BACKGROUND: QUESTIONS/PURPOSES: METHODS: RESULTS: CONCLUSIONS: LEVEL OF EVIDENCE:Level II, systematic review.
Subcoracoid impingement (SCI) is one of the possible causes in anterior shoulder pain that can be misdiagnosed or missed. It results from a conflict between the coracoid process and the lesser tuberosity of the humeral head. The collision mainly affects the subscapularis tendon that is at risk of degeneration and tearing. The symptoms arise by positioning the shoulder in flexion, adduction and internal rotation, dynamically decreasing the coracohumeral distance, the most important diagnostic parameter in the SCI. The impingement has been associated with shoulder overuse that may occur in specific sport activities, such as freestyle swimming and overhead throwing. Ultrasound scan, MRI and arthroscopy may help in the identification of pathology. Although not suitable for soft tissue imaging, X-ray may be helpful in detecting bony factors contributing to SCI. The first and main line of treatment is usually conservative, but when it fails, bursectomy followed by mild coracoplasty is a safe and effective method. Patients may also need a repair of the subscapularis tears.
Congenital scoliosis and congenital vertebral malformations arise from heterogeneous disruptions of vertebral segmentation and formation, leading to a highly variable clinical morphology and associated anomalies. Over the past decade (2015-2025), human genetics and developmental biology have clarified core etiologic pathways, particularly somitogenesis/segmentation clock-wavefront signaling and TBX6-associated congenital scoliosis, while supporting multi-factorial contributions in many apparently sporadic cases. This review integrates morphology with spatiotemporal embryologic windows, linking axial patterning (e.g. RA-HOX context), epigenetic regulation, segmentation clock signaling (Notch/WNT/FGF), and downstream tissue-scale effectors to vertebral segmentation defects and three-dimensional curve phenotypes. We propose an evidence-grading scheme (levels A-D) to differentiate well-supported mechanisms and clinically actionable genetic findings from emerging hypotheses and preclinical signals. The synthesis highlights practical implications for molecular diagnosis and variant interpretation, phenotype-informed test selection, and counseling, while outlining priority directions for resolving non-coding/structural variation, gene-environment interactions, and mechanistic validation.
Deltoid ligament (DL) injuries are common in ankle trauma, yet their optimal management remains debated. Most trauma literature considers DL injury as an isolated ankle problem, whereas foot-and-ankle specialists view the ankle and the foot as a complex. This disconnect leaves a critical knowledge gap that our work aims to address. As we know, every post-traumatic collapsing foot deformity involves a DL injury, but not every DL necessarily progresses to such a deformity. We introduce the concept of the DL as a tri-articular stabilizer within the medial ankle ligament complex, contributing to the stability of the tibio-talar, subtalar (ST), and talo-navicular (TN) joints. Neglecting this broader stabilizing role may lead to irreversible foot sequelae, such as post-traumatic plano-valgus or plano-abductus deformities. Therefore, DL injuries should be systematically recognized in both acute and chronic settings, whether treated conservatively or surgically. In this expert opinion, we synthesize current anatomical, biomechanical, and clinical evidence together with our experience to outline key diagnostic principles and therapeutic considerations for the management of DL injuries.
Spinal tumors encompass a heterogeneous group of primary and metastatic lesions requiring individualized management strategies based on tumor biology, patient prognosis, and mechanical stability. Decision-making frameworks, such as NOMS, SINS, and Tokuhashi score, provide structured guidance for selecting metastatic patients for surgery and defining individualized treatment strategies. En bloc resection remains the gold standard for selected primary malignant tumors, whereas separation surgery combined with stereotactic radiosurgery represents the cornerstone of modern metastatic spine disease management. Minimally invasive techniques represent a paradigm shift toward less invasive, patient-tailored surgical strategies in spine oncology, complementing rather than replacing traditional open approaches. Future developments in robotics, ablation technologies, and biomaterials are expected to further refine surgical precision and expand treatment indications.
