Publications by authors named "Mattia Loppini"

81 Publications

Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict.

Arthroscopy 2021 05;37(5):1397-1399

IRCCS Humanitas Research Hospital.

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.
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http://dx.doi.org/10.1016/j.arthro.2021.02.005DOI Listing
May 2021

Complications, readmission and reoperation rates in one-stage bilateral versus unilateral total hip arthroplasty: a high-volume single center case-control study.

Sci Rep 2021 Mar 18;11(1):6299. Epub 2021 Mar 18.

IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.

The study aimed to assess the safety of one-stage bilateral total hip arthroplasty (THA) compared with unilateral THA. In this retrospective observational case-control study were included patients undergoing unilateral (group 1) and one-stage bilateral (group 2) THA in a high-volume center. The groups were matched for gender, age at surgery, and pre-operative American Society of Anesthesiology score. The following variables were assessed: local and systemic complications, postoperative anemia, 30-day and 1-year readmission and reoperation rates, length of hospital stay, and ambulation time. Group 1 reported a significantly higher rate of local and systemic complications compared with group 2 (5.4% versus 3.9% and 29.6% versus 4.7%, respectively). Postoperative anemia was significantly lower in group 1 compared with group 2 (8.1% versus 30%). There was no significant difference in terms of 30-day and 1-year readmission rates between the two groups. The average length of hospital stay was 5.1 ± 2.3 days in group 1, and 5.3 ± 1.9 days in group 2 (p = 0.78). Ambulation time was significantly lower for group 1 (day 0.9 ± 0.9 in group 1, and day 1 ± 0.8 in group 2, p = 0.03). In a high-volume center, one-stage bilateral THA is a safe procedure compared with unilateral THA in terms of postoperative local and systemic complications, 30-day readmission and 1-year reoperation rates, and length of hospital stay.
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http://dx.doi.org/10.1038/s41598-021-85839-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973798PMC
March 2021

Conversion of Fused Hip to Total Hip Arthroplasty: Long-Term Clinical and Radiological Outcomes.

J Arthroplasty 2021 03 17;36(3):1060-1066. Epub 2020 Oct 17.

Department of Orthopedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy.

Background: Despite promising results at the mid-term followup, several aspects of conversion of the fused hip to total hip arthroplasty (THA) remain controversial. The aim of this study was to evaluate clinical and radiological outcomes with a minimum 5-year followup in patients who underwent conversion of the fused hip to THA.

Methods: Fifty-seven patients (59 hips) were evaluated. The Harris Hip Score (HHS), range of motion (ROM), and the Visual Analogue Scale (VAS) were used to assess hip function and low back pain. Subjective satisfaction with surgery and the presence of the Trendelenburg sign was also evaluated. Radiological assessment was performed pre- and postoperatively to evaluate loosening and heterotopic ossification (HO).

Results: After a mean followup of 13.0 ± 6.2 years, HHS and VAS significantly improved from 46.0 ± 16.7 to 80.8 ± 18.8 and from 4.4 ± 1.5 to 2.1 ± 1.4 (both P < .001), respectively. Twenty-three patients (40.4%) had a positive Trendelenburg sign, and HOs were found in 29 cases (49.1%). An overall 29.8% complication rate was noted. Smoking habits and rheumatoid arthritis were predictive of Trendelenburg sign (P = .046 and P = .038, respectively). Implant survival rate as the end point was 98.7 ± 1.3% at 5 years, 92.4 ± 3.3% at 10 years, 82.1 ± 5.7% at 15 years, and 73.4 ± 8.0% at 20 and 25 years. A worse cumulative implant survival rate was noted in patients who underwent previous hip surgery, defined as any hip operation before fusion (P = .005).

Conclusion: Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. An implant survival rate higher than 70% can be expected 25 years postoperatively.
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http://dx.doi.org/10.1016/j.arth.2020.09.030DOI Listing
March 2021

Deep deltoid ligament injury is related to rotational instability of the ankle joint: a biomechanical study.

Knee Surg Sports Traumatol Arthrosc 2021 May 12;29(5):1577-1583. Epub 2020 Oct 12.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128, Rome, Trigoria, Italy.

Purpose: In the athletic population, the prevalence of isolated syndesmotic lesions is high. To detect potential instability of the ankle is crucial to define those lesions in need of surgical management. The aim was to define how the extent of tibio-fibular syndesmotic ligament injury influences the overall stability of the ankle joint in a cadaver model.

Methods: Twenty fresh-frozen through knee cadaveric leg specimens were subjected to different simulated syndesmotic ligament lesions. In Group 1 (n = 10), the order of ligament sectioning was: anterior tibio-fibular ligament (ATFL), superficial deltoid ligament (SDL), deep deltoid ligament (DDL), posterior tibio-fibular ligament (PTFL), and progressive sectioning at 10, 50 and 100 mm of the distal interosseous membrane (IOM). In Group 2 (n = 10), the sequence was: ATFL, PITFL, 10 and then 50 mm of the distal IOM, SDL, DDL, and 100 mm of the distal IOM. Diastasis of 4 mm in the coronal or sagittal plane and external rotation of the ankle greater than 20° were considered indicative of instability.

Results: Both coronal and sagittal diastasis exceeded 4 mm with injury patterns characterized by IOM lesions extending beyond 5 cm. External rotation of the ankle exceeded 20° with injury patterns characterized by a DDL lesion.

Conclusion: Coronal and sagittal plane diastases of the tibio-fibular syndesmosis are particularly affected by sequential lesions involving the IOM, whereas increased external rotation of the ankle most depends on DDL. The identification of the specific syndesmotic and deltoid ligament injuries is crucial to understanding which lesions need operative management. The knowledge of which pattern of tibio-fibular syndesmotic ligament injury influences the ankle joint stability is crucial in defining which lesions need for surgical management.
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http://dx.doi.org/10.1007/s00167-020-06308-7DOI Listing
May 2021

Blood loss in primary total hip arthroplasty with a short versus conventional cementless stem: a retrospective cohort study.

