip arthroplasty.

MATERIALS AND METHODS

Patients who underwent a THA with posterolateral approach during a 15 years period were included. The exclusion criteria were absence of X-rays follow-up or HO prophylaxis protocol adoption. The following data were collected: age, sex, type of approach (classical/minimal-invasive), surgical time, time from surgery to drainage removal. Two orthopedic surgeons independently reviewed the 2 years follow-up X-rays and classified the HO according to Brooker classification. Severe HO was defined if HO were classified as major than grade 2. Correlation between severe HO and risk factor has been tested with multivariable analysis.

RESULTS

About 1225 patients were included: mean age of 63.8 years, 504 were men. HO were found in 67.6%. Men showed higher severe HO rate than woman (44.1% vs 29.1%, p = 0.001). Patients older than 65 years showed higher severe HO rate (30.3% vs 39.9%, p = 0.002). Standard posterolateral approach was performed in 75.4% and severe HO rate was 32.8% versus 27.1% in those treated with the minimally invasive approach (p = 0.067). In 75.6% of cases surgery lasted less than 90 min and this group showed a severe HO rate in 29.1%, while patient with longer surgical time showed a rate of 35.7% (p = 0.033). In 47.4% of patients, the drainage was removed in the first post-operative day, in this group severe HO rate was significantly lower than the others: 24.8 versus 36.2% (p = 0.001).

DISCUSSION

Male sex, age older than 65 years, surgical time longer than 90 min and delayed drainage removal are risk factors for severe HO. Patients with one or more of those risk factors should be identified as good candidates for HO prophylaxis.

Rehabilitation Protocol After Hip Arthroscopy: A 2015-2020 Systematic Review

OBJECTIVE

Although many rehabilitation protocols after hip arthroscopy have been described, there is still significant variability about duration, goals, restrictions, and techniques to apply by the physical therapy after the surgical procedure. The aim of the study was to systematically review rehabilitation after hip arthroscopy.

DESIGN

The data sources were PubMed, Scopus, and Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for the systematic review. Level I-IV evidence clinical studies and clinical reviews that focused on rehabilitation protocols after hip arthroscopy have been used as study eligibility criteria. Major limitations include the retrospective nature of most of the studies selected (level IV evidence) and the use of different clinical scores to report the outcomes.

RESULTS

This review showed that although a standardized guideline on rehabilitation after hip arthroscopy is still missing, the most recent studies and clinical trials are focusing on a four-phase program, which includes goals, recommendations, and a progression of exercises.

CONCLUSIONS

Rehabilitation after hip arthroscopy is strongly suggested, but different authors recommended different rehabilitation programs. There is not a defined program, but as of today, the current standard of care is composed of phase-based programs.

Metallosis in Sequelae of Prosthetic Revision for Ceramic Components Fracture: A Case Report with Clinical Presentation Mimicking Periprosthetic Hip Infection

Ceramic on ceramic total hip arthroplasties have been developed and widely used during last decades because of their long-term survival and biomechanical properties. One of the most dangerous complication of these implants is the fracture of the ceramic components. The management of this condition should be carefully planned and the choice of the new implant is crucial. We describe a rare case of severe hip synovitis due to massive metallosis in sequelae of mismanaged prosthetic revision for fracture of the ceramic acetabular liner with an unusual clinical presentation that simulate a periprosthetic infection.

Contralateral non-simultaneous proximal femoral fractures in patients over 65 years old

Purpose

Epidemiological and clinical parameters according to the Parker-Palmer Index (PPI) have not been specifically studied as predictors of re-fracture time in patients over 65 years old with contralateral hip fracture. The main purpose of this study was to assess whether these parameters could represent a prognostic factor in this population.

Methods

This retrospective study included all consecutive patients older than 65 years that suffered from a proximal femoral fracture, 31 according to Association for Osteosynthesis/Orthopaedic Trauma Association classification, treated at our unit between Feb 1st 2019 and Feb 1st 2020.

