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Klippel-Trenaunay syndrome is a rare congenital malformation which may be associated with macrodactyly. The main problem is the need for custom-made shoes. We describe the case of a female newborn affected by Klippel-Trenaunay syndrome, with a larger and longer right foot; the difference increased progressively and, at 5 years of age, the right foot was 50% larger and 38% longer than the left one. Due to the progression of the deformity, reduction surgery was advised to reduce the foot’s width. Resection of the second ray and 2nd cuneiform was performed. The result was excellent and there were no complications during a 10-year follow-up period with a decrease of width and length difference to 10% and 4%, respectively, in comparison to the contralateral foot. There were no gait anomalies. Abnormal foot width and length represented the main problems and guided the surgical strategy. Second ray resection was effective, without complications and with a good long-term functional outcome. Possibility of wearing fashionable conventional shoes without insoles was achieved to the patient’s satisfaction

Resumo Objetivo Dados experimentais ultrassonográficos sugerem que o estresse oxidativo desempenha um papel importante na patogênese das tendinopatias. No entanto, essa hipótese permanece especulativa em humanos, dado que faltam dados clínicos para comprová-la. Recentemente, uma nova metodologia permitiu quantificar o estresse oxidativo in vivo medindo a concentração de hidroperóxidos de compostos orgânicos, que tem sido utilizada como um marcador relacionado ao estresse oxidativo em várias condições patológicas e fisiológicas. Dada a confiabilidade desse teste e a falta de informação em sujeitos com tendinopatias, o objetivo do presente estudo foi avaliar o status de estresse oxidativo em jogadores profissionais de elite com e sem características ultrassonográficas de dano tendinoso. Métodos Em 73 jogadores de elite foram avaliados parâmetros metabólicos e o estresse oxidativo foi medido por meio de um teste específico (expresso como unidades U-Carr). Por isso, foi realizada uma avaliação ultrassonográfica dos tendões de Aquiles e patelar. Resultados Não foram observadas relações significativas entre parâmetros metabólicos e biomarcadores de estresse oxidativo. Os tendões de Aquiles e patelar mostraram um padrão ecográfico normal em 58 atletas, e anormalidades ultrassonográficas em 15. Os atletas com alterações, em comparação com aqueles com quadro normal, apresentaram níveis significativamente mais elevados de U-Carr (p = 0,000), índice de massa corporal (IMC) (p = 0,03) e eram mais velhos (p = 0,005). A diferença nos valores de U-Carr entre os sujeitos permaneceu significativa também após ajuste por idade e IMC. Conclusão Os resultados deste estudo corroboram a hipótese de que as substâncias oxidativas, também aumentadas a nível sistêmico e não apenas a nível local, podem favorecer danos no tendão. Nível de Evidência IV (estudo piloto).

Nonsteroidal anti-inflammatory drugs (NSAIDs) remain the most commonly utilised prophylaxis to reduce arthrofibrosis (AF) related to the inflammatory response which leads to a pathological condition called arthrofibrosis. Several NSAIDs have shown to be effective, although postoperative indomethacin has been the historical gold standard. More recently, credit has been given to the use of COX-2 selective inhibitors, due to concerns over gastrointestinal effects, as peptic ulcers, with non-selective COX. However, to date, few studies have compared the therapeutic effects of the two drugs. The aim of this study is to compare the postoperative administration of indomethacin and celecoxib in patients with diagnosis of AF treated with arthroscopic lysis and evaluate joint recovery. In this prospective study, 42 patients were diagnosed with hip, knee and elbow residual AF. The inclusion criteria were age > 18 years and a diagnosis of residual AF, following exposure to a previous traumatic event or surgical treatment; exclusion criteria were patients with 35 or < 18 kg/m2, affected by peripherical neuropathies and presence of heavy functional limitations, active infection, complex regional pain syndrome diagnoses. All patients underwent to arthroscopy, operated by a single surgeon with the same team in the same clinic and postoperatively were randomly divided into two groups, one treated with indomethacin, and the other with celecoxib. Of the patients examined, the following parameter was considered: joint range of motion (ROM) preintervention and post-intervention at 3 months and after 12 months. ROM was analysed with Student t test. The comparison of the ROM between both the 3 months postoperative groups has been shown to be not statistically significant. On the other hand, after 1 year, t-Student test referred to preoperative condition was significantly in favour of the group treated with celecoxib (p = 0.02). Lastly, neither celecoxib nor indomethacin showed any gastrointestinal side effects.

The efficacy of platelet-rich plasma in the treatment for Achilles tendinopathy is debated. Therefore, it is important to know which factors, related to the subjects and/or the disease, are associated with positive or negative outcomes. Aim of this study was to evaluate in a large cohort of patients with Achilles mid-portion tendinopathy which variables were independently associated with a positive outcome after platelet-rich plasma treatment. Eighty-four subjects with Achilles tendinopathy were evaluated by means of VISA-A score and ultrasound and treated with a single platelet-rich plasma injection once a week for 3 weeks. Afterward, a rehabilitation program, based on eccentric training, was implemented. At 3 and 6 months, the relationship between the mean VISA-A score and the following putative predictors was evaluated: sex, age, physical activity, sport, smoking, metabolic risk factors, BMI, symptoms duration, tendon damage, neovessels, adherence to eccentric training. Finally, the percentage of clinically evident positive outcomes (defined as an increase in VISA-A score ≥ 20 points) related to each variable was computed. At final follow-up, using the General Linear Model for Repeated Measures procedure, male sex (0.02), age ≤ 40 (0.05) and adequate eccentric training (0.02) were found to be independently associated with a significant increase in the mean VISA-A score. Moreover, the clinically evident positive outcomes, as previously defined, were significantly associated with male sex (0.01), age ≤ 40 (0.000), BMI ≤ 25 (0.001), symptoms duration ≤ 12 months (0.02) and good adherence to eccentric training (0.004). Younger age, male sex and good adherence to eccentric training can be considered predictors of better results after platelet-rich plasma therapy in Achilles tendinopathy

Background Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted. The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy. Methods In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2). Discussion Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery. Trial registration ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016.

Stress fractures are common injuries caused by repetitive micro-traumas of the bone. Nowadays, they are widespread amongst the athletes and their treatment is mostly based on the limitation of physical activity, the application of ice, and the administration of analgesics and anti-inflammatory drugs. We present a case of a 26-year-old woman who reported a mono-cortical stress fracture in the anatomical neck portion of the right femur treated with Clody® 200 mg/4 ml. The patient is an amateur runner who complained a progressive pain and functional limitation of the hip joint. No history of recent trauma was present as well as X-rays evidence of fractures. A subsequent magnetic resonance imaging study showed the presence of a mono-cortical stress fracture in the anatomical neck portion of the right femur. The patient was treated with 1 vial of Clody® 200 mg/4 ml a day for 7 days, following 1 vial every 15 days for 2 months without any further therapy as well as physical activity limitation, showing a faster clinical and radiological recovery compared with the most of therapies described in the literature. Concerning our positive experience, the purpose of this study is to give a starting point for further research in order to enlarge the number of studies about that specific approach.

