Gabriele Giuca

Background: Elastic Stable Intramedullary Nailing (ESIN) is a common treatment for pediatric tibial fractures, especially in standard diaphyseal fracture patterns and normal body mass index (BMI). However, ESIN may be technically limited in complex fracture morphologies (AO 42B-C, 43A2-A3) and in heavier children. Minimally Invasive Plate Osteosynthesis (MIPO), a technique widely embraced in adult orthopaedic trauma, may provide more stable fixation in these challenging scenarios through mini-incisions, indirect reduction strategies, and a stable “sliding plate” construct that preserves fracture biology. Objective: To compare clinical and radiographic outcomes of MIPO versus ESIN in diaphyseal AO 42B-C and extra-articular distal AO 43A2-A3 fractures. Methods: Single-center, retrospective cohort over 7 years, including skeletally immature patients (6 to 15 y) with diaphyseal AO/OTA 42B-C or extra-articular distal AO/OTA 43A2-A3 fractures. Intra-articular distal (43B-C) and physeal injuries were excluded. Primary outcomes were time to radiographic union and major complications (deep infection, loss of alignment requiring unplanned surgery, and implant bending/migration). Secondary outcomes included return to full sport, minor complications (superficial irritation/entry-site), residual deformity >5 degrees, and shortening >1 cm. Results: Fifty-eight children were analyzed (MIPO n=25; ESIN n=33). Union occurred sooner after MIPO (10.6±1.8 wk) than ESIN (15.8±2.5 wk) ( P P 5 degrees (24% vs. 27%, P =0.564). Findings were directionally consistent in overweight children. Conclusions: For complex extra-articular tibial fractures (42B-C; 43A2-A3), MIPO yielded faster union, earlier return to sport, and fewer reoperations than ESIN. Simple mid-diaphyseal fractures in lightweight children may still be managed nonoperatively or with standard ESIN. Level of Evidence: Level III.

Purpose: Multiple, nonharmonised classification systems exist for posterior medial meniscus root tears (PMMRT), yet their diagnostic accuracy and observer reliability remain unclear. This PRISMA‐2020 systematic review aimed to catalogue available PMMRT classifications and to summarise accuracy and reliability metrics. Methods: Searches (PubMed, Scopus, Cochrane CENTRAL, Ovid MEDLINE/Embase; English; humans; no date/design limits; 9 September 2025) identified 2849 records; 1920 unique records were screened and 228 full texts assessed; six studies were eligible. Risk of bias followed QUADAS‐2 for diagnostic accuracy and GRRAS/COSMIN for reliability. Study‐specific interobserver κ and measurement ICC (with 95% confidence interval [CIs]) were extracted. Arthroscopy‐validated diagnostic accuracy was available from one study; no pooling was performed. Results: One arthroscopy‐validated MRI study reported high accuracy for radial PMMRT (sensitivity 0.90; specificity 0.94). Interobserver agreement for MRI‐based classification/diagnosis was high in two studies ( κ = 0.86–0.93). MRI measurement repeatability for extrusion/tear‐gap was good‐to‐excellent (ICC: 0.80–0.92). No study prospectively linked subtype to treatment or outcomes. Conclusion: MRI‐based PMMRT classifications show high interobserver agreement, but arthroscopy‐validated accuracy evidence remains limited (single study); no system can be endorsed as most robust. A consensus, outcome‐anchored anatomical taxonomy and multicenter, arthroscopy‐validated studies linked to clinical outcomes are required before standardisation. Clinical Trial Registration: PROSPERO registration number: CRD420251103590. Level of Evidence: Level III.

Aim of the Study: To determine whether adding a lateral extra-articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) lowers graft-failure risk and improves functional recovery in competitive athletes with high-grade pivot-shift. Methods: Multicentre retrospective cohort with 1:1 propensity-score matching (age, sex, sport, graft, centre). Competitive athletes with pivot-shift grade ≥ 2 who underwent primary ACLR with hamstring or bone–patellar tendon–bone (BPTB) autografts (2018–2024) were eligible. The primary outcome was graft failure within 24 months (composite of revision ACLR, symptomatic rotatory laxity with pivot-shift ≥ 2 plus KT-1000 > 5 mm, or MRI-confirmed rupture). Time-to-event was summarised with Kaplan–Meier (KM) curves and log-rank tests. Secondary outcomes included residual rotatory laxity and functional performance (single-leg hop, side hop, Y-Balance) analysed as the proportion achieving Limb Symmetry Index ≥ 90% at 6 and 24 months and as continuous LSI means. Two-sided α = 0.05; secondary outcomes were prespecified without multiplicity adjustment. Results: Of 1368 ACL reconstructions screened, 97 eligible athletes were identified; 92 were analysed after matching (46 isolated ACLR; 46 ACLR + LET; mean follow-up 30.0 ± 4.2 months). KM survival at 24 months was 95.7% after ACLR + LET versus 82.6% after isolated ACLR (log-rank p = 0.046). The absolute risk reduction was 13.0% (Number Needed to Treat 8; 95% CI 4→∞). In graft-type subgroups, failures were 6/32 vs. 1/30 for hamstring and 2/14 vs. 1/16 for BPTB (ACLR vs. ACLR + LET, respectively); there was no evidence of interaction (Breslow–Day p = 0.56). At 6 months, a higher proportion of ACLR + LET athletes achieved LSI ≥ 90% across tests—single-leg hop 77.8% vs. 40.9% (p = 0.0005), side hop 62.2% vs. 34.9% (p = 0.012), Y-Balance 84.4% vs. 59.1% (p = 0.010), with a larger mean LSI (between-group differences +8.2 to +9.1, all p < 0.001). By 24 months, threshold attainment largely converged (all p ≥ 0.06), while mean LSI differences persisted but were smaller (+3.9 to +4.9, all p ≤ 0.001). Conclusion: In competitive athletes with high-grade pivot-shift undergoing accelerated, criteria-based rehabilitation, adding LET to primary ACLR was associated with lower graft-failure risk and earlier functional symmetry, with consistent effects across hamstring and BPTB autografts. Given the observational design, causal inference is limited; confirmation in randomized and longer-term studies is warranted.