PurposeTo synthesise and critically appraise the existing literature and to report on the recurrence rates following all types of arthroscopic treatment of chronic ankle instability (CAI). Furthermore, this systematic review aims to provide an evidence-based overview of the risk factors for the recurrence of CAI. MethodsThe authors conducted a structured electronic literature search limited to articles published between 2004 and 2024 following the PRISMA guidelines. Studies were included if they i) reported on recurrence of instability or sprain following surgical treatment for CAI and ii) investigated factors associated with recurrence of instability or sprain following surgical treatment for CAI. ResultsA total of 15 studies were included in this review. Pooling of the data revealed that post-operative talar tilt had a significant association with the recurrence of CAI. Included studies further identified generalised joint laxity, state of ATFL remnant, hypersignal on MRI, varus tilted distal tibial plafond, hindfoot varus alignment, tibio-talar sector, pre- and post-operative talar tilt angles, pre-operative anterior displacement, pre-operative tibiocalcaneal angle, tibiofibular syndesmosis, and sports as risk factors. ConclusionThis review identified post-operative talar tilt angle as a risk factor for the recurrence of CAI following arthroscopic surgery. These findings suggest that the choice of arthroscopic technique and adjuvant procedures should take into consideration patient characteristics to limit the recurrence of CAI following surgery. Level of evidenceMeta-analysis, Level IV
PurposeTo investigate whether biologic adjuvants improve outcomes such as union rate and time to union of isolated subtalar arthrodesis. MethodsThe authors conducted a structured electronic literature search on December 29, 2025, using MEDLINE, EMBASE, and Cochrane. This review included prospective and retrospective comparative clinical studies comparing union rates following primary isolated subtalar arthrodesis, using biological adjuvants, which had a follow-up ≥ 6 months. ResultsThe systematic search returned 929 records, of which 119 were duplicates, leaving 810 for screening. A total of 781 studies were excluded by examining their titles and/or abstracts, and a further 17 studies were excluded after a full-text review. This left 12 eligible studies. The pooled union rate using allografts was 92% (CI: 0.86–0.96), using autografts 97% (CI: 0.94–0.99), using synthetic/artificial grafts 96% (CI: 0.80–1.00), and without using any graft 96% (CI: 0.91–0.99), but the differences were not statistically significant. There was no statistically significant difference in time to union between allografts (13.7; CI: 12.8–14.6), autografts (14.0; CI: 13.3–14.6), synthetic/artificial grafts (12.7; CI: 12.0–13.4), and no grafts (13.7; CI: 11.8–15.7). ConclusionNo statistically significant differences in union rates, time to union, and postoperative AOFAS of subtalar arthrodesis were found between autografts, allografts, synthetic/artificial grafts, and no grafts. For union rate, there was a tendency of lower fusion rates following allografts compared with the other types. The clinical relevance of these findings is that, as there was no difference in union rates, surgeons should take into account the donor-site morbidity and cost when considering the different graft types.
This review compares the outcomes of total ankle replacement (TAR) and ankle fusion (AF) in patients with end-stage ankle osteoarthritis (OA) based on recent comparative studies (1 January 2023 to 31 December 2025). Racial/ethnic, socioeconomic, and payer status disparities have been reported in the likelihood of experiencing TAR versus AF for ankle OA. A prospective multicentre study with level II evidence found that the long-term clinical results of TAR and AF were similar. A meta-analysis identified TAR as the superior intervention, demonstrating significant advantages in patient-reported outcome measures. Three systematic reviews have reached the following conclusions: i) postoperative outcomes are similar in TAR and AF; ii) TAR and AF have similar complication rates (both minor and major); iii) both TAR and AF are safe and effective surgical treatments for ankle OA; besides, TAR had notable lower total complications, implant removals, adjacent level fusion surgeries, and non-union/open reduction and internal fixation surgeries after the index procedure. The existence of mixed evidence found in the literature makes it necessary to select the surgical technique to be used (TAR or AF) on an individual basis. To definitively determine which procedure is more appropriate in advanced ankle OA, more and better-designed studies are required, given that the results reported thus far do not permit to determine with absolute certainty which of the two procedures, TAR or AF, is more adequate.