Dual Mobility (DM) implants provide greater stability especially in Revision Total Hip Arthroplasty (R-THA) when compared to primary THA. Aim: to identify the current evidence regarding outcomes of DM in R-THA when compared to fixed-bearing (FB) implants. Review in accordance with PRISMA guidelines. Structured electronic searches. Primary outcome measure: dislocation rate following R-THA. Secondary outcome measures: implant survival, aseptic loosening, infection rate. Studies' methodology quality assessed using MINORS criteria. All articles published from 2016 to December 2019 included. 1777 R-THAs were reported (49.9% with DM acetabular component, 50.1% with FB component). Sample size: 67-426 patients. Mean age: 57-73. Mean follow-up period: 12-60 months. Significant risk ratio of 1.08 [1.05, 1.12] (95% CI, I2 = 37%, P DM implants are beneficial in R-THA when compared to FB implants. However, one needs to balance the benefits of using DM implant considering the patient’s clinical conditions and the costs involved.

Nowadays venous VTE represents an important perioperative and postoperative complication in patients undergoing elective Major Orthopedic Surgery (MOS). There are significant discrepancies between clinical practice, international recommendations, and published guidelines. Although thromboembolic events may be less common these days than in the past, they can still lead to serious medical complications. Therefore, most patients undergoing MOS procedures are provided with one of the thromboprophylactic treatments. The optimum timing of LMWH administrations remains debated. Customized structured electronic searches in PubMed and Cochrane database. Meta-Analysis, Randomized Controlled Trials, Systematic Reviews on different strategies of the use of LMWH for MOS. Studies on prophylactic regimens showed that subcutaneous LMWH plays a key role in the management of thromboprophylaxis in MOS. However, some controversies still stand. Among those most relevant, it remains unclear whether to start thromboprophylaxis before or after MOS to better balance the risks of clotting and bleeding. With regards to different times of LMWH administration, there is no convincing evidence that starting prophylaxis 12 hours preoperatively is associated with lower risks of VTE compared to prophylaxis started 12 to 24 hours postoperatively. Furthermore, it seems that the most safe and efficient LMWH regimen is the one called “Just-in-time” (LMWH started 6 hours post-op).

the worldwide spread of the 2019 novel coronavirus (SarS-cov-19) has profoundly affected the way daily healthcare procedures are performed Italy had a large number of confirmed cases of Coronavirus disease (COVID-19) and related fatalities Since the beginning of this pandemic, many changes in routine clinical and surgical activity have been made and are described in this short manuscript © 2020 Edizioni Minerva Medica

Introduction: Running is a very popular modality of physical activity, which may help to lose weight and normalize pathological values of blood parameters in subjects suffering from metabolic disorders. Given that both overuse and metabolic pathologies are responsible for the onset of tendon damage, aim of the present study was to evaluate whether the first group of pathogenetic factors or the latter was more responsible for mid-portion Achilles tendinopathy. Method: Thirty-six and 28 subjects with and without mid-portion Achilles tendinopathy, who were regular runners and started running for metabolic disorders, were enrolled, respectively. Information about body weight and blood parameters at baseline was collected. The characteristics of running practice, dietary habits and anthropometric measures were registered. An ultrasound evaluation of the tendon was performed, and the blood metabolic parameters were evaluated. Results: The amount of running years and mileage was equivalent in both groups. A similar weight loss was observed; the subjects with mid-portion Achilles tendinopathy showed a worse metabolic profile (Hb1aC%, p = 0.008; total cholesterol, p = 0.04; HDL cholesterol, p = 0.003; triglycerides, p = 0.009). Conclusions: These findings suggest that the subjects with less evident positive effects of running on metabolism are more exposed to the onset of mid-portion Achilles tendinopathy.

Introduction Assessing the outcomes of Platelet Rich Plasma (PRP) treatment in Achilles Tendinopathy (AT) may prove difficult due to several methodological reasons. For example, given that the simple mean of VISA-A score is just the result of positive, negative or null values, this may provide incomplete information, and therefore the size of individual changes can remain unknown. On the contrary, calculating the score changes in each subject after treatment would allow a more appropriate evaluation of the clinical results. However, this method has been applied only to few small-scale studies. Therefore we performed a retrospective study aiming to determine: (1) are the percentages of positive outcomes of the present research comparable to those of previous studies performed in different settings? (2) Is there a relationship between the size of increase of the clinical score and the patient satisfaction? Hypotheses The percentages of positive outcomes of the present research are comparable to those of previous studies performed in different settings. Material and methods This is a retrospective observational study. Eighty-four patients submitted to PRP treatment for mid-portion AT were enrolled. Pain and function were evaluated by means of VISA-A scale. Besides the mean, in each subject the pre- and post-treatment difference of VISA-A score was computed and the outcome was defined clinically no detectable, detectable and evident according to the increasing values of the score (0 to 9 points, 10 to 19, and ≥ 20 points change, respectively). The Likert's scale for the patients satisfaction was also used. Results The mean VISA-A increased significantly after treatment (from 50.1 ± 9.1 at baseline to 63.7 ± 13.8 at 3 months (p = 0.00001) and 67.2 ± 14.1 at 6 months (p = 0.00001)). At 3 and 6 months the subjects belonging to the prefixed categories were 15, 45, 24 and 19, 36, 29, respectively. Moreover, large discrepancies were observed between the size of increase of the clinical score and patients satisfaction, mainly for intermediate increases of the score. Discussion The percentages of positive outcomes found in this study are slightly lower than those reported in literature. The different patients expectations about the efficacy of the therapy can explain the discrepancies between the size of increase of the clinical score and the individual satisfaction. In comparison to the simple mean, the individual changes of VISA-A score allow a proper evaluation of the outcomes. The research shows that discrepancies can be present in the percentage of positive clinical outcomes between different studies. The size of increase of the clinical score does not always match patient satisfaction. Level of proof IV retrospective study without control group.