Arch Orthop Trauma Surg 2020 Oct 2;140(10):1551-1558. Epub 2020 Aug 2.

Humanitas Clinical and Research Center - IRCCS, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy.

Introduction: To evaluate the impact of short cementless stem on several clinical and radiographic outcomes, with particular focus on blood loss, in comparison with conventional cementless stem in total hip arthroplasty (THA).

Materials And Methods: Patients undergoing THA with GTS short stem or CLS conventional stem were included. Clinical data were retrospectively collected including preoperative and postoperative day 1 value for haemoglobin (HB); rate of postoperative blood transfusions; intraoperative bone infractions; stem alignment; 5-year follow-up Harris Hip Score (HHS) and rate of stem revision at 5 years of follow-up of the short and conventional cementless stem.

Results: GTS and CLS stem group included 374 and 321 patients, respectively. The mean difference between the preoperative and postoperative day 1 HB value was 3.98 g/dL (SD 1.12) and 3.67 g/dL (SD 1.19) in the GTS and CLS group, respectively, which correspond to a crude effect (β) of 0.32 (95% CI 0.15; 0.49) and adjusted effect of 0.11 (95% CI - 0.08; 0.3). GTS group reported a significantly higher number of patients with excellent results in terms of HHS (p = 0.001). The rate of intraoperative bone infractions was 1.6% and 0.3% in the GTS and CLS group, respectively (p = 0.013). At radiographic assessment, the rate of varus position of the stem was 14% in the GTS group and 6% in the CLS group (p < 0.0001). The rate of stem revision at 5 years of follow-up was 0.8% and 0.4% in the GTS and CLS group, respectively (p = 0.63).

Conclusions: GTS short stem was not associated with a clinically significant lower blood loss in the immediately postoperative period. Unadjusted exploratory analyses show that GTS stem provides the same results of CLS stem in terms of HHS and rate of stem revision at 5 years of follow-up.
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http://dx.doi.org/10.1007/s00402-020-03561-wDOI Listing
October 2020

Total Hip Arthroplasty With a Monoblock Conical Stem in Dysplastic Hips: A 20-Year Follow-Up Study.

J Arthroplasty 2020 11 1;35(11):3242-3248. Epub 2020 Jun 1.

Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.

Background: Total hip arthroplasty in patients with hip dysplasia is challenging as a result of complex anatomic deformities in the hip. The aim of the study was to evaluate the survivorship, the clinical and radiographic outcomes of cementless Wagner Cone stem in patients with dysplastic hip.

Methods: This retrospective study reports on 102 patients (135 hips) who have undergone total hip arthroplasty between 1993 and 1997. The mean age of patients was 51 years (range, 21-73). Minimum follow-up was 20 years. According to the Crowe classification, 38 hips presented dysplasia of grade I, 41 of grade II, 37 of grade III, and 19 of grade IV.

Results: Kaplan-Meier survivorship for aseptic loosening was 97% (95% confidence interval, 94.4-99.6) at 20 years. The average Harris hip score increased from 43.4 points (range, 22-51) to 86.4 points (range, 39-100) (P < .0001) and average Merle d'Aubignè score increased from 8.4 (range, 4-13) to 15 (range, 5-18) (P < .0001); at the last follow-up, average University of California at Los Angeles activity score and visual analog score were 4.53 (range, 1-9) and 1.25 (range, 0-6), respectively; 17% of heterotopic ossification and 19.2% of radiolucency lines around the stem were reported.

Conclusion: Monoblock Wagner Cone stem is a reliable option in dysplastic hip with an excellent survivorship and good clinical and radiographic outcome in the long term.
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http://dx.doi.org/10.1016/j.arth.2020.05.069DOI Listing
November 2020

Static and dynamic pelvic kinematics after one-stage bilateral or unilateral total hip arthroplasty.

Hip Int 2020 May 4:1120700020921120. Epub 2020 May 4.

Humanitas University, Milan, Italy.

Introduction: The pelvis rotates simultaneously around both hips along sagittal, frontal and transversal planes and its kinematics change in patients after total hip arthroplasty (THA). Consequently, it is reasonable to expect different pelvic kinematic profiles in bilateral or unilateral THA. Therefore, the aim of this study was to compare pelvic kinematics in patients with bilateral or unilateral THA.

Methods: 40 patients undergoing bilateral ( 20) or unilateral ( 20) THA were evaluated for pelvic kinematics during standing and walking tasks using an optoelectronic system. Mean pelvic orientation was assessed during standing, whereas the Gait Variable Score (GVS), maximum and minimum peaks, range and values of pelvic tilt, obliquity and rotation during Heel-Strike and Toe-Off phases of gait cycle were calculated during walking. Data were collected the day before and at seven days after surgery.

Results: At baseline, no between-group differences were found. At 7 days, GVS for pelvic tilt ( 0.029) and rotation ( 0.046) were closer to normative data in bilateral patients, who also revealed lower maximum peak of anterior tilt ( 0.013) and lower range of pelvic tilt during gait ( 0.031) with respect to unilateral cases. No between-group differences were found for pelvic orientation during standing at any time-point.

Conclusions: Bilateral patients revealed more physiological pelvic kinematics than unilateral cases. These findings underline the advantage of patients undergoing 1-stage bilateral THA and may be helpful in selecting personalised rehabilitative approaches.
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http://dx.doi.org/10.1177/1120700020921120DOI Listing
May 2020

Arthroscopic rotator cuff repair with and without subacromial decompression is safe and effective: a clinical study.

BMC Musculoskelet Disord 2020 Jan 11;21(1):24. Epub 2020 Jan 11.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Rome, Italy.

