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The purpose of this review was to conduct a literature search assessing the efficacy of various conservative treatments of BMES.According to the PRISMA guidelines, a literature search was conducted in April 2021 in MEDLINE database via PubMed and Embase to identify original articles describing the results of conservative treatments for BMES of hip and knee published in the last ten years. For each study, information regarding study characteristics, description of the treatment, patient's demographic and clinical data, length of follow-up, clinical outcome measure, disability, adverse events, classification, and extent and of edema on MRI, were extracted.A total of 12 studies were identified. Two studies described treatment with iloprost, three with hyperbaric oxygen (HBO), two with bisphosphonates, five with extracorporeal shockwave therapy (ESWT). The total number of patients was 351: 34 treated with iloprost, 64 with hyperbaric oxygen, 37 with bisphosphonates, 216 with ESWT. In ESWT studies, treatment with a higher flux density and a higher number of therapy sessions lead to better clinical and radiological scores. In iloprost studies, a more remarkable improvement in the VAS scale was observed in the study on hip patients.The treatment of idiopathic bone marrow edema is currently not standardized, making it difficult to find data that can be compared in a highly reliable way. The studies available in the literature show promising results as for the possibility to cure bone marrow edema efficiently. Standardized radiological scores for evaluating bone marrow edema area are needed in future studies.

The aim of the study is to compare, at 10-year follow-up, the clinical and radiological outcomes of arthroscopic rotator cuff repair with or without the addition of platelet-rich plasma (PRP) over the tendon-bone interface at the end of the surgical procedure.Of 53 patients recruited in the study, and randomly divided into 2 groups (PRP = 26; control = 27), 38 were re-evaluated at least 10 years after the index procedure. The clinical evaluation was carried out through: University of California at Los Angeles (UCLA) Shoulder Score, Visual Analogue Scale (VAS), Simple Shoulder Test, Constant-Murley Score (CMS), Single Assessment Numerical Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) and isometric strength in abduction, forward flexion and external rotation. Musculoskeletal ultrasonography had been used to evaluate the integrity of the repaired cuff.A number of 38 (71%) patients (PRP = 17; control = 21) with a median age of 71 [64.75-76.50] years have been evaluated. Satisfaction at follow-up is high (90%), without statistically significant difference between the two groups. We report good and excellent clinical results in both groups (PRP vs control): CMS (81.62 [72.47-85.75] vs 77.97 [69.52-82.55] points), UCLA (34 [29.00-35.00] vs 33 [29.00-35.00] points), VAS (0.34 [0.00-1.85] vs 0.70 [0.00-2.45] cm). It was not possible to find a statistically significant difference for the variables analyzed, except for ASES and SANE. On average, 37% of the operated patients had a re-rupture at the ultrasound examination, regardless of the treatment group (P = 1.00). Compared with the previous radiological control at the 2-year follow-up, new retears occurred in 6% of the patients who received PRP treatment, whereas in the control group the percentage raises to 14% (P = .61).The clinical and radiological outcomes at the 10-year follow-up show a substantial uniformity of results between the 2 groups. The minor differences that had been observed at 2-year follow-up disappeared at long term. Patients' satisfaction is still high 10 years after surgical treatment.Level II, randomized controlled trial, treatment study.

Introduction Periprosthetic fractures are increasing. The treatment is mostly surgical, but it has a high complication rate. Re-fracture and non-union with implant failure are the more frequent complications. Those complications are difficult to treat and can lead to severe disability. The purpose of this study is to determine the clinical results of periprosthetic femoral re-fracture treatment. Materials and methods Twenty patients were treated for femoral re-fractures (17 women, 3 men). The mean age and follow-up are 75.7 years (46–95) and 6.15 years (0.4–15) respectively. The diagnosis of new periprosthetic fracture according to Vancouver classification were: 3 type A, 5 type B1, 1 type B2, 2 B3, 8 type C; 1 Lewis-Rorabeck type II. Patients were followed-up clinically, with a Harris Hip Score, and radiologically at 2, 4, 6, 12 months, and then annually. Results All patients healed except for two cases in which an infection occurred. Two cases, treated with plate osteosynthesis, had a malunion in varus. Six patients died for unrelated reasons after fracture healing. One patient was excluded because of a follow-up shorter than 12 months. In 16 cases (84%) a Trendelenburg gait or the use of aids for walking has been necessary. At final follow-up the mean HHS was 65 (range 45–82). Fractures treatment differed depending on the type of the fracture, prosthesis stability and bone loss. Tension band wiring, long plate fixation, revision with a long stem with cables or a sandwich technique (two plates or one plate plus one strut graft) have been performed according to fracture type. Conclusions Re-fractures and non-union with implant failure are common after periprosthetic fracture treatment. Infection and malunion are the main complications of their treatment. Residual limping with the necessity of aids even after fracture healing is often present. The choice of a correct surgical strategy is essential to minimize the risk of new complications and ensure the highest possibility to heal. The most important factor is to achieve a good stability, a reasonable vital environment and don’t leave new areas of lower resistance uncovered. Poor functional outcome has to be expected especially in refracture after a revision surgery.