PurposeTo evaluate how the timing of surgery impacts mortality and postoperative complications in hip fracture patients. MethodsWe searched PubMed, EMBASE, and Web of Science databases from May 2017 to April 12, 2024, to identify relevant clinical trials. Data extraction was performed independently by two authors. Summary effect size measures were calculated using a random-effects model with robust variance estimation. ResultsOur analysis included 14 clinical studies involving 3,395,673 patients. For cohort studies, patients who underwent surgery after 12 h demonstrated similar risks of 1-year and 30-day mortality and postoperative complications, such as pneumonia and atrial fibrillation/flutter, compared with those operated on within 12 h. Conversely, surgery performed after 24 h was linked to significantly higher risks of in-hospital mortality, 3-month mortality, cardiovascular complications, delirium, stroke, infections, and atrial fibrillation/flutter compared with surgeries within 24 h. Patients who had surgery after 48 h experienced significantly higher 30-day and in-hospital mortality rates, pulmonary embolism, pneumonia, cardiovascular complications, deep venous thrombosis, delirium, and stroke compared with those operated on within 48 h. For RCTs, surgical delay beyond 24 h significantly increased the risks of delirium and stroke. ConclusionThis meta-analysis suggested that hip surgery within 48 h is generally associated with lower risks of mortality and major postoperative complications. This time window should be interpreted as a pragmatic clinical benchmark rather than a strict biological threshold.
This review presents how surgeons should choose femoral interference screw in anterior cruciate ligament (ACL) reconstruction – insertion direction (inside-out vs outside-in), tunnel shape (round vs rectangular), screw position (anterior vs posterior), and screw material (metal, bioabsorbable, PEEK, magnesium) – to balance fixation strength, anatomic fidelity, and revision feasibility. Inside-out maximizes aperture compression and preserves the lateral femoral cortex but requires deep flexion and precise trajectory (risk of iatrogenic cartilage contact/posterior wall breach). Outside-in improves visualization and guide control yet needs a large lateral cortical socket and can push the bone plug intra-articularly as the screw advances from cortex to joint. Rectangular tunnels better match the native footprint, improving rotational control and interface congruity, while round tunnels simplify preparation but allow plug rotation and may use bone less efficiently at the aperture. Posterior screw placement (particularly with the inside-out technique) enhances cancellous-to-cancellous compression but risks posterior cortical breach injury; anterior placement protects fibers and favors footprint fidelity but may reduce cancellous compression. Metal offers high stiffness and no tapping but creates MRI artifact and requires removal if present at revision. Bioabsorbable materials avoid artifact/removal yet are weaker and may fracture in sclerotic tunnels. PEEK (metal-like without artifact) and magnesium (osteoconductive/resorbable) are promising but lack long-term data. No single method is universally optimal. Decisions should be individualized to visualization needs, cortical/bone-stock preservation, expected revision strategy, and patient factors (age, activity, bone quality).
The purpose of this article is to introduce the angiosome concept in the lower legs and its consideration in severe soft tissue injuries in open tibial fractures. The main aim is to focus on the vascularity and perforators in the crura and to emphasise step-by-step time management and proper debridement for securing the maximal viability of the soft tissue before the reconstruction phase. So far, many publications have presented optimal traumatological protocols and timing in lower leg injuries and many reviews have compared fracture stabilisation and flap reconstruction options; however, no consensus exists. Radical and immediate debridement is crucial for minimising infection complications, revision surgeries and total healthcare costs, early definitive reconstruction, limb salvage success, decreased hospitalisation stay and better long-term quality-of-life outcome for the patients. The fundamental orthoplastic approach has been an indisputably accepted strategy since its introduction in the 1990s by Levin. Unfortunately, not all centres are staffed with a plastic surgeon 24/7. Furthermore, transportation to the tertiary specialist centre is often delayed; hence, we believe that a correct primary soft tissue and antibiotics administration protocol can be provided in all medical centres by orthopaedists. So, the basic knowledge of the principles of lower leg vascularity is, therefore, essential. In the difficult cases of the Anderson–Gustilo IIIC fractures, we provide some of the latest recommendations for soft tissue viability verification and blood perfusion improvement, when considering limb salvage versus amputation. This narrative review was developed in accordance with PRISMA 2020 recommendations for transparency in study selection and reporting.