Objective Femoroacetabular impingement (FAI) is a condition that has been increasingly recognized as a source of hip pain and a possible risk factor to early development of hip osteoarthritis (OA). To our knowledge, the use of HA in the treatment of femoroacetabular FAI has been investigated only by two studies, both using a high molecular weight HA. The aim of this study was to evaluate the efficacy of two weekly injections of an hexadecylamide derivative of HA (HYADD4-G, HYMOVIS, Fidia Farmaceutici) in FAI. Methods All patients received two weekly intra-articular injections of Hymovis at baseline and after 7 days. Clinical and functional assessments were performed at baseline and was repeated after 1, 3, 6 and 12 months. Functional measures included visual analogue scale (VAS) for pain, Harris Hip score (HHS), Lequesne Index (LI), Tegner activity level scale (TALS) and monthly consumption of nonsteroidal anti-inflammatory drugs (NSAIDs). Results Twenty-one hips (19 patients, 2 bilateral cases) were treated. The variables VAS, HHS as well as Lequesne improved significantly from T0 to T4 (at 12 months) with the best improvement between T0 and T1. At the same time, a reduction in NSAIDs monthly intake was registered. On the other hand, a significant improvement in Tegner scale was not observed. No adverse events were registered. Conclusion This study states that one cycle of HYADD4-G could be a safe and effective treatment in patients with FAI, showing significative results in term of pain control as well as hip functionality and quality of life up to 1 year.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Currently, there is no general consensus about the management of osteoporotic vertebral fractures (OVF). In the past, conservative treatment for at least one month was deemed appropriate for the majority of vertebral fractures. When pain persisted after conservative treatment, it was necessary to consider surgical interventions including: vertebroplasty for vertebral fractures with less than 30% loss of height of the affected vertebral body and kyphoplasty for vertebral fractures with greater than 30% loss of height. Currently, this type of treatment is not feasible. Herein we review the characteristics and methods of operation of three of the most common percutaneous vertebral augmentation systems (PVAS) for the treatment of OVF: Vertebral Body Stenting(®) (VBS), OsseoFix(®) and Spine Jack(®). VBS is a titanium device accompanied by a hydraulic (as opposed to mechanical) working system which allows a partial and not immediate possibility to control the opening of the device. On the other hand, OsseoFix(®) and Spine Jack(®) are accompanied by a mechanical working system which allows a progressive and controlled reduction of the vertebral fracture. Another important aspect to consider is the vertebral body height recovery. OsseoFix(®) has an indirect mechanism of action: the compaction of the trabecular bone causes an increase in the vertebral body height. Unlike the Vertebral Body Stenting(®) and Spine Jack(®), the OsseoFix(®) has no direct lift mechanism. Therefore, for these characteristics and for the force that this device is able to provide. In our opinion, Spine Jack(®) is the only device also suitable for the treatment OVF, traumatic fracture (recent, old or inveterate) and primary or secondary bone tumors.

Rationale: Posterior sternoclavicular joint dislocations (PSCJDs) are particularly rare injuries, accounting for 3% to 5% of sternoclavicular joint dislocations. With very few cases reported in the literature, these injuries are often misdiagnosed and imaging is not always clear, thus making physicians often unaware of them. The present case report aims to investigate a rare case involving a clavicular Salter-Harris II fracture with associated posterior displacement of the diaphysis, a term coined a “pseudodislocation.” Patient concerns: We present a case of a 14-year-old adolescent who sustained a traumatic injury to the shoulder while falling during a soccer match. His main concern was about recovery time and the return to daily life activities. Diagnoses: Multiple imaging studies imaging (X-rays, computed tomography, magnetic resonance imaging) revealed a Salter-Harris II fracture of the right clavicle with posterior displacement of the diaphysis. Interventions: The patient underwent primary surgery to reduce the fracture, using an articular locking compression plate, and secondary surgery to remove the hardware. Outcomes: Following the removal of the hardware at 60 days after the initial surgery and a number of cycles of physiotherapy the patient reported a pain-free range of motion with slight limitation at extremes. Full return to recreational and everyday life activities were achieved at 3 months from the initial surgery. Lessons: The PSCJDs are challenging injuries, as they are surrounded by delicate structures inside the mediastinum. Attention must be taken while diagnosing and treating these injuries as the risk of complications and iatrogenic injuries is high. To the author's knowledge, this case is one of the first of its kind described in the literature where we have a Salter-Harrys type II fracture associated with a posterior pseudodislocation of the lateral clavicle. Given the positive results of the case, we recommend the above-mentioned treatment protocol in PSCJD with associated Salter-Harris II fractures in adolescent patients.

Background The aim of this retrospective study was to evaluate the outcome of patients with intra-articular calcaneal fractures treated using a minimally invasive locking nail (Calcanail®). Methods Between January 2016 and April 2017, 15 patients (9 men and 6 women) with a calcaneal fracture were consecutively treated with Calcanail®. The Bohler angle was recorded on standard X-rays pre- and post-operatively. The articular reduction of the posterior facet was evaluated with the Goldzak index in a CT scan 3 months post-operatively. The mean age of the patients was 53 years (range, 24–78). Mean final follow-up was 18 months (range, 12–24). Results Six fractures were classified as Sanders II, 7 as Sanders III and 2 as Sanders IV. In 13 out of the 15 patients treated, the post-operative Bohler angle was of more than 20°. Goldzak index was deemed as excellent in 73.5% of the cases (11 patients), good in 20% of cases (3 patients), and poor in 6.5% (1 patient). Post-operative mean AOFAS score was 85 (range, 60–96). Conclusions The Calcanail® provides good restoration of the subtalar joint and the calcaneal angles with the advantages of a minimally invasive approach. It was effectively used in Sanders types II and III, even in the presence of poor cutaneous conditions.

The combined use of hyaluronic acid and platelet-rich plasma has never been reported in the treatment for osteoarthritis. Aim of this paper was to evaluate the efficacy of this association and to compare retrospectively these results with those of a cohort of patients treated with platelet-rich plasma only. Subjects with mild-to-moderate knee osteoarthritis were enrolled. After clinical and ultrasound evaluation, patients received a weekly intra-articular injection of 2 ml of hyaluronic acid added with 2 ml of platelet-rich plasma for 3 weeks. Follow-up was performed at 1, 3, and 6 months. The same clinical parameters were retrospectively collected from a cohort of patients treated with 4–5 ml of platelet-rich plasma only. Forty knees were treated in both groups. The intra-group comparison showed a significant improvement in clinical and functional outcomes at 1, 3, and 6 months, while the infra-group comparison did not show any significant difference. The association of platelet-rich plasma + hyaluronic acid has the same efficacy of platelet-rich plasma only, administered in higher volume. We may infer that hyaluronic acid works synergically and improves the activity of several molecules contained in platelet-rich plasma.

Background Chronic ankle instability is defined by an instability lasting more than 6 months, in those cases where a comprehensive conservative treatment fails a surgical stabilization is required. Several surgical techniques have been proposed for the management of the chronic lateral instability of the ankle and even after 50 years, the Brostrom–Gould technique is still considered the gold standard for the treatment of this pathology. Recently, many authors have developed completely arthroscopic lateral ligament repair and the use of these procedures is rapidly increasing. The aim of this review is to provide an updated overview of open and new arthroscopic lateral ligament repair techniques in order to summarize and compare the effectiveness of these strategies. Methods A systematic literature review using PubMed/Medline databases was performed (July 1972–July 2015). Clinical results, satisfaction rate and complications of both patient populations were recorded and statistically analyzed. Results The total ankles treated with an open Brostrom ATFL repair in the 13 studies was 505 with a mean follow up of 73.4 months (range 9 months–27.9 years). Postoperative AOFAS score was reported in 11 studies, with a mean value of 90.1 (range, 60–100), patient's satisfaction rate was 91.7%. Surgery-related complications occurred in 40 (7.92%) out of 505 treated ankles. The total number of ankles treated within the 6 arthroscopic studies was 216 with a mean follow up of 37.2 months (range 6 months–14 years). Five studies reported a mean postoperative AOFAS score of 92.48 (range, 44–100) with a patient's satisfaction rate of 96.4%. Surgery-related complications were observed in 33 (15.27%) cases. Conclusions The results of this review show the excellent efficacy of open and arthroscopic surgical procedures in the treatment of the chronic ankle instability. The higher complication rate of arthroscopic procedures respect to the open ones represents the major issue: however, this does not seem to affect the patient's satisfaction. Because of statistical heterogeneity observed no definitive conclusions can be statistically drawn. Finally, to definitively validate the effectiveness of arthroscopic procedures prospective and comparative studies are needed.