Aim of the Study: To determine whether adding a lateral extra-articular tenodesis (LET) to primary anterior cruciate ligament reconstruction (ACLR) lowers graft-failure risk and improves functional recovery in competitive athletes with high-grade pivot-shift. Methods: In this Retrospective cohort study, 97 subjects (39 women and 58 men) aged ≥18 years, all of whom were competitive athletes and had pivot shifts ≥2 were included. Forty-seven patients underwent combined reconstruction (ACLR + LET), while the re-maining 50 received isolated reconstruction. The outcomes assessed included pa-tient-reported scores (sIKDC, ACL-RSI), stability measures (pivot shift, VAS stability), pain levels (VAS pain), muscle strength (LSI and isokinetic tests), and athletic performance (Single Leg Hop, Side Hop, Y-Balance). Statistical analysis was conducted using ANOVA tests for comparisons of continuous variables and linear regression models adjusted for age, gender, and concomitant meniscal procedures. The level of statistical significance was set at p< 0.05. Results: Among 92 propensity-matched competitive athletes (mean age 24.7 ± 4.4 years; 63 % men), eight graft failures occurred after isolated ACL reconstruction (ACLR) versus two after ACLR combined with lateral extra-articular tenodesis (LET), corresponding to an adjusted odds ratio of 0.21 (95 % CI 0.04–0.98; p = 0.047). Persistent pivot-shift (grade ≥ 1) was observed in 37 % of isolated ACLR knees and 13 % of ACLR + LET knees (p = 0.010). At 24 months, athletes with LET reported higher IKDC-Subjective (86.4 ± 6.1 vs 80.2 ± 7.4; p < 0.001) and ACL-RSI scores (78.5 ± 9.2 vs 69.1 ± 10.4; p = 0.001) and regained unrestricted sport 1.9 months earlier (5.3 ± 1.1 vs 7.2 ± 1.3; p < 0.001). One superficial wound infection after LET resolved with oral antibiotics. Conclusion: In high-level athletes with marked rotatory laxity, augmenting ACLR with LET halves residual instability, cuts graft-failure odds by 79 % and accelerates safe RTS by nearly two months, with minimal morbidity. The findings support selective use of LET when risk factors for failure are present.

Background/Objectives: Flatfoot is a common pediatric foot deformity characterized by a reduced or absent medial longitudinal arch (MLA). The condition can lead to altered gait, pain, and potential long-term morbidity if untreated. Identifying potential risk factors—such as body mass index (BMI), ligamentous or joint instability, shoe choices, and physical activity—is crucial for prevention and management. The objectives are to systematically review and synthesize current evidence on how flatfoot severity correlates with BMI and other risk factors in children and adolescents, and to highlight methodological considerations essential for future research. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched five electronic databases from inception to February 2024. Flatfoot severity was measured by various clinical or radiographic indices. Two reviewers independently screened and assessed the risk of bias. Results: Thirty-seven studies met the inclusion criteria. Children with high BMI had increased odds of flatfoot (pooled Odds Ratio = 2.3, 95% Confidence Interval: 1.6–3.1), with one outlier reporting an OR of 9.08. Heterogeneity (I² up to 70%) stemmed from varied diagnostic methods. Other factors, including joint instability, shoe choices, and physical activity, showed mixed associations. Conclusions: Elevated BMI strongly correlates with pediatric flatfoot severity, highlighting the importance of proactive weight management and foot assessments. Future standardized, longitudinal studies are needed to clarify causality and refine interventions.

Purpose: To translate and culturally adapt the Western Ontario Meniscal Evaluation Tool (WOMET) into Italian to examine its reliability, measurement precision, and responsiveness in patients undergoing arthroscopic meniscal surgery. Methods: Patients with magnetic resonance imaging–confirmed meniscal injuries completed the Italian WOMET at baseline and again at 3 and 6 months postoperatively. The translation followed established guidelines for cross‐cultural adaptation, including forward‐backward translation and cognitive debriefing. Test‐retest reliability was assessed using the intraclass correlation coefficient, and measurement precision was evaluated by calculating the standard error of measurement and the minimal detectable change. Responsiveness was measured via the standardized response mean. The Knee Injury and Osteoarthritis Outcome Score 4 questionnaire was administered for comparison. Results: A total of 97 patients (mean age, 38 years; age range, 22‐58 years) were included. The Italian WOMET showed excellent test‐retest reliability (intraclass correlation coefficient, 0.87). The standard error of measurement was 109.68 points, and the minimal detectable change was 307 points, indicating a high level of precision for detecting true clinical changes. The standardized response means were 1.94 at 3 months and 2.44 at 6 months, indicating strong responsiveness. A high correlation ( r = 0.85, P < .001) with the Knee Injury and Osteoarthritis Outcome Score 4 supported concurrent validity. Conclusions: The Italian WOMET is a reliable, precise, and highly responsive patient‐reported outcome measure for assessing health‐related quality of life in patients undergoing arthroscopic meniscal surgery. Clinical Relevance: Given the increasing prevalence of meniscal injuries in Italy and the need for culturally relevant diagnostic tools, the validation of the WOMET in Italian is important for patients, health care providers, and scientists.