Background: Subacromial decompression, that consists of the release of the coracoid-acromial ligament, subacromial bursectomy and anterior-inferior acromioplasty, has traditionally been performed in the management of this pathology. However, the purpose of subacromial decompression procedure is not clearly explained. Our reaserch aimed to analyse the differences among the outcomes of arthroscopic rotator cuff repair (RCR) made with suture anchors, with or without the subacromial decompression procedure.

Methods: 116 shoulders of 107 patients affected by rotator cuff (RC) tear were treated with Arthroscopic RCR. In 54 subjectes, the arthroscopic RCR and the subacromial decompression procedure (group A) were executed, whereas 53 took only arthroscopic RCR (group B). Clinical outcomes were evaluated through the use of the modified UCLA shoulder rating system, Wolfgang criteria shoulder score and Oxford shoulder score (OSS). Functional outcomes were assessed utilizing active and passive range of motion (ROM) of the shoulder, and muscle strength. The duration of the follow up and the configuration of the acromion were used to realize the comparison between the two groups.

Results: In patients with 2 to 5 year follow up, UCLA score resulted greater in group A patients. In subjectes with longer than five years of follow up, group B patients showed considerably greater UCLA score and OSS if related with group A patients. In subjectes that had the type II acromion, group B patients presented a significant greater strength in external rotation.

Conclusion: The long term clinical outcomes resulted significantly higher in patients treated only with RCR respect the ones in patients underwent to RCR with subacromial decompression.
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http://dx.doi.org/10.1186/s12891-019-3032-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955088PMC
January 2020

Metallic versus biodegradable suture anchors for rotator cuff repair: a case control study.

BMC Musculoskelet Disord 2019 Oct 25;20(1):477. Epub 2019 Oct 25.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy.

Backgrounds: Repair of full-thickness rotator cuff (RC) tears is routinely performed using suture anchors, which produce secure and effective soft tissue fixation to bone. The aim of this prospective study is to compare the long-term outcomes of single row arthroscopic rotator cuff repair (RCR) performed using metal or biodegradable suture anchors. The null hypothesis is that there is no difference in shoulder function using metal or biodegradable suture anchors as evaluated by UCLA shoulder score, Wolfgang criteria, and Oxford shoulder score.

Methods: Arthroscopic RCR was performed in 110 patients included in this case control study. They were divided into 2 groups of 51 and 59 patients respectively. Metal suture anchors were used in group 1, and biodegradable suture anchors in group 2. Results were obtained at a mean follow up of 4.05 + 2 years. Clinical outcomes and functional outcomes were evaluated.

Results: The mean modified UCLA shoulder score was 26.9 + 7.1 in group 1, and 27.7 + 6.5 in group 2 (P = 0.5); the mean Wolfgang score was 13.3 + 3.3 in group 1, and 14 + 2.6 in group 2 (P = 0.3); the mean OSS was 23.7 + 11.4 in group 1, and 20.7 + 9.2 points in group 2 (P = 0.1). The mean active anterior elevation was 163.5° + 28.2° in group 1 and 163.6° + 26.9 in group 2 (P = 0.9); the mean active external rotation was 46° + 19.7° in group 1 and 44.6° + 16.3° in group 2 (P = 0.7). The mean strength in anterior elevation was 4.8.02 + 23.52 N in group 1, and 43.12 + 17.64 N in group 2 (P = 0.2); the mean strength in external rotation was 48.02 + 22.54 N in group 1 and 46.06 + 17.64 N in group 2 (P = 0.6); the mean strength in internal rotation was 67.62 + 29.4 N in group 1, and 68.6 + 25.48 N in group 2 (P = 0.9).

Conclusions: There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm.
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http://dx.doi.org/10.1186/s12891-019-2834-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815043PMC
October 2019

Functional and postural recovery after bilateral or unilateral total hip arthroplasty.

J Electromyogr Kinesiol 2019 Oct 14;48:205-211. Epub 2019 Aug 14.

Physiotherapy Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Humanitas University, Pieve Emanuele, Milan, Italy. Electronic address:

One-stage bilateral total hip arthroplasty (THA) implies similar complication rate and hospitalization time to unilateral THA, but no studies have evaluated the functional and postural recovery in these patients. The aim of this study was to assess short-term functional and postural recovery in patients after one-stage bilateral or unilateral THA. Forty patients undergoing bilateral (n = 20) or unilateral (n = 20) THA were assessed by Timed Up and Go (TUG), Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia (TSK) and Body Weight Distribution Symmetry Index (BWDSI) during stand-to-sit (STS). Centre of Pressure (CoP) parameters and BWDSI during standing with eyes open (EO) and closed (EC) were also assessed. Data were collected one day before surgery, at three and seven days. No between-group differences were found for TUG, NRS and TSK at any time-point, showing similar mobility, pain and fear of movement in both groups. BWDSI during STS (P = 0.001) and standing (OE P = 0.007; CE P = 0.012) revealed differences over time in favor of patients with bilateral THA, who showed better symmetry in weight distribution. Shorter CoP path length was observed during standing in patients with unilateral THA (OE P = 0.023; CE P = 0.018), who mainly used their non-affected limb to maintain balance.
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http://dx.doi.org/10.1016/j.jelekin.2019.08.002DOI Listing
October 2019

Conservative Rehabilitation Provides Superior Clinical Results Compared to Early Aggressive Rehabilitation for Rotator Cuff Repair: A Retrospective Comparative Study.

Medicina (Kaunas) 2019 Jul 24;55(8). Epub 2019 Jul 24.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, 00128 Rome, Italy.