PURPOSE:Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages.METHODS:Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months).RESULTS:In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated.CONCLUSIONS:The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance.LEVEL OF EVIDENCE: III.

A fit 26 year-old-man presented to our Department with an open fracture of the left tibial shaft (AO 42-C3). The fracture was initially treated with an External Fixator, which was replaced by an intramedullary Grosse Kempf nail after 4 months. In the following year he developed an atrophic non-union and we witnessed the increasing bone resorption at the fracture site which led to the nail breakage. An accurate CT pre-operative planning was made and a revision surgery was successfully performed: the broken nail was removed and intercalary allograft reconstruction was made, using a compressible intramedullary nail. Whereas in literature it is well described how intercalary allografts can be used to fill the massive diaphyseal defects after tumor resections, we assumed it could also be an adequate technique to treat a large bone defect at a non-union site.

Background: To evaluate the role of third generation percutaneous vertebral augmentation systems (Spine Jack ® ) as alternative to the corpectomies and expandable cages replacement (X-Core ® Adjustable VBR System) in the treatment of vertebra plana (VP) as complication of the osteoporosis vertebral fracture (OVF). Methods: Spine Jack ® is a new device for mechanical kyphoplasty (MK). It is a titanium implant designed to restore the height of the vertebral body in OVF, primary or secondary bone tumors, or traumatic fractures. The X-Core ® adjustable VBR System is a vertebral body replacement device indicated for use in the thoracolumbar spine (T1 to L5). The preoperative radiographic exams, computed tomography (CT), and magnetic resonance imaging (MRI) were performed in all cases. Clinical outcome measures included preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale pain score (VAS), neurologic examination, complications, estimated blood loss, and operating time. Postoperative radiographic evaluations were made at 1, 6, and 12 months. Results: The anterior and middle column reconstruction by Spine Jack represents a valid alternative to the corpectomy in the patients affected by VP, especially in case elderly and/or high operative risk. In case of Spine Jack use, the correct indications must be respected: the hyperintense signal in STIR MRI sequences to the level of the fractures must be present. The eventual posterior spinal cord compression represents a relative contraindication. In case it would be superior to 1/3 and 2/3 respectively in case of fractures level above and below the spinal cord, a direct posterior spinal cord decompression must be performed. Conclusions: Avoiding the corpectomy, it is possible to reduce the operating time and the associated risks, as well as reducing blood loss.

Distal humerus fractures are uncommon injuries requiring specific clinical and radiographic analysis in order to plan the optimal therapeutic strategy. In particular, bicolumnar distal humerus fractures (Type A2, A3 and C) are complex fractures. In the last years, double plating fixation became the standard treatment: this procedure helped surgeons to obtain a stable and anatomical fixation and an early mobilization, which is the main outcome for obtaining valuable functional results. In this retrospective study, we evaluated the use of open bicolumnar 90-90 plating for fixation of acute fragility fractures of the distal humerus in elderly patients, using the olecranon osteotomy as surgical approach.

Between the 80% and 90% of vertebral fractures in over 65 years people are due to osteoporosis. Over the 30% of patients affected by vertebral osteoporosis fractures needs of surgical treatment and the 12% presents complications requiring an invasive surgical approach. We report an unusual case of spontaneous corpectomy and anterior arthrodesis occurred in a patient suffering from Ankylosing Spondylitis. This event invites us to reflect about the magnitude of the biological power of the bone healing, even in adverse conditions.

Study Design Retrospective study. Objective The interlaminar approach represents the standard procedure for the surgical treatment of lumbar disk herniation (LDH). In the case of disk herniations in the “hidden zone,” it could be necessary to perform laminotomies or laminectomies and partial or total facetectomies to remove the herniated fragment, thus leading to iatrogenic instability. The objective of the study is to evaluate the translaminar approach, in terms of the results, safety, and efficacy compared with the standard approach. Methods Since February 2010, 38 patients (26 men and 12 women; mean age 50.9 years, range 31 to 78 years) with LDH and migration into the hidden zone underwent a microdiskectomy by the translaminar approach. Using a micro-diamond dust-coated burr, a translaminar hole (8 ± 2 mm) was made, with subsequent exposure of the involved root and removal of the fragment. A clinical follow-up was performed at months 1, 3, 6, and 12 using the visual analog scale and the Oswestry Disability Index. All patients were evaluated according to the Spangfort score. Postoperative radiographic evaluations were done at 1, 6, and 12 months (dynamic radiographic studies done at 6 and 12 months). Results In over 60% of cases, L4–L5 was the involved disk. The visualization of the roots was successfully achieved through a translaminar approach. No laminotomies, laminectomies, or partial or total facetectomies were performed. The flavum ligament was always spared. A severe intraoperative bleeding episode occurred in 5% of the cases, due to involvement of the epidural veins, but it did not result in prolonged operative time (mean duration 60 ± 10 minutes). The patients showed a gradual resolution of the back pain and a progressive resolution of the radicular pain and the neurologic deficits. No sign of radiographic instability was documented during the follow-up. No infections, dural tears, or spinal cord injuries occurred. No revision surgery was performed. Conclusion The translaminar approach is the only tissue-sparing technique viable in case of cranially migrated LDH encroaching on the exiting nerve root in the preforaminal zones, for the levels above L2–L3, and in the preforaminal and foraminal zones, for the levels below L3–L4 (L5–S1 included, if a total microdiskectomy is not necessary). The possibility to spare the flavum ligament is one of the main advantages of this technique. According to our experience, the translaminar approach is an effective and safe alternative minimally invasive surgical option.

This study aimed to check the effect of zoledronic acid (ZA) at subtoxic dose on human osteoblasts (HOs) in terms of cell viability, apoptosis occurrence, and differentiation induction. ZA belongs to the family of bisphosphonates (BPs), largely used in the clinical practice for the treatment of bone diseases, often associated with jaw osteonecrosis onset. Their pharmacological action consists in the direct block of the osteoclast-mediated bone resorption along with indirect action on osteoblasts. HOs were treated choosing the highest limit concentration (10−5 M) which does not induce toxic effects. Live/dead staining, flow cytometry, mitochondrial membrane potential assay, osteocalcin western blotting, gp38 RT-PCR, collagen type I, PGE2, and IL-6 ELISA assays were performed. Similar viability level between control and ZA-treated samples is found along with no significant increase of apoptotic and necrotic cells in ZA-treated sample. To establish if an early apoptotic pathway was triggered, Bax expression and mitochondrial membrane potential were evaluated finding a higher protein expression in control sample and a good integrity of mitochondrial membrane in both experimental points. Type I collagen secretion and alkaline phosphatase (ALP) activity appear increased in ZA-treated sample, osteocalcin expression level is reduced in ZA-treated cells, whereas no modifications of gp38 mRNA level are evidenced. No statistical differences are identified in PGE2 secretion level whereas IL-6 secretion is lower in ZA-treated HOs with respect to control ones. These results highlight that ZA, delaying the osteoblastic differentiation process versus the osteocytic lineage, strengthens its pharmacological activity enhancing bone density. The knowledge of ZA effects on osteoblasts at subtoxic dose allows to improve therapeutic protocols in order to strengthen drug pharmacological activity through a combined action on both osteoclastic and osteoblastic cells.

