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We investigated the correlation between the musculoskeletal features and the cardiovascular anomalies in pediatric patients affected by Marfan syndrome, in order to identify possible orthopedic deformities that could be a warning sign for severe aortic dilatation. Moreover, we analyzed the role of the orthopedic aspects in the early diagnosis of the disease in a pediatric population. Seventy-two patients from 3 to 14 years of age, underwent interdisciplinary evaluation that included an orthopedic and cardiological examination. At the orthopedic examination, we analyzed the musculoskeletal features included in the systemic score of the revised Ghent criteria. Cardiological evaluation included a transthoracic echocardiography with definition of the cardiac Z-score, which is an index that evaluates aortic diameter. A statistical analysis was performed. We identified a statistically significant correlation between the presence of pectus excavatum and cardiac Z-score ≥3 (P = 0.022). Clinically, this data means that pectus excavatum is frequently observed in patients with larger aortic root diameter. On the contrary, no statistically significant correlation was found between the other investigated musculoskeletal features and a pathological Z-score. In the pediatric population, the diagnosis of Marfan syndrome remains difficult because many clinical manifestations are age-dependent and the Ghent criteria, usually used for adults, are not reliable in children. Our results show that the presence of pectus excavatum could help in the early identification of patients at greater risk of developing possibly fatal aortic disease. However, it is always indicated to screen all patients with Marfan syndrome for cardiac abnormalities, even in absence of pectus excavatum.

Background/aims The study of the effects of simulated microgravity on primary cultures of human satellite cells represents a reliable model for identifying the biomolecular processes involved in mechanic load-related muscle mass loss. Therefore, this study aims to investigate the role of myostatin and Bone Morphogenetic Protein-2 in human satellite cells response to simulated microgravity condition. Methods In order to identify the main molecules involved in the phenomena of degeneration/regeneration of muscle tissue related to the alteration of mechanic load, we performed a morphological and immunohistochemical study on 27 muscle biopsies taken from control, osteoporotic and osteoarthritic patients, underwent hip arthroplasty. For each patient, we set up primary satellite cell cultures subjected to normogravity and simulated microgravity (110h) regimens. Cellular functionality has been studied through a morphological evaluation performed by optical microscopy, and an ultrastructural evaluation carried out by transmission electron microscopy. Furthermore, we evaluated the expression of Bone Morphogenetic Protein-2 and myostatin through immunocytochemical reactions. Results Our results showed that in the very early phases of simulated microgravity condition the satellite cells are more active than those subjected to the normogravity regime, as demonstrated by both the increase in the number of myotubes and the significant increase in the expression of Bone Morphogenetic Protein-2 in all experimental groups. However, with prolongated exposure to simulated microgravity regime (>72h), satellite cells and new formed myotubes underwent to cell death. It is important to note that, in early phases, simulated microgravity can stimulate the formation of new myotubes from satellite cells derived by osteoporotic patients. Furthermore, we observed that simulated microgravity can induce changes in myostatin expression levels by group-dependent variations. Conclusion The results obtained allowed us to hypothesize a possible molecular mechanism of response to simulated microgravity, confirming the importance of Bone Morphogenetic Protein-2 and myostatin in the physio-pathogenesis of muscle tissue. In addition, these data can lay the foundation for new therapeutic approached in the prevention/cure of osteoporosis and sarcopenia.