To compare the long term clinical outcomes, range of motion (ROM) and strength of two different postoperative rehabilitation protocols after arthroscopic rotator cuff repair (RCR) for full-thickness rotator cuff (RC) tears. Patients undergoing RCR were divided into two groups. In 51 patients (56 shoulders), rehabilitation was performed without passive external rotation, anterior elevation ROM, and active pendulum exercises in the first 2 weeks after surgery (Group A). In 49 patients (50 shoulders) aggressive rehabilitation was implemented, with early free passive external rotation, anterior elevation ROM, and active pendulum exercises were allowed from the day after surgery (Group A). No statistically significant differences were found in clinical scores, muscle strength, passive forward flexion, passive and active internal/external rotation between the two groups. However, the mean active forward flexion was 167.3° ± 26° (range 90-180°) in group A and 156.5° ± 30.5° (range 90-180°) in group B ( = 0.04). A statistically significant difference between the 2 groups was found in active forward flexion ROM, which was better in patients of group A.
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http://dx.doi.org/10.3390/medicina55080402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723961PMC
July 2019

Gait analysis in patients after bilateral versus unilateral total hip arthroplasty.

Gait Posture 2019 07 23;72:46-50. Epub 2019 May 23.

Physiotherapy Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Humanitas University, Pieve Emanuele, Milan, Italy. Electronic address:

Background: Gait abnormalities were reported in patients after total hip arthroplasty (THA). One-stage bilateral THA was introduced for bilateral hip pathologies, showing similar clinical and surgical outcome to unilateral procedure. However, no studies analyze the gait features after bilateral THA surgery compared to unilateral THA.

Research Question: Are there differences in gait characteristics between bilateral and unilateral THA patients and are there differences between these cases and asymptomatic age-matched healthy subjects?

Methods: In this prospective observational study, thirty-five patients with bilateral (n = 18) or unilateral THA (n = 17) and twenty asymptomatic age-matched volunteers were studied. Participants underwent three-dimensional gait analysisin order to detect gait spatial-temporal and kinematic (Gait Variable Score - GVS) parameters. Mobility (Timed Up and Go - TUG), fear of movement (Tampa Scale of Kinesiophobia - TSK) and pain during walking (Numeric Rating Scale - NRS) were also assessed. Patients were evaluated the day before surgery and at seven days, whereas healthy subjects underwent a single evaluation. ANOVA was used to assess differences between the three groups at each time-point and within-group differences in bilateral and unilateral groups.

Results: At baseline, no differences between the two groups of patients were found. As expected, their gait spatial-temporal and kinematic parameters and functional variables were impaired with respect to healthy subjects, both before and after surgery. After surgery, GVS Pelvic-TILT closer to normative values, longer stance and shorter swing phases were found in bilateral cases compared to unilateral patients. Moreover, a higher NRS score was found in bilateral patients, whereas TUG and TSK revealed no differences between the two groups of patients.

Significance: The current findings, focusing on short-term effectiveness of bilateral THA, could assist physiotherapists in selecting the best ambulation training and an appropriate rehabilitation approach immediately after surgery.
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http://dx.doi.org/10.1016/j.gaitpost.2019.05.026DOI Listing
July 2019

Double-trabecular metal cup technique for the management of Paprosky type III defects without pelvic discontinuity.

Hip Int 2018 Nov;28(2_suppl):66-72

2 Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Milan, Italy.

Introduction:: Modular reconstruction systems based on trabecular metal (TM) prosthetic components have been increasingly used in the last decade for the management of severe acetabular bone defects. The aim of this study was to assess the clinical and radiographic outcomes of double-cup technique for the management of Paprosky type III defects without pelvic discontinuity.

Methods:: A retrospective review was performed for all patients undergoing acetabular reconstruction with 2 TM cups at a tertiary referral centre between 2010 and 2015. Harris Hip Scores (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at the latest follow-up. Radiographic assessment of the hip centre of rotation (COR) position and leg length discrepancy (LLD) was performed preoperatively and postoperatively. Osteolysis and radiolucencies, loosening of the implants, and heterotopic ossifications were evaluated with the latest follow-up radiographs.

Results:: Patients included 5 men and 11 women (16 hips) with an average age of 68 (45-81) years. Acetabular bone defects included 9 Paprosky type IIIB and 7 type IIIA defects. No pelvic discontinuities were registered. The mean follow-up was 34 (24-72) months. HHS and WOMAC scores, LLD and COR position significantly improved after surgery. In only 1 (6.3%) hip a not progressive radiolucent line adjacent the acetabular construct was noted. Heterotopic ossifications were found in 2 (12.5%) hips. No patients underwent acetabular components revision surgery for any reason.

Conclusion:: The double-cup technique could be considered an effective management of selected Paprosky type III defects without pelvic discontinuity providing excellent clinical and radiographic outcomes in the short term.
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http://dx.doi.org/10.1177/1120700018813208DOI Listing
November 2018

Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?

Arthroscopy 2019 02 3;35(2):361-366. Epub 2019 Jan 3.

Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Orthopaedic and Trauma Surgery, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.

Purpose: To assess the validity of the Instability Severity Index Score in predicting the rate of recurrence of dislocation in patients undergoing arthroscopic Bankart repair.

Methods: The inclusion criteria were recurrent anterior traumatic glenohumeral instability and a minimum follow-up of 5 years. According to the preoperative Instability Severity Index Score, patients were divided into the following groups: ≤3 points (A), 4 to 6 points (B), and >6 points (C). The recurrence rate was determined by telephone interviews. The estimated overall rate of success at 5 years was defined as the estimated overall percentage of patients free of recurrence at 5 years.

Results: Six hundred seventy patients (572 men and 98 women) were included. The average age was 27 years (range, 18 to 39 years) at the time of surgery. One hundred fourteen of 670 patients had a recurrence of instability, with an overall recurrence rate of 17% (95% confidence interval [CI] 14.2%-19.9%). The Instability Severity Index Score had a significant association with recurrence. Compared with patients in group A, those in group B had double the risk of recurrence (hazard ratio [HR] = 2.43, 95% CI 1.38-4.28, P = .002), and patients in group C a 9 times greater risk of recurrence (HR = 9.42, 95% CI 5.20-17.7, P < .001). The estimated overall rate of success at 5 years was 84.8% (95% CI 81.8-87.3). The rate of success with an Instability Severity Index Score ≤3 points was 93.7% (95% CI 89.6-96.2), but it dropped to 85.7% (95% CI 81.7-88.9) in those with an Instability Severity Index Score of 4 to 6 points and became 54.6% (95% CI 42.8-64.9) in those with an Instability Severity Index Score >6 points. On multivariable analysis, the Instability Severity Index Score was found to significantly affect the risk of recurrence, corrected by type of sport and glenoid bone loss.