Results

This study enrolled 387 patients. Thirty-seven of them had already incurred a contralateral hip fracture: seven males and 30 females. The median time between the first and second hip fractures was 3.5 years. This study revealed that increasing age (p = 0.003), male sex (p = 0.029) and a PPI value ≥ 5 between the first and second hip fracture (p = 0.015) are risk factors associated with a contralateral hip fracture in the first three years after the first episode. There were no statistically significant differences regarding anti-osteoporotic therapy and the anatomic site of the first hip fracture episode.

Conclusion

The results of the present study suggest that several risk factors have a crucial role in hip re-fracture time in patients over 65 years old.

Fracture-dislocations of the forearm joint: a systematic review of the literature and a comprehensive locker-based classification system

BACKGROUND

Monteggia, Galeazzi, and Essex-Lopresti injuries are the most common types of fracture-dislocation of the forearm. Uncommon variants and rare traumatic patterns of forearm fracture-dislocations have sometimes been reported in literature. In this study we systematically review the literature to identify and classify all cases of forearm joint injury pattern according to the forearm joint and three-locker concepts.

METHODS

A comprehensive search of the PubMed database was performed based on major pathological conditions involving fracture-dislocation of the forearm. Essex-Lopresti injury, Monteggia and Galeazzi fracture-dislocations, and proximal and/or distal radioulnar joint dislocations were sought. After article retrieval, the types of forearm lesion were classified using the following numerical algorithm: proximal forearm joint 1 [including proximal radioulnar joint (PRUJ) dislocation with or without radial head fractures], middle radioulnar joint 2, if concomitant radial fracture R, if concomitant interosseous membrane rupture I, if concomitant ulnar fracture U, and distal radioulnar joint 3 [including distal radioulnar joint (DRUJ) dislocation with or without distal radial fractures].

RESULTS

Eighty hundred eighty-four articles were identified through PubMed, and after bibliographic research, duplication removal, and study screening, 462 articles were selected. According to exclusion criteria, 44 full-text articles describing atypical forearm fracture-dislocation were included. Three historical reviews were added separately to the process. We detected rare patterns of two-locker injuries, sometimes referred to using improper terms of variant or equivalent types of Monteggia and Galeazzi injuries. Furthermore, we identified a group of three-locker injuries, other than Essex-Lopresti, associated with ulnar and/or radial shaft fracture causing longitudinal instability. In addition to fracture-dislocations commonly referred to using historical eponyms (Monteggia, Galeazzi, and Essex-Lopresti), our classification system, to the best of the authors' knowledge, allowed us to include all types of dislocation and fracture-dislocation of the forearm joint reported in literature. According to this classification, and similarly to that of the elbow, we could distinguish between simple dislocations and complex dislocations (fracture-dislocations) of the forearm joint.

CONCLUSIONS

All injury patterns may be previously identified using an alphanumeric code. This might avoid confusion in forearm fracture-dislocations nomenclature and help surgeons with detection of lesions, guiding surgical treatment.

LEVEL OF EVIDENCE

V.

One bone forearm with vascularized fibular graft. Clinical experience and literature review

One-Bone-Forearm (OBF) is a procedure in which the proximal stump of the ulna is fixed to the distal stump of the radius. Historically, the indications for OBF have been represented by forearm instability due to trauma, infection, tumor resection, and congenital deformities with severe radius and ulna bone loss. When major bone loss prevents direct fixation between ulna and radius a Vascularized Fibular Bone Graft (VFBG) may allow forearm bone reconstruction and fixation. In this study we report our clinical experience in 4 cases of OBF with VFBG performed in 3 patients. Compared to standard OBF technique with direct osteodesis, OBF with VFBG showed similar clinical results and high rate of healing even in case of bone infection. Moreover, composite osteocutaneous VFBG might concurrently allow to treat local soft tissue defects.

Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up

PURPOSE

The anterior cruciate ligament (ACL) tear is one of the most common sports injuries of the knee, and the arthroscopic reconstruction is the gold standard. Nevertheless, controversies about the surgical techniques and the type of graft still exist. Allografts have been considered by many surgeons as valid alternative to autografts. The aim of this study was to assess the effectiveness of allografts compared to autografts at approximately 10 years of follow-up, investigating the level of physical activity currently performed by patients of each group.

METHODS

Ninety-four patients, divided into two groups (allografts and autografts), have been retrospectively studied. The two groups did not significantly differ in preoperative sport activity level, age (mean 40.70 years for autografts and 41.23 for allografts) and characteristics. Allograft group received a fresh-frozen graft from the musculoskeletal tissues bank. Evaluations were made using the International Knee Documentation Committee (IKDC) and Lysholm score; every patient was interviewed for complications.

RESULTS

The mean follow-up time was approximately 10 years for both groups, with a minimum of 8 years. There were no statistically significant differences between the two groups. Average IKDC scores were 75.21 (SD 15.36) and 80.69 (SD 13.65) for the allograft and autograft groups, respectively. The mean Lysholm score was 87.57 (SD 9.43) for the allografts and 89.10 (SD 8.33) for the autografts. No major complications linked to the allograft tissue arose.

CONCLUSION

Both groups achieved almost the same functional outcomes at an average 10 years of follow-up, indicating fresh-frozen allografts as a reasonable alternative for ACL reconstruction.

LEVEL OF EVIDENCE

IV, Retrospective case-control study.

Third generation delta ceramic-on-ceramic bearing for total hip arthroplasty at mid-term follow-up

Purpose

to evaluate the results of Delta ceramic-on-ceramic (CoC) for total-hip-arthroplasty (THA).

Methods

261 THA using Delta-CoC, retrospectively analyzed. A 36 mm head was used in 189 cases and a 32/40 mm in the others. The series have been compared to a group of 89 THA with Forte-CoC.

Results

The Harris-Hip-Score improved from 49.1 ± 14.3 to 92.0 ± 8.9 (P < 0.001). In the Delta group there were one ceramic fracture and 2 dislocations. Two hips underwent revision. There were one revision in the Forte group for instability and one squeaking hip.

Conclusions

The new ceramic bearings provides a safe bearing for THA, with rare complications.

Bone Loss in Distal Radial Fractures Treated with A Composite Xenohybrid Bone Substitute: A Two Years Follow-Up Retrospective Study

(1) Background: Recently, surgical treatment of distal radius fractures has increased exponentially. Many locking plates' fixation systems have been developed allowing a more stable reduction and early mobilization. Sometimes, open reduction and fixation of distal radius fractures may leave a residual bone loss requiring grafting. This retrospective study reports clinical and radiologic outcomes of distal radius fractures treated with xenohybrid bone grafting in order to assess (i) the safety of the investigated bone graft; (ii) its radiological integration and biomechanical performances, and (iii) clinical outcomes of the patients; (2) Methods: We performed a retrospective study on a cohort of 19 patients. Preoperative X-ray and CT scan were performed. The mean clinical and radiographical follow-up was two years. Safety of the xenohybrid bone graft was constantly evaluated. Clinical results were assessed through the DASH score and Mayo wrist score; (3) Results: No adverse reactions, infections, and local or general complication were related to the use of xenohybrid bone graft. The radiolucency of the xenografts suggested progressive osteointegration. No evidence of bone graft resorption was detected. All the patients reached consolidation with good to excellent clinical results; and (4) Conclusions: Clinical and radiological data demonstrated that xenohybrid bone grafting promotes new bone formation and healing in osteopenic areas caused by fracture reduction.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Sarcopenia in distal radius fractures: systematic review of the literature and current findings

INTRODUCTION

Sarcopenia is a clinical syndrome characterized by the reduction in muscle mass, strength and physical ability. Although proximal femur fractures are one of the major burdens affecting the ageing population, distal radius fractures are equally important for frequency, clinical and social consequences. The aim of this study is to evaluate the incidence of sarcopenia in distal radius fractures and clinical implications in functional recovery.