OBJECTIVE: Rotator cuff tendon tears increase with age, but no study has specifically addressed prevalence changes in women from premenopause to postmenopause. The aims of this study were to evaluate the prevalence of rotator cuff asymptomatic tears in postmenopausal women and to study their relationship with anthropometric and metabolic measures. METHODS: Premenopausal and postmenopausal women who were free from shoulder pain/functional impairment were enrolled. Body mass index (BMI), fasting glucose, triglycerides, total cholesterol, and high-density lipoprotein (HDL) cholesterol were evaluated. Both shoulders were examined by ultrasound imaging. For the purposes of this study, only full-thickness tears (classified as small, large, or massive) were taken into account. RESULTS: The prevalence of full-thickness tears (mainly localized in the supraspinatus tendon of the dominant side) was significantly higher in the postmenopausal group (8.9\% vs 3.1\%), with small, medium, and large tears in 60\%, 20\%, and 20\% of cases, respectively. In women with tears, intragroup comparison showed significantly higher values for BMI and fasting glucose, and lower levels of HDL cholesterol; no difference was found for triglycerides and total cholesterol in premenopausal and postmenopausal women, respectively. On multiple logistic regression analysis, the probability of detecting a tear in both groups was positively related to high values of BMI and lower levels of HDL cholesterol. CONCLUSIONS: The prevalence of asymptomatic full-thickness tears is increased in the postmenopausal period, and there is an association between tears and metabolic disorders. Because asymptomatic tears have a great potential to evolve into symptomatic painful shoulder, a precocious discovery of this pathology may allow the planning of preventive and therapeutic measures.

BACKGROUND: Treatment recommendations for congenital talipes equinovarus are focused on conservative treatments. OBJECTIVES: The aim of this paper is to present a case report of bilateral congenital talipes equinovarus treated with two short-leg serial casting in combination with osteopathic manipulative treatment. METHODS: A newborn, 12 days old, with severe bilateral congenital talipes equinovarus entered to the Department of Orthopedics at the University of Chieti, Italy. The pediatric orthopedic surgeon applied two single series of short-leg casts, at 12 and 20 days of age. The osteopath scheduled 4 indirect myofascial release techniques sessions. RESULTS: At day 33 the newborn achieved a complete correction of the congenital talipes equinovarus deformity and there was no need to apply a third series of casts. CONCLUSIONS: Results from this single case study create an interesting and clear precedent for considering OMT in future clinical trials. Copyright © 2013 Elsevier Ltd. All rights reserved. KEYWORDS: Clubfoot; Complementary and alternative treatment; Congenital talipes equinovarus; Conservative treatment; Foot; Manipulation; Newborn; Osteopathic manipulative treatment Background: Treatment recommendations for congenital talipes equinovarus are focused on conservative treatments. Objectives: The aim of this paper is to present a case report of bilateral congenital talipes equinovarus treated with two short-leg serial casting in combination with osteopathic manipulative treatment. Methods: A newborn, 12 days old, with severe bilateral congenital talipes equinovarus entered to the Department of Orthopedics at the University of Chieti, Italy.The pediatric orthopedic surgeon applied two single series of short-leg casts, at 12 and 20 days of age. The osteopath scheduled 4 indirect myofascial release techniques sessions. Results: At day 33 the newborn achieved a complete correction of the congenital talipes equinovarus deformity and there was no need to apply a third series of casts. Conclusions: Results from this single case study create an interesting and clear precedent for considering OMT in future clinical trials. © 2013 Elsevier Ltd.

The combined use of low and high molecular weight hyaluronic acid (HA) has never been reported in the treatment of osteoarthritis (OA). The aim of this paper was to evaluate the efficacy of a new hybrid association of both preparations in patients suffering from hip OA and to compare the results with those obtained retrospectively from a cohort of patients treated with high molecular weight HA. Twenty patients with moderate-severe hip OA (grade II–IV according to Kellgren-Lawrence score) were enrolled in the study group. After clinical and functional evaluation (Visual Analogue Scale [VAS] for pain, Lequesne Index, Harris Hip Score), each participant received an intra-articular ultrasound-guided injection of the new HA compound at baseline and after 40 days. The measures were repeated at three and six months. The data collected were retrospectively compared with those obtained in a cohort of 20 patients, matched for sex, age, and severity of hip OA, treated with high molecular weight hyaluronic acid. The intra-group comparison showed a significant improvement in clinical and functional outcomes at three and six months in both cohorts, while the infra-group comparison showed better results in the patients treated with the study compound at six months (VAS at rest, P The present study is the first which demonstrates that a combination of low and high molecular weight HA is effective and safe in the management of patients suffering from hip OA and provides better therapeutic results in comparison to high molecular weight HA. We may infer that both HA preparations work synergically, enhancing their positive activities.

Introduction Overuse, micro-traumas, and impingement, isolated or combined, are the more common etiological factors for rotator cuff tears. Metabolic disorders (diabetes, adiposity, hypercholesterolemia), hypertension, cigarette smoking and a genetic predisposition are considered risk factors. However, no study has compared the prevalence of these risk factors in subjects with bilateral and monolateral tears. Hypothesis Controlateral tears can be observed in patients with symptomatic monolateral rotator cuff lesions, especially in those with comorbidities. Material and methods In patients with symptomatic rotator cuff tear, the controlateral shoulders were evaluated by means of ultrasound imaging. Age, BMI, diabetes, hypercholesterolemia, hypertension, cigarette smoking, work habits were registered. Risk factors in subjects with bilateral tears were compared with those with monolateral lesions. Results Of the 180 subjects recruited, 69 had a tear in the controlateral shoulder. Higher age and BMI values, heavy repetitive work and diabetes were significantly prevalent in these patients. At multivariate analysis, these factors were independently related to a higher probability to detect bilateral tears. Discussion Metabolic risk factors are more heavily involved in presence of bilateral rotator cuff tears, in comparison to monolateral. Type of study Original study. Level of proof IV.

Previous research has shown that plantar fascia and Achilles tendon thickness is increased in diabetes. The aims of present study were to assess whether tendon changes can occur in the early stages of the disease and to evaluate the extent of the influence of body mass index (BMI). The study population included 51 recent-onset type II diabetic subjects, who were free from diabetic complications, divided according to BMI into three groups (normal weight, overweight, and obese). Eighteen non-diabetic, normal-weight subjects served as controls. Plantar fascia and Achilles tendon thickness was measured by means of sonography. The groups were well balanced for age and sex. In all the diabetic subjects, plantar fascia and Achilles tendon thickness was increased compared to the controls (p < 0.001, p = 0.01, p = 0.003, respectively). A significant relationship was found between plantar fascia thickness and BMI values (r = 0.749, p < 0.0001), while the correlation between BMI and Achilles tendon was weaker (r = 0.399, p = 0.004). This study shows that plantar fascia and Achilles tendon thickness is increased in the early stages of type II diabetes and that BMI is related more to plantar fascia than Achilles tendon thickness. Further longitudinal studies are needed to evaluate whether these early changes can overload the metatarsal heads and increase the stress transmitted to plantar soft tissues, thus representing an additional risk factor for foot ulcer development.