Conclusions: The Instability Severity Index Score is a validated tool with which to assess the recurrence rate of dislocation after arthroscopic surgery in patients with shoulder instability. Arthroscopic stabilization in patients with an Instability Severity Index Score ≤3 is associated with a significantly lower risk of recurrence of glenohumeral instability compared with that in patients with an Instability Severity Index Score >3 points.

Level Of Evidence: III, case-control study.
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http://dx.doi.org/10.1016/j.arthro.2018.09.027DOI Listing
February 2019

Total hip arthroplasty with a monoblock conical stem and subtrochanteric transverse shortening osteotomy in Crowe type IV dysplastic hips.

Int Orthop 2019 01 5;43(1):77-83. Epub 2018 Sep 5.

Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Center, Via Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.

Purpose: This series assessed the clinical and radiographic outcomes of total hip arthroplasty (THA) with femoral shortening osteotomy for the management of patients with Crowe type IV hip dysplasia.

Methods: Only patients with Crowe type IV hip dysplasia who underwent primary THA combined with a subtrochanteric transverse osteotomy with an uncemented monoblock conical stem were included. The clinical and radiographic evaluations were performed before and immediately after surgery, and at last follow-up. The hip function was assessed with the Harris Hip Score (HHS).

Results: Seventy-four patients (102 hips) with a mean age of 53.9 (range, 20-83) were evaluated at an average follow-up of 11.3 years (range, 5-25). Stem revision occurred in two (1.9%) cases, with a survivorship of 95.9% (95%IC, 91.9-99.9%) at ten years. The average HHS increased from 44 (range, 15-78) pre-operatively to 90.3 (range, 62-100) at last follow-up (p < 0.001). Osteotomy site non-union and early dislocation were observed in 3.9 and 3.8%, respectively. No cases of nerve palsy were reported.

Conclusions: THA with a monoblock conical stem associated with subtrochanteric transverse osteotomy provides good long-term survival, clinical and radiographic results. It may be considered an effective management of patients with Crowe IV hip dysplasia.
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http://dx.doi.org/10.1007/s00264-018-4122-5DOI Listing
January 2019

Surgical management of chordoma: A systematic review.

J Spinal Cord Med 2020 11 26;43(6):797-812. Epub 2018 Jul 26.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.

Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management. The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies. We performed a systematic search using the keywords "chordoma" in combination with "surgery", "spine", "sacrum" and "radiotherapy". Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas. Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival. Systematic review; level III.
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http://dx.doi.org/10.1080/10790268.2018.1483593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808319PMC
November 2020

Uncemented short stems in primary total hip arthroplasty: The state of the art.

EFORT Open Rev 2018 May 9;3(5):149-159. Epub 2018 May 9.

Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Center, Italy.

Over the last two decades, several conservative femoral prostheses have been designed. The goals of conservative stems include: the spearing of the trochanteric bone stock; a more physiological loading in the proximal femur reducing the risk of stress shielding; and to avoid a long stem into the diaphysis preventing impingement with the femoral cortex and thigh pain.All stems designed to be less invasive than conventional uncemented stems are commonly named 'short stems'. However, this term is misleading because it refers to a heterogeneous group of stems deeply different in terms of design, biomechanics and bearing. In the short-term follow-up, all conservative stems provided excellent survivorship. However, variable rates of complications were reported, including stem malalignment, incorrect stem sizing and intra-operative fracture.Radiostereometric analysis (RSA) studies demonstrated that some conservative stems were affected by an early slight migration and rotation within the first months after surgery, followed by a secondary stable fixation. Dual-energy x-ray absorptiometry (DEXA) studies demonstrated an implant-specific pattern of bone remodelling.Although the vast majority of stems demonstrated a good osseointegration, some prostheses transferred loads particularly to the lateral and distal-medial regions, favouring proximal stress shielding and bone atrophy in the great trochanter and calcar regions. Cite this article: 2018;3:149-159. DOI: 10.1302/2058-5241.3.170052.
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http://dx.doi.org/10.1302/2058-5241.3.170052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994625PMC
May 2018

The Royal London Hospital Test for the clinical diagnosis of patellar tendinopathy.

Muscles Ligaments Tendons J 2017 Apr-Jun;7(2):315-322. Epub 2017 Sep 18.

Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospita, London, England.

Purpose: To ascertain whether the Royal London Hospital test is reproducible, sensitive, and specific for diagnosis of patellar tendinopathy.

Methods: Fifteen consecutive athletes with patellar tendinopathy were prospectively enrolled and compared with a control group of 15 non consecutive athletes with Achilles tendinopathy. Two testers examined separately each patient, using manual palpation and the Royal London Hospital test for diagnosis of patellar tendinopathy. High resolution real time ultrasonography was used as standard for diagnosis of tendinopathy and assessment of tendon thickness.

Results: The palpation test presented significantly higher sensitivity compared to the Royal London Hospital test (98 88%; P=0.01); specificity was 94% for the palpation test and 98% for the Royal London Hospital test (P>0.05). Positive and negative predictive values were 94 and 98% for palpation test, 98 and 89% for the Royal London Hospital test, respectively. The two tests showed good to very good intra-tester and inter-tester agreement. At ultrasonography, pathological patellar tendons were significantly thicker compared to controlateral healthy tendon (P<0.001).

Conclusions: In symptomatic patients with patellar tendinopathy, the Royal London Hospital test showed lower sensitivity and higher specificity than manual palpation. Both tests should be performed for a correct clinical diagnosis of patellar tendinopathy. Imaging assessment should be performed as a confirmatory test.