Personalization is a type of medical care in which the treatment is customized for an individual patient. When treating shoulder instability, we need to consider not only soft-tissue damage but also the bony lesion and patient characteristics. Of particular importance is the consideration of whether there is anterior glenoid bone loss, together with the presence of a Hill-Sachs lesion, on or off-track, as well as whether the patient is hyperlax and/or is an athlete, in which case in what type of sport. In hyperlax, nonoverhead sport athletes with recurrent anterior instability and glenoid bone loss

We tested the technical feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon (LHBT) in cadavers. Both shoulders of two fresh cadavers were scanned anteriorly to evaluate the extra-articular portion of the LHBT. Under ultrasound monitoring, a scalpel was advanced obliquely up to touch the superficial medial side of the LHBT, cutting it until the tendon was not visible anymore. Ultrasound evaluation was repeated after the procedure, and anatomic dissection was performed. The procedure was 100% feasible: four cuts were made to completely sever the tendon; the duration was less than 1 min. Skin incision measured 5 mm in two cases and 6 mm in two cases. Anatomic dissection confirmed complete tendon cut in all cases with proximal and distal tendon stumps very close to each other. Ultrasound-guided percutaneous LHBT tenotomy was 100% technically feasible in cadavers with a quick procedure and minimal cutaneous incision.

Rotator cuff tear is a common cause of shoulder pain and disability, and arthroscopic repair is a frequently performed procedure. To improve results and reduce failure rate of this surgery, biological solutions to enhance tendon repair are being investigated. Mesenchymal stem cells contribute in creating a suitable microenvironment for tissue repair, and therefore therapeutic use of tendon tissue-specific stem cells in clinical practice is one of the most promising challenges in regenerative medicine approaches to rotator cuff repair. The aim of this article is to revise the current literature on tendon-derived stem cells for rotator cuff repair. Identification and characterization of a reservoir of progenitor cells in human shoulder periarticular tissues has been successfully confirmed by different authors. The first animal studies on the healing potential of these mesenchymal stem cells showed encouraging results. No clinical trials have been published yet. Rigorous preclinical translational studies are needed to ensure safety and efficacy of stem cells–based treatments before routine use in clinical practice.

Importance Humeral head defects are a common finding after acute and recurrent shoulder dislocations. Different hypotheses exist on the real significance of these defects and on their relevance in predicting dislocations after surgical repair. Objective This review study was designed to evaluate if humeral head defects are a negative prognostic factor for recurrence after arthroscopic Bankart repair. Evidence review A systematic review of the available literature (1980–2015) was performed using EMBASE and MEDLINE databases. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included. Findings A meta-analysis on instability recurrence risk after arthroscopic Bankart repair and recurrence rate stratification for time from intervention were not possible for lack of data. 23 studies were eligible for inclusion. The ratio between recurrence cases and total cases was 0.1254. This ratio rose to 0.1314 in the group with Hill-Sachs lesions and dropped to 0.1044 in the group without. 10 patients reported the dimension of the Hill-Sachs encountered and 6 reported precisely the time to instability recurrence in presence or absence of Hill-Sachs lesions. Conclusions and relevance A Hill-Sachs lesion could not be confirmed as a statistically significant negative prognostic factor after arthroscopic Bankart repair. With increased follow-up length, a slight tendency to higher redislocation rates was observed in presence of a Hill-Sachs lesion. Higher quality studies with repair survival analysis are needed to assess recurrence risk after arthroscopic Bankart repair and evaluate the prognostic relevance of the presence of a Hill-Sachs lesion.