Rare side-effects of fluoroquinolone therapy are tendinitis and tendon rupture. Many reports have demonstrated that the concomitant use of corticosteroids, in patients aged 60 years or older, increase the risk substantially. We present a case of spontaneous bilateral Achilles tendon rupture induced by ciprofloxacin and methylprednisolone. A 61-year-old woman was diagnosed with Bronchiolitis Obliterans with Organizing Pneumonia (BOOP) and was started on oral ciprofloxacin 500 mg twice daily for 3 weeks and on oral methylprednisolone 16 mg twice daily for 2 weeks. The diagnosis was made after doctors, rather than stop drug therapy and advise complete rest, had mistakenly prescribed for the woman to undergo physiotherapy and local NSAIDs, thus favoring the onset of tendon ruptures and resulting in surgical and legal implications. Inspired by this case, we also submit a brief review on professional liability in Orthopaedics. Copyright © by BIOLIFE, s.a.s.

Platelet rich plasma has been used in the treatment of tendinopathies, but the sonographic modifications of tendons have received less attention. In this paper we report the results of an ultrasound evaluation, performed during and after plasma injection, in patients with tendinopathy. The sonographic abnormalities and neovascularization were registered in twenty tendons. Three plasma injections (once a week) were performed, and a rehabilitation program was recommended. Pain and patients' satisfaction were evaluated. During the injections plasma spread along the collagen fibers, and an intratendineous cleft produced by the injected volume was observed. At 12 months two tendons regained a normal echotexture, while neovessels were absent in seven. The remaining tendons showed less abnormalities and neovascularization in comparison with baseline. The clinical improvement was earlier and more consistent. The discrepancy between the ultrasound and clinical results may be explained by the peculiar modalities of tendon healing induced by plasma administration.

Relapses are frequently observed in subjects with chronic tendinopathies. Corticosteroid injections are usually performed with positive results, but are uncomfortable for the patient and not free from side effects. The aim of this pilot study is to evaluate the short-term efficacy and tolerability of an occlusive Betamethasone Valerate medicated Plaster (BMVP). Fifteen subjects with relapses of chronic tendinopathies (clinical and ultrasound diagnosis) were enrolled, and treated according to RICE (Rest - Ice - Compression - Elevation) protocol. An BMVP plaster was also applied on the affected tendon. Clinical examination, at baseline and after 7, 14, 21 and 28 days, included pain (VAS at rest and during activities) and functional evaluation. Local side effects on the area and drop-outs were also recorded. Pain, both at rest and during activities, significantly decreased at 28 days (from 3.7 ± 2.7 to 1.1 ± 1.7 [p < 0.01], and from 7.3 ± 1.7 to 3.3 ± 1.4 [p < 0.0000], respectively). Moreover, the patients reported a significant improvement in the functional limitation. Five subjects dropped out of the study. No side effects were reported. The release of the steroid in pharmacologically-active concentrations over 12–24 hours and the good penetration of the drug in subcutaneous tissues explain the positive results. BMVP application may be considered a reliable first therapeutic approach in relapses of chronic tendinopathies.

The need for bone grafting procedures to replace skeletal defects has become more considerable because of increased opportunities to save major bone loss. We report our experience and a critical analysis about the role of bone grafts and bone graft substitutes in prosthetic hip surgery replacement.

The rate of non-union is estimated to be 1.1% to 10% following closed treatment of proximal humerus fracture. Treatment options include revision of fixation and biological enhancement using osteoprogenitor cells, growth factors and scaffolds. However, it is essential to plan the correct type of reconstructive strategy based on the evaluation of the non-union type. The use of the Non-Union Scoring System (NUSS) in this respect can aid the clinician to reach the right decision. We report a case of a 40 years old man who developed an aseptic proximal humerus non-union treated initially with ORIF (Philos(®) plate), bone substitute (Orthoss(®)) and bone morphogenetic protein 7 (BMP-7). Due to implant failure, twelve weeks later the fixation was revised to Titanium Cannulated Humeral Nail. Osseous healing was noted 5 months later.

BACKGROUND:Platelet Rich Plasma (PRP) has shown positive and long-lasting effects in patients with tendinopathies. However, information about age-related differences in the clinical outcome is limited. Aim of this retrospective study was to compare the efficacy of PRP therapy in young and elderly subjects suffering for Achilles tendinopathy.MATERIALS AND METHOD:Patients with recalcitrant non-insertional Achilles tendinopathy were enrolled. Clinical (VISA-A) and instrumental (ultrasonography) data were collected at baseline and after 1, 3, 6, and 12 months. PRP injections (once a week for 3 weeks) were performed in sterile conditions and under ultrasound (US) control.RESULTS:Forty-four subjects (29 young: mean age 39.5 ± 6.9; 15 elderly: mean age 61.5 ± 5.3) were retrospectively evaluated. At baseline, no significant differences were observed in the clinical and US parameters. Throughout the whole length of the study, a significant increase of VISA-A score was seen in both groups (from 50.3 ± 8.8 to 76.1 ± 6.6 in the young group, and from 48.7 ± 7.6 to 61.1 ± 9.4 in the elderly group); however, the infra-groups comparison showed better results in young patients, compared to the aged counterpart.CONCLUSION:Our results show that PRP is less effective in aged people. This finding can be ascribed to several biochemical and biomechanical differences documented in tendons of young and elderly subjects (reduced number and functionality of tenocytes and tenoblasts), which becomes more evident in the long-term tissue healing. However, prospective trials, using different PRP preparations and enrolling a larger number of subjects, are needed to draw more sound and definitive conclusions.KEYWORDS:Achilles tendinopathy; aging; platelet rich plasma; ultrasonography; young