Background:Distal biceps brachii tendon avulsions are a significant clinical issue, particularly in physically active, middle-aged men. The choice of postoperative rehabilitation strategy, specifically early mobilization versus immobilization, and the effectiveness of different immobilization tools, remains unclear. Purpose:This study aims to clarify these aspects by analysing the impact of rehabilitation protocols on clinical outcomes following tendon reinsertion. Methods:A detailed systematic literature search was conducted in January 2025 using multiple databases, including PubMed, Web of Science, and grey literature sources. The selection process followed PRISMA guidelines and included 50 studies encompassing 1,577 patients. The primary outcomes assessed were re-rupture rates, DASH scores, and functional outcomes, such as range of motion and strength ratios. The Downs and Black quality assessment checklist was used to evaluate the risk of bias, and the GRADE guidelines were applied to assess the quality of evidence. Results:The meta-analysis showed no significant differences in re-rupture rates, DASH scores, or strength ratios between early mobilization and immobilization groups. Similarly, the type of immobilization tool (splint, sling, or hinged brace) did not significantly affect these outcomes. The overall risk of bias was predominantly rated as poor to fair, and the quality of evidence was low to very low. Conclusion:This study suggests that both early mobilization and immobilization are viable postoperative rehabilitation strategies following distal biceps tendon reinsertion, with no significant difference in patient outcomes. The choice of immobilization tool also does not appear to significantly affect recovery. However, due to the low quality of evidence and risk of bias in the included studies, further high-quality research is needed to establish definitive postoperative care guidelines.
Purpose:This systematic review aimed to synthesize current literature on in vivo biomechanics following total hip arthroplasty, emphasizing objective laboratory assessments and surgical modifiers to address persistent functional deficits despite favorable clinical outcomes. Methods:A PRISMA-guided systematic review was conducted across seven databases (PROSPERO: CRD42024550457). Eligible studies included human subjects with objective postoperative biomechanical assessments (e.g. 3D motion analysis, force plates, dual fluoroscopy) compared against healthy or contralateral limbs. Data on spatiotemporal parameters, kinematics, kinetics, and surgical subgroups were extracted from 50 included studies. Results:Key findings revealed persistent reductions in hip joint power, gait speed, and stride length, along with joint loading asymmetries >1 year post-operatively. While the direct anterior approach showed faster early gait normalization, the surgical approach had a minimal long-term impact. Conversely, restoring femoral offset and anteversion was strongly associated with improved kinetics. Older patients exhibited greater compensatory trunk movements. Conclusion:The choice of surgical approach has a limited influence on long-term biomechanical restoration. Surgeons should instead prioritize offset restoration, implant choice, and functional component orientation, as static imaging fails to capture dynamic edge-loading. Future rehabilitation must target persistent kinetic asymmetries that standard clinical scores overlook.
Hereditary multiple osteochondromas (HMO), previously known as hereditary multiple exostoses (HME), is a congenital skeletal developmental anomaly characterized by multiple osteochondromas that commonly grow outward from the metaphyses of long bones. Hereditary multiple exostoses is an autosomal dominant genetic disease characterized by multiple cartilage growth disorders, which affect the long bones of the limbs, scapula, and ribs, among others. Consensus on the diagnosis and treatment of spinal involvement is relatively lacking. For such patients, experience in terms of clinical screening, preoperative evaluation, surgical intervention indications and timing, surgical expertise and lessons learned, and follow-up is needed and critical. This review focuses on the clinical evaluation and orthopedic surgical treatment of HME patients with spinal involvement. It summarizes the patients' diagnosis, clinical features, and treatment strategies based on evidence from the published literature. The clinical manifestations, location of onset, and surgical intervention are summarized in detail in this review. The above contents will help improve the clinical diagnosis and treatment level of HME patients with spinal involvement internationally.