Highlights • Simultaneous bilateral hip fractures in the elderly are rare and usually have a symmetric pattern. • Intracapsular fractures on one side and trochanteric on the other are even rarer. • They are caused by a spontaneous fracture which causes a fall on the contralateral side. • The trochanteric fracture should be operated first to avoid possible complications., Introduction Simultaneous bilateral hip fractures are usually associated with high energy trauma, seizures, metabolic diseases and bisphosphonates use. They are observed rarely in the elderly population after simple trauma and usually have the same fracture pattern (symmetric). We report a rare case of asymmetric fracture and discuss mechanism of injury and treatment, analyzing the literature. Presentation of case We report a case of an 86-year old woman with a simultaneous bilateral asymmetric hip fracture (trochanteric on the right side and subcapital on the left), occurred after a fall at home. The patient was surgically treated by open reduction and internal fixation with an intramedullary nail on the right and by hemiarthroplasty on the left performed during the same surgical session, with good results. Discussion Simultaneous bilateral hip fractures in the elderly are rare and usually are symmetric. In the majority of the cases these fractures are intracapsular and are treated by hemiarthroplasties. On the contrary, simultaneous bilateral hip fractures with a different pattern, as the described case, are extremely rare. The possible mechanism of injury is a spontaneous fracture on one side, which causes a fall the contralateral side. The surgical treatment may be performed bilaterally, treating first the trochanteric fracture. Conclusion Simultaneous bilateral asymmetric hip fracture are extremely rare and may occur in elderly patient with a specific mechanism of injury. We believe that the trochanteric fracture should be operated first to avoid possible complications.

Introduction Acromioclavicular joint cyst (AJC) is a very uncommon condition of the shoulder observed in elderly patients, caused by a degenerative acromioclavicular (AC) joint, frequently associated to a rotator cuff tendon tear. There are two possible cause for the cyst formation. We report two different cases of a AC synovial cyst, with and without rotator cuff tear. Presentation of cases We report two cases, in patients aged respectively 80 and 77 years, with a very large AJC. In one case, the cyst was associated to a rotator cuff tear, while in the other case, the rotator cuff did not present any evident lesion. Both cysts were successfully surgical excised and a distal clavicle resection was performed. Discussion AJC is a rare complication observed in degenerative AC joint and in the majority of cases is associated to a rotator cuff tear. The diagnosis may be made by ultrasound and conventional radiographic examination, although MRI of the shoulder is generally preferred as it allows to better identify the condition of the rotator cuff. Generally, local aspiration of the cyst and corticosteroid injection fails with recurrence of the cyst and surgically treatment is indicated, especially in painful cases. Conclusion Painful AJC should be surgically treated by excision of the cyst associated to a lateral clavicle resection; when a symptomatic massive rotator cuff is present, a reverse total shoulder arthroplasty may be considered. However, in elderly patients, who have no discomfort, watchful waiting may be the treatment of choice.

BackgroundLimb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley’s technique, in 28 patients, followed up after a mean period of 8 years.Materials and methodsTwenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae.ResultsThe mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley’s evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail.DiscussionWe believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation.Level of evidence4.

Background Historical papers on the treatment of congenital dislocation of the hip suggest the use of preliminary traction to facilitate closed reduction or to decrease the risk of avascular necrosis (AVN) of the femoral head. In the 1980s, some authors questioned the role of preliminary traction and suspended its use, yielding satisfactory results. Since then, several studies called into question this method, and some authors have continued to recommend preliminary traction while other authors have discouraged its use. Materials and methods We reanalysed the full set of radiographs of 71 hips (52 patients) surgically treated by a medial approach after 4 weeks of preoperative longitudinal traction. The mean age at operation was 16 months. Before and after traction, the height of the dislocation was graded according to the Gage and Winter method. The hips were divided into two groups: group 1, in which the traction was effective, and group 2, in which the traction was not effective. These two groups were statistically analysed regarding the severity of the dislocation, the age of the patient at surgery and the incidence of AVN. Results Preliminary traction was effective in 48 hips (68%, group 1), while it was not effective in the remaining 23 (32%, group 2). The effectiveness of preliminary traction was statistically related to the height of the dislocation and to the age of the patient at surgery, with traction being less effective in more severe dislocations and in older children. The incidence of AVN was statistically lower in group 1 than in group 2. Conclusions In our study population, despite not having a control group, preliminary traction—when effective—seemed to reduce the incidence of AVN in patients surgically treated for congenital dislocation of the hip. The effectiveness of the traction was influenced by the severity of the dislocation and the age of the patient; it worked better for less severe dislocations and in younger children. To reduce hospital costs, traction should be applied at home. Level of evidence 3.