Aim The aim of this study was to compare the effective working space in the axial plane of three different elbow arthroscopy portals to fix radial head (Rh) fractures. Background Arthroscopic fixation of Rh fractures is an alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. Methods A fresh-frozen cadaver specimen was obtained and prepared to mimic an arthroscopic setting. Standard anterolateral (AL), anteromedial (AM), and midlateral (ML) portals were established and circular reference system was marked on the Rh using the radial styloid as an anatomic reference for 0°. Ten independent examiners were then asked to move the forearm from maximal supination to maximal pronation and indicate with a K-wire the range in which they would feel confident with placing a cannulated screw, which would pass through the centre of the articular plane of the Rh (axial contact arc). This process was repeated from all three portals by each examiner. Every examiner remained blinded to other examiners’ measurements. Results The average axial contact arc that could be contacted from the AM portal measured 150 ± 14.14°, or 41.67% of the Rh circumference, while the one from the AL portal measured 257 ± 29.46°, or 71.39% of the Rh circumference, and that from the ML portal 212.5 ± 32.60°, or 59.03% of the Rh circumference. Considering all three portals, the whole Rh circumference could be contacted. The AM portal showed the smallest coefficient of variation (9.43%) as compared to the AL (11.46%), and the ML (15.34%) portals. Conclusions With an appropriate use of the standard AL, AM, and ML portals, the whole Rh circumference can be effectively contacted for fixation of Rh fractures. The AL portal shows a superiority in axial contact arc as compared to the AM and ML portals; the working space of the AM portal presents the smallest variability among different observers.

We present the case report of a 40-year-old woman who was HIV-positive in Highly Active Anti-Retroviral Therapy (HAART) and affected by femural pertrochanteric fracture, which was treated by endomedullary nailing. Two years after the surgical operation, the woman developed an aseptic symptomatic osteolysis around the implant. Hardware removal was resolutive. Aseptic and septic hardware mobilization, hardware removal, and implant decision in HIV patients with pertrochanteric fractures is discussed. The authors suggest close follow-up and prompt hardware removal, as soon as X-rays demonstrate healing signs, in HIV patients with fracture fixation, if general condition allows.

Osteochondral defects (OCDs) of the talus are a common cause of residual pain after ankle injuries. When conservative treatment fails, arthroscopic debridement combined with drilling/microfracturing of the lesion (bone marrow stimulation [BMS] procedures) has been shown to provide good to excellent outcomes. Not uncommonly, talar OCDs involve the borders of the talar dome. These uncontained lesions are sometimes difficult to visualize with the 30° arthroscope, with potential negative effect on the clinical outcome of an arthroscopic BMS procedure. The use of the 70° arthroscope has been described for a multitude of common knee, shoulder, elbow, and hip procedures. The purpose of this article is to show the usefulness of the 70° arthroscope in arthroscopic BMS procedures, pointing out which kinds of talar OCDs can benefit most from its use.

Hypothesis: Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. Study design: Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. Materials and methods: Fifty-threepatientswhounderwentshoulderarthroscopyfortherepairofacomplete rotatorcufftearwererandomlydividedinto2groups,usingablockrandomizationprocedure.Atreatmentgroup (N ¼ 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N ¼ 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. Results: The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 � 1.6 vs 2.1 � 1.3 kg; SST: 8.9 � 2.2 vs 7.1 � 2.7; UCLA: 26.9 � 3v s 24.2 � 4.9; Constant: 65 � 9 vs 57.8 � 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). Conclusion: The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.

Aim The aim of this study was to evaluate survivorship and functional results of arthroscopic rotator cuff (RC) repairs at a minimum follow-up of ten years. Secondary goals were to compare outcomes in patients with and without re-tears and to relate lesions’ characteristics with clinical, functional and radiological results. Background Arthroscopic repair is considered the gold standard treatment for RC tears, but studies describing long-term results after arthroscopic RC repair are still scarce. Methods Patients were prospectively re-evaluated at least ten years after arthroscopic RC repair. American Shoulder and Elbow Surgeons Shoulder Score (ASES), range of motion (ROM), Constant Murley Score (CMS), isometric strength in forward flexion (fl) and abduction (ab) were measured. Shoulder radiographs were used to measure the acromion-humeral distance (AHD) and classify shoulder osteoarthritis (OA) according to Samilson-Prieto. Ultrasound examination was performed to assess supraspinatus (SSp) re-rupture as a dichotomous variable. Results One hundred and two patients were available for functional and radiological evaluation. In 47 of them (46.5%), a discontinuity of the SSp was diagnosed echographically. Two groups of patients were created and compared depending on echographic tendon integrity: significant differences in favour of patients with intact SSp were detected in ASES (P = 0.0086), ROM (ab: P = 0.0143, fl : P = 0.0069), CMS (P > 0.0001), strength (ab and fl: P > 0.0001), and AHD (P > 0.0001). Patients with smaller (C1-C2) lesions (62.4%) developed significantly greater ROM (ab : P = 0.0174, fl: P = 0.0164), CMS (P = 0.0007), strength in ab (P > 0.0006), strength in fl (P > 0.0001), and showed higher AHD (P > 0.0001). Larger (C3-C4) lesions (37.6 %) were significantly more prone to re-tear (P = 0.0002) and progression of OA (P = 0.0003) than smaller ones. Conclusions These long-term results of arthroscopic RC repair indicate that RC integrity is important to maintain functional results and prevent OA progression. Independently from RC integrity, patients with smaller lesions maintain a superior functional level and a slower rate of OA progression.