MATERIALS AND METHODS

Scopus and PubMed search was performed to find relationship between sarcopenia and distal radius fractures. Literature search was performed between 2009 and 2019 including clinical trials and clinical studies related to "sarcopenia and distal radius fracture" and "sarcopenia and wrist fracture". After identification, studies were screened and analysed through the Oxford Level of Evidence.

RESULTS

According to the inclusion and exclusion criteria, five articles were included. Four articles analysed the incidence of sarcopenia and its role as a risk factor in patients with distal radial fractures, while one article focused on sarcopenia and clinical results of surgical treatment of distal radius fractures. Incidence of sarcopenia in patients older than 50 years with distal radius fracture varied between 29.7% and 31.7%. Patients with distal radial fractures did not show a significant inferior muscle mass than control group in examined population. Functional results of surgery were significantly inferior in sarcopenic patients than control group (no sarcopenia).

CONCLUSIONS

About 30% of patients older than 50 years with distal radius fracture suffered by sarcopenia; sarcopenic patients surgically treated had worse clinical results than no sarcopenic patients. Further studies with larger samples are needed to confirm these preliminary results.

Long-term results of Zweymüller SLL femoral stem in revision hip arthroplasty for stage II and IIIA femoral bone defect: a 9-15-year follow-up study

BACKGROUND

Loosening of femoral stem can be associated with a wide spectrum of bone loss that represents the most important factor for choosing the most appropriate revision implant. Positive outcomes in femoral revision were already observed with Zweymüller Alloclassic^® SLL stem in short- and medium-term follow-up. The aim of the study is to analyse the clinical results of 31 patients who underwent prosthetic revision for aseptic loosening of femoral component with Zweymüller femoral stem and long follow-up.

METHODS

The series included 10 men and 21 women with a mean age of 66.24 years at the time of revision surgery and a mean follow-up of 12.25 years. Clinical and radiological evaluation was performed at 2 months, 6 months and yearly, using Harris Hip Score (HHS) and Engh's criteria and Brooker classification for heterotopic ossifications.

RESULTS

At the last follow-up, the survival of the stem was observed in all patients (32 hips). The mean HHS was 77.83 ± 20.90. Clinical results were stated as excellent in 14 cases, good in 5 cases, fair in 4 cases and poor in 9 cases. Radiographic stability with fixation by bone ingrowth was observed in 15 cases and with fibrous ingrowth in 17 cases. Heterotopic ossifications grade III was observed in 4 cases and grade II in 3 cases.

CONCLUSIONS

Zweymüller Alloclassic^® SLL stem showed excellent or good results in about 59% of revision surgery for aseptic loosening. The survival rate of the stem at 9-15 years of follow-up was satisfactory.

Chronic Essex-Lopresti injury: a systematic review of current treatment options

INTRODUCTION

Essex-Lopresti lesion (ELL) is a severe injury. Most of ELL is recognized in chronic phase representing a therapeutic challenge for orthopaedic surgeons. The aim of this systematic review is to highlight and criticize current concepts in the surgical treatment.

MATERIALS AND METHODS

The search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. A comprehensive research of Pubmed database was made using the following Mesh term: ((Essex-Lopresti injury) OR (Essex Lopresti) OR (distal radio ulnar dissociation) OR (distal radio ulnar dislocation) OR (longitudinal forearm instability)). Quality assessment of each article was performed according to Coleman score by two authors.

RESULTS

Eight full articles were included to the systematic review. Surgical treatment was differentiated in five categories according to the most common procedure reported in clinical series. The mean Coleman Score was 51.13 ± 9.76.

DISCUSSION

Case series reported in the literature include a limited number of patients with chronic ELL. Currently, salvage procedure devoted to treat a wrong diagnosis and an incorrect treatment is used. Radial head replacement together with ulnar shortening osteotomy and interosseous membrane reconstruction are the most common treatments of choice, but at present, there is not yet a shared scheme of management for patients with chronic ELL.