Cigarette smoking has a negative impact on the skeletal system, as it reduces bone mass and increases fracture risk through its direct or indirect effects on bone remodeling. Recent evidence demonstrates that smoking causes an imbalance in bone turnover, making bone vulnerable to osteoporosis and fragility fractures. Moreover, cigarette smoking is known to have deleterious effects on fracture healing, as a positive correlation between the daily number of cigarettes smoked and years of exposure has been shown, even though the underlying mechanisms are not fully understood. It is also well known that smoking causes several medical/surgical complications responsible for longer hospital stays and a consequent increase in the consumption of resources. Smoking cessation is, therefore, highly advisable to prevent the onset of bone metabolic disease. However, even with cessation, some of the consequences appear to continue for decades afterwards. Based on this evidence, the aim of our review was to evaluate the impact of smoking on the skeletal system, especially on bone fractures, and to identify the pathophysiological mechanisms responsible for the impairment of fracture healing. Since smoking is a major public health concern, understanding the association between cigarette smoking and the occurrence of bone disease is necessary in order to identify potential new targets for intervention.

Pentraxin 3 (PTX3) is a glycoprotein belonging to the humoral arm of innate immunity that participates in the body’s defence mechanisms against infectious diseases. It has recently been defined as a multifunctional protein, given its involvement in numerous physiological and pathological processes, as well as in the pathogenesis of age-related diseases such as osteoporosis. Based on this evidence, the aim of our study was to investigate the possible role of PTX3 in both the osteoblastic differentiation and calcification process: to this end, primary osteoblast cultures from control and osteoporotic patients were incubated with human recombinant PTX3 (hrPTX3) for 72 h. Standard osteinduction treatment, consisting of β-glycerophosphate, dexamethasone and ascorbic acid, was used as control. Our results showed that treatment with hrPTX3, as well as with the osteogenic cocktail, induced cell differentiation towards the osteoblastic lineage. We also observed that the treatment not only promoted an increase in cell proliferation, but also the formation of calcification-like structures, especially in primary cultures from osteoporotic patients. In conclusion, the results reported here suggest the involvement of PTX3 in osteogenic differentiation, highlighting its osteoinductive capacity, like the standard osteoinduction treatment. Therefore, this study opens new and exciting perspectives about the possible role of PTX3 as biomarker and therapeutic agent for osteoporosis.

INTRODUCTION: Lateral condyle fractures (LCF) of the distal humerus are one of the more common skeletal injuries in the pediatric population. The mean age of patients with these fractures is 6 years. In the majority of the cases, the diagnosis is based on clinical and radiographic examination. The most recent classifcation divides these fractures according to degree of displacement and stability. EVIDENCE ACQUISITION: A literature search was performed using Pubmed and Scopus database, until June 2020. Inclusion criteria were studies regarding lateral humeral condyle fractures in pediatric patients. Case reports were excluded. EVIDENCE SYNTHESIS: Most of the studies in literature are retrospective with contrasting opinions and conclusions on diagnosis, classifcation and management. CONCLUSIONS: Regarding the diagnosis and classifcation, the stability of the fracture remains in some cases diffcult to ascertain and MRI can be helpful in identifying the integrity of the articular cartilage and hence fracture stability. Displaced or unstable fractures are preferably treated by closed reduction and percutaneous pinning, while fractures that have rotation of the condylar fragment need to be treated surgically. ORIF can be performed by using different approaches, and the methods of fxation are K-wires or screws. The main factors associated with long-term results are quality of reduction and timing of treatment. The most serious complications are cubitus varus, nonunion, AVN of the condylar fragment and ulnar nerve palsy.

Thoracic outlet syndrome (TOS) represents a clinical condition caused by compression of the neurovascular structures that cross the thoracic outlet. TOS can be classified in: 1) neurogenic TOS (NTOS), 2) venous TOS (VTOS), 3) arterial TOS (ATOS). Many different causes can determine the syndrome: congenital malformations, traumas, and functional impairments.This manuscript reviews how the congenital malformations play an important role in adult age; however, TOS also affects patients of all ages.Radiological imaging like X-ray (radiography), magnetic resonance and computed tomography can provide useful information to assess TOS causes and decide a potential surgery. 79% of the patients included in the first two stages of nerve, artery, vein (NAV) staging experienced excellent results with kinesiotherapy; whereas patients included in the third and fourth stage of NAV staging were subject to surgery.The treatment of acute forms of TOS involves thrombolysis and anticoagulant therapy; surgery is appropriate for true NTOS, vascular TOS and in some cases when conservative treatment fails.