Aim The aim of this anatomical study was to describe the position of the posterior interosseous nerve (PIN) with respect to the elbow joint capsule and the midline of the radial head, with particular attention on the changes occurring with forearm movements. Background The PIN innervates the supinator and the extensor muscles of the wrist and the digits and its lesion may have dramatic consequences. Measurements of PIN course have been provided from open surgical approaches, but arthroscopic descriptions are lacking. Methods Eleven fresh-frozen cadaver specimens were dissected under arthroscopy. Attention was paid to the possibility of identifying the PIN immediately after anterior capsulectomy. The distance between the nerve and the most anterior part of the radial head was then measured with a graduated hook inserted via the midlateral portal with the forearm in neutral position, full pronation and full supination. Results The PIN was identified as immediately extracapsular only in one specimen. In the other specimens, a thick layer of adipose tissue surrounded it. The relative position of the PIN to the midline of the radial head changed with forearm pronosupination, moving from lateral in supination to medial in pronation in all cases. A statistically significant increase in the distance of the PIN from the radial head in full supination was recorded, as compared to neutral position and full pronation. Conclusions At the level of the radiocapitellar joint, the PIN does not lay just extracapsular but a thick layer of adipose tissue may hide it. Furthermore, movements of the forearm change significantly its position with respect to the radial head. The use of retractors can be helpful in protecting this nerve from accidental injury when performing procedures on the radial head.

Aim The aim of this study was to document the incidence of post-arthroscopic shoulder stiffness (SS) and evaluate the role of certain or supposed risk factors in the development of this pathology. Background Postoperative SS is a complication of arthroscopic rotator cuff repair, which incidence has been reported variably in literature. Numerous risk factors have been described but gastroesophageal diseases have not yet been mentioned among them. Methods Two hundred and fourteen consecutive patients aged between 18 and 75 years with symptomatic degenerative posterosuperior rotator cuff tears that had failed conservative therapy and underwent arthroscopic rotator cuff repair were included. The incidence of post-operative SS and the presence of potential risk factors were documented prospectively. The presence of gastroesophageal reflux disease was specifically investigated with the GERDq questionnaire. Results The incidence of post-arthroscopic SS in the included patients was 7.9%. All but two patients were women, and sex was significantly associated to the development of the pathology (P = 0.0007). Both the presence of a subjective digestive discomfort (P = 0.0042) and the diagnosis gastroesophageal reflux disease (P = 0.0004) were found to be significantly associated with the development of post-arthroscopic SS. A present or past smoking habit were significantly associated with the absence of post-arthroscopic SS (P = 0.0443). Conclusions A significant association between the occurrence of post-arthroscopic SS and the presence of gastroesophageal diseases was identified. This finding deserves investigations with further studies. The incidence of post-arthroscopic SS encountered in this study falls among previously reported ranges, with females being significantly more affected than men.