Level Of Evidence: III.
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http://dx.doi.org/10.11138/mltj/2017.7.2.315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725181PMC
September 2017

Is endoprosthesis safer than internal fixation for metastatic disease of the proximal femur? A systematic review.

Injury 2017 Oct;48 Suppl 3:S48-S54

Department of Orthopaedics and Trauma Surgery, Campus Bio-medico University of Rome, Via Alvaro del Portillo 200, 00128 Rome, Italy.

Introduction: Metastases to the proximal femur are usually managed surgically by tumor resection and reconstruction with an endoprosthesis, or by fixation with osteosynthesis. Still controversy remains regarding the most appropriate surgical treatment. We posed the following questions: (1) Is the frequency of surgical revision greater in patients treated with internal fixation than endoprosthetic reconstruction, and (2) Do complications that do not require surgery occur more frequently in patients treated with internal fixation rather than in those with endoprosthetic reconstruction?

Materials And Methods: A systematic review was performed of those studies reporting on surgical revision and complication rates comparing the two surgical methods. Ten studies including 1107 patients met the inclusion criteria, three with high methodological quality, three intermediate, and four with lowquality, according to the STROBE guidelines.

Results: At present, prosthetic dislocation is the most common complication observed in patients managed by prosthesis replacement of the proximal femur, while loosening was the main cause of reoperation in the fixation group. Time to reintervention ranged from 3 to 11.6 months for the prosthetic replacement and from 7.8 to 22.3 months for the fixation group. Non surgical complications, (mainly dislocations and infections) were more commonly observed in patients operated on by prosthetic replacement.

Conclusions: Implant related complications and surgery-related morbidity should be taken into account in the decision-making process for the surgical management of these patients. These data can improve the surgeon-patient communication and guide further studies on patients' survival and complications with respect to surgery.
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http://dx.doi.org/10.1016/S0020-1383(17)30658-7DOI Listing
October 2017

Femur first surgical technique: a smart non-computer-based procedure to achieve the combined anteversion in primary total hip arthroplasty.

BMC Musculoskelet Disord 2017 Aug 1;18(1):331. Epub 2017 Aug 1.

Hip Diseases and Joint Replacement Surgery Unit, Humanitas Clinical and Research Centre, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy.

Background: The relevance of prosthetic component orientation to prevent dislocation and impingement following total hip arthroplasty (THA) has been widely accepted. We investigated the use of a non-computer-based surgery to address the reciprocal orientation of the acetabular and femoral components.

Methods: In the femur first technique, the cup is positioned relative to the stem. When the definitive antetorsion of femoral component is fixed, the cup is positioned in a compliant anteversion to the stem. Clinical and radiographic assessments were performed before and 3 months after THA. Radiographic assessment was performed in standing position with the EOS 2D/3D radiography system. 3D images were used to preoperative anterior pelvic plane (APP) angle, postoperative acetabular inclination (AI) and anteversion (AA), and postoperative stem antetorsion. Clinical assessment was performed with Harris Hip Score (HHS).

Results: Forty patients (40 hips) underwent primary THA with an average age of 61 years (range, 36-84). Average HHS increased from 43 ± 5 (range, 37-52) preoperatively to 97 ± 6 (range, 86-100) at the last follow-up (P < 0.0001). Average combined anteversion value of cup with liner and stem was 38° ± 9° (range, 12°-55°). Average AI value of cup with liner was 39° ± 6° (range, 30°-55°) in the group with standard stem and 45° ± 7° (range, 39°-58°) in the group with varized stem (P = 0.007). Relationship analysis showed no correlation between the combined anteversion values of the cup with liner and stem with APP angle values (r = 0.26, P = 0.87).

Conclusions: Femur first technique allows the surgeon to achieve a combined anteversion ranging from 25° to 50° with a cup inclination ranging from 30° to 50°. The cup is positioned according to the functional plane of the patient regardless the preoperative pelvic tilt.
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http://dx.doi.org/10.1186/s12891-017-1688-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539744PMC
August 2017

Safety of dorsal wrist arthroscopy portals: A magnetic resonance study.

Surgeon 2018 Apr 14;16(2):101-106. Epub 2016 Nov 14.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Rome, Italy.

In wrist arthroscopy, the standard dorsal portals are the most commonly used. However, their placement can be associated with injuries to the neurovascular structures of the radiocarpal joint. The present study assessed and compared the distance of commonly used dorsal portals to radial and ulnar neurovascular structures. Forty patients (20 males, 20 females) were evaluated with T1-weighted spin-echo (SE) magnetic resonance (MR) sequences. We measured the distance between 1-2 and 3-4 portals and radial vascular bundle and the nearest branch of the superficial branch of radial nerve (SBRN). We also measured the distance between 4 and 5, 6/U and 6/R and ulnar vascular bundle and the nearest branch of the dorsal ulnar nerve (DUN). The median age of patients was 39 years (95% IC 36.97-43.32 years). The 3-4 portal was farther away from the vascular structure than the 1-2 portal (P < 0.0001), 4-5 portal (P = 0.008), 6/R (P < 0.0001), and 6/U portals (P < 0.0001). Moreover, the 3-4 portal was farther away from the nerve branch than the 1-2 portal (P < 0.0001), 4-5 portal (P < 0.0001), 6/R (P < 0.0001), and 6/U portals (P < 0.0001). No statistical significant differences were found between the two genders. The 3-4 and 4-5 portals are the farthest away from the neurovascular structures, and likely reduce the risk to damage these structures. On the other hand, the 1-2 and 6/U portals likely increase the risk of neurovascular damage, because of their proximity to neurovascular structures.

Level Of Evidence: Diagnostic study; Level III.
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http://dx.doi.org/10.1016/j.surge.2016.09.008DOI Listing
April 2018

Analysis of the Pelvic Functional Orientation in the Sagittal Plane: A Radiographic Study With EOS 2D/3D Technology.