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.’s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary’s angle and Costa–Bertani’s angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.’s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary’s angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani’s angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

The rapid spread of the COVID-19 outbreak in Italy has dramatically impacted the National Healthcare System, causing the sudden congestion of hospitals, especially in Northern Italy, thus imposing drastic restriction of almost all routine medical care. This exceptional adaptation of the Italian National Healthcare System has also been felt by non-frontline settings such as Pediatric Orthopaedic Units, where the limitation or temporary suspension of most routine care activities met with a need to maintain continuity of care and avoid secondary issues due to the delay or suspension of the routine clinical practice. The Italian Society of Pediatric Orthopaedics and Traumatology formulated general and specific recommendations to face the COVID-19 outbreak, aiming to provide essential care for children needing orthopaedic treatments during the pandemic and early post-peak period, ensure safety of children, caregivers and healthcare providers and limit the spread of contagion.

BACKGROUND: Obesity has been regarded to be protective against fracture in spite of its association with low levels of vitamin D. Vitamin D is the key regulator of bone metabolism and its deficiency contributes to higher level of parathyroid hormone (PTH), leading to the activation of bone turnover.METHODS: We studied 161 subjects of which 65 were young healthy subjects and 96 were elderly subjects. We measured creatinine, 25(OH)D, 1,25(OH)2D, PTH, albumin, and calcium plasma levels, we evaluated physical activity, and we calculated BMI. A sub-cohort of elderly subjects also underwent DXA scans.RESULTS: Overweight and obese subjects, as well as underweight ones, had lower levels of vitamin D but normal serum concentrations of 1,25(OH)2D and PTH was higher in underweight and obese subjects. Moreover, we found a nonlinear relationship between body mass index (BMI) and PTH with a significant U-shaped exponential regression. Regardless of BMI, 25(OH)D mean levels were higher in subjects who practice physical activity.CONCLUSIONS: These findings suggest that physical activity and BMI had a significant effect on the metabolism of bone and vitamin D, but the effect of BMI was different in underweight, normal weight or obese subjects. In obesity the real vitamin D deficiency could be estimate by serum 1,25(OH)2D concentrations whose lower levels contribute to the higher PTH production and consequently to bone loss and to a greater fracture risk. Refereed/Peer-reviewed

Highlights • Clear Cell Hidradenoma (CCH) is a benign tumor of the sweat glands that very rarely appear on the hand. • CCH needs to be considered as a possible diagnosis for small subcutaneous masses on the extremities in all ages. • Accurate surgical excision is the treatment of choice, to avoid recurrence. • Histological analysis is fundamental for a correct diagnosis., Introduction Clear cell hidradenoma (CCH) is a superficial adnexal tumor of the sweat glands. It generally appears on the trunk or scalp and is uncommon on the upper and lower limbs; it is extremely rare on the hand. CCH tend to be benign, with low malignancy risk. Treatment is based on complete surgical excision. We report a rare case of a CCH of the palm of the hand in an 83-year old patient. Presentation of case An 83-year old male patient presented with a small mass on the palmar surface of his left hand, which was progressively increasing over 5 years. The tumor was surgically excised after sonography and sent for histologic examination, based on which diagnosis of CCH was made. Three months after surgery, the patient had no recurrence and was symptom free. Discussion CCH is a rare tumor of the distal extremities and to the best of our knowledge, only one case of this tumor on the hand has been reported. Our case represents a rare CCH located at the palm of the hand, which was successfully surgical excised without recurrence. Therefore, CCH needs to be considered in the differential diagnosis when encountering masses on the distal extremities. Hidradenocarcinoma is the malignant variant that arises from the same cells. Conclusion We report the second case of CCH on the palmar surface of the hand. Treatment of choice is surgical excision, followed by histological analysis and close follow-up for recurrence.