INTRODUCTION Osteoarthritis (OA) is a degenerative joint disease constantly increasing in elderly population and the knee is one of the most affected joints. It contributed together with other musculoskeletal disorders to the 2nd greatest cause of disability in the WHO Global Burden of Disease [1] and patients no more responding to conservative treatments undergo total knee-arthroplasty (TKA) to remove pain and permit an asymptomatic walking. Radiological reports and questionnaires are the current diagnostic tools employed both for the diagnosis and monitoring of OA progression. However, substantial discordance exists between current diagnostic outcomes using those tools and OA symptoms [2]. Further investigation need to identify more reliable biomarkers for early detection of the disease, correct timing for TKA and post-surgery monitoring. Therefore in this study we aim to describe quantitatively the gait of OA patients undergoing to the TKA, with a specific focus on the 3D body centre of mass (BcOM) trajectory (Locomotion 3D Lissajous Countours [3]). METHODS 7 patients with unilateral knee OA (68.9 ± 4.8 years, 69.1 ± 9.1 kg, 1.60 ± 0.07 m) were tested for 4 times: before surgery (PRE), after 2 months (POST2), after 6 months (POST6) and after 12 months (POST12) from TKA. Each time patients were asked to i) complete a WOMAC questionnaire, ii) walk on a 5-force plates (Bertec, Columbus, OH, U.S.A) corridor to estimate spontaneous velocity (vs), and iii) walk for 1 min on a treadmill at 3 selected velocities (vs, v1 and v2). Two velocities, lower than vs, were calculated starting from the Froude Number (Fr): v1 = -30% Fr and v2 = -15% Fr, respectively). A 18 marker model was used to calculate (VICON, Oxford UK) the 3D BCoM trajectory, its symmetries, stride frequency (SF), double contact (DC) time, right and left duty factor, mechanical external and internal work (Wext and Wint respectively), total work (Wtot) and energy recovery (RE). RESULTS WOMAC indices improved significantly already after 6 months and vs significantly increased from 0.89 ± 0.14 (PRE) to 1.13 ± 0.07 m/s (POST12). The figure shows the average BCoM profiles during walking (pointed arrows refer to vertical (z) and progression (x) axes), where upper boundary reaches a higher vertical position (3%) in the POST12 condition compared to the PRE condition and a more symmetrical shape, significantly in x and z directions. For the same walking speed SF decreased significantly already after two months from TKA, DC time decreased to 20% of the stride length and duty factor also assumed lower values after surgery. Patients after TKA improved their locomotor energy recovery mechanisms, reducing mechanical external work by 10%. WINT was constant along the months, while RE slightly increased after TKA. DISCUSSION The group of quantitatively analysed variables, suggest as patients with prosthesis tend to re-establish their natural locomotion pattern after TKA. Body centre of mass analysis during walking, including symmetry and mechanical energy evaluations, quantitatively assess osteoarthritis disease level and can be employed to monitor patients before and after pharmacological and surgical interventions. The same methodology could be applicable to neurological pathologies and to patients affected by other orthopaedic pathologies affecting other limb joints, like hip or ankle. The effects of different prosthesis or surgical techniques on a single pathology/joint could be equally investigated.

Purpose Articular and peri-articular structures of the hindfoot can be accessed by means of endoscopic techniques. Some recommendations have been produced to guide arthroscopy in the anterior compartment of the ankle joint. The goal of this study is to summarise the quality and quantity of the evidence available regarding hindfoot endoscopy and posterior ankle arthroscopy and to assign a grade of recommendation for the current generally accepted indications to this surgery. Methods A comprehensive review of the literature was performed by use of the PubMed database. Studies enrolling human subjects of all ages who underwent endoscopic or arthroscopic procedures on the hindfoot in the prone position, using posterior portals as described by Van Dijk et al. or with minimal variations were eligible for inclusion. All articles were assigned a level of evidence classification and categorised depending on the indication for the surgical procedure performed. Information regarding authors, journal and year of publication, study design and level of evidence, patient demographics, indication for treatment, modality for diagnosis, surgical technique, follow-up duration, outcomes and complications were extracted and analysed. Results Fifty-two studies, accounting for 985 procedures, were eligible. The most frequent indications of hindfoot endoscopy are posterior ankle impingement (with or without flexor hallucis longus tendonitis), degenerative changes of the subtalar joint and retrocalcanear pain or bursitis; these indications are supported with a grade Cf of recommendation. Achilles tendon pathologies, hindfoot ganglia, talar fractures, posterior tibialis tendon dysfunctions, frozen ankle, chondromatosis or osteoid osteomas have been described as possible indications; for them, only a grade I of recommendation has been defined. Conclusions In spite of promising clinical results, only a low grade of recommendation can be derived from the existing literature to support the most frequent indications for hindfoot endoscopy and posterior ankle arthroscopy. Further high-quality studies on this surgical approach are needed.

Objective We evaluated safety and potential diagnostic value of magnetic resonance (MR) imaging of the knee treated with medial unicompartmental arthroplasty (MUA). Methods The treated knee of 8 patients who underwent MUA was studied with four different 1.5-T MR sequences. Two radiologists independently evaluated eleven anatomical items using a score from 0 (not assessable) to 3 (completely assessable). The sum of the scores for each sequence was divided by the potential maximal sum, obtaining a percentage visibility index (PVI) for each item. Results No adverse effect was reported during or within 30 min after the exam. Posterior cruciate ligament was unseen in all patients by both observers. The following PVIs were reported for the remaining ten items: femoral–patellar relationship 83–100%; femoral–patellar cartilage 92–100%; Hoffa's fat pad 75–92%; patellar ligament 79–100%; lateral meniscus 100%; femoral–tibial lateral joint 100%; lateral collateral ligament 96–100%; anterior cruciate ligament 54–83%; femoral–tibial lateral cartilages 92–100%; posterolateral corner 100%. Agreement between readers was found in 331/352 (94%) evaluations ( k = 0.74–0.78). Conclusions MR imaging after MUA offers a safe and reproducible evaluation of residual knee anatomy except for cruciate ligament, and can be used to follow-up these patients.