CONCLUSIONS

According to current literature, a case-by-case treatment must always be considered. Further investigations, with higher level of evidence, quality of study design, and number of patients, are needed to better assess clinical results and complication of each technique.

LEVEL OF EVIDENCE

IV.

Clinical and radiological union rate evaluation of type 2 odontoid fractures: A comparison between anterior screw fixation and halo vest in elderly patients

Purpose:

Odontoid fracture is a very common cervical injury, especially in elderly patients. Despite the high frequency, the appropriate management is still debated. The aim of this study is to evaluate clinical and radiological outcomes after anterior screw fixation or halo vest (HV) in type II odontoid fracture in elderly patients.

Materials and Methods:

Between January 2013 and December 2015, 135 consecutive patients affected by odontoid process were found. According to inclusion and exclusion criteria, 57 patients were included in the study. Patients were evaluated with visual analog scale (VAS), Smiley–Webster Scale (SWS), Italian Version of the Neck Disability Index (NDI), and patient satisfaction during follow-up. Furthermore, radiological data were evaluated for bone healing. Student's t-test or Fisher's exact test was used between groups, analyzing radiological and clinical results, and level of statistical significance was set at P < 0.05.

Results:

Seventeen patients were female and 40 were male. Twenty-seven patients were included in surgical group (SG) while 30 were included in HV group with a mean follow-up of 37.74 ± 10.52 months. A significant difference (P < 0.05) between groups was found for pseudoarthrosis, with a lower rate for SG. No significant differences in term of VAS, NDI, and SWS were found between groups (P > 0.05); SG reached higher satisfaction than HV group (P = 0.0271).

Conclusions:

Both treatments are equivalent in terms of clinical outcomes, and they are a valuable choice in the management of type II odontoid fracture. However, it must be considered that patients could slightly tolerate HV and may need a change of treatment.

Traumatic Extensor Tendon Injuries to the Hand: Clinical Anatomy, Biomechanics, and Surgical Procedure Review

The extensor apparatus is a complex muscle-tendon system that requires integrity or optimal reconstruction to preserve hand function. Anatomical knowledge and the understanding of physiopathology of extensor tendons are essential for an accurate diagnosis of extensor tendon injuries (ETIs) of the hand and wrist, because these lesions are complex and commonly observed in clinical practice. A careful clinical history and assessment still remain the first step for the diagnosis, followed by US and MR to confirm the suspect of ETI or to investigate some doubtful conditions and rule out associate lesions. During last decades the evolution of surgical techniques and rehabilitative treatment protocol led to gradual improvement in clinical results of ETI treatment and surgical repair. Injury classification into anatomical zones and the evaluation of the characteristics of the lesions are considered key points to select the appropriate treatment for ETI. Both conservative and surgical management can be indicated in ETI, depending on the anatomical zone and on the characteristics of the injuries. As a general rule, an attempt of conservative treatment should be performed when the lesion is expected to have favorable result with nonoperative procedure. Many surgical techniques have been proposed over the time and with favorable results if the tendon injury is not underestimated and adequately treated. Despite recent research findings, a lack of evidence-based knowledge is still observed in surgical treatment and postoperative management of ETI. Further clinical and biomechanical investigations would be advisable to clarify this complex issue.

Megaprostheses in the Revision of Infected Total Hip Arthroplasty. Clinical Series and Literature Review

PURPOSE

The management of severe femoral bone loss associated with hip infection is a major problem in joint replacement surgery. Femoral megaprostheses have been rarely reported in reconstructive procedure for this complex condition. The aim of the study was to evaluate clinical results observed after such uncommon reconstruction in our case series and in a similar group of patients extracted by literature review.