Background: Osteoarthritis and osteoporosis are strongly coupled with alterations of muscles quality and fats metabolism. However, there are no studies for investigating possible differences between osteoporotic and osteoarthritic muscles. Understanding muscle-bone and muscle-cartilage interactions would be of high clinical value. Aim: Investigate potential microstructural and physiological differences between osteoporotic and osteoarthritic muscles by diffusion Nuclear Magnetic Resonance (NMR) imaging (diffusion MRI) and histological findings. Methods: Vastus-lateralis muscles excised from osteoporotic (n = 26, T Score < - 2.5, Kellgren-Lawrence - 2.5, Kellgren--Lawrence 3 and 4) age-matched women were investigated by NMR relaxometry, diffusion-tensor imaging (DTI) at 9.4 T, and histological techniques. Intramyocellular (IMCL) and extramyocellular (EMCL) lipid were quantified. The percentage and mean diameters of fibers I and II were evaluated. Relationship between mean diffusivity (MD), fractional anisotropy (FA), the DTI eigenvalues (?1, ?2, ?3), histological findings in muscles and clinical data (Kellgren-Lawrence and T score, age, menopausal age, body mass index) were studied. Pairwise comparisons between groups were made using one-way analysis of variance and correlation between variables was assessed with linear correlation analysis (Pearson's r coefficient). Results: Osteoporotic muscles showed higher MD, ?1,?2, ?3 compared to osteoarthritis ones. This is explainable with a significant higher density of IMCL droplets found inside the osteoarthritic muscles and a large amount of fibrotic tissue and IMCL infiltration between fibers, i.e. in endomysium and perimysium that lead to a more hindered diffusion. Furthermore, histological analysis suggests mitochondrial degeneration as the origin of the greatest amount of IMCL droplets in osteoarthritic muscles. Conclusion: This work highlights differences between muscles of osteoporotic and osteoarthritic subjects that can be quantified by NMR DTI investigations.

Multidisciplinary approach to osteoarthritis (OA) in older patients, whose functional decline is multifactorial and who present with multiple symptoms, has been long advocated, but it is still seldom implemented in daily practice. Therefore, further indications for the management of OA are eagerly awaited and should consider the specific clinical features of this population, including the presence of frailty and comorbidities. This clinical approach should be based both on well-grounded evidence and practical experience of experts in OA management. This manuscript comments the multidisciplinary integrated approach for OA management in the older population, according to the opinion of a multidisciplinary Panel of Experts. This project was developed by a Steering Committee, which consisted of three experts that were identified by the Italian Society of Physical and Rehabilitation Medicine (Società Italiana di Medicina Fisica e Riabilitativa, SIMFER) and the Italian Society for Unified and Interdisciplinary Management of Musculoskeletal Pain and Algody strophy (Societa Italiana per la Gestione Unificata e Interdisciplinare del Dolore muscolo-scheletrico e dell'Algodistrofia, SI-GUIDA). The Steering Committee identified key evidence on the management of OA in the older through systematic research in MEDLINE and EMBASE, selected the most relevant paper among those identified, and defined some questions concerning current unmet needs in the management of symptomatic OA in the older accordingly. The Panel discussed the identified evidence and questions during two meetings. The discussion was used to generate seven statements with relevance to clinical practice. In conclusion, older adults with symptomatic OA present multiple concomitant issues, including other diseases, marked pain, poly-pharmacy, and often poor psychological and/or socioeconomical status. According to the above-described evidence, it is crucial that the approach to those patients is multidisciplinary and based on the use of dedicated tools. A combination of exercise, mechanical support and properly selected analgesic treatment will greatly help the management of the OA patient, improving at the same time his/her quality of life.