J Arthroplasty 2017 03 28;32(3):1027-1032. Epub 2016 Sep 28.

Department of Orthopaedics and Trauma Surgery, Hip Diseases and Joint Replacement Surgery Unit, Humanitas Research Hospital, Rozzano, Milan, Italy.

Background: We investigated the relationship between pelvic incidence (PI) with anterior pelvic plane angle (APPA), pelvic tilt (PT) angle, and sacral slope (SS) in standing and sitting positions to identify the best parameter expressing the pelvic functional orientation in the sagittal plane.

Methods: We enrolled 109 consecutive patients (M:F = 43:66) eligible for a primary total hip arthroplasty (THA) with an average age of 63.4 years (15-85). EOS 2D/3D radiography was performed in standing and sitting positions before THA to evaluate the functional pelvic orientation. 3D images took into account the patient-specific sagittal balance measuring APPA, PT, SS, and PI.

Results: In standing position, functional parameters measured 5° ± 7.1 for APPA, 11° ± 8.3 for PT, 43° ± 8.5 for SS, and 53° ± 10.9 for PI. In sitting position, they were -18° ± 10.4 for APPA, 34° ± 11.8 for PT, 20° ± 12.6 for SS, and 54° ± 10.9 for PI. There was no significant difference between men and women in terms of the functional parameters in both positions. No relationship was found between APPA and PI in both positions. SS correlated with PI in standing (r = 0.66; P < .0001; R = 0.44) and sitting (r = 0.51; P < .0001; R = 0.26). PT correlated with PI in standing (r = 0.65; P < .0001; R = 0.42) and sitting (r = 0.38; P < .0001; R = 0.14).

Conclusion: SS shows the highest correlation with functional pelvic tilt. The study suggests that adjustments in acetabular anteversion during primary THA should be based on SS.
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http://dx.doi.org/10.1016/j.arth.2016.09.015DOI Listing
March 2017

Stem cells sources for intervertebral disc regeneration.

World J Stem Cells 2016 May;8(5):185-201

Gianluca Vadalà, Fabrizio Russo, Luca Ambrosio, Mattia Loppini, Vincenzo Denaro, Department of Orthopedic and Trauma Surgery, University Campus Bio-Medico of Rome, 00128 Rome, Italy.

Intervertebral disc regeneration field is rapidly growing since disc disorders represent a major health problem in industrialized countries with very few possible treatments. Indeed, current available therapies are symptomatic, and surgical procedures consist in disc removal and spinal fusion, which is not immune to regardable concerns about possible comorbidities, cost-effectiveness, secondary risks and long-lasting outcomes. This review paper aims to share recent advances in stem cell therapy for the treatment of intervertebral disc degeneration. In literature the potential use of different adult stem cells for intervertebral disc regeneration has already been reported. Bone marrow mesenchymal stromal/stem cells, adipose tissue derived stem cells, synovial stem cells, muscle-derived stem cells, olfactory neural stem cells, induced pluripotent stem cells, hematopoietic stem cells, disc stem cells, and embryonic stem cells have been studied for this purpose either in vitro or in vivo. Moreover, several engineered carriers (e.g., hydrogels), characterized by full biocompatibility and prompt biodegradation, have been designed and combined with different stem cell types in order to optimize the local and controlled delivery of cellular substrates in situ. The paper overviews the literature discussing the current status of our knowledge of the different stem cells types used as a cell-based therapy for disc regeneration.
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http://dx.doi.org/10.4252/wjsc.v8.i5.185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877563PMC
May 2016

Single minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg.

J Orthop Surg Res 2016 May 24;11(1):61. Epub 2016 May 24.

Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.

Background: Chronic exertional compartment syndrome (CECS) involves a painful increase in compartment pressure caused by exercise and relieved by rest, common in athletes. The most common site for CECS in the lower limbs is the anterior leg compartment. The aim of this study is to evaluate the outcomes of a single minimal incision fasciotomy in athletes and their capability to return to high level sport activity.

Methods: The study reports mid-term results in a series of 18 consecutive athletes with chronic exertional compartment syndrome of the leg who had undergone minimally invasive fasciotomy. Between 2000 and 2007, we prospectively enrolled 18 consecutive athletes (12 males and six females, median age 27 years) with unilateral or bilateral chronic exertional compartment syndrome undergoing unilateral or bilateral minimally invasive fasciotomy. Clinical outcomes were assessed with Short-Form Health Survey-36 (SF-36) and European Quality of Life-5 Dimension (EQ-5D) scale. The ability to participate in sport before and after surgery and the time to return to training (RTT) and to sport (RTS) were recorded.

Results: The median follow-up after surgery was 36 months. Both questionnaires showed a statistically significant improvement (P < 0.0001) after surgery. At the time of the latest follow-up, 17 of 18 patients (94 %) had returned to pre-injury or higher levels of sport. Only one patient (6 %) returned to sport at lower levels than those of pre-injury status. The median time to return to training and to return to sport was 8 and 13 weeks, respectively. No severe complications or recurrence of the symptoms were recorded.

Conclusions: Minimally invasive fasciotomy is effective and safe for athletes suffering from unilateral or bilateral chronic exertional compartment syndrome of the anterior and lateral compartments of the leg with good results in the mid-term.
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http://dx.doi.org/10.1186/s13018-016-0395-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878063PMC
May 2016

Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and Other Distal Realignment Procedures for the Management of Patellar Dislocation: Systematic Review and Quantitative Synthesis of the Literature.

Arthroscopy 2016 05 23;32(5):929-43. Epub 2016 Feb 23.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Trigoria, Rome, Italy.

Purpose: To evaluate clinical outcomes, rate of recurrence, and complications following distal realignment procedures (Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures) performed alone or in combination with proximal procedures for the management of patellar dislocation.