METHODS

We evaluated clinical outcomes and eradication of sepsis in five patients who underwent femoral revision with modular femoral resection stems at our institution, and we reviewed the literature about this topic. In our case series, the femoral bone loss was grade III-B in three cases and grade IV in two cases according to the Paprosky classification. One patient was operated with one-stage revision, and four patients were operated with two-stage revision. The mean age was 72 years (range: 60 to 81 years), and the mean time of follow-up was 62 months (range: 36 to 82 months).

RESULTS

We observed sepsis eradication in four out of five patients in our series, and clinical results were satisfactory with a mean Harris Hip Score of 74 points (range: 46 to 95 points). Cumulative results obtained considering our series and data obtained by literature review showed a mean Harris Hip Score of 75 points (range: 42 to 95 points) in patients able to walk and an overall incidence of recurrent infection in 33% of patients. Complications were observed in 8 out of 20 patients (dislocation, 6 cases; greater trochanter displacement 2 cases; and transient sciatic palsy, 1 case).

CONCLUSIONS

Revision with megaprostheses in case of infected total hip arthroplasty with severe femoral bone loss have a high risk of complication and should be carefully evaluated and used in selected patients when other surgical procedures are not feasible.

Midfoot reconstruction with serratus anterior-rib osteomuscular free flap following oncological resection of synovial sarcoma

During recent decades, the concept of surgical treatment of malignant bone and soft tissue sarcomas has evolved, with the aim of preserving limb function. In this paper we report a case of metatarsal reconstruction by means of serratus and rib free flap after excision of a synovial sarcoma located in the dorsal aspect of the midfoot. Five years after the operation, the patient was free from recurrence and recovered full foot function. Amputation has been widely used in the past and this procedure still remains a valuable option when limb salvage is not possible. Nevertheless, in selected cases, reconstruction by means of composite free flaps may be successfully used for limb preservation in the treatment of malignant foot tumors after surgical excision.

Glomus tumor of the thenar eminence in neurofibromatosis type 1: case report and literature review

Neurofibromatosis type 1 (NF1) is a disease characterized by increased tumorigenesis susceptibility, caused by mutations of the oncosuppressor gene NF1. The glomus tumor (GT) is a rare, very painful mesenchymal neoplasm, arising from the glomus body. In recent years, it has been highlighted the association between NF1 and GT. We report a case of a man aged 65 years, suffering from NF1, with intense pain at the thenar eminence of the right hand, successfully treated with the excision of the mass.

Multidrug-resistant Acinetobacter baumannii infection following para-articular steroid injection in the knee--a case report

Acinetobacter baumannii is an emerging gram-negative nosocomial pathogen that rarely causes infections in orthopaedic patients. We report a case of imipenem-resistant Acinetobacter baumannii paraarticular infection of the knee occurring in a healthy patient following one ambulatory steroid injection for the treatment of quadriceps tendinopathy. The infection was reduced by early surgical debridement of infected tissues, abscess drainage, and prolonged antibiotic therapy with colistin. To our knowledge, this is the first case in the literature reporting such an infection following single steroid injection in orthopaedic patients.

Surgical treatment of acute fingernail injuries

The fingernail has an important role in hand function, facilitating the pinch and increasing the sensitivity of the fingertip. Therefore, immediate and proper strategy in treating fingernail injuries is essential to avoid aesthetic and functional impairment. Nail-bed and fingertip injuries are considered in this review, including subungual hematoma, wounds, simple lacerations of the nail bed and/or matrix, stellate lacerations, avulsion of the nail bed, ungual matrix defect, nail-bed injuries associated with fractures of the distal phalanx, and associated fingertip injuries. All these injuries require careful initial evaluation and adequate treatment, which is often performed under magnification. Delayed and secondary procedures of fingernail sequelae are possible, but final results are often unpredictable.