Cervical pain is very frequent in the general population. In clinical practice, plain X-ray and, in selected cases, computed tomography or magnetic resonance imaging, are performed. However, the feasibility and utility of ultrasound examination have been poorly investigated. Aim of the present study was to evaluate whether ultrasound could be useful in the diagnosis of localized cervical pain.Subjects suffering from posterior cervical pain without irradiation to surrounding tissues were enrolled. After clinical and functional evaluation (demographic and anthropometric data, VAS at rest and during neck movements, symptoms duration, and characteristics of pain onset [atraumatic or traumatic]), an ultrasound exam of the cervical spine was performed according to standard protocols.The anatomic structures of the neck district were visualized in 124/127 enrolled patients and pathological features were observed in 58. Significant ultrasound differences were registered between the patients with traumatic and atraumatic onset of neck pain. In the first group, articular effusion, capsular bulging, disalignment and avulsion of the articular apex were observed, whereas in the latter cortical irregularities, osteophytosis, and articular ankylosis were prevalent.Ultrasound examination can be used as diagnostic tool in the evaluation of selected patients suffering from localized cervical pain, particularly in cases of pain due to traumatic injuries.Il dolore del rachide cervicale è molto diffuso, specialmente nella popolazione femminile di mezza età. Diversi esami strumentali vengono comunemente utilizzati, fra i quali la radiografia convezionale e, in casi selezionati, la Tomografia Assiale Computerizzata e la Risonanza Magnetica. Tuttavia, l’utilizzo dell’esame ultrasonografico è stato raramente riportato in letteratura. Scopo del presente studio èquello di valutare l’utilità dell’ecografia nella diagnosi del dolore localizzato al rachide cervicale.Sono stati selezionati pazienti affetti da dolore posteriore del rachide cervicale senza irradiazione ai tessuti circostanti. Dopo una valutazione clinica e funzionale (dati demografici ed antropometrici, dolore a riposo e durante i movimenti del collo misurato su scala VAS, durata dei sintomi e caratteristiche di insorgenza del dolore [traumatica, a-traumatica]), è stato eseguito un esame ecografico del rachide cervicale secondo protocolli standard.Le normali strutture del collo (ossa, articolazioni, muscoli, legamenti) sono state visualizzate in 124/127 soggetti ed in 58 di essi sono state riscontrate alterazione ecografiche di significato patologico. Fra i pazienti con genesi traumatica e atraumatica l’analisi statistica ha evidenziato differenze significative in termini di età, BMI, durata dei sintomi ed intensità del dolore. Nei soggetti con danno traumatico l’esame ecografico ha dimostrato effusione articolare e bulging capsulare, disallineamento dei capi articolari ed avulsione dell’apice articolare; nei pazienti con danno a-traumatico sono state invece osservate alterazioni degenerative artrosiche (irregolarità corticale, osteofitosi, anchilosi).L’esame ecografico può essere utilizzato come indagine di primo livello in alcuni pazienti affetti da interessamento del rachide cervicale, soprattutto nel dolore post-traumatico.

Aim To evaluate the therapeutic trajectory of intra-articular injections of hyaluronic acid at high concentration (2%) performed at 4-month intervals. Methods Subjects with knee osteoarthritis received, after a weekly injection of 32 mg/2 mL hyaluronic acid for 3 weeks, a single injection of 50 mg/2.5 mL hyaluronic acid (not cross-linked, molecular weight 800–1200 kDa) at 4-month interval (4, 8 and 12 months). Clinical assessment (visual analogic scale [VAS] for pain at rest and during activities, Lequesne Index [LI], Knee Injury and Osteoarthritis Outcome Score (KOOS), and monthly non-steroidal anti-inflammatory drug consumption) was performed at baseline, and after 1, 4, 6, 8, 12 and 14 months. Results In the 15 knees treated, pain decreased (baseline vs. 14 months: VAS at rest, 3.7 ± 1.7 vs. 1 ± 0.7 [P

Background ThetermBlow back painsyndrome^representsa complex nosological entity. The therapeutic approach is often only symptomatic and not etiologic. Methods Since 2013, 186 patients (97 males and 89 females, mean age 59.8 years) have undergone microsurgery for lumbar disc hernia or lumbar segmental stenosis. Among these patients, 23 had been previously treated with ozone therapy by the intraforaminal approach and 28 by intraforaminal steroid injections in other hospitals between 12 and 24 months before our clinical evaluation. These patients received 16 applications in an 8-week period (standard therapy). Results During the surgery, many hard adhesions between the soft tissues and bony structures were unexpectedly discovered. In particular, it was noted that the root contracted and had firm adhesions to the dural sac and/or fragmented disc, which were difficult to resolve. These specific pathological patterns were observed only in the patients who received ozone injections by the intraforaminal approach. We did not findanypathologicalabnormalitiesinthepatientswhodidnot receive any injections or who received intraforaminal steroid injections. Thus, we could exclude that the tissue damage was due to the mechanical action of the needle. Conclusion It is important to assert that ozone therapy procedures can be associated with several major complications. Therefore, performing a revision of the guidelines and protocols for ozone therapy application is indispensable.

BACKGROUND:Proximal inter-phalangeal (PIP) joint arthrodesis today represents the standard treatment for structured hammertoes; however, recently, a lot of new intramedullary devices for the fixation of this arthrodesis have been introduced. The purpose of this work is to look at the currently available devices and to perform a review of the present literature.MATERIALS AND METHODS:A literature search of PubMed/Medline and Google Scholar databases, considering works published up until September 2014 and using the keywords: hammertoe, arthrodesis, PIP joint, fusion, intramedullary devices, and K-wire, was performed. The published papers were included in the present study only if they met the following inclusion criteria: English articles, arthrodesis of PIP joints for hammertoes with new generation intramedullary devices, series with n > 10. Studies using absorbable pins or screws that are considered as another kind of fixation that involved more than one articulation, as well as comments, letters to the editor, or newsletters were excluded.RESULTS:Nine publications were included. Of the patients' reports, 93-100 % were good or excellent concerning satisfaction. Radiological arthrodesis was achieved in 60.5-100 % of cases. Three of the publications compared the new devices with the K-wire. Of these three articles, two employed the traditional technique and one the buried technique. The AOFAS score, evaluated in three publications, showed a delta of 19, 45 and 58 points. Major complications, which required a secondary surgical revision, were between 0 and 8.6 %. The complications of the K-wire and the new devices were similar; also the reoperation rate was close to equal (maximal difference 2 %). On the other hand, these kinds of devices definitely have a higher price, compared to the K-wire.CONCLUSION:The use of these new devices provides good results; however, their high price is currently a problem. For this reason, cost-benefit studies seem to be necessary to justify their use as standard treatment.KEYWORDS:Arthrodesis; Fusion; Hammertoe; Intramedullary devices; K-wire; PIP joint; Review

Objective: To evaluate the efficacy of a specific rehabilitation program for patients in whom ultrasound-guided percutaneous treatment (UGPT) was performed for rotator cuff calcific tendinopathy (RCCT). Subjects and Methods: In this prospective observational study, 86 patients (22 males and 64 females) with shoulder calcific tendinopathy treated with UGPT were enrolled. At the end of the procedure, a corticosteroid injection into the subacromial-subdeltoid bursa was performed. The patients were then asked to follow a specific rehabilitation protocol (2 times/week for 5 weeks) that focused on mobility, strength and function. At baseline and after 6 weeks, clinical parameters, visual analog scale (VAS) and Constant-Murley scale (CMS) scores and ultrasound (US) features were collected. Results: The mean age of the patients was 48.9 ± 8.4 years and their mean BMI was 22.7 ± 2.1. Considering the whole cohort, the treatment was effective, with a significant decrease in the VAS score and an improvement in the CMS score. Thereafter, on the basis of the compliance to the rehabilitation program (by self-report), 53 and 33 patients were included in the rehabilitation group (Rehab group; performed exercises ≥2 times/week) and the No Rehab group (performed exercises Conclusions: UGPT, followed by a specific postprocedure rehabilitation program, was an effective treatment for RCCT.