We analyzed for the first-time hospitalizations and costs for hip fractures in the elderly Italian population at the regional level from 2007 to 2014. The number of fractures and the overall costs increased, mainly due to people aged > 85 in all the Italian regions, although at different rates. We aimed at evaluating the burden of hip fractures in elderly Italian population at the regional level. We analyzed national hospitalizations records 2007–2014 to compute standardized hospitalizations rates (SHR) due to hip fractures per 10,000 inhabitants at the regional level and average annual percent change (AAPC), along with related costs. Hip fractures occurred in people over 65 years increased from 89,601 to 94,525 over 8 years. The overall increase in the number of hospitalizations is attributable only to people aged ≥85. Actually, in the 65–74 and 74–84 age groups, total hospitalizations decreased from 13,396 to 12,268 and from 40,733 to 37,786 respectively, while they increased from 35,472 to 44,471 in people aged ≥85 (women = 28,605 and men = 6,867 in 2007; women = 34,636 and men = 9,835 in 2014). Almost 50% of hip fractures were found to have been experienced by patients aged 85 or older in 2014 (with women ≥ 85 representing 36.6% of total fractures), in accordance with the higher prevalence of osteoporosis in this age group. Fractures increase in people aged ≥ 85 was two-folds higher in males (AAPC: + 5.0%; P > 0.05) than in females (AAPC: + 2.6%; P > 0.05). Increases in the number of hospitalizations and related costs were observed for all the regions, with the only exception of Lazio (AAPC: − 4.6%; P

Background Primary trapezio-metacarpal osteoarthritis can be painful and disabling. Surgical treatment is used when conservative treatment, such as splinting or oral analgesics, fails. The purpose of this study was to report the long-term outcomes obtained in 40 patients (50 thumbs) surgically treated for thumb osteoarthritis by trapeziectomy and ligament reconstruction without tendon interposition. Materials and methods Forty patients (50 thumbs), with severe trapezio-metacarpal osteoarthritis, surgically treated by trapeziectomy and ligament reconstruction without tendon interposition were reviewed after an average follow-up of 8 years. All patients were women. At follow-up, clinical results were evaluated on the basis of the DASH score, possible presence of pain and the following criteria: palmar abduction of the thumb, carpometacarpal joint opposition of the thumb (Kapandji), extension of the metacarpophalangeal joint and strength of the hand. Results The DASH score improved from 42.65 (preoperatively) to 16 (at follow-up), and most patients were asymptomatic. Palmar abduction of the thumb averaged 57 mm. Carpometacarpal joint opposition averaged 8.8. Metacarpophalangeal extension was abnormally increased in 86% of the cases. The strength of the operated hand was comparable to the contralateral side in 46 cases. Radiographic examinations showed a slight proximal migration of the first metacarpal bone (

Aim The aim of this study is to evaluate the relationship between OPG and the degree of glycaemic control in a population of elderly subjects. Methods and results Data presented included 172 elderly subjects, of whom 107 were hospitalized for a hip fracture and 65 were non fractured outpatients. All participants received a multidimensional geriatric evaluation and underwent blood sampling. HbA1c, OPG, CTX and OC were measured and DXA scans were performed. Carotid intima-media thickness (IMT) was measured in all outpatients. Diabetic patients had more comorbidities, higher mean values of lumbar spine and femoral neck BMD and T-score, lower circulating levels of OC and CTX, and higher circulating levels of OPG compared to non-diabetic subjects. OPG was directly correlated with HbA1c. This association was most evident in non-fractured elderly subjects. Moreover, diabetic patients with IMT>1.5 mm had greater mean values of OPG than non-diabetic subjects with high IMT and than elderly subjects with IMT Conclusions Diabetic patients have reduced circulating levels of OC and CTX, and elevated serum levels of OPG, suggesting a state of low bone turnover. Reduced bone turnover causes an increase of BMD and could lead to a poor bone quality. OPG and HbA1c were directly correlated and OPG mean values were higher in diabetic patients with poor glucose control. Diabetic osteopathy could be considered a late complication of T2DM, directly related with the degree of glucose control and the duration of the disease.