Methods: A systematic literature review was performed following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A search in PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Google Scholar databases using various combinations of the keywords "patellar," "dislocation," "tibial transfer," "Elmslie-Trillat," "Roux Goldthwait," "tibial tubercle osteotomy," "Fulkerson," "Maquet," "procedure," "clinical," and "outcome."

Results: Thirty-eight articles were included in the systematic review. A total of 1,182 knees belonging to 1,023 patients were grouped according to the duration of the follow-up period. The overall rate of recurrence was 7% (83 of 1,182 knees). Approximately 5.3% (28 of 520 knees) of the redislocation occurred in the short-medium term, and 8.3% (55 of 662 knees) occurred in the long-term.

Conclusions: Distal realignment procedures performed alone or in combination with proximal procedures for the management of patellar dislocation have shown good clinical outcomes and a low rate of recurrence highlighting the efficacy of these procedures. To date no randomized controlled clinical trials are available on the topic.

Level Of Evidence: Level IV, systematic review of Level III and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2015.10.019DOI Listing
May 2016

Surgical Versus Nonoperative Treatment in Patients Up to 18 Years Old With Traumatic Shoulder Instability: A Systematic Review and Quantitative Synthesis of the Literature.

Arthroscopy 2016 05 23;32(5):944-52. Epub 2016 Feb 23.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, Rome, Italy.

Purpose: To compare the outcome of surgical and nonoperative treatment in patients aged 18 years or younger with traumatic shoulder instability.

Methods: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. A complete search of PubMed, Medline, Cochrane, CINAHL, Embase, and Google Scholar databases was performed using various combinations of the keywords "shoulder," "instability," "glenohumeral instability," "pediatric," "adolescent," "skeletally immature," "young," "open physis," "children," "management," "treatment," "surgical," "stabilization," and "recurrence." There was no time restriction.

Results: Fifteen articles met our inclusion criteria, including a total of 693 patients with 705 shoulders aged 18 years or younger. Of 411 shoulders, 293 (71.3%) treated with a nonoperative approach experienced a redislocation compared with 55 of 314 shoulders (17.5%) that received surgical treatment. The results of the quantitative synthesis showed that the recurrence rate was significantly lower in the surgical group compared with the nonoperative group.

Conclusions: The recurrence rate is lower in patients undergoing surgical treatment. Further studies are necessary to clarify several points in the treatment of skeletally immature patients with traumatic shoulder instability.

Level Of Evidence: Level III, systematic review of Level II and III studies and 1 case series.
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http://dx.doi.org/10.1016/j.arthro.2015.10.020DOI Listing
May 2016

Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

Knee Surg Sports Traumatol Arthrosc 2016 Apr 4;24(4):1217-27. Epub 2016 Feb 4.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.

Purpose: Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries.

Methods: A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015.

Results: The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries.

Conclusions: The ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-016-4017-1DOI Listing
April 2016

Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines.

Knee Surg Sports Traumatol Arthrosc 2016 Apr 24;24(4):1200-16. Epub 2015 Dec 24.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.

Purpose: The aim of the present study was to perform a systematic review of the current classification systems, and the clinical and radiological tests for the acute isolated syndesmotic injuries to identify the best method of classification and diagnosis allowing the surgeon to choose the appropriate management.

Methods: A systematic review of the literature according to the PRISMA guidelines has been performed. A comprehensive search using various combinations of the keywords "classification", "grading system", "ankle injury", "ligament", "syndesmotic injury", "internal fixation", "acute", "synostosis", "ligamentoplasties", "clinical", "radiological" over the years 1962-2015 was performed. The following databases were searched: MEDLINE, Google Scholar, EMBASE and Ovid.

Results: The literature search resulted in 345 references for classification systems and 308 references for diagnosis methods, of which 283 and 295 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included 27 articles describing classification systems and 13 articles describing diagnostic tests for acute isolated syndesmotic injuries.

Conclusions: The ESSKA-AFAS consensus panel recommends distinguishing acute isolated syndesmotic injury as stable or unstable. Stable injuries should be treated non-operatively with a short-leg cast or brace, while unstable injuries should be managed operatively. The recommended clinical tests include: tenderness on palpation over the anterior tibiofibular ligament, the fibular translation test and the Cotton test. Radiographic imaging must include an AP view and a mortise view of the syndesmosis to check the tibiofibular clear space, medial clear space overlap, tibial width and fibular width.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-015-3942-8DOI Listing
April 2016

Multidirectional Instability of the Shoulder: A Systematic Review.

Arthroscopy 2015 Dec 21;31(12):2431-43. Epub 2015 Jul 21.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy.

Purpose: To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI).

Methods: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed.

Results: Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy.

Conclusions: Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift.

Level Of Evidence: Level IV, systematic review of Level I to IV studies.
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http://dx.doi.org/10.1016/j.arthro.2015.06.006DOI Listing
December 2015

Management of cervical fractures in ankylosing spondylitis: anterior, posterior or combined approach?

Br Med Bull 2015 Sep 22;115(1):57-66. Epub 2015 Mar 22.

Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy.

Introduction: Ankylosing spondylitis (AS) can lead to an increased risk of cervical fractures.

Sources Of Data: A systematic review was undertaken using the keywords 'ankylosing spondylitis', 'spine fractures', 'cervical fractures', 'surgery' and 'postoperative outcomes' on Medline, Pubmed, Google Scholar, Ovid and Embase, and the quality of the studies included was evaluated according to the Coleman Methodology Score.

Areas Of Agreement: Surgery ameliorates neurological function in patients with unstable AS-related cervical fractures. The combined anterior/posterior and the posterior approaches are more effective than the anterior approach.

Areas Of Controversy: The optimal approach, anterior, posterior or combined anterior/posterior, for the management of AS related cervical fractures has not been defined.

Growing Points: Open reduction and internal fixation allows avoiding worsening and enhances neurological function in AS patients with cervical fractures.

Areas Timely For Developing Research: Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.
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http://dx.doi.org/10.1093/bmb/ldv010DOI Listing
September 2015