Termino-lateral nerve suture in lesions of the digital nerves: clinical experience and literature review

Documented experience of treatment of digital nerve lesions with the termino-lateral (end-to-side) nerve suture is limited. Our clinical experience of this technique is detailed here alongside a systematic review of the previous literature. We performed, from 2002 to 2008, seven termino-lateral sutures with epineural window opening for digital nerve lesions. Functional outcome was analysed using the two-point discrimination test and the Semmes-Weinstein monofilament test. The results showed a sensory recovery of S3+ in six cases and S3 in one case. The mean distance found in the two-point discrimination test was 12.7 mm (range 8-18 mm). After a review of the literature, we were able to obtain homogeneous data from 17 additional patients operated by termino-lateral coaptation. The overall number of cases included in our review was 24. A sensory recovery was observed in 23 out of 24 patients. The functional results were S0 in one case, S3 in one case, S3+ in twenty cases and S4 in two cases. Excluding the one unfavourable case, the mean distance in the two-point discrimination test was 9.7 mm (range 3-18 mm). It can thus be concluded that the treatment of digital nerve lesions with termino-lateral suture showed encouraging results. Based on the results obtained in this current study we believe that in case of loss of substance, end-to-side nerve coaptation may be an alternative to biological and synthetic tubulisation when a digital nerve reconstruction by means of nerve autograft is declined by the patient.

End-to-side nerve suture in traumatic injuries of brachial plexus: review of the literature and personal case series

We used end-to-side nerve coaptation combined with standard end-to-end neurotisations to treat 11 patients who presented with complete (six cases) or incomplete (five cases) traumatic brachial plexus injuries. All patients were available for functional evaluation at a minimum of 2 years postoperatively. In three patients with shoulder abduction recovery, electromyographical studies (EMG) showed a contribution from the end-to-side neurotisation. In the remaining cases end-to-side neurotisations were unsuccessful. Our study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery. We believe that at present end-to-side suture must not be a substitute for standard reconstructive techniques in brachial plexus surgery. Occasionally termino-lateral nerve sutures may represent a support to standard reconstructive procedures especially in case of severe injuries when few undamaged donor nerves are available.

A simple sterile polypropylene fingernail substitute

Traumatic nail injuries are often observed in clinical practice. Usually the fingernail can be preserved, cleaned and disinfected in order to use it in the reconstructive procedure. However, in some cases the nail can be avulsed and lost or too damaged to be used. In cases when the nail is not available it should be replaced by a substitute in order to protect nail bed and avoid adherences along the proximal nail bed and the nail fold. Furthermore the substitute serves to protect the tender nail bed from painful stimuli during the healing process. We used, as fingernail substitute, a polypropylene sheet in eight patients with fingernail avulsion or disruption. The polypropylene foil was trimmed reproducing the profile of the avulsed fingernail and thinned at the proximal edge to reduce thickness in order to ease the insertion into the nail fold. A small hole was then created in the center of the foil to allow blood drainage. The substitute was usually removed one month after the application. In our clinical experience we had not complications related to the polypropylene device. The new fingernail had good cosmetic appearance in most cases and all the patients reported a good protection of the fingertip during the healing period. The substitute used in this series is sterile, inexpensive and easily available in emergency and elective operatory theater. This polypropylene foil is flexible and can be shaped and adapted to the nail curvature radius. The substitute used in our clinical series protected the nail bed during healing until the growth of the new fingernail and respected our functional expectations.

Heterotopic ossification after hip surgery in cerebral palsy

Heterotopic ossification is a post-surgery complication occasionally observed in patients with infantile cerebral palsy. In the majority of the cases such lesions are found at the hip after surgery on the skeleton and the soft tissues. At our Institute in the last five years, this complication has been observed four times, in 39 patients, who underwent mainly soft tissue releases because of flexion and adduction contracture of the hip. In these cases, as in a further patient with myelomeningocele, the periarticular heterotopic ossification appeared in the hip after tenotomy of the ilio-psoas at the lesser tronchater associated to other surgical procedures. Conversely, no cases of ossification have been found after tenotomy of the adductors or the gracilis or selective tenotomy of the psoas at the pelvic brim. The exact causes of this complication are still unclear, but after an analysis of the literature and patient history it can be hypothesised that it may be related to the surgical procedures carried out.