Introduction Ozone is able to react with proteoglycans, glycosaminoglycans, and other macromolecular complex and to induce galactose glucuronic acid, glycine, and 4-hydroxyproline oxidation. In this way, intra- and intermolecular chemical bonds are broken, releasing an amount of entrapped water. Subsequently, after the water reabsorption, intradiscal and periradicular pressure decrease and as a consequence pain and symptoms improves. Nowadays, oxygen-ozone therapy is increasingly used to treat lumbar disc hernia not responsive to conservative management. In most cases, this therapy is proposed as an alternative to surgery, although its effects could be often only temporary. Patients and Methods From June 2013, 23 patients (14 M and 9 F, mean age 51.3 years) underwent spinal surgery for lumbar disc hernia or lumbar segmental stenosis. Each of them were previously subjected to ozone therapy in a period between 12 and 24 months. Before surgery, all the patients were subjected to an MRI evaluation, as standard protocol. In eight of them a contrast-enhanced MRI was also performed. Results During surgery, many hard adhesions between soft tissue and bony structures were evaluated. Specifically, the dural and periradicular adhesions required a more demolition approach, to achieve the resolution of the disease. In one case, an iatrogenic dural cysts with roots invagination was noticed. This lesion was also detected at the preoperative MRI, but it had appeared only after ozone therapy treatment. It is necessary to observe that none of these patients were previously subjected to spine surgery and that these specific pathologic pattern of adhesion were not observed in patients that did not receive ozone therapy. Conclusion Our observation is a crucial starting point. Although these data are preliminary and it is important not to create unnecessary alarms, it is mandatory to assert that ozone therapy procedure may be associated with major complications. Therefore, it would be necessary a guideline revision and protocols adaptation with regard to ozone therapy application.

OBJECT:The purpose of this study was to assess the effectiveness and safety of an alternative minimally invasive technique for the treatment of carpal tunnel syndrome (CTS).METHODS:This was designed as a prospective, randomized, open-label, blinded end point evaluation (PROBE) study. The active comparison was double tunnels technique (DTT) (Group A, 110 patients) versus standard open decompression of the median nerve (control [Group B], 110 patients). Patient recruitment started in January 2011. The primary outcomes were the functional Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores and visual analog scale (VAS) scores for pain (pVAS) at Weeks 2 and 4, and at Months 3, 6, and 12. The secondary outcome was the aesthetics (aVAS) score at Weeks 2 and 4, and at Months 3, 6, and 12.RESULTS:The Student t-test and ANOVA were used, and the results were considered statistically significant if the p value was ≤0.05 for continuous variables. The DTT is a tissue-sparing approach that allows the surgeon to limit the length of the incision (0.6±0.05 cm) and to respect the palmar fascia and the subcutaneous tissue. Recovery from wrist pain, night pain, numbness, stiffness, and weakness was achieved more effectively and quickly compared with the standard approach. Better BCTSQ, pVAS, and aVAS scores were observed in Group A.CONCLUSIONS:The DTT is a safe and effective approach for the treatment of CTS. This technique entails faster recovery times, better aesthetic outcomes, and lower risks of complications.KEYWORDS:BCTSQ = Boston Carpal Tunnel Syndrome Questionnaire; CTS = carpal tunnel syndrome; DTT = double tunnels technique; PF = palmar fascia; PROBE = prospective, randomized, open-label, blinded end point evaluation; TCL = transverse carpal ligament; aVAS, pVAS = aesthetic visual analog scale, pain VAS; carpal tunnel syndrome; minimally invasive technique; peripheral nerve; tissue-sparing surgery

The aim of this retrospective study is evaluating the long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) treated with administration of single platelet-rich plasma (PRP).A total of 83 tendons (73 patients, 59 males and 14 females; age 43±17.5 years) affected by non-insertional CRAT were treated with single PRP injection. These were evaluated with the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire, Blazina score and satisfaction index at baseline at intervals of 3 weeks, 3 months, 6 months. Final follow-up was carried out at a mean of 50.1 months (range, 24-96).Baseline VISA-A was 45±15. Results relative to the final follow-up improved significantly to a mean of 88±8 (p00.1). Blazina was used for patients practicing sports (54 tendons out of 46 different patients): 37 tendons were grade IIIa, 11 II, and 6 IIIbis. Final follow-up Blazina scores improved for 45 grade 0, 5 I, 4 II (p00.5). Seventy-six tendons (91.6%) were rated as satisfactory and patients would repeat the treatment. Seven tendons (8.4%) were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection. In addition to this, patients reported no Achilles tendon rupture.The study shows beneficial effects and low complication rate following of single PRP injections on a large cohort of patients with mid-long-term follow-up. No cases reported Achilles tendon rupture, in contrast to literature, which described CRAT as one of the most common risk factors. The use of a single PRP injection can therefore be a safe and attractive alternative in the treatment of non-insertional CRATs.

Introduction Overuse, micro-traumas, and impingement, isolated or combined, are the more common etiological factors for rotator cuff tears. Metabolic disorders (diabetes, adiposity, hypercholesterolemia), hypertension, cigarette smoking and a genetic predisposition are considered risk factors. However, no study has compared the prevalence of these risk factors in subjects with bilateral and monolateral tears. Hypothesis Controlateral tears can be observed in patients with symptomatic monolateral rotator cuff lesions, especially in those with comorbidities. Material and methods In patients with symptomatic rotator cuff tear the controlateral shoulders were evaluated by means of ultrasound imaging. Age, BMI, diabetes, hypercholesterolemia, hypertension, cigarette smoking, work habits were registered. Risk factors in subjects with bilateral tears were compared with those with monolateral lesions. Results Of the 180 subjects recruited 69 had a tear in the controlateral shoulder. Higher age and BMI values, heavy repetitive work and diabetes were significantly prevalent in these patients. At multivariate analysis, these factors were independently related to a higher probability to detect bilateral tears. Discussion Metabolic risk factors are more heavily involved in presence of bilateral rotator cuff tears, in comparison to monolateral. Type of study Original study. Level of evidence IV.

We present a clinical case of a 52-year-old man with bilateral traumatic rupture of the Achilles tendon (AT) in absence of risk factors. In medical history, the patient does not report pre-existing tendon diseases. AT ruptures occurred following a skiing injury in which the forward fall caused a severe stress and elongation of the AT. Associated with tendon injury there was a fracture of the right humeral greater tuberosity. The patient was subjected to percutaneous tenorraphy according to Maffulli's technique and subsequently topical injection of autologous platelet-rich plasma (PRP) 7 days after the injury. After surgery, the patient followed an accelerated rehabilitation protocol, allowing the weight bearing with guards (Rom-Walker) and crutches to four weeks then freely to 8 weeks. We performed a clinical (AOFAS ankle-hindfoot score) and ultrasonography follow-up at month 1, 3, 6 and 12, with excellent results in the end. To the best of our knowledge bilateral cases like this have not been described in the literature.