Background: Osteosarcopenia is a recently identified condition caused by the coexistence of osteoporosis and sarcopenia that affects the frail elderly population, leading to an increased risk of falls and fractures. Given the recent socio-economic interest associated with osteosarcopenia, the aim of this meta-analysis is to provide an overview of the factors potentially involved in its pathogenesis, assessing its population type, prevalence, and associated variables. Methods: A comprehensive systematic search for relevant studies, published from 2015 to 2020, was performed by using PubMed, EMBASE, and Cochrane databases. We analysed the variables of age, vitamin D, handgrip, and T-score in four different groups: healthy, osteopenic–osteoporotic, sarcopenic, and osteosarcopenic. Results: A total of 6504 patients from 16 studies were included in the final meta-analysis. The analysis of the individual variables reveals a statistically significant correlation between the handgrip test data and T-score (p < 0.001). Conclusions: The correlation between T-score values and handgrip strength suggests a new potential parameter in the development of predictive models that could be used in clinical practice, highlighting its importance for the diagnosis of osteosarcopenia.

Background: In this work, we aimed to establish a clinical target in the management of knee osteoarthritis (KOA) and to propose good clinical practice (GCP) statements for carrying out a treat-to-target strategy. Methods: A steering committee of seven experts had formulated a provisional set of recommendations that were exposed for discussion and modification to a technical expert panel (TEP) of 25 multidisciplinary experts from Europe, North America, South America and Asia. The level of evidence and strength of each recommendation was discussed. The TEP formulated overarching principles and GCP statements based on the level of agreement for each item with a vote using a 10-point numerical scale. Results: Two overarching principles and 10 GCP statements were formulated by the TEP. These GCP statements suggest: treatment should achieve clinical improvement bringing the patient to the Patient Acceptable Symptom State (PASS); pharmacological and nonpharmacological treatment should begin as early as possible, with an early diagnosis of symptomatic KOA; the patient should be evaluated every 3–6 months; risk factors of KOA progression should be identified and managed with patients at the beginning of the treatment and monitored regularly; treatment should be adapted according to patient phenotype and disease severity; healthy lifestyle must be promoted and monitored. The level of agreement average ranged from 8.7 to 9.6 on scale. Conclusions: The proposed overarching principles and GCP statements have the aim of involving patients, general practitioners and multidisciplinary specialists in sharing a therapeutic treat-to-target strategy for KOA management based on the best evidence and expert opinions.

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Osteoporosis is currently considered a skeletal disease characterized by a diminished resistance of bone tissue, which predisposes to a greater risk of fractures. This disease, which affects mainly postmenopausal women, is constantly increasing, especially owing to a longer life-span; reliable epidemiological studies have reported that all over the world there are more than 200 million osteoporotic subjects. Osteoporosis is evaluated by calculating bone mineral density (BMD), analyzing bone quality, and estimating risk factors. BMD is calculated using DEXA (Dual-Energy Xray Absorptiometry), QCT (Quantitative Computed Tomography), and QUS (Quantitative Ultrasonography). The analysis of bone quality includes various factors such as microarchitecture, geometry, bone turnover, mineralization, and the properties of collagen and the extracellular matrix. The most common risk factors for osteoporosis are hereditary predisposition, sex, age, early menopause, smoking, use of corticosteroid drugs for long periods of time, malabsorption, and endocrine disorders. The orthopedic surgeon is increasingly more involved in treating so-called fragility fractures caused by osteoporosis. The sites most frequently affected by these fractures are the femoral neck, the proximal part of the humerus, the vertebrae, and the distal part of the radius. Currently, fragility fractures are often treated surgically by using devices, which allow obtaining stable internal fixation in a less resistant bone and early joint mobilization. In fact, the study of the most recent surgical devices has been oriented toward finding materials with osteoconductive and osteoinductive properties, which can be used while respecting and supporting the bone’s regenerative capacity. As far as medical treatment of osteoporosis is concerned, the most widely used drugs are bisphosphonates, peptides of the parathyroid hormone, selective modulators of estrogen receptors, and strontium ranelate. At present, the researchers involved in this problem are studying new drugs which not only treat the disease but can also be used to support the healing process of fractures in osteoporotic patients including those treated surgically, thereby enhancing the bone tissue’s regenerative potential and improving its mechanical properties.